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Leng JX, Carpenter DJ, Huang C, Qazi J, Arshad M, Mullikin TC, Reitman ZJ, Kirkpatrick JP, Floyd SR, Fecci PE, Chmura SJ, Hong JC, Salama JK. Determinants of Symptomatic Intracranial Progression After an Initial Stereotactic Radiosurgery Course. Adv Radiat Oncol 2024; 9:101475. [PMID: 38690297 PMCID: PMC11059392 DOI: 10.1016/j.adro.2024.101475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/04/2024] [Indexed: 05/02/2024] Open
Abstract
Purpose Clinical and imaging surveillance of patients with brain metastases is important after stereotactic radiosurgery (SRS) because many will experience intracranial progression (ITCP) requiring multidisciplinary management. The prognostic significance of neurologic symptoms at the time of ITCP is poorly understood. Methods and Materials This was a multi-institutional, retrospective cohort study from 2015 to 2020, including all patients with brain metastases completing an initial course of SRS. The primary outcome was overall survival (OS) by presence of neurologic symptoms at ITCP. OS, freedom from ITCP (FF-ITCP), and freedom from symptomatic ITCP (FF-SITCP) were assessed via Kaplan-Meier method. Cox proportional hazard models tested parameters impacting FF-ITCP and FF-SITCP. Results Among 1383 patients, median age was 63.4 years, 55% were female, and common primaries were non-small cell lung (49%), breast (15%), and melanoma (9%). At a median follow-up of 8.72 months, asymptomatic and symptomatic ITCP were observed in 504 (36%) and 194 (14%) patients, respectively. The majority of ITCP were distant ITCP (79.5%). OS was worse with SITCP (median, 10.2 vs 17.9 months, P < .001). SITCP was associated with clinical factors including total treatment volume (P = .012), melanoma histology (P = .001), prior whole brain radiation therapy (P = .003), number of brain metastases (P < .001), interval of 1 to 2 years from primary and brain metastasis diagnosis (P = .012), controlled extracranial disease (P = .042), and receipt of pre-SRS chemotherapy (P = .015). Patients who were younger and received post-SRS chemotherapy (P = .001), immunotherapy (P < .001), and targeted or small-molecule inhibitor therapy (P < .026) had better FF-SITCP. Conclusions In this cohort study of patients with brain metastases completing SRS, neurologic symptoms at ITCP is prognostic for OS. This data informs post-SRS surveillance in clinical practice as well as future prospective studies needed in the modern management of brain metastases.
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Affiliation(s)
- Jim X. Leng
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - David J. Carpenter
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
- Department of Radiation Oncology, Wellstar Paulding Hospital, Hiram, Georgia
| | - Christina Huang
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Jamiluddin Qazi
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Muzamil Arshad
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Trey C. Mullikin
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Zachary J. Reitman
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - John P. Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Scott R. Floyd
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Peter E. Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Steven J. Chmura
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Julian C. Hong
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, California
- Joint Program in Computational Precision Health, University of California, San Francisco, California and University of California, Berkeley, California
| | - Joseph K. Salama
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
- Radiation Oncology Clinical Service, Durham VA Health Care System, Durham, North Carolina
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Vaios EJ, Shenker RF, Hendrickson PG, Wan Z, Niedzwiecki D, Winter SF, Shih HA, Dietrich J, Wang C, Salama AKS, Clarke JM, Allen K, Sperduto P, Mullikin T, Kirkpatrick JP, Floyd SR, Reitman ZJ. Long-Term Intracranial Outcomes With Combination Dual Immune-Checkpoint Blockade and Stereotactic Radiosurgery in Patients With Melanoma and Non-Small Cell Lung Cancer Brain Metastases. Int J Radiat Oncol Biol Phys 2024; 118:1507-1518. [PMID: 38097090 PMCID: PMC11056239 DOI: 10.1016/j.ijrobp.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 10/26/2023] [Accepted: 12/02/2023] [Indexed: 01/18/2024]
Abstract
PURPOSE The intracranial benefit of offering dual immune-checkpoint inhibition (D-ICPI) with ipilimumab and nivolumab to patients with melanoma or non-small cell lung cancer (NSCLC) receiving stereotactic radiosurgery (SRS) for brain metastases (BMs) is unknown. We hypothesized that D-ICPI improves local control compared with SRS alone. METHODS AND MATERIALS Patients with melanoma or NSCLC treated with SRS from 2014 to 2022 were evaluated. Patients were stratified by treatment with D-ICPI, single ICPI (S-ICPI), or SRS alone. Local recurrence, intracranial progression (IP), and overall survival were estimated using competing risk and Kaplan-Meier analyses. IP included both local and distant intracranial recurrence. RESULTS Two hundred eighty-eight patients (44% melanoma, 56% NSCLC) with 1,704 BMs were included. Fifty-three percent of patients had symptomatic BMs. The median follow-up was 58.8 months. Twelve-month local control rates with D-ICPI, S-ICPI, and SRS alone were 94.73% (95% CI, 91.11%-96.90%), 91.74% (95% CI, 89.30%-93.64%), and 88.26% (95% CI, 84.07%-91.41%). On Kaplan-Meier analysis, only D-ICPI was significantly associated with reduced local recurrence (P = .0032). On multivariate Cox regression, D-ICPI (hazard ratio [HR], 0.4003; 95% CI, 0.1781-0.8728; P = .0239) and planning target volume (HR, 1.022; 95% CI, 1.004-1.035; P = .0059) correlated with local control. One hundred seventy-three (60%) patients developed IP. The 12-month cumulative incidence of IP was 41.27% (95% CI, 30.27%-51.92%), 51.86% (95% CI, 42.78%-60.19%), and 57.15% (95% CI, 44.98%-67.59%) after D-ICPI, S-ICPI, and SRS alone. On competing risk analysis, only D-ICPI was significantly associated with reduced IP (P = .0408). On multivariate Cox regression, D-ICPI (HR, 0.595; 95% CI, 0.373-0.951; P = .0300) and presentation with >10 BMs (HR, 2.492; 95% CI, 1.668-3.725; P < .0001) remained significantly correlated with IP. The median overall survival after D-ICPI, S-ICPI, and SRS alone was 26.1 (95% CI, 15.5-40.7), 21.5 (16.5-29.6), and 17.5 (11.3-23.8) months. S-ICPI, fractionation, and histology were not associated with clinical outcomes. There was no difference in hospitalizations or neurologic adverse events between cohorts. CONCLUSIONS The addition of D-ICPI for patients with melanoma and NSCLC undergoing SRS is associated with improved local and intracranial control. This appears to be an effective strategy, including for patients with symptomatic or multiple BMs.
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Affiliation(s)
- Eugene J Vaios
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Rachel F Shenker
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Peter G Hendrickson
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Zihan Wan
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | - Donna Niedzwiecki
- Duke Cancer Institute Biostatistics, Duke University Medical Center, Durham, North Carolina
| | - Sebastian F Winter
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jorg Dietrich
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Chunhao Wang
- Departments of Medical Physics, Duke University Medical Center, Durham, North Carolina
| | - April K S Salama
- Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey M Clarke
- Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Karen Allen
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Paul Sperduto
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Trey Mullikin
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - John P Kirkpatrick
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina; Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Scott R Floyd
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Zachary J Reitman
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina; Neurosurgery, Duke University Medical Center, Durham, North Carolina; Pathology, Duke University Medical Center, Durham, North Carolina.
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Wang Z, Chen H, Chen Q, Zhu Y, Li M, Zhou J. Multi-institutional study of 'Sandwich treatment' for motor area large brain metastases (LBM) with diameter over 3 cm. Radiol Oncol 2024; 58:145-152. [PMID: 38183280 PMCID: PMC10878778 DOI: 10.2478/raon-2024-0002] [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: 07/03/2023] [Accepted: 09/23/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND The objective of the present study was to explore the effectiveness and safety of 'Sandwich treatment' strategy for large brain metastases (LBM) with diameter over 3 cm (minimum volume >= 15 cm3) located in motor area. PATIENTS AND METHODS Patients from four gamma knife center that received 'Sandwich treatment' were retrospectively studied from January 2016 to March 2023. The strategy was one-week treatment course including 2 stages of stereotactic radiosurgery (SRS) and using bevacizumab once during SRS gap. The tumor volume and peri-tumor edema changes were analyzed before and after 'Sandwich treatment'. Manual muscle testing (MMT) score and Barthel Index (BI) score were used to evaluate the changes of patients' movement and physical strength rehabilitation. The patients' overall survival (OS) and tumor local control (TLC) rate was calculated. Cox regression model was used to analyze the risk factors that related to TLC. RESULTS 61 patients with 72 lesions received the 'Sandwich treatment'. The median prescription dose was 13.0 Gy and 12.5 Gy at the first- and second-stage SRS. The mean tumor volume at the time of 'Sandwich treatment' and 3 months later was 20.1 cm3 and 12.3, respectively (P < 0.01). The mean peri-tumor edema volume at the first- and second-stage SRS was 12.6 cm3 and 5.2 cm3, respectively (P < 0.01). Patients' median MMT score improved from 6 at the beginning to 8 at the end of 'Sandwich treatment' (P < 0.01), BI score was also greatly improved from 45 at the time of 'Sandwich treatment' to 95 after 3 months (P < 0.01). Patients' median OS was 14.0 months, and the 3, 6, 12 months OS rate was 92.0%, 86.0% and 66.0%, respectively. The TLC rate at 3, 6, 12 months was 98.4%, 93.4%, and 85.3%, respectively. Patients with lung cancer had lower risk of tumor relapse. The cumulative incidence of patient's hemorrhage and radiation necrosis was 4.92% (3/61) and 13.11% (8/61) after 'Sandwich treatment'. CONCLUSIONS 'Sandwich treatment' strategy is safe and effective for LBM located in motor area. The strategy could rapidly improve the patients' movement and enhance their physical strength rehabilitation.
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Affiliation(s)
- Zheng Wang
- Cancer Center, Gamma Knife Treatment Center, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital of Hangzhou Medical College, Hangzhou, China
| | - Haining Chen
- Gamma Knife Treatment Center, Anhui Provincial Hospital, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Qun Chen
- Gamma Knife Treatment Center. Jiangsu Province People’s Hospital, the First Affiliated Hospital of Nanjing Medical UniversityNanjing, China
| | - Yucun Zhu
- Gamma Knife Treatment Center, Ming ji Hospital, Affiliated to Nanjing Medical University, Nanjing, China
| | - Min Li
- Cancer Center, Gamma Knife Treatment Center, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital of Hangzhou Medical College, Hangzhou, China
| | - Jia Zhou
- Cancer Center, Gamma Knife Treatment Center, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital of Hangzhou Medical College, Hangzhou, China
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Borius PY, Amelot A, Boustany E, Boskos C, Mazeron JJ, Valéry CA. Two fractions staged Gammaknife radiosurgery for "large" cerebral metastases. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107043. [PMID: 37856987 DOI: 10.1016/j.ejso.2023.107043] [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: 12/12/2022] [Revised: 08/02/2023] [Accepted: 08/20/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Gammaknife radiosurgery (GKRS) is a valuable option to control cerebral metastases. However, the risk (adverse radiation effect (ARE))-benefit (local control (LC)) ratio switches when the target is too large. OBJECTIVE In order to balance this ratio, two fractions staged GKRS protocol was conducted for "large" cerebral metastases. The aim of this study is to evaluate the outcome (LC, ARE). METHODS A total of 39 large cerebral metastases in 35 patients were treated. The initial mean tumor volume was 14.6 cc [6.1; 35.8]. The prescription margin dose was 12 Gy on the 50% isodose line, with 2 weeks between them. A majority of primary cancer were from lung (43%), melanoma (20%) or breast (17%) origin. The mean age was 63 years old (31-89). Mean Graded Prognostic Assessment (GPA) was 2. RESULTS At the second fraction, mean tumor volume was 10.3 cc [1.9-27.4]. The mean percentage of volume variation for decreasing lesions was 29%. At last follow-up, mean tumor volume was 7.4 cc [0-25.2]; 34 lesions decreased volume (mean 35%). A decreased volume of more than 45% after first stage GKRS was able to predict a long-term local response to staged GKRS treatment. Local control rate at 6 months and 1 year was 87.3% and 75% respectively. The rate of ARE was 7.7%. No predictive factor of local control or ARE was found in a univariate analysis. CONCLUSION The new 2-fractions-dose-staged GKRS concept seems to be a well-tolerated and effective treatment option for large cerebral metastases.
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Affiliation(s)
- Pierre-Yves Borius
- Neurosurgery Department and GammaKnife Unit, Pitié Salpêtrière Sorbonne University Hospital, Paris, France
| | - Aymeric Amelot
- Neurosurgery Department and GammaKnife Unit, Pitié Salpêtrière Sorbonne University Hospital, Paris, France
| | - Eli Boustany
- Neurosurgery Department and GammaKnife Unit, Pitié Salpêtrière Sorbonne University Hospital, Paris, France
| | | | - Jean-Jacques Mazeron
- Radiation Therapy Department, Pitié Salpêtrière Sorbonne University, Paris, France
| | - Charles Ambroise Valéry
- Neurosurgery Department and GammaKnife Unit, Pitié Salpêtrière Sorbonne University Hospital, Paris, France.
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Chambrelant I, Jarnet D, Bou-Gharios J, Le Fèvre C, Kuntz L, Antoni D, Jenny C, Noël G. Stereotactic Radiation Therapy of Single Brain Metastases: A Literature Review of Dosimetric Studies. Cancers (Basel) 2023; 15:3937. [PMID: 37568753 PMCID: PMC10416831 DOI: 10.3390/cancers15153937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/29/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
Stereotactic radiotherapy (SRT) plays a major role in treating brain metastases (BMs) and can be delivered using various equipment and techniques. This review aims to identify the dosimetric factors of each technique to determine whether one should be preferred over another for single BMs treatment. A systematic literature review on articles published between January 2015 and January 2022 was conducted using the MEDLINE and ScienceDirect databases, following the PRISMA methodology, using the keywords "dosimetric comparison" and "brain metastases". The included articles compared two or more SRT techniques for treating single BM and considered at least two parameters among: conformity (CI), homogeneity (HI) and gradient (GI) indexes, delivery treatment time, and dose-volume of normal brain tissue. Eleven studies were analyzed. The heterogeneous lesions along with the different definitions of dosimetric indexes rendered the studied comparison almost unattainable. Gamma Knife (GK) and volumetric modulated arc therapy (VMAT) provide better CI and GI and ensure the sparing of healthy tissue. To conclude, it is crucial to optimize dosimetric indexes to minimize radiation exposure to healthy tissue, particularly in cases of reirradiation. Consequently, there is a need for future well-designed studies to establish guidelines for selecting the appropriate SRT technique based on the treated BMs' characteristics.
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Affiliation(s)
- Isabelle Chambrelant
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), UNICANCER, Paul Strauss Comprehensive Cancer Center, 67200 Strasbourg, France; (I.C.); (C.L.F.); (L.K.); (D.A.)
| | - Delphine Jarnet
- Department of Medical Physics, Institut de Cancérologie Strasbourg Europe (ICANS), UNICANCER, Paul Strauss Comprehensive Cancer Center, 67200 Strasbourg, France;
| | - Jolie Bou-Gharios
- Radiobiology Laboratory, Institut de Cancérologie Strasbourg Europe (ICANS), Paul Strauss Comprehensive Cancer Center, 67200 Strasbourg, France;
| | - Clara Le Fèvre
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), UNICANCER, Paul Strauss Comprehensive Cancer Center, 67200 Strasbourg, France; (I.C.); (C.L.F.); (L.K.); (D.A.)
| | - Laure Kuntz
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), UNICANCER, Paul Strauss Comprehensive Cancer Center, 67200 Strasbourg, France; (I.C.); (C.L.F.); (L.K.); (D.A.)
| | - Delphine Antoni
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), UNICANCER, Paul Strauss Comprehensive Cancer Center, 67200 Strasbourg, France; (I.C.); (C.L.F.); (L.K.); (D.A.)
| | - Catherine Jenny
- Department of Medical Physics, AP-HP, Sorbonne Université, CEDEX 13, 75651 Paris, France;
| | - Georges Noël
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), UNICANCER, Paul Strauss Comprehensive Cancer Center, 67200 Strasbourg, France; (I.C.); (C.L.F.); (L.K.); (D.A.)
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Noda R, Kawashima M, Segawa M, Tsunoda S, Inoue T, Akabane A. Fractionated versus staged gamma knife radiosurgery for mid-to-large brain metastases: a propensity score-matched analysis. J Neurooncol 2023; 164:87-96. [PMID: 37525086 DOI: 10.1007/s11060-023-04374-8] [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: 05/18/2023] [Accepted: 06/14/2023] [Indexed: 08/02/2023]
Abstract
PURPOSE To compare treatment results between fractionated gamma knife radiosurgery (f-GKRS) and staged gamma knife radiosurgery (s-GKRS) for mid-to-large brain metastases (BMs). METHODS We retrospectively analyzed data of patients with medium (4-10 mL) to large (> 10 mL) BMs who underwent s-GKRS or f-GKRS between March 2008 and September 2022. Patients were treated with (i) s-GKRS before May 2018 and (ii) f-GKRS after May 2018. Patients who underwent follow-up magnetic resonance imaging at least once were enrolled. Case-matched studies were conducted by applying propensity score matching to minimize treatment selection bias and potential confounding. Local control (LC) was set as the primary endpoint and overall survival (OS) as the secondary endpoint. RESULTS This study included 129 patients with 136 lesions and 70 patients with 78 lesions who underwent s-GKRS and f-GKRS, respectively. Overall, 124 lesions (62 lesions in each group) were selected in the case-matched group. No differences were observed in the 6-month and 1-year cumulative incidences of LC failure between the s-GKRS and f-GKRS groups (15.6% vs. 15.9% at 6 months and 25.6% vs. 25.6% at 1 year; p = 0.617). One-year OS rates were 62.6% (95% confidence interval [CI]: 45.4-75.7%) and 73.9% (95% CI: 58.8-84.2%) in the s-GKRS and f-GKRS groups, respectively. The post-GKRS median survival time was shorter in the s-GKRS group than in the f-GKRS group (17 vs. 36 months), without significance (p = 0.202). CONCLUSIONS This is the first study to compare f-GKRS and s-GKRS in large BMs. Fractionation is as effective as staged GKRS for treating mid-to-large BMs.
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Affiliation(s)
- Ryuichi Noda
- Gamma Knife Center, NTT Medical Center Tokyo, 141-8625 5-9-22, Higashi-Gotanda, Shinagawa-Ku, Tokyo, Japan.
- Department of Neurosurgery, NTT Medical Center Tokyo, 141-8625 5-9-22, Higashi-Gotanda, Shinagawa-Ku, Tokyo, Japan.
| | - Mariko Kawashima
- Gamma Knife Center, NTT Medical Center Tokyo, 141-8625 5-9-22, Higashi-Gotanda, Shinagawa-Ku, Tokyo, Japan
| | - Masafumi Segawa
- Department of Neurosurgery, NTT Medical Center Tokyo, 141-8625 5-9-22, Higashi-Gotanda, Shinagawa-Ku, Tokyo, Japan
| | - Sho Tsunoda
- Department of Neurosurgery, NTT Medical Center Tokyo, 141-8625 5-9-22, Higashi-Gotanda, Shinagawa-Ku, Tokyo, Japan
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, 141-8625 5-9-22, Higashi-Gotanda, Shinagawa-Ku, Tokyo, Japan
| | - Atsuya Akabane
- Gamma Knife Center, NTT Medical Center Tokyo, 141-8625 5-9-22, Higashi-Gotanda, Shinagawa-Ku, Tokyo, Japan
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Mishra A, Koffler D, Calugaru E, Rowe N, Viswanatha SD, Begley S, Bajaj V, Schulder M, Goenka A. Let's make size not matter: tumor control and toxicity outcomes of hypofractionated Gamma Knife radiosurgery for large brain metastases. J Neurooncol 2023; 163:587-595. [PMID: 37410346 DOI: 10.1007/s11060-023-04365-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/06/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE Management of patients with large brain metastases poses a clinical challenge, with poor local control and high risk of adverse radiation events when treated with single-fraction stereotactic radiosurgery (SF-SRS). Hypofractionated SRS (HF-SRS) may be considered, but clinical data remains limited, particularly with Gamma Knife (GK) radiosurgery. We report our experience with GK to deliver mask-based HF-SRS to brain metastases greater than 10 cc in volume and present our control and toxicity outcomes. METHODS Patients who received hypofractionated GK radiosurgery (HF-GKRS) for the treatment of brain metastases greater than 10 cc between January 2017 and June 2022 were retrospectively identified. Local failure (LF) and adverse radiation events of CTCAE grade 2 or higher (ARE) were identified. Clinical, treatment, and radiological information was collected to identify parameters associated with clinical outcomes. RESULTS Ninety lesions (in 78 patients) greater than 10 cc were identified. The median gross tumor volume was 16.0 cc (range 10.1-56.0 cc). Prior surgical resection was performed on 49 lesions (54.4%). Six- and 12-month LF rates were 7.3% and 17.6%; comparable ARE rates were 1.9% and 6.5%. In multivariate analysis, tumor volume larger than 33.5 cc (p = 0.029) and radioresistant histology (p = 0.047) were associated with increased risk of LF (p = 0.018). Target volume was not associated with increased risk of ARE (p = 0.511). CONCLUSIONS We present our institutional experience treating large brain metastases using mask-based HF-GKRS, representing one of the largest studies implementing this platform and technique. Our LF and ARE compare favorably with the literature, suggesting that target volumes less than 33.5 cc demonstrate excellent control rates with low ARE. Further investigation is needed to optimize treatment technique for larger tumors.
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Affiliation(s)
- Akash Mishra
- Department of Radiation Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
| | - Daniel Koffler
- Department of Radiation Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
| | - Emel Calugaru
- Department of Radiation Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
| | - Niara Rowe
- Department of Radiation Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
| | - Sirisha Devi Viswanatha
- Department of Radiation Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
| | - Sabrina Begley
- Department of Radiation Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
| | - Vikram Bajaj
- Department of Radiation Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
| | - Michael Schulder
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
| | - Anuj Goenka
- Department of Radiation Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA.
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Matsui JK, Perlow HK, Upadhyay R, McCalla A, Raval RR, Thomas EM, Blakaj DM, Beyer SJ, Palmer JD. Advances in Radiotherapy for Brain Metastases. Surg Oncol Clin N Am 2023; 32:569-586. [PMID: 37182993 DOI: 10.1016/j.soc.2023.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Radiotherapy remains a cornerstone treatment of brain metastases. With new treatment advances, patients with brain metastases are living longer, and finding solutions for mitigating treatment-related neurotoxicity and improving quality of life is important. Historically, whole-brain radiation therapy (WBRT) was widely used but treatment options such as hippocampal sparing WBRT and stereotactic radiosurgery (SRS) have emerged as promising alternatives. Herein, we discuss the recent advances in radiotherapy for brain metastases including the sparing of critical structures that may improve long-term neurocognitive outcomes (eg, hippocampus, fornix) that may improve long-term neurocognitive outcome, evidence supporting preoperative and fractionated-SRS, and treatment strategies for managing radiation necrosis.
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Shiue K, Sahgal A, Lo SS. Precision Radiation for Brain Metastases With a Focus on Hypofractionated Stereotactic Radiosurgery. Semin Radiat Oncol 2023; 33:114-128. [PMID: 36990629 DOI: 10.1016/j.semradonc.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
There are multiple published randomized controlled trials supporting single-fraction stereotactic radiosurgery (SF-SRS) for patients presenting with 1 to 4 brain metastases, with the benefit of minimizing radiation-induced neurocognitive sequelae as compared to whole brain radiotherapy . More recently, the dogma of SF-SRS as the only means of delivering an SRS treatment has been challenged by hypofractionated SRS (HF-SRS). The ability to deliver 25-35 Gy in 3-5 HF-SRS fractions is a direct consequence of the evolution of radiation technologies to allow image guidance, specialized treatment planning, robotic delivery and/or patient positioning corrections in all 6 degrees-of-freedom, and frameless head immobilization. The intent is to mitigate the potentially devastating complication of radiation necrosis and improve rates of local control for larger metastases. This narrative review provides an overview of outcomes specific to HF-SRS in addition to the more recent developments of staged SRS, preoperative SRS, and hippocampal avoidance-whole brain radiotherapy with simultaneous integrated boost.
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Benjamin C, Gurewitz J, Nakamura A, Mureb M, Mullen R, Pacione D, Silverman J, Kondziolka D. Up-front single-session radiosurgery for large brain metastases-volumetric responses and outcomes. Acta Neurochir (Wien) 2023; 165:1365-1378. [PMID: 36702970 DOI: 10.1007/s00701-023-05491-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 01/01/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND Patients presenting with large brain metastases (LBM) pose a management challenge to the multidisciplinary neuro-oncologic team. Treatment options include surgery, whole-brain or large-field radiation therapy (WBRT), stereotactic radiosurgery (SRS), or a combination of these. OBJECTIVE To determine if corticosteroid therapy followed by SRS allows for efficient minimally invasive care in patients with LBMs not compromised by mass effect. METHODS We analyzed the change in tumor volume to determine the efficacy of single-session SRS in the treatment of LBM in comparison to other treatment modalities. Twenty-nine patients with systemic cancer and brain metastasis (≥ 2.7 cm in greatest diameter) who underwent single-session SRS were included. RESULTS Among 29 patients, 69% of patients had either lung, melanoma, or breast cancer. The median initial tumor size (maximal diameter) was 32 mm (range 28-43), and the median initial tumor volume was 9.56 cm3 (range 1.56-25.31). The median margin dose was 16 Gy (range 12-18). The average percent decrease in tumor volume compared to pre-SRS volume was 55% on imaging at 1-2 months, 58% at 3-5 months, 64% at 6-8 months, and 57% at > 8 months. There were no adverse events immediately following SRS. Median corticosteroid use after SRS was 21 days. Median survival after radiosurgery was 15 months. CONCLUSION Initial high-dose corticosteroid therapy followed by prompt single-stage SRS is a safe and efficacious method to manage patients with LBMs (defined as ≥ 2.7 cm).
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Affiliation(s)
- Carolina Benjamin
- Department of Neurosurgery, University of Miami Health System, 1095 N.W. 14Th Terrace, 2Nd Floor, Miami, FL, 33136, USA.
| | - Jason Gurewitz
- Department of Radiation Oncology, NYU Langone Medical Center, New York, NY, USA
| | - Aya Nakamura
- Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Monica Mureb
- Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Reed Mullen
- Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Donato Pacione
- Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Joshua Silverman
- Department of Radiation Oncology, NYU Langone Medical Center, New York, NY, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
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Chang S, Liu G, Zhao L, Zheng W, Yan D, Chen P, Li X, Yang K, Deraniyagala R, Stevens C, Grills I, Chinnaiyan P, Li X, Ding X. Redefine the Role of Spot-Scanning Proton Beam Therapy for the Single Brain Metastasis Stereotactic Radiosurgery. Front Oncol 2022; 12:804036. [PMID: 35664795 PMCID: PMC9160604 DOI: 10.3389/fonc.2022.804036] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 04/14/2022] [Indexed: 12/30/2022] Open
Abstract
Purpose To explore the role of using Pencil Beam Scanning (PBS) proton beam therapy in single lesion brain stereotactic radiosurgery (SRS), we developed and validated a dosimetric in silico model to assist in the selection of an optimal treatment approach among the conventional Volumetric Modulated Arc Therapy (VMAT), Intensity Modulated Proton Therapy (IMPT) and Spot-scanning Proton Arc (SPArc). Material and Methods A patient’s head CT data set was used as an in silico model. A series of targets (volume range from 0.3 cc to 33.03 cc) were inserted in the deep central and peripheral region, simulating targets with different sizes and locations. Three planning groups: IMPT, VMAT, and SPArc were created for dosimetric comparison purposes and a decision tree was built based on this in silico model. Nine patients with single brain metastases were retrospectively selected for validation. Multiple dosimetric metrics were analyzed to assess the plan quality, such as dose Conformity Index (CI) (ratio of the target volume to 100% prescription isodose volume); R50 (ratio of 50% prescription isodose volume to the target volume); V12Gy (volume of brain tissue minus GTV receiving 12 Gy), and mean dose of the normal brain. Normal tissue complication probability (NTCP) of brain radionecrosis (RN) was calculated using the Lyman-Kutcher-Burman (LKB) model and total treatment delivery time was calculated. Six physicians from different institutions participated in the blind survey to evaluate the plan quality and rank their choices. Results The study showed that SPArc has a dosimetric advantage in the V12Gy and R50 with target volumes > 9.00 cc compared to VMAT and IMPT. A significant clinical benefit can be found in deep centrally located lesions larger than 20.00 cc using SPArc because of the superior dose conformity and mean dose reduction in healthy brain tissue. Nine retrospective clinical cases and the blind survey showed good agreement with the in silico dosimetric model and decision tree. Additionally, SPArc significantly reduced the treatment delivery time compared to VMAT (SPArc 184.46 ± 59.51s vs. VMAT: 1574.78 ± 213.65s). Conclusion The study demonstrated the feasibility of using Proton beam therapy for single brain metastasis patients utilizing the SPArc technique. At the current stage of technological development, VMAT remains the current standard modality of choice for single lesion brain SRS. The in silico dosimetric model and decision tree presented here could be used as a practical clinical decision tool to assist the selection of the optimal treatment modality among VMAT, IMPT, and SPArc in centers that have both photon and proton capabilities.
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Affiliation(s)
- Sheng Chang
- Department of Radiation Oncology, Renmin Hospital, Wuhan University, Wuhan, China
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Gang Liu
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lewei Zhao
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Weili Zheng
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Di Yan
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Peter Chen
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Xiangpan Li
- Department of Radiation Oncology, Renmin Hospital, Wuhan University, Wuhan, China
| | - Kunyu Yang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rohan Deraniyagala
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Craig Stevens
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Inga Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Prakash Chinnaiyan
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Xiaoqiang Li
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
- *Correspondence: Xuanfeng Ding,
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Metastatic Neoplasm Volume Kinetics Following Two-Staged Stereotactic Radiosurgery. World Neurosurg 2022; 161:e210-e219. [PMID: 35123024 DOI: 10.1016/j.wneu.2022.01.109] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Multisession staged stereotactic radiosurgery (2-SSRS) represents an alternative approach for management of large brain metastases (LBMs), with potential advantages over fractionated SRS. We investigated the clinical efficacy and safety of 2-SSRS in patients with LBMs. METHODS LBMs patients treated with 2-SSRS between 2014-2020 were evaluated. Demographic, clinical, and radiologic information was obtained. Volumetric measurements at first SSRS, second SSRS, and follow-up imaging studies were obtained. Characteristics that might predict response to 2-SSRS were evaluated through Fischer-exact or Mann-Whitney U test. RESULTS Twenty-four patients with 26 LBMs were included in the study. Median marginal doses for first and second SSRS were 15 Gy (14-18 Gy) and 15 Gy (12-16 Gy), respectively. Median tumor volumes at first SSRS, second SSRS, and 3-month follow-up were 8.1 cm3 (1.5-28.5 cm3), 3.3 cm3 (0.8-26.1 cm3), and 2.2 cm3 (0.2-10.1 cm3), respectively. Overall, 24/26 lesions (92%) demonstrated early local control following the first SSRS with 17 lesions (71%) demonstrating a decrease of >30% in the T1 post-contrast MRI volume before the second SSRS and 3 lesions (12%) remaining stable. Eventually, four lesions showed disease progression after 2-SSRS. The median time to local progression was not reached and the median time to intracranial progression was 9.1 months. CONCLUSIONS Our study supports the effectiveness and safety of 2-SSRS as a treatment modality for patients with large, symptomatic brain metastases, especially in poor surgical candidates. The local failure rate and low occurrence of adverse effects are comparable to other staged radiosurgery studies.
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Myrehaug S, Hudson J, Soliman H, Ruschin M, Tseng CL, Detsky J, Husain Z, Keith J, Atenafu EG, Maralani P, Heyn C, Das S, Lipsman N, Sahgal A. Hypofractionated Stereotactic Radiation Therapy for Intact Brain Metastases in 5 Daily Fractions: Effect of Dose on Treatment Response. Int J Radiat Oncol Biol Phys 2021; 112:342-350. [PMID: 34537313 DOI: 10.1016/j.ijrobp.2021.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/13/2021] [Accepted: 09/01/2021] [Indexed: 01/09/2023]
Abstract
PURPOSE Multileaf collimator (MLC) linear accelerator (Linac)-based hypofractionated stereotactic radiation therapy (HSRT) is increasingly used not only for large brain metastases or those adjacent to critical structures but also for those metastases that would otherwise be considered for single-fraction radiosurgery (SRS). However, data on outcomes in general are limited, and there is a lack of understanding regarding optimal dosing. Our aim was to report mature image-based outcomes for MLC-Linac HSRT with a focus on clinical and dosimetric factors associated with local failure (LF). METHODS AND MATERIALS A total of 220 patients with 334 brain metastases treated with HSRT were identified. All patients were treated using a 5-fraction daily regimen and were followed with clinical evaluation and volumetric magnetic resonance imaging every 2 to 3 months. Overall survival and progression-free survival were calculated using the Kaplan-Meier method, with LF determined using Fine and Gray's competing risk method. Predictive factors were identified using Cox regression multivariate analysis. RESULTS Median follow-up was 10.8 months. Median size of treated metastasis was 1.9 cm; 60% of metastases were <2 cm in size. The median total dose was 30 Gy in 5 fractions; 36% of the cohort received <30 Gy. The median time to LF and 12-month cumulative incidence of LF was 8.5 months and 23.8%, respectively. Median time to death and 12-month overall survival rates were 11.8 months and 48.2%, respectively. Fifty-two metastases (15.6%) had an adverse radiation effect, of which 32 (9.5%) were symptomatic necrosis. Multivariable analysis identified worse LF in patients who received a total dose of <30 Gy (hazard ratio, 1.62; P = .03), with LF at 6 and 12 months of 13% and 33% for patients treated with <30 Gy versus 5% and 19% for patients treated with >30 Gy. Exploratory analysis demonstrated a dose-response effect observed in all histologic types, including among breast cancer subtypes. CONCLUSION Optimal local control is achieved with HSRT of ≥30 Gy in 5 daily fractions, independent of tumor volume and histology, with an acceptable risk of radiation necrosis.
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Affiliation(s)
- Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada.
| | - John Hudson
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Mark Ruschin
- Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Julia Keith
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, Ontario, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Chris Heyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Sunit Das
- Department of Neurosurgery, St. Michaels Hospital, Ontario, Canada
| | - Nir Lipsman
- Department of Neurosurgery, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
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Park JH, Choi BS, Han JH, Kim CY, Cho J, Bae YJ, Sunwoo L, Kim JH. MRI Texture Analysis for the Prediction of Stereotactic Radiosurgery Outcomes in Brain Metastases from Lung Cancer. J Clin Med 2021; 10:jcm10020237. [PMID: 33440723 PMCID: PMC7827024 DOI: 10.3390/jcm10020237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/08/2021] [Accepted: 01/08/2021] [Indexed: 12/30/2022] Open
Abstract
This study aims to evaluate the utility of texture analysis in predicting the outcome of stereotactic radiosurgery (SRS) for brain metastases from lung cancer. From 83 patients with lung cancer who underwent SRS for brain metastasis, a total of 118 metastatic lesions were included. Two neuroradiologists independently performed magnetic resonance imaging (MRI)-based texture analysis using the Imaging Biomarker Explorer software. Inter-reader reliability as well as univariable and multivariable analyses were performed for texture features and clinical parameters to determine independent predictors for local progression-free survival (PFS) and overall survival (OS). Furthermore, Harrell’s concordance index (C-index) was used to assess the performance of the independent texture features. The primary tumor histology of small cell lung cancer (SCLC) was the only clinical parameter significantly associated with local PFS in multivariable analysis. Run-length non-uniformity (RLN) and short-run emphasis were the independent texture features associated with local PFS. In the non-SCLC (NSCLC) subgroup analysis, RLN and local range mean were associated with local PFS. The C-index of independent texture features was 0.79 for the all-patients group and 0.73 for the NSCLC subgroup. In conclusion, texture analysis on pre-treatment MRI of lung cancer patients with brain metastases may have a role in predicting SRS response.
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Affiliation(s)
- Jung Hyun Park
- Department of Radiology, Ajou University School of Medicine, Ajou University Medical Center, Suwon 443-380, Korea;
- Department of Radiology, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea; (J.C.); (Y.J.B.); (L.S.); (J.H.K.)
| | - Byung Se Choi
- Department of Radiology, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea; (J.C.); (Y.J.B.); (L.S.); (J.H.K.)
- Correspondence: ; Tel.: +82-31-787-7625; Fax: +82-31-787-4011
| | - Jung Ho Han
- Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea; (J.H.H.); (C.-Y.K.)
| | - Chae-Yong Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea; (J.H.H.); (C.-Y.K.)
| | - Jungheum Cho
- Department of Radiology, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea; (J.C.); (Y.J.B.); (L.S.); (J.H.K.)
| | - Yun Jung Bae
- Department of Radiology, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea; (J.C.); (Y.J.B.); (L.S.); (J.H.K.)
| | - Leonard Sunwoo
- Department of Radiology, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea; (J.C.); (Y.J.B.); (L.S.); (J.H.K.)
| | - Jae Hyoung Kim
- Department of Radiology, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea; (J.C.); (Y.J.B.); (L.S.); (J.H.K.)
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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: 2] [Impact Index Per Article: 0.7] [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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Schelin ME, Liu H, Ali A, Shi W, Yu Y, Mooney KE. Dosimetric comparison of Gamma Knife® Icon TM and linear accelerator-based fractionated stereotactic radiotherapy (FSRT) plans for the re-irradiation of large (>14 cm 3) recurrent glioblastomas. JOURNAL OF RADIOSURGERY AND SBRT 2021; 7:233-243. [PMID: 33898087 PMCID: PMC8055238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 01/07/2021] [Indexed: 06/12/2023]
Abstract
Our objective is to investigate dosimetric differences between clinically deliverable Gamma Knife® (GK) Icon™ and linac-based FSRT plans on the basis of normal brain dose sparing for large (>14 cm3) recurrent glioblastomas (GBM). Sixteen patients with large, recurrent GBM were treated using re-irradiation via linac-based FSRT, 35 Gy in 10 fractions. For each patient, a new GK FSRT plan was created in Leksell GammaPlan® V11 (LGP). To maintain clinical deliverability, the LGP optimization included a planning goal of treatment time <20 minutes per fraction. Dosimetric comparison of coverage and normal brain dose between the linac and GK treatment plans was performed in MIM. The GK FSRT plans had significantly (p < 0.05) lower mean normal brain dose values (-8.85%), mean values of normal brain V20 (-32.4%) and V12 (-25.9%), and a lower mean V4 (-10.0%). GK FSRT plans have the potential to reduce the risk of radiation-related toxicities.
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Affiliation(s)
- Matthew E Schelin
- Department of Radiation Oncology, Thomas Jefferson University, Bodine Center for Radiation Therapy, 111 S. 11th Street, Philadelphia, PA 19107, USA
| | - Haisong Liu
- Department of Radiation Oncology, Thomas Jefferson University, Bodine Center for Radiation Therapy, 111 S. 11th Street, Philadelphia, PA 19107, USA
| | - Ayesha Ali
- Department of Radiation Oncology, Thomas Jefferson University, Bodine Center for Radiation Therapy, 111 S. 11th Street, Philadelphia, PA 19107, USA
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Bodine Center for Radiation Therapy, 111 S. 11th Street, Philadelphia, PA 19107, USA
| | - Yan Yu
- Department of Radiation Oncology, Thomas Jefferson University, Bodine Center for Radiation Therapy, 111 S. 11th Street, Philadelphia, PA 19107, USA
| | - Karen E Mooney
- Department of Radiation Oncology, Thomas Jefferson University, Bodine Center for Radiation Therapy, 111 S. 11th Street, Philadelphia, PA 19107, USA
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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: 64] [Impact Index Per Article: 16.0] [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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Gutschenritter T, Venur VA, Combs SE, Vellayappan B, Patel AP, Foote M, Redmond KJ, Wang TJC, Sahgal A, Chao ST, Suh JH, Chang EL, Ellenbogen RG, Lo SS. The Judicious Use of Stereotactic Radiosurgery and Hypofractionated Stereotactic Radiotherapy in the Management of Large Brain Metastases. Cancers (Basel) 2020; 13:cancers13010070. [PMID: 33383817 PMCID: PMC7795798 DOI: 10.3390/cancers13010070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/11/2020] [Accepted: 12/18/2020] [Indexed: 12/31/2022] Open
Abstract
Simple Summary Brain metastases are the most common cause of cancerous brain tumors in adults. Large brain metastases are an especially difficult clinical scenario as patients often have debilitating symptoms from these tumors, and large tumors are more difficult to control with traditional single treatment radiation regimens alone or after surgery. Hypofractionated stereotactic radiotherapy is a novel way to deliver the higher doses of radiation to control large tumors either after surgery (most common), alone (common), or potentially before surgery (uncommon). Herein, we describe how delivering high doses over three or five treatments may improve tumor control and decrease complication rates compared to more traditional single treatment regimens for brain metastases larger than 2 cm in maximum dimension. Abstract Brain metastases are the most common intracranial malignant tumor in adults and are a cause of significant morbidity and mortality for cancer patients. Large brain metastases, defined as tumors with a maximum dimension >2 cm, present a unique clinical challenge for the delivery of stereotactic radiosurgery (SRS) as patients often present with neurologic symptoms that require expeditious treatment that must also be balanced against the potential consequences of surgery and radiation therapy—namely, leptomeningeal disease (LMD) and radionecrosis (RN). Hypofractionated stereotactic radiotherapy (HSRT) and pre-operative SRS have emerged as novel treatment techniques to help improve local control rates and reduce rates of RN and LMD for this patient population commonly managed with post-operative SRS. Recent literature suggests that pre-operative SRS can potentially half the risk of LMD compared to post-operative SRS and that HSRT can improve risk of RN to less than 10% while improving local control when meeting the appropriate goals for biologically effective dose (BED) and dose-volume constraints. We recommend a 3- or 5-fraction regimen in lieu of SRS delivering 15 Gy or less for large metastases or resection cavities. We provide a table comparing the BED of commonly used SRS and HSRT regimens, and provide an algorithm to help guide the management of these challenging clinical scenarios.
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Affiliation(s)
- Tyler Gutschenritter
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA 98195, USA;
| | - Vyshak A. Venur
- Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA 98195, USA;
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany;
- Institute for Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute, Singapore 119074, Singapore;
| | - Anoop P. Patel
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA 98195, USA; (A.P.P.); (R.G.E.)
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, University of Queensland, ICON Cancer Care, Brisbane 4072, Australia;
| | - Kristin J. Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, MD 21093, USA;
| | - Tony J. C. Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY 10032, USA;
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Toronto, ON M4N 3M5, Canada;
| | - Samuel T. Chao
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA; (S.T.C.); (J.H.S.)
| | - John H. Suh
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA; (S.T.C.); (J.H.S.)
| | - Eric L. Chang
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA;
| | - Richard G. Ellenbogen
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA 98195, USA; (A.P.P.); (R.G.E.)
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA 98195, USA;
- Correspondence: ; Tel.: +1-206-598-4100
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Ampil FL, Richards TA. Necessary treatment of brain metastases in poor‐performance status patients: for all, for no one, or for whom? PRECISION RADIATION ONCOLOGY 2020. [DOI: 10.1002/pro6.1102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Federico L. Ampil
- Department of Radiology Division of Radiation Oncology Louisiana State University Health Sciences Center Shreveport Louisiana USA
| | - Troy A. Richards
- Department of Radiology Division of Radiation Oncology Louisiana State University Health Sciences Center Shreveport Louisiana USA
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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: 4] [Impact Index Per Article: 1.0] [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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Koide Y, Tomita N, Adachi S, Tanaka H, Tachibana H, Kodaira T. Retrospective analysis of hypofractionated stereotactic radiotherapy for tumors larger than 2 cm. NAGOYA JOURNAL OF MEDICAL SCIENCE 2020; 81:397-406. [PMID: 31579330 PMCID: PMC6728199 DOI: 10.18999/nagjms.81.3.397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Stereotactic radiosurgery for large brain metastases (BM) not amenable to surgical resection is associated with limited local control and neurotoxicity, while hypofractionated stereotactic radiotherapy (HFSRT) has emerged as a promising option. We retrospectively evaluated 61 patients with BM larger than 2 cm in the maximum diameter, who were treated with HFSRT (mainly 35 Gy/5 fractions) in our center between 2006–2016, focusing on the effect of BM size on outcomes. Eligible patients were divided according to the maximum BM diameter (group A [23 patients]: ≥3 cm, group B [22 patients]: <3 cm) to assess the relationship between tumor size and prognosis or safety. The primary outcome was the local control rate (LCR), and secondary outcomes were the response rate (RR), brain progression-free survival (BPFS), median survival time (MST), and radionecrosis (RN). Univariate and multivariate analyses for LCR were conducted using Cox’s proportional hazards model. In the 45 eligible patients (58 lesions) enrolled in this study, the RR was 86.4% with an overall LCR of 64.7% at 12 months (67.1% for group A and 61.5% for group B [p = 0.45]). The median BPFS and MST were 11.6 and 14.2 months, respectively. Univariate analyses revealed that female patients and gynecological cancer patients had poorer LCR, but they were not significantly independent prognostic factors (p = 0.06, 0.09, respectively). Two patients (4.4%) experienced RN that was detected more than 4 years after HFSRT. We conclude that HFSRT is safe for large BM but further studies are needed to determine optimal doses and fractions.
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Affiliation(s)
- Yutaro Koide
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Chikusa-ku, Nagoya, Japan
| | - Natsuo Tomita
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Chikusa-ku, Nagoya, Japan
| | - Sou Adachi
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Chikusa-ku, Nagoya, Japan
| | - Hiroshi Tanaka
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Chikusa-ku, Nagoya, Japan
| | - Hiroyuki Tachibana
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Chikusa-ku, Nagoya, Japan
| | - Takeshi Kodaira
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Chikusa-ku, Nagoya, Japan
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Ito D, Aoyagi K, Nagano O, Serizawa T, Iwadate Y, Higuchi Y. Comparison of two-stage Gamma Knife radiosurgery outcomes for large brain metastases among primary cancers. J Neurooncol 2020; 147:237-246. [PMID: 32026433 DOI: 10.1007/s11060-020-03421-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 01/31/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) is typically considered for patients who cannot undergo surgical resection for large (> 10 cm3) brain metastases (BMs). Staged SRS requires adaptive planning during each stage of the irradiation period for improved tumor control and reduced radiation damage. However, there has been no study on the tumor reduction rates of this method. We evaluated the outcomes of two-stage SRS across multiple primary cancer types. METHODS We analyzed 178 patients with 182 large BMs initially treated with two-stage SRS. The primary cancers included breast (BC), non-small cell lung (NSCLC), and gastrointestinal tract cancers (GIC). We analyzed the overall survival (OS), neurological death, systemic death (SD), tumor progression (TP), tumor recurrence (TR), radiation necrosis (RN), and the tumor reduction rate during both stages. RESULTS The median survival time after the first Gamma Knife surgery (GKS) procedure was 6.6 months. Compared with patients with BC and NSCLC, patients with GIC had shorter OS and a higher incidence of SD. Compared with patients with NSCLC and GIC, patients with BC had significantly higher tumor reduction rates in both sessions. TP rates were similar among primary cancer types. There was no association of the tumor reduction rate with tumor control. The overall cumulative incidence of RN was 4.2%; further, the RN rates were similar among primary cancer types. CONCLUSIONS Two-stage SRS should be considered for BC and NSCLC if surgical resection is not indicated. For BMs from GIC, staged SRS should be carefully considered and adapted to each unique case given its lower tumor reduction rate and shorter OS.
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Affiliation(s)
- Daisuke Ito
- Gamma Knife House, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba, 2900512, Japan.
| | - Kyoko Aoyagi
- Gamma Knife House, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba, 2900512, Japan
| | - Osamu Nagano
- Gamma Knife House, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba, 2900512, Japan
| | - Toru Serizawa
- Tokyo Gamma Unit Center, Tsukiji Neurological Clinic, Tokyo, Japan
| | - Yasuo Iwadate
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshinori Higuchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
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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: 42] [Impact Index Per Article: 8.4] [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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Noel G, Keller A, Antoni D. [Stereotactic radiotherapy of brain metastases in complex situations]. Cancer Radiother 2019; 23:708-715. [PMID: 31477442 DOI: 10.1016/j.canrad.2019.07.146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 07/11/2019] [Indexed: 02/07/2023]
Abstract
Stereotactic radiation therapy of brain metastases is a treatment recognized as effective, well tolerated, applicable for therapeutic indications codified and validated by national and international guidelines. However, the effectiveness of this irradiation, the evolution of patient care and the technical improvements enabling its implementation make it possible to consider it in more complex situations: proximity of brain metastases to organs at risk; large, cystic, haemorrhagic or multiple brain metastases, combination with targeted therapies and immunotherapy, stereotactic radiotherapy in patients with a pacemaker. This article aims to put forward the arguments available to date in the literature and those resulting from clinical practice to provide decision support for the radiation oncologists.
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Affiliation(s)
- G Noel
- Department of radiotherapy, comprehensive cancer center Paul-Strauss, UNICANCER, 3, rue de la porte de l'Hôpital, 67065 Strasbourg cedex, France; Strasbourg University, CNRS, IPHC UMR 7178, Centre Paul-Strauss, UNICANCER, 67000 Strasbourg, France.
| | - A Keller
- Department of radiotherapy, comprehensive cancer center Paul-Strauss, UNICANCER, 3, rue de la porte de l'Hôpital, 67065 Strasbourg cedex, France
| | - D Antoni
- Department of radiotherapy, comprehensive cancer center Paul-Strauss, UNICANCER, 3, rue de la porte de l'Hôpital, 67065 Strasbourg cedex, France; Strasbourg University, CNRS, IPHC UMR 7178, Centre Paul-Strauss, UNICANCER, 67000 Strasbourg, France
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Kim KH, Kong DS, Cho KR, Lee MH, Choi JW, Seol HJ, Kim ST, Nam DH, Lee JI. Outcome evaluation of patients treated with fractionated Gamma Knife radiosurgery for large (> 3 cm) brain metastases: a dose-escalation study. J Neurosurg 2019; 133:675-684. [PMID: 31419791 DOI: 10.3171/2019.5.jns19222] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 05/21/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Fractionated Gamma Knife radiosurgery (GKS) represents a feasible option for patients with large brain metastases (BM). However, the dose-fractionation scheme balanced between local control and radiation-induced toxicity remains unclear. Therefore, the authors conducted a dose-escalation study using fractionated GKS as the primary treatment for large (> 3 cm) BM. METHODS The exclusion criteria were more than 3 lesions, evidence of leptomeningeal disease, metastatic melanoma, poor general condition, and previously treated lesions. Patients were randomized to receive 24, 27, or 30 Gy in 3 fractions (8, 9, or 10 Gy per fraction, respectively). The primary endpoint was the development of radiation necrosis assessed by a neuroradiologist blinded to the study. The secondary endpoints included the local progression-free survival (PFS) rate, change in tumor volume, development of distant intracranial progression, and overall survival. RESULTS Between September 2016 and April 2018, 60 patients were eligible for the study, with 46 patients (15, 17, and 14 patients in the 8-, 9-, and 10-Gy groups, respectively) available for analysis. The median follow-up duration was 9.6 months (range 2.5-25.1 months). The 6-month estimated cumulative incidence of radiation necrosis was 0% in the 8-Gy group, 13% (95% confidence interval [CI] 0%-29%) in the 9-Gy group, and 37% (95% CI 1%-58%) in the 10-Gy group. Being in the 10-Gy group was a significant risk factor for the development of radiation necrosis (p = 0.047; hazard ratio [HR] 7.2, 95% CI 1.1-51.4). The 12-month local PFS rates were 65%, 80%, and 75% in the 8-, 9-, and 10-Gy groups, respectively. Being in the 8-Gy group was a risk factor for local treatment failure (p = 0.037; HR 2.5, 95% CI 1.1-29.6). The mean volume change from baseline was a 47.5% decrease in this cohort. Distant intracranial progression and overall survival did not differ among the 3 groups. CONCLUSIONS In this dose-escalation study, 27 Gy in 3 fractions appeared to be a relevant regimen of fractionated GKS for large BM because 30 Gy in 3 fractions resulted in unacceptable toxicities and 24 Gy in 3 fractions was associated with local treatment failure.
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Affiliation(s)
- Kyung Hwan Kim
- 1Department of Neurosurgery, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon; and
| | | | | | | | | | | | - Sung Tae Kim
- 3Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Single-fraction versus hypofractionated stereotactic radiosurgery for medium-sized brain metastases of 2.5 to 3 cm. J Neurooncol 2019; 145:49-56. [PMID: 31420793 DOI: 10.1007/s11060-019-03265-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 08/12/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE Given recently suggested utility of hypofractionated stereotactic radiosurgery (SRS) in treating large brain metastases (BMs) > 3 cm, we sought to prospectively control tumor size variable to investigate the efficacy and safety of hypofractionated SRS for medium-sized BMs (2.5 to 3 cm) compared with single-fraction SRS. METHODS Between 2011 and 2015, a total of 100 patients with newly diagnosed BMs (n = 105) of 2.5 to 3 cm had been treated with either single-fraction (n = 67; median dose 20 Gy) or hypofractionated SRS (n = 38; median cumulative dose 35 Gy in 5 daily fractions). No patients received any prior or upfront whole brain radiotherapy. In each patient, treatment outcome was measured by local tumor control (LTC), overall and progression-free survival (OS and PFS), and the occurrence of radiation necrosis (RN). RESULTS With a median follow-up of 14 months, significant differences were observed between the single-fraction versus hypofractionated SRS groups in the incidence of RN (29.9% vs. 5.3%, P < 0.001) and LTC (1-year LTC rates 66.6% vs. 92.4%, P = 0.028). There were no differences in PFS (median 6 months vs. 6 months, P = 0.381) and OS (median 13 months vs. 18 months, P = 0.239). Treatment-related adverse events ( ≥ grade 2 toxicity by CTCAE ver. 4.0) occurred more frequently in single-fraction group, although the difference did not reach statistical significance (56.3% vs. 36.1%, P = 0.084). CONCLUSIONS Our results suggest a better safety and efficacy profile of hypofractionated SRS for medium-sized BMs compared with single-fraction SRS. Further prospective studies are needed to confirm these results.
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Park K, Kim JW, Chung HT, Paek SH, Kim DG. Single-Session versus Multisession Gamma Knife Radiosurgery for Large Brain Metastases from Non-Small Cell Lung Cancer: A Retrospective Analysis. Stereotact Funct Neurosurg 2019; 97:94-100. [PMID: 31117101 DOI: 10.1159/000496154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 12/09/2018] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate the efficacy of Gamma Knife radiosurgery (GKS) in patients with large brain metastases by comparing single-session radiosurgery (S-GKS) and multisession radiosurgery (M-GKS), we retrospectively analyzed the clinical outcomes of patients who underwent GKS for brain metastases from non-small cell lung cancer (NSCLC). MATERIALS AND METHODS Between January 2010 and December 2016, 66 patients with 74 lesions ≥10 cm3 from large brain metastases from only NSCLC were included. Fifty-five patients with 60 lesions were treated with S-GKS; 11 patients with 14 lesions were treated with M-GKS. Median doses were 16 Gy (range, 11-18 Gy) for the S-GKS group and 8 Gy (range, 7-10 Gy) in three fractions for the M-GKS group. RESULTS With a mean follow-up period of 13.1 months (range, 1.3-76.4 months), the median survival duration was 21.1 months for all patients. Median tumor volume was 14.3 cm3 (range, 10.0-58.3 cm3). The local control rate was 77.0% and the progression-free survival rate was 73.6% at the last follow-up. There were no significant between-group differences in terms of local control rate (p = 0.10). Compared with S-GKS, M-GKS did not differ significantly in radiation-induced complications (38.1 vs. 45.4%, p =0.83). While 8 patients who underwent S-GKS experienced major complications of grade ≥3, no toxicity was observed in patients treated with M-GKS. CONCLUSIONS M-GKS may be an effective alternative for large brain metastases from NSCLC. Specifically, severe radiation-induced toxicity (≥grade 3) did not occur in M-GKS for large-volume metastases. Although the long-term effects and results from larger samples remain unclear, M-GKS may be a suitable palliative treatment for preserving neurological function.
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Affiliation(s)
- Kawngwoo Park
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Jin Wook Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea,
| | - Hyun-Tai Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sun Ha Paek
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dong Gyu Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
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Bi N, Ma Y, Xiao J, Zhang H, Xu Y, Tian Y, Li J, Zhang Y, Liu Q, Wang K, Deng L, Wang W, Chen X, Liu F, Zhao R, Yang S, Huang X, Yi J, Hu C, Li Y. A Phase II Trial of Concurrent Temozolomide and Hypofractionated Stereotactic Radiotherapy for Complex Brain Metastases. Oncologist 2019; 24:e914-e920. [PMID: 30996008 DOI: 10.1634/theoncologist.2018-0702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 02/11/2019] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Complex brain metastases (BMs), such as large lesions, lesions within or close to eloquent locations, or multiple recurrent/progressive BMs, remain the most challenging forms of brain cancer because of decreased intracranial control rates and poor survival. In the present study, we report the results from a single institutional phase II trial of concurrent temozolomide (TMZ) with hypofractionated stereotactic radiotherapy (HFSRT) in patients with complex brain metastases, including assessment of its feasibility and toxicity. PATIENTS AND METHODS Fifty-four patients with histologically proven primary cancer and complex BMs were enrolled between 2010 and 2015. All the patients were treated with concurrent HFSRT and TMZ (administrated orally at a dosage of 75 mg/m2 per day for at least 20 days). The primary endpoint was overall survival (OS). RESULTS The median follow-up time was 30.6 months. The local control rates at 1 and 2 years were 96% and 82%, respectively. The median OS was 17.4 months (95% confidence interval [CI], 12.6-22.2), and the OS rates at 1 and 2 years were 65% (95% CI, 52%-78%) and 33% (19%-47%). Only six patients (15.8%) died of intracranial disease. The median brain metastasis-specific survival was 46.9 months (95% CI, 35.5-58.4). Treatment-related grade 3-4 adverse events were rare and included one grade 3 hematological toxicity and two grade 3 liver dysfunctions. CONCLUSION Treatment using HFSRT concurrent with TMZ was well tolerated and could significantly extend OS compared with historical controls in complex BMs. Large randomized clinical trials are warranted. Trial registration ID: NCT02654106. IMPLICATIONS FOR PRACTICE The treatment using hypofractionated stereotactic radiotherapy concurrent with temozolomide appeared to be safe and could significantly extend overall survival compared with historical control in complex brain metastases. Large randomized clinical trials are warranted to verify our results.
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Affiliation(s)
- Nan Bi
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yuchao Ma
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jianping Xiao
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Hongmei Zhang
- Department of Radiology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yingjie Xu
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yuan Tian
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Junling Li
- Medical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Ye Zhang
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Qingfeng Liu
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Kai Wang
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Lei Deng
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Wenqing Wang
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xuesong Chen
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Feng Liu
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Ruizhi Zhao
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Siran Yang
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xiaodong Huang
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Junlin Yi
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Chen Hu
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yexiong Li
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Lehrer EJ, Peterson JL, Zaorsky NG, Brown PD, Sahgal A, Chiang VL, Chao ST, Sheehan JP, Trifiletti DM. Single versus Multifraction Stereotactic Radiosurgery for Large Brain Metastases: An International Meta-analysis of 24 Trials. Int J Radiat Oncol Biol Phys 2018; 103:618-630. [PMID: 30395902 DOI: 10.1016/j.ijrobp.2018.10.038] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 10/09/2018] [Accepted: 10/24/2018] [Indexed: 02/03/2023]
Abstract
PURPOSE Multifraction (MF) stereotactic radiosurgery (SRS) purportedly reduces radionecrosis risk over single-fraction (SF) SRS in the treatment of large brain metastases. The purpose of the current work is to compare local control (LC) and radionecrosis rates of SF-SRS and MF-SRS in the definitive (SF-SRSD and MF-SRSD) and postoperative (SF-SRSP and MF-SRSP) settings. METHODS AND MATERIALS Population, Intervention, Control, Outcomes, Study Design/Preferred Reporting Items for Systematic Reviews and Meta-analyses and Meta-analysis of Observational Studies in Epidemiology guidelines were used to select articles in which patients had "large" brain metastases (Group A: 4-14 cm3, or about 2-3 cm in diameter; Group B: >14 cm3, or about >3 cm in diameter); 1-year LC and/or rates of radionecrosis were reported; radiosurgery was administered definitively or postoperatively. Random effects meta-analyses using fractionation scheme and size as covariates were conducted. Meta-regression and Wald-type tests were used to determine the effect of increasing tumor size and fractionation on the summary estimate, where the null hypothesis was rejected for P < .05. RESULTS Twenty-four studies were included, published between 2008 and 2017, with 1887 brain metastases. LC random effects estimate at 1 year was 77.6% for Group A/SF-SRSD and 92.9% for Group A/MF-SRSD (P = .18). LC random effects estimate at 1 year was 77.1% for Group B/SF-SRSD and 79.2% for Group B/MF-SRSD (P = .76). LC random effects estimate at 1 year was 62.4% for Group B/SF-SRSP and 85.7% for Group B/MF-SRSP (P = .13). Radionecrosis incidence random effects estimate was 23.1% for Group A/SF-SRSD and 7.3% for Group A/MF-SRSD (P = .003). Radionecrosis incidence random effects estimate was 11.7% for Group B/SF-SRSD and 6.5% for Group B/MF-SRSD (P = .29). Radionecrosis incidence random effects estimate was 7.3% for Group B/SF-SRSP and 7.5% for Group B/MF-SRSP (P = .85). Metaregression assessing 1-year LC and radionecrosis as a continuous function of increasing tumor volume was not statistically significant. CONCLUSIONS Treatment for large brain metastases with MF-SRS regimens may offer a relative reduction of radionecrosis while maintaining or improving relative rates of 1-year LC compared with SF-SRS. These findings are hypothesis-generating and require validation by ongoing and planned prospective clinical trials.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jennifer L Peterson
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida; Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Arjun Sahgal
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Veronica L Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida; Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida.
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30
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Masucci GL. Hypofractionated Radiation Therapy for Large Brain Metastases. Front Oncol 2018; 8:379. [PMID: 30333955 PMCID: PMC6176274 DOI: 10.3389/fonc.2018.00379] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 08/23/2018] [Indexed: 12/21/2022] Open
Abstract
Single fraction radiosurgery (SRS) treatment is an effective and recognized alternative to whole brain radiation for brain metastasis. However, SRS is not always possible, especially in tumors of a larger diameter where the administration of high dose in a single fraction is limited by the possibility of acute and late side effects and the dose to the surrounding organs at risk. Hypofractionated radiation therapy allows the delivery of high doses of radiation per fraction while minimizing adverse events, all the while maintaining good local control of lesions. The optimal dose fractionation has however not been established. This overwiew presents available evidence and rationale supporting usage of hypofractionated radiation therapy in the treatment of large brain metastases.
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Affiliation(s)
- Giuseppina Laura Masucci
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
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31
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Tailored Treatment Options for Patients with Brain Metastases by a Relocatable Frame System with Gamma Knife Radiosurgery. World Neurosurg 2018; 119:e338-e348. [PMID: 30059780 DOI: 10.1016/j.wneu.2018.07.157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 07/16/2018] [Accepted: 07/18/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To report on our experience with the Elekta Extend system, a relocatable frame system used in patients with brain metastases for single-session, hypofractionated, or staged hypofractionated Gamma Knife radiosurgery (GKRS); and the evaluation of its efficacy. METHODS From March 2014 to September 2016, 856 patients with brain metastases underwent GKRS at our hospital. Of them, 35 patients who were retrospectively investigated, were selected for treatment with GKRS using the relocatable frame system. Individualized treatment strategy was chosen according to prior treatment history, number, size and location of tumor, or tumor harboring gene mutation. RESULTS Thirty-two (91.4%) patients underwent treatment with hypofractionated GKRS or staged hypofractionated GKRS, whereas 3 (8.6%) patients underwent single session GKRS. The mean radial setup difference from the reference measurements was 0.50 ± 0.16 mm. The median follow-up time after GKRS with the Extend system was 12 months (range, 1-45 months). The median overall survival time was 12 months (95% confidence interval 6.43-17.57). On multivariable analysis, performance status and extracranial metastases were independently prognostic factors for overall survival. Radiation necrosis developed in 4 cases (11.4%) during the follow-up period (2 with common terminology criteria for adverse events grade 2 and 2 with its grade 3). CONCLUSIONS The relocatable frame system can maintain submillimetric accuracy and provide tailored treatment option with reasonable tumor control and good survival benefits in selected patients with brain metastases. Especially, hypofractionated GKRS or staged hypofractionated GKRS with noninvasive frame is a safe and effective treatment option for large brain metastases or tumor adjacent to eloquent structures.
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Ganau M, Foroni RI, Gerosa M, Zivelonghi E, Longhi M, Nicolato A. Radiosurgical Options in Neuro-oncology: A Review on Current Tenets and Future Opportunities. Part I: Therapeutic Strategies. TUMORI JOURNAL 2018. [DOI: 10.1177/1636.17912] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Mario Ganau
- Department of Neurosciences, University Hospital, Azienda Ospedaliera Universitaria Integrata, Verona
- Department of Biomedical Engineering, University of Cagliari, Cagliari
| | - Roberto Israel Foroni
- Department of Pathology and Diagnosis, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Massimo Gerosa
- Department of Neurosciences, University Hospital, Azienda Ospedaliera Universitaria Integrata, Verona
| | - Emanuele Zivelonghi
- Department of Pathology and Diagnosis, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Michele Longhi
- Department of Neurosciences, University Hospital, Azienda Ospedaliera Universitaria Integrata, Verona
| | - Antonio Nicolato
- Department of Neurosciences, University Hospital, Azienda Ospedaliera Universitaria Integrata, Verona
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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: 60] [Impact Index Per Article: 8.6] [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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34
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Cleary RK, Meshman J, Dewan M, Du L, Cmelak AJ, Luo G, Morales-Paliza M, Weaver K, Thompson R, Chambless LB, Attia A. Postoperative Fractionated Stereotactic Radiosurgery to the Tumor Bed for Surgically Resected Brain Metastases. Cureus 2017; 9:e1279. [PMID: 28656127 PMCID: PMC5484602 DOI: 10.7759/cureus.1279] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Introduction Stereotactic radiosurgery (SRS) is increasingly used as an alternative to whole brain radiotherapy (WBRT) following surgical resection of brain metastases. We analyzed the outcomes of postoperative frameless fractionated stereotactic radiosurgery (fSRS) cases for surgically resected brain metastases at our institution. Materials and Methods We performed a retrospective review of 85 patients who underwent fSRS to 87 resection beds from 2006 - 2014 with a median follow-up of 6.4 months. Clinically relevant outcomes were assessed with analysis to determine predictors of these outcomes. Results The median target volume was 9.8 cm3 (1.1 - 43.1 cm3). The most frequently used fractionation scheme was 3,000 cGy in five fractions. The rates of local control (LC), distant brain failure (DBF), and overall survival (OS) at one-year were 87%, 52%, and 52%, respectively. Five patients (5.9%) experienced Grade >2 toxicity related to fSRS, including seizures (two), symptomatic radionecrosis (two), and potential treatment-related death (one). A multivariable analysis revealed that tumor volume (p < 0.001) and number of fractions (p < 0.001) were associated with LC, while recursive partitioning analysis (RPA) class (p < .0001), tumor volume (p = .0181), and the number of fractions (p = .0181) were associated with OS. Conclusions Postoperative fSRS for surgically resected brain metastases is well-tolerated and achieves durable LC. Further studies are needed to determine the optimal dose and fractionation for fSRS as well as to compare outcomes with WBRT.
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Affiliation(s)
- Ryan K Cleary
- Department of Radiation Oncology, Vanderbilt University Medical Center
| | - Jessica Meshman
- Department of Radiation Oncology, Vanderbilt University Medical Center
| | - Michael Dewan
- Department of Neurological Surgery, Vanderbilt University Medical Center
| | - Liping Du
- Center for Quantitative Sciences, Vanderbilt University School of Medicine
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center
| | | | - Kyle Weaver
- Department of Neurological Surgery, Vanderbilt University Medical Center
| | - Reid Thompson
- Department of Neurological Surgery, Vanderbilt University Medical Center
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center
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Shi Y, Sun Y, Yu J, Ding C, Ma Z, Wang Z, Wang D, Wang Z, Wang M, Wang Y, Lu Y, Ai B, Feng J, Liu Y, Liu X, Liu J, Wu G, Qu B, Li X, Li E, Li W, Song Y, Chen G, Chen Z, Chen J, Yu P, Wu N, Wu M, Xiao W, Xiao J, Zhang L, Zhang Y, Zhang Y, Zhang S, Song X, Luo R, Zhou C, Zhou Z, Zhao Q, Hu C, Hu Y, Nie L, Guo Q, Chang J, Huang C, Han B, Han X, Li G, Huang Y, Shi Y. [China Experts Consensus on the Diagnosis and Treatment of Brain Metastases of Lung Cancer (2017 version)]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2017; 20:1-13. [PMID: 28103967 PMCID: PMC5973287 DOI: 10.3779/j.issn.1009-3419.2017.01.01] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Yuankai Shi
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, 100021 Beijing, China
| | - Yan Sun
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, 100021 Beijing, China
| | - Jinming Yu
- Shandong Province Cancer Hospital, 250117 Jinan, China
| | - Cuimin Ding
- The Fourth Hospital of Hebei Medical University, 050000 Shijiazhuang, China
| | - Zhiyong Ma
- Henan Province Cancer Hospital, 450008 Zhengzhou, China
| | - Ziping Wang
- Beijing Cancer Hospital, 100142 Beijing, China
| | - Dong Wang
- Daping Hospital, Third Military Medical University, 400042 Chongqing, China
| | - Zheng Wang
- National Center for Geriatric Medicine/Beijing Hospital, 100730 Beijing, China
| | - Mengzhao Wang
- Peking Union Medical College Hospital, 100730 Beijing, China
| | - Yan Wang
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, 100021 Beijing, China
| | - You Lu
- West China Hospital of Sichuan University, 610041 Chengdu, China
| | - Bin Ai
- National Center for Geriatric Medicine/Beijing Hospital, 100730 Beijing, China
| | - Jifeng Feng
- Jiangsu Cancer Hospital, 210009 Nanjing, China
| | - Yunpeng Liu
- The First Hospital of China Medical University, 110001 Shenyang, China
| | - Xiaoqing Liu
- The 307th Hospital of Chinese People's Liberation Army, 100071 Beijing, China
| | - Jiwei Liu
- The First Affiliated Hospital of Dalian Medical University, 116011 Dalian, China
| | - Gang Wu
- Huazhong University of Science and Technology Union Hospital, 430022 Wuhan, China
| | - Baolin Qu
- Chinese People's Liberation Army General Hospital, 100853 Beijing, China
| | - Xueji Li
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100021 Beijing, China
| | - Enxiao Li
- The First Affiliated Hospital of Xi 'an Jiaotong University, 710061 Xi'an, China
| | - Wei Li
- The First Hospital of Jilin University, 130021 Changchun, China
| | - Yong Song
- Nanjing General Hospital, 210002 Nanjing, China
| | - Gongyan Chen
- Harbin Medical University Cancer Hospital, 150081 Harbin, China
| | - Zhengtang Chen
- Xinqiao Hospital of Third Military medical University, 400037 Chongqing, China
| | - Jun Chen
- The Second Hospital of Dalian Medical University, 116027 Dalian, China
| | - Ping Yu
- Sichuan Cancer Hospital, 610047 Chengdu, China
| | - Ning Wu
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100021 Beijing, China
| | - Milu Wu
- Qinghai University Affiliated Cancer Hospital, 810000 Xining, China
| | - Wenhua Xiao
- The First Affiliated Hospital of Chinese People's Liberation Army General Hospital, 100048 Beijing, China
| | - Jianping Xiao
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100021 Beijing, China
| | - Li Zhang
- Peking Union Medical College Hospital, 100730 Beijing, China
| | - Yang Zhang
- The Second Hospital of Dalian Medical University, 116027 Dalian, China
| | - Yiping Zhang
- Zhejiang Cancer Hospital, 310022 Hangzhou, China
| | - Shucai Zhang
- Beijing Chest Hospital, Capital Medical University, 101149 Beijing, China
| | - Xia Song
- Shanxi Province Cancer Hospital, 030013 Taiyuan, China
| | - Rongcheng Luo
- TCM-Integrated Cancer Center of Southern Medical University, 510315 Guangzhou, China
| | - Caicun Zhou
- Tongji University Affiliated Shanghai Pulmonary Hospital, 200433 Shanghai, China
| | - Zongmei Zhou
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100021 Beijing, China
| | - Qiong Zhao
- The First Affiliated Hospital, Zhejiang University, 310003 Hangzhou, China
| | - Chengping Hu
- Xiangya Hospital Central South University, 410008 Changsha, China
| | - Yi Hu
- Chinese People's Liberation Army General Hospital, 100853 Beijing, China
| | - Ligong Nie
- Peking University First Hospital, 100034 Beijing, China
| | - Qisen Guo
- The Fourth Hospital of Hebei Medical University, 050000 Shijiazhuang, China
| | - Jianhua Chang
- Fudan Universitay Shanghai Cancer Center, 200032 Shanghai, China
| | - Cheng Huang
- Fujian Cancer Hospital, 350014 Fuzhou, China
| | - Baohui Han
- Shanghai Chest Hospital, Shanghai Jiaotong University, 200030 Shanghai, China
| | - Xiaohong Han
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, 100021 Beijing, China
| | - Gong Li
- General Hospital of Armed Police, 100039 Beijing, China
| | - Yu Huang
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, 100021 Beijing, China
| | - Youwu Shi
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, 100021 Beijing, China
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Fractionated Stereotactic Gamma Knife Radiosurgery for Large Brain Metastases: A Retrospective, Single Center Study. PLoS One 2016; 11:e0163304. [PMID: 27661613 PMCID: PMC5035085 DOI: 10.1371/journal.pone.0163304] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 09/07/2016] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Stereotactic radiosurgery (SRS) is widely used for brain metastases but has been relatively contraindicated for large lesions (>3 cm). In the present study, we analyzed the efficacy and toxicity of hypofractionated Gamma Knife radiosurgery to treat metastatic brain tumors for which surgical resection were not considered as the primary treatment option. METHODS AND MATERIALS Thirty-six patients, forty cases were treated with Gamma Knife-based fractionated SRS for three to four consecutive days with the same Leksell frame on their heads. The mean gross tumor volume was 18.3 cm³, and the median dose was 8 Gy at 50% isodose line with 3 fractions for three consecutive days (range, 5 to 11 Gy and 2 to 4 fractions for 2 to 4 consecutive days). Survival rates and prognostic factors were analyzed. RESULTS The overall survival rate at one and two years was 66.7 and 33.1%, respectively. The median survival time was 16.2 months, and the local control rate was 90%. RTOG toxicity grade 1 was observed in 3 (8.3%) patients, grade 2 in 1 (2.7%) patient and grade 3 in 1 (2.7%) patient respectively. Radiation necrosis was developed in 1 (2.7%) patient. KPS scores and control of primary disease resulted in significant differences in survival. CONCLUSIONS Our findings suggest that consecutive hypofractionated Gamma Knife SRS could be applied to large metastatic brain tumors with effective tumor control and low toxicity rates.
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Seed migration to the spinal canal after postresection brachytherapy to treat a large brain metastasis. Brachytherapy 2016; 15:637-41. [DOI: 10.1016/j.brachy.2016.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 06/04/2016] [Accepted: 06/18/2016] [Indexed: 11/19/2022]
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Bohoudi O, Bruynzeel AME, Lagerwaard FJ, Cuijpers JP, Slotman BJ, Palacios MA. Isotoxic radiosurgery planning for brain metastases. Radiother Oncol 2016; 120:253-7. [PMID: 27212141 DOI: 10.1016/j.radonc.2016.05.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 04/13/2016] [Accepted: 05/01/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE/OBJECTIVE(S) Radionecrosis (RN) has previously been correlated with radiosurgery (RS) dose, lesion volume, and the volume of the brain receiving specific doses, i.e. V10-14Gy. A knowledge-based individualized estimation of the optimum RS dose has been derived based on lesional volume and brain toxicity parameters. METHODS AND MATERIALS A prediction model for brain toxicity parameters and estimation of the optimum RS dose was derived using 30 historical linac-based dynamic conformal arc RS plans for single brain metastases (BM) (0.2-20.3cc) with risk-adapted dose prescription ranging from 15 to 24Gy. Derivation of the model followed a three-step process: (1) Derivation of formulas for the prediction of brain toxicity parameters V10-18Gy; (2) Establishing the relationship of the coefficients used for the prediction of V12Gy with prescription dose; (3) Derivation of the optimum prescription dose for a given maximum V12Gy as a function of a given lesion volume. Model validation was performed on 65 new patients with 138 lesions (44 with multiple BM) treated with non-coplanar volumetric modulated stereotactic arc treatment (VMAT). RESULTS A linear dependence with the PTV size was found for all investigated brain toxicity parameters (V10-18Gy). Individualized RS prescription doses can be calculated for any given PTV size based on a linear relationship between V12Gy and PTV size, according to the formula PD=[V12Gy+0.96+(1.44×PTV)]/[0.12+(0.12×PTV)]. A very good correlation (R(2)=0.991) was found between the predicted V12Gy and the resulting V12Gy in 65 new patients with 138 lesions treated with non-coplanar VMAT technique in our clinic. CONCLUSIONS A simple formula is proposed for estimation of the optimal individual RS dose for any given lesion volume for patients with (multiple) BM. This formula is based on calculation of the brain toxicity parameter, V12Gy, for the normal brain minus PTV.
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Affiliation(s)
- Omar Bohoudi
- Dept. Of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Anna M E Bruynzeel
- Dept. Of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Frank J Lagerwaard
- Dept. Of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Johan P Cuijpers
- Dept. Of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Ben J Slotman
- Dept. Of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Miguel A Palacios
- Dept. Of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands.
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Minniti G, Scaringi C, Paolini S, Lanzetta G, Romano A, Cicone F, Osti M, Enrici RM, Esposito V. Single-Fraction Versus Multifraction (3 × 9 Gy) Stereotactic Radiosurgery for Large (>2 cm) Brain Metastases: A Comparative Analysis of Local Control and Risk of Radiation-Induced Brain Necrosis. Int J Radiat Oncol Biol Phys 2016; 95:1142-8. [PMID: 27209508 DOI: 10.1016/j.ijrobp.2016.03.013] [Citation(s) in RCA: 287] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 02/06/2016] [Accepted: 03/11/2016] [Indexed: 11/12/2022]
Abstract
PURPOSE To investigate the local control and radiation-induced brain necrosis in patients with brain metastases >2 cm in size who received single-fraction or multifraction stereotactic radiosurgery (SRS); factors associated with clinical outcomes and the development of brain radionecrosis were assessed. METHODS AND MATERIALS Two hundred eighty-nine consecutive patients with brain metastases >2.0 cm who received SRS as primary treatment at Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy, were analyzed. Cumulative incidence analysis was used to compare local control and radiation-induced brain necrosis between groups from the time of SRS. To achieve a balanced distribution of baseline covariates between treatment groups, a propensity score analysis was used. RESULTS The 1-year cumulative local control rates were 77% in the single-fraction SRS (SF-SRS) group and 91% in the multifraction SRS (MF-SRS) group (P=.01). Recurrences occurred in 25 and 11 patients who received SF-SRS or MF-SRS (P=.03), respectively. Thirty-one patients (20%) undergoing SF-SRS and 11 (8%) subjected to MF-SRS experienced brain radionecrosis (P=.004); the 1-year cumulative incidence rate of radionecrosis was 18% and 9% (P=.01), respectively. Significant differences between the 2 groups in terms of local control and risk of radionecrosis were maintained after propensity score adjustment. CONCLUSIONS Multifraction SRS at a dose of 27 Gy in 3 daily fractions seems to be an effective treatment modality for large brain metastases, associated with better local control and a reduced risk of radiation-induced radionecrosis as compared with SF-SRS.
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Affiliation(s)
- Giuseppe Minniti
- Unit of Radiation Oncology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy; IRCCS Neuromed, Pozzilli, Italy.
| | - Claudia Scaringi
- Unit of Radiation Oncology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | | | | | - Andrea Romano
- Unit of Neuroradiology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Francesco Cicone
- Unit of Nuclear Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Mattia Osti
- Unit of Radiation Oncology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Jeon JP, Kim JE, Ahn JH, Cho WS, Cho YD, Son YJ, Bang JS, Kang HS, Sohn CH, Chung HT, Oh CW, Kim DG. Long-term treatment outcome of venous-predominant arteriovenous malformation. J Neurosurg 2015; 124:1100-6. [PMID: 26406791 DOI: 10.3171/2015.4.jns142475] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Treatment strategies for venous-predominant arteriovenous malformation (vp-AVM) remain unclear due to the limited number of cases and a lack of long-term outcomes. The purpose of this study was to report the authors' experience with treatment outcomes with a review of the pertinent literature in patients with vp-AVM. METHODS Medical and radiological data from 1998 to 2011 were retrospectively evaluated. The degree of the arteriovenous (AV) shunt was categorized into 2 groups, a high- and low-flow AV shunt based on the angiographic findings. RESULTS Sixteen patients with a mean age of 45.3 years (range 16-78 years) and a mean follow-up of 79.9 months (range 25-264 months) were examined. Symptomatic lesions were noted in 13 patients: intracranial hemorrhage (ICH) in 9, seizure in 1, and headache in 3. A high-flow shunt was observed on angiography in 13 patients. Among these 13 patients, 12 patients were symptomatic. Nine patients presenting with ICH underwent hematoma removal with additional Gamma Knife surgery (GKS; n = 4), GKS only (n = 2), or conservative treatment (n = 3). The 3 asymptomatic patients received conservative treatment, and 1 rebleeding episode was observed. Seven of 8 patients who underwent GKS as an initial or secondary treatment modality experienced a marked reduction in the AV shunt on follow-up angiography, but complete obliteration was not observed. CONCLUSIONS Poor lesion localization makes a vp-AVM challenging to treat. Symptomatic patients with a high-flow shunt are supposedly best treated with GKS, despite the fact that only 87.5% of the vp-AVMs treated this way showed a reduction in the malformation volume, and none were cured.
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Affiliation(s)
- Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon; and
| | | | - Jun Hyong Ahn
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon; and
| | | | - Young Dae Cho
- Radiology, Seoul National University College of Medicine, Seoul, Korea
| | | | | | | | - Chul-Ho Sohn
- Radiology, Seoul National University College of Medicine, Seoul, Korea
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Frakes JM, Figura NB, Ahmed KA, Juan TH, Patel N, Latifi K, Sarangkasiri S, Strom TJ, Chinnaiyan P, Rao NG, Etame AB. Potential role for LINAC-based stereotactic radiosurgery for the treatment of 5 or more radioresistant melanoma brain metastases. J Neurosurg 2015; 123:1261-7. [PMID: 26140482 DOI: 10.3171/2014.12.jns141919] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) is a treatment option for patients with melanoma in whom brain metastases have developed. Very limited data are available on treating patients with ≥5 lesions. The authors sought to determine the effectiveness of SRS in patients with ≥5 melanoma brain metastases. METHODS A retrospective analysis of metastatic melanoma treated with SRS in a single treatment session for ≥5 lesions was performed. Magnetic resonance imaging studies were reviewed post-SRS to evaluate local control (LC). Disease progression on imaging was defined using the 2009 Response Evaluation Criteria in Solid Tumors (RECIST). Survival curves were calculated from the date of brain metastases diagnosis or the date of SRS by using the Kaplan-Meier (KM) method. Univariate and multivariate analysis (UVA and MVA, respectively) were performed using the Cox proportional-hazards model. RESULTS The authors identified 149 metastatic brain lesions treated in 28 patients. The median patient age was 60.5 years (range 38-83 years), and the majority of patients (24 [85.7%]) had extracranial metastases. Four patients (14.3%) had received previous whole-brain radiotherapy (WBRT), and 11 (39.3%) had undergone previous SRS. The median planning target volume (PTV) was 0.34 cm3 (range 0.01-12.5 cm3). Median follow-up was 6.3 months (range 1-46 months). At the time of treatment, 7% of patients were categorized as recursive partitioning analysis (RPA) Class I, 89% as RPA Class II, and 4% as RPA Class III. The rate of local failure was 11.4%. Kaplan-Meier LC estimates at 6 and 12 months were 91.3% and 82.2%, respectively. A PTV volume≥0.34 cm3 was a significant predictor of local failure on UVA (HR 16.1, 95% CI 3.2-292.6, p<0.0001) and MVA (HR 14.8, 95% CI 3.0-268.5, p=0.0002). Sixteen patients (57.1%) were noted to have distant failure in the brain with a median time to failure of 3 months (range 1-15 months). Nine patients with distant failures received WBRT, and 7 received additional SRS. Median overall survival (OS) was 9.4 and 7.6 months from the date of brain metastases diagnosis and the date of SRS, respectively. The KM OS estimates at 6 and 12 months were 57.8% and 28.2%, respectively, from the time of SRS treatment. The RPA class was a significant predictor of KM OS estimates from the date of treatment (p=0.02). Patients who did not receive WBRT after SRS treatment had decreased OS on MVA (HR 3.5, 95% CI 1.1-12.0, p=0.03), and patients who did not receive WBRT prior to SRS had improved OS (HR 0.11, 95% CI 0.02-0.53, p=0.007). CONCLUSIONS Stereotactic radiosurgery for ≥5 lesions appears to be effective for selected patients with metastatic melanoma, offering excellent LC. This is particularly important for patients as new targeted systemic agents are improving outcomes but still have limited efficacy within the central nervous system.
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Affiliation(s)
| | - Nicholas B Figura
- University of South Florida, Morsani College of Medicine, Tampa, Florida
| | | | | | - Neha Patel
- University of South Florida, Morsani College of Medicine, Tampa, Florida
| | | | | | | | - Prakash Chinnaiyan
- Departments of 1 Radiation Oncology.,University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Nikhil G Rao
- Departments of 1 Radiation Oncology.,University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Arnold B Etame
- Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute; and.,University of South Florida, Morsani College of Medicine, Tampa, Florida
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Dhermain F, Reyns N, Colin P, Métellus P, Mornex F, Noël G. Radiothérapie en conditions stéréotaxiques des métastases cérébrales. Cancer Radiother 2015; 19:25-9. [DOI: 10.1016/j.canrad.2014.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 12/02/2014] [Indexed: 11/17/2022]
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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: 1.6] [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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Toma-Dasu I, Sandström H, Barsoum P, Dasu A. To fractionate or not to fractionate? That is the question for the radiosurgery of hypoxic tumors. J Neurosurg 2014; 121 Suppl:110-5. [DOI: 10.3171/2014.8.gks141461] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectThis study aimed to investigate the impact of tumor hypoxia on treatment outcome for metastases commonly treated with radiosurgery using 1 fraction of radiation and the potential gain from reoxygenation if the treatment is delivered in a few radiation fractions.MethodsIn silico metastasis-like radiosurgery targets were modeled with respect to size, density of clonogenic cells, and oxygenation. Treatment plans were produced for the targets using Leksell GammaPlan, delivering clinically relevant doses and evaluating the tumor control probability (TCP) that could be expected in each case. Fractionated schedules with 3, 4, and 5 fractions resulting in similar biological effective doses were also considered for the larger target, and TCP was determined under the assumption that local reoxygenation takes place between fractions.ResultsThe results showed that well-oxygenated small- and medium-size metastases are well controlled by radiosurgery treatments delivering 20 or 22 Gy at the periphery, with TCPs ranging from 90% to 100%. If they are moderately hypoxic, the TCP could decrease to 60%. For large metastases, the TCPs from single-fraction treatments ranged from 0% to 19%, depending on tumor oxygenation. However, for fractionated treatments, the TCP for hypoxic tumors could significantly increase up to 51%, if reoxygenation occurs between fractions.ConclusionsThis study shows that hypoxia worsens the response to single-fraction radiosurgery, especially for large tumors. However, fractionated therapy for large hypoxic tumors might considerably improve the TCP and might constitute a simple way to improve the outcome of radiosurgery for patients with hypoxic tumors.
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Affiliation(s)
- Iuliana Toma-Dasu
- 1Medical Radiation Physics, Stockholm University and Karolinska Institutet
| | - Helena Sandström
- 1Medical Radiation Physics, Stockholm University and Karolinska Institutet
| | - Pierre Barsoum
- 2Department of Medical Physics, Karolinska University Hospital, Stockholm; and
| | - Alexandru Dasu
- 3Departments of Radiation Physics and Medical and Health Sciences, Linköping University, Linköping, Sweden
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Narayanasamy G, Smith A, Van Meter E, McGarry R, Molloy JA. Total target volume is a better predictor of whole brain dose from gamma stereotactic radiosurgery than the number, shape, or location of the lesions. Med Phys 2014; 40:091714. [PMID: 24007147 DOI: 10.1118/1.4818825] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To assess the hypothesis that the volume of whole brain that receives a certain dose level is primarily dependent on the treated volume rather than on the number, shape, or location of the lesions. This would help a physician validate the suitability of GammaKnife(®) based stereotactic radiosurgery (GKSR) prior to treatment. METHODS Simulation studies were performed to establish the hypothesis for both oblong and spherical shaped lesions of various numbers and sizes. Forty patients who underwent GKSR [mean age of 54 years (range 7-80), mean number of lesions of 2.5 (range 1-6), and mean lesion volume of 4.4 cm(3) (range 0.02-22.2 cm(3))] were also studied retrospectively. Following recommendations of QUANTEC, the volume of brain irradiated by the 12 Gy (VB12) isodose line was measured and a power-law based relation is proposed here for estimating VB12 from the known tumor volume and the prescription dose. RESULTS In the simulation study on oblong, spherical, and multiple lesions, the volume of brain irradiated by 50%, 10%, and 1% of maximum dose was found to have linear, linear, and exponentially increasing dependence on the volume of the treated region, respectively. In the retrospective study on 40 GKSR patients, a similar relationship was found to predict the brain dose with a Spearman correlation coefficient >0.9. In both the studies, the volume of brain irradiated by a certain dose level does not have a statistically significant relationship (p ≥ 0.05) with the number, shape, or position of the lesions. The measured VB12 agrees with calculation to within 1.7%. CONCLUSIONS The results from the simulation and the retrospective clinical studies indicate that the volume of whole brain that receives a certain percentage of the maximum dose is primarily dependent on the treated volume and less on the number, shape, and location of the lesions.
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Affiliation(s)
- Ganesh Narayanasamy
- Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky 40536, USA
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Fractionated stereotactic radiotherapy to the post-operative cavity for radioresistant and radiosensitive brain metastases. J Neurooncol 2014; 118:179-86. [DOI: 10.1007/s11060-014-1417-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 02/25/2014] [Indexed: 11/25/2022]
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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: 59] [Impact Index Per Article: 5.9] [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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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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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: 117] [Impact Index Per Article: 11.7] [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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50
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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: 44] [Impact Index Per Article: 4.4] [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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