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Ortiz de Mendivil A, Martín-Medina P, García-Cañamaque L, Jiménez-Munarriz B, Ciérvide R, Diamantopoulos J. Challenges in radiological evaluation of brain metastases, beyond progression. RADIOLOGIA 2024; 66:166-180. [PMID: 38614532 DOI: 10.1016/j.rxeng.2024.03.003] [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: 11/15/2022] [Accepted: 04/02/2023] [Indexed: 04/15/2024]
Abstract
MRI is the cornerstone in the evaluation of brain metastases. The clinical challenges lie in discriminating metastases from mimickers such as infections or primary tumors and in evaluating the response to treatment. The latter sometimes leads to growth, which must be framed as pseudo-progression or radionecrosis, both inflammatory phenomena attributable to treatment, or be considered as recurrence. To meet these needs, imaging techniques are the subject of constant research. However, an exponential growth after radiotherapy must be interpreted with caution, even in the presence of results suspicious of tumor progression by advanced techniques, because it may be due to inflammatory changes. The aim of this paper is to familiarize the reader with inflammatory phenomena of brain metastases treated with radiotherapy and to describe two related radiological signs: "the inflammatory cloud" and "incomplete ring enhancement", in order to adopt a conservative management with close follow-up.
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Affiliation(s)
- A Ortiz de Mendivil
- Servicio de Radiodiagnóstico, Sección de Neurorradiología, Hospital Universitario HM Sanchinarro, Madrid, Spain.
| | - P Martín-Medina
- Servicio de Radiodiagnóstico, Sección de Neurorradiología, Hospital Universitario HM Sanchinarro, Madrid, Spain
| | | | - B Jiménez-Munarriz
- Servicio de Oncología Médica, Hospital Universitario HM Sanchinarro, Madrid, Spain
| | - R Ciérvide
- Servicio de Oncología Radioterápica, Hospital Universitario HM Sanchinarro, Madrid, Spain
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2
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Peña-Pino I, Chen CC. Stereotactic Radiosurgery as Treatment for Brain Metastases: An Update. Asian J Neurosurg 2023; 18:246-257. [PMID: 37397044 PMCID: PMC10310446 DOI: 10.1055/s-0043-1769754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
Stereotactic radiosurgery (SRS) is a mainstay treatment option for brain metastasis (BM). While guidelines for SRS use have been outlined by professional societies, consideration of these guidelines should be weighed in the context of emerging literature, novel technology platforms, and contemporary treatment paradigms. Here, we review recent advances in prognostic scale development for SRS-treated BM patients and survival outcomes as a function of the number of BM and cumulative intracranial tumor volume. Focus is placed on the role of stereotactic laser thermal ablation in the management of BM that recur after SRS and the management of radiation necrosis. Neoadjuvant SRS prior to surgical resection as a means of minimizing leptomeningeal spread is also discussed.
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Affiliation(s)
- Isabela Peña-Pino
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, Minnesota, United States
| | - Clark C. Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, United States
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3
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Shanker MD, Garimall S, Gatt N, Foley H, Crowley S, Le Cornu E, Muscat K, Soon W, Atkinson V, Xu W, Watkins T, Huo M, Foote MC, Pinkham MB. Stereotactic radiosurgery for melanoma brain metastases: Concurrent immune checkpoint inhibitor therapy associated with superior clinicoradiological response outcomes. J Med Imaging Radiat Oncol 2022; 66:536-545. [PMID: 35343063 PMCID: PMC9311698 DOI: 10.1111/1754-9485.13403] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/22/2022] [Accepted: 03/09/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION/PURPOSE This study assessed long-term clinical and radiological outcomes following treatment with combination stereotactic radiosurgery (SRS) and immunotherapy (IT) for melanoma brain metastases (BM). METHODS A retrospective review was performed in a contemporary cohort of patients with melanoma BM at a single tertiary institution receiving Gamma Knife® SRS for melanoma BM. Multivariate Cox proportional-hazards modelling was performed with a P <0.05 for significance. RESULTS 101 patients (435 melanoma BM) were treated with SRS between January-2015 and June-2019. 68.3% of patients received IT within 4 weeks of SRS (concurrent) and 31.7% received SRS alone or non-concurrently with IT. Overall, BM local control rate was 87.1% after SRS. Median progression free survival was 8.7 months. Median follow-up was 29.2 months. On multivariate analysis (MVA), patients receiving concurrent SRS-IT maintained a higher chance of achieving a complete (CR) or partial response (PR) [HR 2.6 (95% CI: 1.2-5.5, P = 0.012)] and a reduced likelihood of progression of disease (PD) [HR 0.52 (95% CI: 0.16-0.60), P = 0.048]. Any increase in BM volume on the initial MRI 3 months after SRS predicted a lower likelihood of achieving long-term CR or PR on MVA accounting for concurrent IT, BRAF status and dexamethasone use [HR = 0.048 (95% CI: 0.007-0.345, P = 0.0026)]. Stratified volumetric change demonstrated a sequential relationship with outcomes on Kaplan-Meier analysis. CONCLUSION Concurrent SRS-IT has favourable clinical and radiological outcomes with respect to CR, PR and a reduced likelihood of PD. Changes in BM volume on the initial MRI 3 months after SRS were predictive of long-term outcomes for treatment response.
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Affiliation(s)
- Mihir D Shanker
- Gamma Knife Centre of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Princess Alexandra Hospital Research Foundation, Brisbane, Queensland, Australia
| | - Sidyarth Garimall
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Nick Gatt
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Heath Foley
- Gamma Knife Centre of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Samuel Crowley
- Gamma Knife Centre of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Emma Le Cornu
- Gamma Knife Centre of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Kendall Muscat
- Gamma Knife Centre of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Wei Soon
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Victoria Atkinson
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Wen Xu
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Trevor Watkins
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Michael Huo
- Gamma Knife Centre of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Matthew C Foote
- Gamma Knife Centre of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Mark B Pinkham
- Gamma Knife Centre of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Salvage Treatment for Progressive Brain Metastases in Breast Cancer. Cancers (Basel) 2022; 14:cancers14041096. [PMID: 35205844 PMCID: PMC8870695 DOI: 10.3390/cancers14041096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/31/2022] [Accepted: 02/17/2022] [Indexed: 11/24/2022] Open
Abstract
Simple Summary Thirty percent of patients with human epidermal growth factor receptor 2-positive breast cancer and triple-negative breast cancer, and 15% of patients with the remaining subtypes of breast cancer will develop brain metastases. Available treatment methods include surgery and radiotherapy. However, some individuals will experience intracranial progression despite prior local treatment. This situation remains a challenge. In the case of progressing lesions amenable to local therapy, the choice of a treatment method must consider performance status, cancer burden, possible toxicity, and previously applied therapy. Stereotactic radiosurgery or fractionated radiotherapy rather than whole-brain radiotherapy should be used only if feasible. If local therapy is unfeasible, selected patients, especially those with human epidermal growth factor receptor 2-positive breast cancer, may benefit from systemic therapy. Abstract Survival of patients with breast cancer has increased in recent years due to the improvement of systemic treatment options. Nevertheless, the occurrence of brain metastases is associated with a poor prognosis. Moreover, most drugs do not penetrate the central nervous system because of the blood–brain barrier. Thus, confirmed intracranial progression after local therapy is especially challenging. The available methods of salvage treatment include surgery, stereotactic radiosurgery (SRS), fractionated stereotactic radiotherapy (FSRT), whole-brain radiotherapy, and systemic therapies. This narrative review discusses possible strategies of salvage treatment for progressive brain metastases in breast cancer. It covers possibilities of repeated local treatment using the same method as applied previously, other methods of local therapy, and options of salvage systemic treatment. Repeated local therapy may provide a significant benefit in intracranial progression-free survival and overall survival. However, it could lead to significant toxicity. Thus, the choice of optimal methods should be carefully discussed within the multidisciplinary tumor board.
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Liu YM, Peng YL, Li QW, Shen G, Ma YR, Chen MN, Zhang J, Fu LR, Qiu B, Liu H, Deng XW. Computed Tomography-Based Evaluation of Volume and Position Changes of the Target Region and Organs at Risk During Radiotherapy for Esophageal Cancer: A Pilot Study. Front Oncol 2021; 11:702400. [PMID: 34395275 PMCID: PMC8355816 DOI: 10.3389/fonc.2021.702400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/12/2021] [Indexed: 11/27/2022] Open
Abstract
Objective To analyze changes in volume and position of target regions and organs at risk (OARs) during radiotherapy for esophageal cancer patients. Methods Overall, 16 esophageal cancer patients who underwent radiotherapy, including 10 cases of intensity-modulated radiation therapy (IMRT) and six of three-dimensional conformal radiotherapy (3D-CRT), were enrolled. The prescription doses for the planning target volumes (PTVs) were as follows: PTV1, 64 Gy/32 fractions; and PTV2, 46 Gy/23 fractions. Repeat computed tomography (CT) was performed for patients after the 5th, 10th, 15th, 20th, and 25th fractions. Delineation of the gross tumor volume (GTV) and OAR volume was determined using five repeat CTs performed by the same physician. The target and OAR volumes and centroid positions were recorded and used to analyze volume change ratio (VCR), center displacement (ΔD), and changes in the distance from the OAR centroid positions to the planned radiotherapy isocenter (distance to isocenter, DTI) during treatment. Results No patient showed significant changes in target volume (TV) after the first week of radiotherapy (five fractions). However, TV gradually decreased over the following weeks, with the rate slowing after the fourth week (40 Gy). The comparison of TV from baseline to 40 Gy (20 fractions) showed that average GTVs decreased from 130.7 ± 63.1 cc to 92.1 ± 47.2 cc, with a VCR of −29.21 ± 13.96% (p<0.01), while the clinical target volume (CTV1) decreased from 276.7 ± 98.2 cc to 246.7 ± 87.2 cc, with a VCR of −10.34 ± 7.58% (p<0.01). As TVs decreased, ΔD increased and DTI decreased. After the fourth week of radiotherapy (40 Gy), centroids of GTV, CTV1, and prophylactic CTV (CTV2) showed average deviations in ΔD of 7.6 ± 4.0, 6.9 ± 3.4, and 6.0 ± 3.0 mm, respectively. The average DTI of the heart decreased by 4.53 mm (from 15.61 ± 2.96 cm to 15.16 ± 2.27 cm). Conclusion During radiotherapy for esophageal cancer, Targets and OARs change significantly in volume and position during the 2nd–4th weeks. Image-guidance and evaluation of dosimetric changes are recommended for these fractions of treatment to appropriate adjust treatment plans.
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Affiliation(s)
- Yi-Mei Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China.,Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ying-Lin Peng
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China
| | - Qi-Wen Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China
| | - Guanzhu Shen
- Department of Radiation Oncology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ya-Ru Ma
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China
| | - Mei-Ning Chen
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China
| | - Jun Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China
| | - Li-Rong Fu
- Department of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Bo Qiu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China
| | - Hui Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China
| | - Xiao-Wu Deng
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China
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Rauch M, Tausch D, Stera S, Blanck O, Wolff R, Meissner M, Urban H, Hattingen E. MRI characteristics in treatment for cerebral melanoma metastasis using stereotactic radiosurgery and concomitant checkpoint inhibitors or targeted therapeutics. J Neurooncol 2021; 153:79-87. [PMID: 33761055 PMCID: PMC8131338 DOI: 10.1007/s11060-021-03744-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/18/2021] [Indexed: 11/04/2022]
Abstract
Introduction Combination therapy for melanoma brain metastases (MM) using stereotactic radiosurgery (SRS) and immune checkpoint-inhibition (ICI) or targeted therapy (TT) is currently of high interest. In this collective, time evolution and incidence of imaging findings indicative of pseudoprogression is sparsely researched. We therefore investigated time-course of MRI characteristics in these patients. Methods Data were obtained retrospectively from 27 patients (12 female, 15 male; mean 61 years, total of 169 MMs). Single lesion volumes, total MM burden and edema volumes were analyzed at baseline and follow-up MRIs in 2 months intervals after SRS up to 24 months. The occurrence of intralesional hemorrhages was recorded. Results 17 patients (80 MM) received ICI, 8 (62 MM) TT and 2 (27 MM) ICI + TT concomitantly to SRS. MM-localization was frontal (n = 89), temporal (n = 23), parietal (n = 20), occipital (n = 10), basal ganglia/thalamus/insula (n = 10) and cerebellar (n = 10). A volumetric progression of MM 2–4 months after SRS was observed in combined treatment with ICI (p = 0.028) and ICI + TT (p = 0.043), whereas MMs treated with TT showed an early volumetric regression (p = 0.004). Edema volumes moderately correlated with total MM volumes (r = 0.57; p < 0.0001). Volumetric behavior did not differ significantly over time regarding lesions’ initial sizes or localizations. No significant differences between groups were observed regarding rates of post-SRS intralesional hemorrhages. Conclusion Reversible volumetric increases in terms of pseudoprogression are observed 2–4 months after SRS in patients with MM concomitantly treated with ICI and ICI + TT, rarely after TT. Edema volumes mirror total MM volumes. Medical treatment type does not significantly affect rates of intralesional hemorrhage.
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Affiliation(s)
- Maximilian Rauch
- Institute for Neuroradiology, Johann Wolfgang Goethe-University, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany.
| | - Daniel Tausch
- Institute for Neuroradiology, Johann Wolfgang Goethe-University, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Susanne Stera
- Department of Radiation Oncology, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center, Frankfurt am Main, Germany
| | - Robert Wolff
- Saphir Radiosurgery Center, Frankfurt am Main, Germany
| | - Markus Meissner
- Department of Dermatology, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Hans Urban
- Institute for Neurooncology, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Elke Hattingen
- Institute for Neuroradiology, Johann Wolfgang Goethe-University, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany
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7
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Oft D, Schmidt MA, Weissmann T, Roesch J, Mengling V, Masitho S, Bert C, Lettmaier S, Frey B, Distel LV, Fietkau R, Putz F. Volumetric Regression in Brain Metastases After Stereotactic Radiotherapy: Time Course, Predictors, and Significance. Front Oncol 2021; 10:590980. [PMID: 33489888 PMCID: PMC7820888 DOI: 10.3389/fonc.2020.590980] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/26/2020] [Indexed: 11/13/2022] Open
Abstract
Background There is insufficient understanding of the natural course of volumetric regression in brain metastases after stereotactic radiotherapy (SRT) and optimal volumetric criteria for the assessment of response and progression in radiotherapy clinical trials for brain metastases are currently unknown. Methods Volumetric analysis via whole-tumor segmentation in contrast-enhanced 1 mm³-isotropic T1-Mprage sequences before SRT and during follow-up. A total of 3,145 MRI studies of 419 brain metastases from 189 patients were segmented. Progression was defined using a volumetric extension of the RANO-BM criteria. A subset of 205 metastases without progression/radionecrosis during their entire follow-up of at least 3 months was used to study the natural course of volumetric regression after SRT. Predictors for volumetric regression were investigated. A second subset of 179 metastases was used to investigate the prognostic significance of volumetric response at 3 months (defined as ≥20% and ≥65% volume reduction, respectively) for subsequent local control. Results Median relative metastasis volume post-SRT was 66.9% at 6 weeks, 38.6% at 3 months, 17.7% at 6 months, 2.7% at 12 months and 0.0% at 24 months. Radioresistant histology and FSRT vs. SRS were associated with reduced tumor regression for all time points. In multivariate linear regression, radiosensitive histology (p=0.006) was the only significant predictor for metastasis regression at 3 months. Volumetric regression ≥20% at 3 months post-SRT was the only significant prognostic factor for subsequent control in multivariate analysis (HR 0.63, p=0.023), whereas regression ≥65% was no significant predictor. Conclusions Volumetric regression post-SRT does not occur at a constant rate but is most pronounced in the first 6 weeks to 3 months. Despite decreasing over time, volumetric regression continues beyond 6 months post-radiotherapy and may lead to complete resolution of controlled lesions by 24 months. Radioresistant histology is associated with slower regression. We found that a cutoff of ≥20% regression for the volumetric definition of response at 3 months post-SRT was predictive for subsequent control whereas the currently proposed definition of ≥65% was not. These results have implications for standardized volumetric criteria in future radiotherapy trials for brain metastases.
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Affiliation(s)
- Dominik Oft
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Manuel Alexander Schmidt
- Department of Neuroradiology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Weissmann
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Johannes Roesch
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Veit Mengling
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Siti Masitho
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sebastian Lettmaier
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Benjamin Frey
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Luitpold Valentin Distel
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Florian Putz
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Abstract
Along with chemotherapy, surgery and immunotherapy, radiotherapy is a mainstay of cancer treatment. Considering the improving survival rates for various malignancies during the past decades, the importance of radiation-induced late normal tissue response is increasing. Quality of life is becoming an important issue in modern cancer treatment and is correlated with acute and late normal tissue response after radiotherapy. A profound understanding of radiation-induced normal tissue response is necessary to sufficiently diagnose and treat radiation-induced side effects and thereby increase the patients' quality of life. Here, the various normal tissue responses in consideration of the radiation biology are specified and prospective options to attenuate radiation-induced side effects are discussed.
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Affiliation(s)
- A Rühle
- Abteilung für RadioOnkologie und Strahlentherapie, Universitätsklinik Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.,KKE Molekulare und RadioOnkologie, Deutsches Krebsforschungszentrum (dkfz), Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland
| | - P E Huber
- Abteilung für RadioOnkologie und Strahlentherapie, Universitätsklinik Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland. .,KKE Molekulare und RadioOnkologie, Deutsches Krebsforschungszentrum (dkfz), Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland.
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9
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Mehrabian H, Detsky J, Soliman H, Sahgal A, Stanisz GJ. Advanced Magnetic Resonance Imaging Techniques in Management of Brain Metastases. Front Oncol 2019; 9:440. [PMID: 31214496 PMCID: PMC6558019 DOI: 10.3389/fonc.2019.00440] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 05/08/2019] [Indexed: 01/18/2023] Open
Abstract
Brain metastases are the most common intracranial tumors and occur in 20–40% of all cancer patients. Lung cancer, breast cancer, and melanoma are the most frequent primary cancers to develop brain metastases. Treatment options include surgical resection, whole brain radiotherapy, stereotactic radiosurgery, and systemic treatment such as targeted or immune therapy. Anatomical magnetic resonance imaging (MRI) of the tumor (in particular post-Gadolinium T1-weighted and T2-weighted FLAIR) provide information about lesion morphology and structure, and are routinely used in clinical practice for both detection and treatment response evaluation for brain metastases. Advanced MRI biomarkers that characterize the cellular, biophysical, micro-structural and metabolic features of tumors have the potential to improve the management of brain metastases from early detection and diagnosis, to evaluating treatment response. Magnetic resonance spectroscopy (MRS), chemical exchange saturation transfer (CEST), quantitative magnetization transfer (qMT), diffusion-based tissue microstructure imaging, trans-membrane water exchange mapping, and magnetic susceptibility weighted imaging (SWI) are advanced MRI techniques that will be reviewed in this article as they pertain to brain metastases.
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Affiliation(s)
- Hatef Mehrabian
- Physical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Radiology and Biomedical Imaging, University of California, San Francisco (UCSF), San Francisco, CA, United States
| | - Jay Detsky
- Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Hany Soliman
- Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Arjun Sahgal
- Physical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Greg J Stanisz
- Physical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Neurosurgery and Pediatric Neurosurgery, Medical University, Lublin, Poland
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10
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Trommer-Nestler M, Marnitz S, Kocher M, Rueß D, Schlaak M, Theurich S, von Bergwelt-Baildon M, Morgenthaler J, Jablonska K, Celik E, Ruge MI, Baues C. Robotic Stereotactic Radiosurgery in Melanoma Patients with Brain Metastases under Simultaneous Anti-PD-1 Treatment. Int J Mol Sci 2018; 19:ijms19092653. [PMID: 30205431 PMCID: PMC6164579 DOI: 10.3390/ijms19092653] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 08/28/2018] [Accepted: 09/03/2018] [Indexed: 12/30/2022] Open
Abstract
Combination concepts of radiotherapy and immune checkpoint inhibition are currently of high interest. We examined imaging findings, acute toxicity, and local control in patients with melanoma brain metastases receiving programmed death 1 (PD-1) inhibitors and/or robotic stereotactic radiosurgery (SRS). Twenty-six patients treated with SRS alone (n = 13; 20 lesions) or in combination with anti-PD-1 therapy (n = 13; 28 lesions) were analyzed. Lesion size was evaluated three and six months after SRS using a volumetric assessment based on cranial magnetic resonance imaging (cMRI) and acute toxicity after 12 weeks according to the Common Terminology Criteria for Adverse Events (CTCAE). Local control after six months was comparable (86%, SRS + anti-PD-1, and 80%, SRS). All toxicities reported were less than or equal to grade 2. One metastasis (5%) in the SRS group and six (21%) in the SRS + anti-PD-1 group increased after three months, whereas four (14%) of the six regressed during further follow-ups. This was rated as pseudoprogression (PsP). Three patients (23%) in the SRS + anti-PD-1 group showed characteristics of PsP. Treatment with SRS and anti-PD-1 antibodies can be combined safely in melanoma patients with cerebral metastases. Early volumetric progression of lesions under simultaneous treatment may be related to PsP; thus, the evaluation of combined radioimmunotherapy remains challenging and requires experienced teams.
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Affiliation(s)
- Maike Trommer-Nestler
- Department of Radiation Oncology and Cyberknife Center, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany.
- Center for Integrated Oncology (CIO Köln Bonn), University of Cologne, 50937 Cologne, Germany.
- Radio Immune-Oncology Consortium (RIO), University Hospital of Cologne, 50937 Cologne, Germany.
| | - Simone Marnitz
- Department of Radiation Oncology and Cyberknife Center, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany.
- Center for Integrated Oncology (CIO Köln Bonn), University of Cologne, 50937 Cologne, Germany.
- Radio Immune-Oncology Consortium (RIO), University Hospital of Cologne, 50937 Cologne, Germany.
| | - Martin Kocher
- Center for Integrated Oncology (CIO Köln Bonn), University of Cologne, 50937 Cologne, Germany.
- Department of Stereotaxy and Functional Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, 50937 Cologne, Germany.
- Institute for Neuroscience and Medicine, Research Center Juelich, Wilhelm-Johnen-Str., 52425 Juelich, Germany.
| | - Daniel Rueß
- Center for Integrated Oncology (CIO Köln Bonn), University of Cologne, 50937 Cologne, Germany.
- Department of Stereotaxy and Functional Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, 50937 Cologne, Germany.
| | - Max Schlaak
- Radio Immune-Oncology Consortium (RIO), University Hospital of Cologne, 50937 Cologne, Germany.
- Department of Dermatology and Allergology, Ludwig-Maximilians University (LMU), Frauenlobstr. 9-11, 80377 Munich, Germany.
| | - Sebastian Theurich
- Radio Immune-Oncology Consortium (RIO), University Hospital of Cologne, 50937 Cologne, Germany.
- Department III of Internal Medicine, Hematology and Oncology, University Hospital Munich, Ludwig-Maximilians University (LMU), 81377 Munich, Germany.
| | - Michael von Bergwelt-Baildon
- Radio Immune-Oncology Consortium (RIO), University Hospital of Cologne, 50937 Cologne, Germany.
- Department III of Internal Medicine, Hematology and Oncology, University Hospital Munich, Ludwig-Maximilians University (LMU), 81377 Munich, Germany.
| | - Janis Morgenthaler
- Department of Radiation Oncology and Cyberknife Center, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany.
- Center for Integrated Oncology (CIO Köln Bonn), University of Cologne, 50937 Cologne, Germany.
| | - Karolina Jablonska
- Department of Radiation Oncology and Cyberknife Center, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany.
- Center for Integrated Oncology (CIO Köln Bonn), University of Cologne, 50937 Cologne, Germany.
| | - Eren Celik
- Department of Radiation Oncology and Cyberknife Center, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany.
- Center for Integrated Oncology (CIO Köln Bonn), University of Cologne, 50937 Cologne, Germany.
| | - Maximilian I Ruge
- Center for Integrated Oncology (CIO Köln Bonn), University of Cologne, 50937 Cologne, Germany.
- Department of Stereotaxy and Functional Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, 50937 Cologne, Germany.
| | - Christian Baues
- Department of Radiation Oncology and Cyberknife Center, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany.
- Center for Integrated Oncology (CIO Köln Bonn), University of Cologne, 50937 Cologne, Germany.
- Radio Immune-Oncology Consortium (RIO), University Hospital of Cologne, 50937 Cologne, Germany.
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11
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Nordmann N, Hubbard M, Nordmann T, Sperduto PW, Clark HB, Hunt MA. Effect of Gamma Knife Radiosurgery and Programmed Cell Death 1 Receptor Antagonists on Metastatic Melanoma. Cureus 2017; 9:e1943. [PMID: 29468099 PMCID: PMC5811164 DOI: 10.7759/cureus.1943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Learning objectives To evaluate radiation-induced changes in patients with brain metastasis secondary to malignant melanoma who received treatment with Gamma Knife radiosurgery (GKRS) and programmed cell death 1 (PD-1) receptor antagonists. Introduction Stereotactic radiosurgery and chemotherapeutics are used together for treatment of metastatic melanoma and have been linked to delayed radiation-induced vasculitic leukoencephalopathy (DRIVL). There have been reports of more intense interactions with new immunotherapeutics targeting PD-1 receptors, but their interactions have not been well described and may result in an accelerated response to GKRS. Here we present data on subjects treated with this combination from a single institution. Methods Records from patients who underwent treatment for metastatic melanoma to the brain with GKRS from 2011 to 2016 were reviewed. Demographics, date of brain metastasis diagnosis, cause of death when applicable, immunotherapeutics, and imaging findings were recorded. The timing of radiation therapy and medications were also documented. Results A total of 79 subjects were treated with GKRS, and 66 underwent treatment with both GKRS and immunotherapy. Regarding the 30 patients treated with anti-PD-1 immunotherapy, 21 patients received pembrolizumab, seven patients received nivolumab, and two patients received pembrolizumab and nivolumab. Serial imaging was available for interpretation in 25 patients, with 13 subjects who received GKRS and anti-PD-1 immunotherapy less than six weeks of each other. While four subjects had indeterminate/mixed findings on subsequent magnetic resonance imaging (MRI), nine subjects were noted to have progression. Two of these patients showed progression but subsequent imaging revealed a decrease in progression or improvement on MRI to previously targeted lesions by GKRS. None of the 13 subjects had surgery following their combined therapies. Conclusions This data suggests that there is need for further investigation of the role for concurrent treatment with PD-1 inhibitors and GKRS to enhance the treatment of metastatic melanoma. We present data on 13 patients who appear to have some radiologic benefit to this treatment combination, two of whom had radiographic pseudoprogression.
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Affiliation(s)
| | | | | | - Paul W Sperduto
- Minneapolis Radiation Oncology & Gamma Knife Center, University of Minnesota
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Detection of residual metastatic tumor in the brain following Gamma Knife radiosurgery using a single or a series of magnetic resonance imaging scans: An autopsy study. Oncol Lett 2017; 14:2033-2040. [PMID: 28789434 PMCID: PMC5530089 DOI: 10.3892/ol.2017.6359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 03/24/2017] [Indexed: 11/05/2022] Open
Abstract
The aim of the present study was to investigate the usefulness of magnetic resonance image (MRI) for the detection of residual tumors following Gamma Knife radiosurgery (GKR) for brain metastases based on autopsy cases. The study investigated two hypotheses: i) Whether a single MRI may detect the existence of a tumor; and ii) whether a series of MRIs may detect the existence of a tumor. The study is a retrospective case series in a single institution. A total of 11 brain metastases in 6 patients were treated with GKR between 2002 and 2011. Histopathological specimens from autopsy were compared with reconstructed follow-up MRIs. The maximum diameters of the lesions on MRI series were measured, and the size changes classified. The primary sites in the patients were the kidneys (n=2), lung (n=1), breast (n=1) and colon (n=1), as well as 1 adenocarcinoma of unknown origin. The median prescribed dose for radiosurgery was 20 Gy (range, 18-20 Gy), and median time interval between GKR and autopsy was 10 months (range, 1.6-20 months). The pathological outcomes included 7 remissions and 4 failures. Enhanced areas on gadolinium-enhanced MRI contained various components: Viable tumor cells, tumor necrosis, hemorrhage, inflammation and vessels. Regarding the first hypothesis, it was impossible to distinguish pathological failure from remission with a single MRI scan due to the presence of various components. Conversely, in treatment response (remission or failure), on time-volume curves of MRI scans were in agreement with pathological findings, with the exception of progressive disease in the acute phase (0-3 months). Thus, regarding the second hypothesis, time-volume curves were useful for predicting treatment responses. In conclusion, it was difficult to predict treatment response using a single MRI, and a series of MRI scans were required to detect the existence of a tumor.
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Jung TY, Kim IY, Lim SH, Park KS, Kim DY, Jung S, Moon KS, Jang WY, Kang SR, Cho SG, Min JJ, Bom HS, Kwon SY. Optimization of diagnostic performance for differentiation of recurrence from radiation necrosis in patients with metastatic brain tumors using tumor volume-corrected 11C-methionine uptake. EJNMMI Res 2017; 7:45. [PMID: 28536967 PMCID: PMC5442037 DOI: 10.1186/s13550-017-0293-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 05/15/2017] [Indexed: 02/04/2023] Open
Abstract
Background Tumor to normal tissue ratio (T/N ratio) on 11C-methionine (11C-MET) positron emission tomography/computed tomography (PET/CT) is affected by variable factors. We investigated whether T/N ratio cutoff values corrected according to metabolic tumor volume (MTV) could improve the diagnostic performance of 11C-MET PET/CT for diagnosis of recurrence in patients with metastatic brain tumor. Forty-eight patients with metastatic brain tumors underwent 11C-MET PET/CT for differential diagnosis between recurrence and radiation necrosis after gamma knife radiosurgery (GKR). Both T/N ratio and MTV were estimated in each lesion on 11C-MET PET/CT. The lesions were classified into three groups based on MTV criteria (≤ 0.5 cm3; > 0.5, ≤ 4.0 cm3; and > 4.0 cm3). The optimal cutoff values of the T/N ratio from receiver operating characteristic (ROC) curve were determined in each group (MTV-corrected) as well as total lesions (non-corrected). Finally, diagnostic performance of 11C-MET PET/CT was compared with the MTV-corrected cutoff values. Results Among 77 lesions, 51 were diagnosed with recurrence. The mean T/N ratio was 2.25 (± 1.12) for recurrent lesions and 1.44 (± 0.22) for radiation necrosis (P < 0.001). T/N ratio of 1.61 (non-corrected) provided the best sensitivity, specificity, and diagnostic accuracy (70.6, 80.8, and 74.0%, respectively). Using the MTV criteria, optimal cutoff values of the T/N ratios in each group were 1.23 (MTV ≤ 0.5 cm3), 1.54 (0.5 cm3 < MTV ≤ 4.0 cm3), and 1.85 (MTV > 4.0 cm3). In small-sized lesions (MTV ≤ 0.5 cm3), MTV-corrected cutoff values (1.23) could maintain favorable diagnostic performance with sensitivity, specificity, and diagnostic accuracy (70.0, 80.0, and 73.3%, respectively), compared to non-corrected cutoff values. Conclusions MTV-corrected cutoff values of T/N ratio could maintain the diagnostic performance of 11C-MET PET/CT in small sized, metastatic brain tumors. We expect our results to contribute to reproducible and standardized interpretation of 11C-MET PET/CT.
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Affiliation(s)
- Tae-Young Jung
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, Republic of Korea
| | - In-Young Kim
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, Republic of Korea
| | - Sa-Hoe Lim
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, Republic of Korea
| | - Ki Seong Park
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, Republic of Korea
| | - Dong-Yeon Kim
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, Republic of Korea
| | - Shin Jung
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, Republic of Korea
| | - Kyung-Sub Moon
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, Republic of Korea
| | - Woo-Youl Jang
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, Republic of Korea
| | - Sae-Ryung Kang
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, Republic of Korea
| | - Sang-Geon Cho
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, Republic of Korea
| | - Jung-Joon Min
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, Republic of Korea
| | - Hee-Seung Bom
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, Republic of Korea
| | - Seong Young Kwon
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, Republic of Korea.
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Mehrabian H, Desmond KL, Soliman H, Sahgal A, Stanisz GJ. Differentiation between Radiation Necrosis and Tumor Progression Using Chemical Exchange Saturation Transfer. Clin Cancer Res 2017; 23:3667-3675. [PMID: 28096269 DOI: 10.1158/1078-0432.ccr-16-2265] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 12/15/2016] [Accepted: 01/06/2017] [Indexed: 11/16/2022]
Abstract
Purpose: Stereotactic radiosurgery (SRS) is a common treatment used in patients with brain metastases and is associated with high rates of local control, however, at the risk of radiation necrosis. It is difficult to differentiate radiation necrosis from tumor progression using conventional MRI, making it a major diagnostic dilemma for practitioners. This prospective study investigated whether chemical exchange saturation transfer (CEST) was able to differentiate these two conditions.Experimental Design: Sixteen patients with brain metastases who had been previously treated with SRS were included. Average time between SRS and evaluation was 12.6 months. Lesion type was determined by pathology in 9 patients and the other 7 were clinically followed. CEST imaging was performed on a 3T Philips scanner and the following CEST metrics were measured: amide proton transfer (APT), magnetization transfer (MT), magnetization transfer ratio (MTR), and area under the curve for CEST peaks corresponding to amide and nuclear Overhauser effect (NOE).Results: Five lesions were classified as progressing tumor and 11 were classified as radiation necrosis (using histopathologic confirmation and radiographic follow-up). The best separation was obtained by NOEMTR (NOEMTR,necrosis = 8.9 ± 0.9%, NOEMTR,progression = 12.6 ± 1.6%, P < 0.0001) and AmideMTR (AmideMTR,necrosis = 8.2 ± 1.0%, AmideMTR,progression = 12.0 ± 1.9%, P < 0.0001). MT (MTnecrosis = 4.7 ± 1.0%, MTprogression = 6.7 ± 1.7%, P = 0.009) and NOEAUC (NOEAUC,necrosis = 4.3 ± 2.0% Hz, NOEAUC,progression = 7.2 ± 1.9% Hz, P = 0.019) provided statistically significant separation but with higher P values.Conclusions: CEST was capable of differentiating radiation necrosis from tumor progression in brain metastases. Both NOEMTR and AmideMTR provided statistically significant separation of the two cohorts. However, APT was unable to differentiate the two groups. Clin Cancer Res; 23(14); 3667-75. ©2017 AACR.
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Affiliation(s)
- Hatef Mehrabian
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada. .,Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Kimberly L Desmond
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Hany Soliman
- Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Greg J Stanisz
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Neurosurgery and Pediatric Neurosurgery, Medical University, Lublin, Poland
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Alomari AK, Cohen J, Vortmeyer AO, Chiang A, Gettinger S, Goldberg S, Kluger HM, Chiang VL. Possible Interaction of Anti-PD-1 Therapy with the Effects of Radiosurgery on Brain Metastases. Cancer Immunol Res 2016; 4:481-7. [PMID: 26994250 DOI: 10.1158/2326-6066.cir-15-0238] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 02/16/2016] [Indexed: 11/16/2022]
Abstract
Delayed radiation-induced vasculitic leukoencephalopathy related to stereotactic radiosurgery (SRS) of brain metastases has been reported to manifest clinically 9 to 18 months after treatment. Immune-modulating therapies have been introduced to treatment regimens for malignancies with metastatic predilection to the brain. The interaction of these systemic therapies with other modalities of treatment for brain metastases, namely, SRS, has not been fully characterized. We report two patients with metastatic malignancies to the brain who received SRS followed by immunotherapy with monoclonal antibodies (mAb) to programmed death 1 (PD-1). Both patients appeared to have early clinical and radiologic progression of their treated lesions, which was highly suspicious for tumor progression. Both patients underwent surgical resection of their lesions and the material was submitted for histopathologic examination. Pathologic examination in both cases showed predominantly radiation-induced changes characterized by reactive astrocytosis and vascular wall infiltration by T lymphocytes. The accelerated response to SRS in these two patients was temporally related to the initiation of immunotherapy. We propose a possible biologic interaction between SRS and the PD-1 mAbs. Additionally, awareness of this potential occurrence is critical for accurate interpretation and proper management of clinical and radiologic findings in these patients. Cancer Immunol Res; 4(6); 481-7. ©2016 AACR.
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Affiliation(s)
- Ahmed K Alomari
- Department of Pathology, Yale University, School of Medicine, New Haven, Connecticut.
| | - Justine Cohen
- Department of Medicine (Medical Oncology), Yale University, School of Medicine, New Haven, Connecticut
| | - Alexander O Vortmeyer
- Department of Pathology, Yale University, School of Medicine, New Haven, Connecticut
| | - Anne Chiang
- Department of Medicine (Medical Oncology), Yale University, School of Medicine, New Haven, Connecticut
| | - Scott Gettinger
- Department of Medicine (Medical Oncology), Yale University, School of Medicine, New Haven, Connecticut
| | - Sarah Goldberg
- Department of Medicine (Medical Oncology), Yale University, School of Medicine, New Haven, Connecticut
| | - Harriet M Kluger
- Department of Medicine (Medical Oncology), Yale University, School of Medicine, New Haven, Connecticut
| | - Veronica L Chiang
- Department of Neurosurgery, Yale University, School of Medicine, New Haven, Connecticut
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16
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Kiess AP, Wolchok JD, Barker CA, Postow MA, Tabar V, Huse JT, Chan TA, Yamada Y, Beal K. Stereotactic radiosurgery for melanoma brain metastases in patients receiving ipilimumab: safety profile and efficacy of combined treatment. Int J Radiat Oncol Biol Phys 2015; 92:368-75. [PMID: 25754629 PMCID: PMC4955924 DOI: 10.1016/j.ijrobp.2015.01.004] [Citation(s) in RCA: 276] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 11/25/2014] [Accepted: 01/05/2015] [Indexed: 12/24/2022]
Abstract
PURPOSE Ipilimumab (Ipi), a monoclonal antibody against cytotoxic T-lymphocyte antigen-4, has been shown to improve survival in patients with metastatic melanoma. In this single-institution study, we investigated the safety and efficacy of stereotactic radiosurgery (SRS) for patients with melanoma brain metastases (BMs) who also received Ipi. METHODS AND MATERIALS From 2005 to 2011, 46 patients with melanoma received Ipi and underwent single-fraction SRS for BMs. A total of 113 BMs (91% intact, 9% postoperative) were treated with a median dose of 21 Gy (range, 15-24 Gy). Ipi was given at 3 mg/kg (54%) or 10 mg/kg (46%) for a median of 4 doses (range, 1-21). Adverse events were recorded with the use of the Common Terminology Criteria for Adverse Events 3.0. Kaplan-Meier methods were used to estimate survival, and Cox regression was used to investigate associations. RESULTS Fifteen patients received SRS during Ipi, 19 received SRS before Ipi, and 12 received SRS after Ipi. Overall survival (OS) was significantly associated with the timing of SRS/Ipi (P=.035) and melanoma-specific graded prognostic assessment (P=.013). Patients treated with SRS during or before Ipi had better OS and less regional recurrence than did those treated with SRS after Ipi (1-year OS 65% vs 56% vs 40%, P=.008; 1-year regional recurrence 69% vs 64% vs 92%, P=.003). SRS during Ipi also yielded a trend toward less local recurrence than did SRS before or after Ipi (1-year local recurrence 0% vs 13% vs 11%, P=.21). On magnetic resonance imaging, an increase in BM diameter to >150% was seen in 50% of patients treated during or before Ipi but in only 13% of patients treated after Ipi. Grade 3 to 4 toxicities were seen in 20% of patients. CONCLUSION Overall, the combination of Ipi and SRS appears to be well tolerated. Concurrent delivery of Ipi and SRS is associated with favorable locoregional control and possibly longer survival. It may also cause a temporary increase in tumor size, possibly because of an enhanced immunomodulatory effect.
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Affiliation(s)
- Ana P Kiess
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, Maryland; Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Jedd D Wolchok
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Christopher A Barker
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Michael A Postow
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Viviane Tabar
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Jason T Huse
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Timothy A Chan
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York.
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18
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19
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Wang JZ, Li JB, Wang W, Qi HP, Ma ZF, Zhang YJ, Li FX, Fan TY, Shao Q, Xu M. Changes in tumour volume and motion during radiotherapy for thoracic oesophageal cancer. Radiother Oncol 2015; 114:201-5. [DOI: 10.1016/j.radonc.2014.12.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 12/02/2014] [Accepted: 12/22/2014] [Indexed: 12/01/2022]
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Clinical Benefit of 11C Methionine PET Imaging as a Planning Modality for Radiosurgery of Previously Irradiated Recurrent Brain Metastases. Clin Nucl Med 2014; 39:939-43. [DOI: 10.1097/rlu.0000000000000561] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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21
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Grand S, Pasteris C, Attye A, Le Bas JF, Krainik A. The different faces of central nervous system metastases. Diagn Interv Imaging 2014; 95:917-31. [DOI: 10.1016/j.diii.2014.06.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Farjam R, Tsien CI, Lawrence TS, Cao Y. DCE-MRI defined subvolumes of a brain metastatic lesion by principle component analysis and fuzzy-c-means clustering for response assessment of radiation therapy. Med Phys 2014; 41:011708. [PMID: 24387500 DOI: 10.1118/1.4842556] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To develop a pharmacokinetic modelfree framework to analyze the dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) data for assessment of response of brain metastases to radiation therapy. METHODS Twenty patients with 45 analyzable brain metastases had MRI scans prior to whole brain radiation therapy (WBRT) and at the end of the 2-week therapy. The volumetric DCE images covering the whole brain were acquired on a 3T scanner with approximately 5 s temporal resolution and a total scan time of about 3 min. DCE curves from all voxels of the 45 brain metastases were normalized and then temporally aligned. A DCE matrix that is constructed from the aligned DCE curves of all voxels of the 45 lesions obtained prior to WBRT is processed by principal component analysis to generate the principal components (PCs). Then, the projection coefficient maps prior to and at the end of WBRT are created for each lesion. Next, a pattern recognition technique, based upon fuzzy-c-means clustering, is used to delineate the tumor subvolumes relating to the value of the significant projection coefficients. The relationship between changes in different tumor subvolumes and treatment response was evaluated to differentiate responsive from stable and progressive tumors. Performance of the PC-defined tumor subvolume was also evaluated by receiver operating characteristic (ROC) analysis in prediction of nonresponsive lesions and compared with physiological-defined tumor subvolumes. RESULTS The projection coefficient maps of the first three PCs contain almost all response-related information in DCE curves of brain metastases. The first projection coefficient, related to the area under DCE curves, is the major component to determine response while the third one has a complimentary role. In ROC analysis, the area under curve of 0.88 ± 0.05 and 0.86 ± 0.06 were achieved for the PC-defined and physiological-defined tumor subvolume in response assessment. CONCLUSIONS The PC-defined subvolume of a brain metastasis could predict tumor response to therapy similar to the physiological-defined one, while the former is determined more rapidly for clinical decision-making support.
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Affiliation(s)
- Reza Farjam
- Department of Radiation Oncology, University of Michigan, 1500 East Medical Center Drive, SPC 5010, Ann Arbor, Michigan 48109-5010
| | - Christina I Tsien
- Department of Radiation Oncology, University of Michigan, 1500 East Medical Center Drive, SPC 5010, Ann Arbor, Michigan 48109-5010
| | - Theodore S Lawrence
- Department of Radiation Oncology, University of Michigan, 1500 East Medical Center Drive, SPC 5010, Ann Arbor, Michigan 48109-5010
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, 1500 East Medical Center Drive, SPC 5010, Ann Arbor, Michigan 48109-5010; Department of Radiology, University of Michigan, 1500 East Medical Center Drive, Med Inn Building C478, Ann Arbor, Michigan 48109-5842; and Department of Biomedical Engineering, University of Michigan, 2200 Bonisteel Boulevard, Ann Arbor, Michigan 48109-2099
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Saito AI, Olivier KR, Li JG, Liu C, Newlin HE, Schmalfuss I, Kyogoku S, Dempsey JF. Lung tumor motion change during stereotactic body radiotherapy (SBRT): an evaluation using MRI. J Appl Clin Med Phys 2014; 15:4434. [PMID: 24892328 PMCID: PMC5711053 DOI: 10.1120/jacmp.v15i3.4434] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 01/07/2014] [Accepted: 12/27/2013] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study is to investigate changes in lung tumor internal target volume during stereotactic body radiotherapy treatment (SBRT) using magnetic resonance imaging (MRI). Ten lung cancer patients (13 tumors) undergoing SBRT (48 Gy over four consecutive days) were evaluated. Each patient underwent three lung MRI evaluations: before SBRT (MRI-1), after fraction 3 of SBRT (MRI-3), and three months after completion of SBRT (MRI-3m). Each MRI consisted of T1-weighted images in axial plane through the entire lung. A cone-beam CT (CBCT) was taken before each fraction. On MRI and CBCT taken before fractions 1 and 3, gross tumor volume (GTV) was contoured and differences between the two volumes were compared. Median tumor size on CBCT before fractions1 (CBCT-1) and 3 (CBCT-3) was 8.68 and 11.10 cm3, respectively. In 12 tumors, the GTV was larger on CBCT-3 compared to CBCT-1 (median enlargement, 1.56 cm3). Median tumor size on MRI-1, MRI-3, and MRI-3m was 7.91, 11.60, and 3.33 cm3, respectively. In all patients, the GTV was larger on MRI-3 compared to MRI-1 (median enlargement, 1.54 cm3). In all patients, GTV was smaller on MRI-3m compared to MRI-1 (median shrinkage, 5.44 cm3). On CBCT and MRI, all patients showed enlargement of the GTV during the treatment week of SBRT, except for one patient who showed minimal shrinkage (0.86 cm3). Changes in tumor volume are unpredictable; therefore, motion and breathing must be taken into account during treatment planning, and image-guided methods should be used, when treating with large fraction sizes.
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Assessment of irradiated brain metastases using dynamic contrast-enhanced magnetic resonance imaging. Neuroradiology 2014; 56:437-43. [PMID: 24652530 DOI: 10.1007/s00234-014-1344-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 02/14/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION The purpose of this study was to evaluate the effect of stereotactic radiosurgery (SRS) on cerebral metastases using the transfer constant (K trans) assessed by dynamic contrast-enhanced (DCE) MRI. Furthermore, we aimed to evaluate the ability of K trans measurements to predict midterm tumor outcomes after SRS. METHODS The study received institutional review board approval, and informed consent was obtained from all subjects. Twenty-six adult patients with a total of 34 cerebral metastases underwent T1-weighted DCE MRI in a 1.5-T magnet at baseline (prior to SRS) and 4-8 weeks after treatment. Quantitative analysis of DCE MRI was performed by generating K trans parametric maps, and region-of-interest-based measurements were acquired for each metastasis. Conventional MRI was performed at least 16 weeks after SRS to assess midterm tumor outcome using volume variation. RESULTS The mean (±SD) K trans value was 0.13 ± 0.11 min(-1) at baseline and 0.08 ± 0.07 min(-1) after 4-8 weeks post-treatment (p < 0.001). The mean (±SD) total follow-up time was 7.9 ± 4.7 months. Seventeen patients (22 lesions) underwent midterm MRI. Of those, nine (41 %) lesions had progressed at the midterm follow-up. An increase in K trans after SRS was predictive of tumor progression (hazard ratio = 1.50; 95 % CI = 1.16-1.70, p < 0.001). An increase of 15 % in K trans showed a sensitivity of 78 % and a specificity of 85 % for the prediction of progression at midterm follow-up. CONCLUSION SRS was associated with a reduction of K trans values of the cerebral metastases in the early post-treatment period. Furthermore, K trans variation as assessed using DCE MRI may be helpful to predict midterm outcomes after SRS.
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Farjam R, Tsien CI, Feng FY, Gomez-Hassan D, Hayman JA, Lawrence TS, Cao Y. Investigation of the diffusion abnormality index as a new imaging biomarker for early assessment of brain tumor response to radiation therapy. Neuro Oncol 2013; 16:131-9. [PMID: 24327584 DOI: 10.1093/neuonc/not153] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Diffusion MRI, although having the potential to be a biomarker for early assessment of tumor response to therapy, could be confounded by edema and necrosis in or near the brain tumors. This study aimed to develop and investigate the ability of the diffusion abnormality index (DAI) to be a new imaging biomarker for early assessment of brain metastasis response to radiation therapy (RT). METHODS Patients with either radiosensitive or radioresistant brain metastases that were treated by whole brain RT alone or combined with bortezomib as a radiation sensitizer had diffusion-weighted (DW) MRI pre-RT and 2 weeks (2W) after starting RT. A patient-specific diffusion abnormality probability function (DAProF) was created to account for abnormal low and high apparent diffusion coefficients differently, reflecting respective high cellularity and edema/necrosis. The DAI of a lesion was then calculated by the integral of DAProF-weighted tumor apparent diffusion coefficient histogram. The changes in DAI from pre-RT to 2W were evaluated for differentiating the responsive, stable, and progressive tumors and compared with the changes in gross tumor volume and conventional diffusion metrics during the same time interval. RESULTS In lesions treated with whole brain RT, the DAI performed the best among all metrics in predicting the posttreatment response of brain metastases to RT. In lesions treated with whole brain RT + bortezomib, although DAI was the best predictor, the performance of all metrics worsened compared with the first group. CONCLUSIONS The ability of DAI for early assessment of brain metastasis response to RT depends upon treatment regimes.
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Affiliation(s)
- Reza Farjam
- Corresponding author: Yue Cao, PhD, Department of Radiation Oncology, University of Michigan, 519 W William St, Ann Arbor, MI 48103.
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Ruzevick J, Kleinberg L, Rigamonti D. Imaging changes following stereotactic radiosurgery for metastatic intracranial tumors: differentiating pseudoprogression from tumor progression and its effect on clinical practice. Neurosurg Rev 2013; 37:193-201; discussion 201. [PMID: 24233257 DOI: 10.1007/s10143-013-0504-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 08/18/2013] [Accepted: 08/24/2013] [Indexed: 02/07/2023]
Abstract
Stereotactic radiosurgery has become standard adjuvant treatment for patients with metastatic intracranial lesions. There has been a growing appreciation for benign imaging changes following radiation that are difficult to distinguish from true tumor progression. These imaging changes, termed pseudoprogression, carry significant implications for patient management. In this review, we discuss the current understanding of pseudoprogression in metastatic brain lesions, research to differentiate pseudoprogression from true progression, and clinical implications of pseudoprogression on treatment decisions.
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Affiliation(s)
- Jacob Ruzevick
- Department of Neurological Surgery, The Johns Hopkins University School of Medicine, Phipps Building, Room 126, 600 N. Wolfe Street, Baltimore, MD, 21287, USA,
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Wang JZ, Li JB, Wang W, Qi HP, Ma ZF, Zhang YJ, Fan TY, Shao Q, Xu M. Detection of interfraction displacement and volume variance during radiotherapy of primary thoracic esophageal cancer based on repeated four-dimensional CT scans. Radiat Oncol 2013; 8:224. [PMID: 24074144 PMCID: PMC4016114 DOI: 10.1186/1748-717x-8-224] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 09/24/2013] [Indexed: 01/01/2023] Open
Abstract
Background To investigate the interfraction displacement and volume variation of primary thoracic esophagus carcinoma with enhanced four-dimensional computed tomography (4DCT) scanning during fractionated radiotherapy. Methods 4DCT data sets were acquired at the time of treatment simulation and every ten fraction for each of 32 patients throughout treatment. Scans were registered to baseline (simulation) 4DCT scans by using bony landmarks. The gross tumor volumes (GTVs) were delineated on each data set. Coordinates of the GTV centroids were acquired on each respiration phase. Distance between center of the GTV contour on the simulation scan and the centers on subsequent scans were used to assess interfraction displacement between fractions. Volumes were constructed using three approaches: The GTV delineated from the maximum intensity projection (MIP) was defined IGTVMIP, all 10 GTVs were combined to form IGTV10, GTVmean was the average of all 10 phases of each GTV. Results Interfraction displacement in left-right (LR), anterior-posterior (AP), superior-inferior (SI) directions and 3D vector were 0.13 ± 0.09 cm, 0.16 ± 0.12 cm, 0.34 ± 0.26 cm and 0.43 ± 0.24 cm, respectively between the tenth fraction and simulation 4DCT scan. 0.14 ± 0.09 cm, 0.19 ± 0.16 cm, 0.45 ± 0.43 cm and 0.56 ± 0.40 cm in LR, AP, SI and 3D vector respectively between the twentieth fraction and simulation 4DCT scan. Displacement in SI direction was larger than LR and AP directions during treatment. For distal esophageal cancer, increased interfraction displacements were observed in SI direction and 3D vector (P = 0.002 and P = 0.001, respectively) during radiotherapy. The volume of GTVmean, IGTVMIP, and IGTV10 decreased significantly at the twentieth fraction for middle (median: 34.01%, 33.09% and 28.71%, respectively) and distal (median: 22.76%, 25.27% and 23.96%, respectively) esophageal cancer, but for the upper third, no significant variation were observed during radiotherapy. Conclusions Interfractional displacements in SI direction were larger than LR and AP directions. For distal location, significant changes were observed in SI direction and 3D vector during radiotherapy. For middle and distal locations, the best time to reset position should be selected at the twentieth fraction when the primary tumor target volume changed significantly, and it was preferable to guide target correction and planning modification.
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Affiliation(s)
- Jin Zhi Wang
- Department of Radiation Oncology (Chest Section), Shandong Cancer Hospital, Jinan, Shandong Province 250117, P,R, China.
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Kickingereder P, Dorn F, Blau T, Schmidt M, Kocher M, Galldiks N, Ruge MI. Differentiation of local tumor recurrence from radiation-induced changes after stereotactic radiosurgery for treatment of brain metastasis: case report and review of the literature. Radiat Oncol 2013; 8:52. [PMID: 23497597 PMCID: PMC3608155 DOI: 10.1186/1748-717x-8-52] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 02/23/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Structural follow-up magnetic resonance imaging (MRI) after stereotactic radiosurgery (SRS) for brain metastases frequently displays local changes in the area of applied irradiation, which are often difficult to interpret (e.g., local tumor recurrence, radiation-induced changes). The use of stereotactic biopsy for histological assessment of these changes has a high diagnostic accuracy and can be considered as method of choice. In order to solve this relevant clinical problem non-invasively, advanced MRI techniques and amino acid positron-emission-tomography (PET) are increasingly used. CASE PRESENTATION We report the long-term follow-up of a patient who had been treated with linear accelerator based SRS for cerebral metastases of a lung cancer. Fifty-eight months after SRS, the differentiation of local recurrent brain metastasis from radiation-induced changes using structural MRI was difficult. For further differentiation, perfusion-weighted MRI (PWI), proton magnetic resonance spectroscopy (MRS), and (11)C-methyl-L-methionine (MET) PET was performed. Due to artifacts and technical limitations, PWI MRI and MRS findings were not conclusive. In contrast, MET PET findings were suggestive for radiation-induced changes. Finally, a stereotactic biopsy for histological assessment of these changes demonstrated clearly a radiation-induced necrosis and the absence of vital tumor. CONCLUSION The use of stereotactic biopsy for histological assessment of indistinguishable lesions on structural MRI after SRS for treatment of brain metastasis represents a highly reliable method to differentiate local tumor recurrence from radiation-induced changes. In this field, results of studies with both advanced MRI techniques and amino acid PET suggest encouraging results. However, artifacts and technical limitations (e.g., lesion size) are still a problem and comparative studies are needed to investigate the relationship, diagnostic performance, and complementary character of advanced MRI techniques and amino acid PET.
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Affiliation(s)
- Philipp Kickingereder
- Department for Stereotaxy and Functional Neurosurgery, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
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Farjam R, Tsien CI, Feng FY, Gomez-Hassan D, Hayman JA, Lawrence TS, Cao Y. Physiological imaging-defined, response-driven subvolumes of a tumor. Int J Radiat Oncol Biol Phys 2012; 85:1383-90. [PMID: 23257692 DOI: 10.1016/j.ijrobp.2012.10.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 10/16/2012] [Accepted: 10/23/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE To develop an image analysis framework to delineate the physiological imaging-defined subvolumes of a tumor in relating to treatment response and outcome. METHODS AND MATERIALS Our proposed approach delineates the subvolumes of a tumor based on its heterogeneous distributions of physiological imaging parameters. The method assigns each voxel a probabilistic membership function belonging to the physiological parameter classes defined in a sample of tumors, and then calculates the related subvolumes in each tumor. We applied our approach to regional cerebral blood volume (rCBV) and Gd-DTPA transfer constant (K(trans)) images of patients who had brain metastases and were treated by whole-brain radiation therapy (WBRT). A total of 45 lesions were included in the analysis. Changes in the rCBV (or K(trans))-defined subvolumes of the tumors from pre-RT to 2 weeks after the start of WBRT (2W) were evaluated for differentiation of responsive, stable, and progressive tumors using the Mann-Whitney U test. Performance of the newly developed metrics for predicting tumor response to WBRT was evaluated by receiver operating characteristic (ROC) curve analysis. RESULTS The percentage decrease in the high-CBV-defined subvolumes of the tumors from pre-RT to 2W was significantly greater in the group of responsive tumors than in the group of stable and progressive tumors (P<.007). The change in the high-CBV-defined subvolumes of the tumors from pre-RT to 2W was a predictor for post-RT response significantly better than change in the gross tumor volume observed during the same time interval (P=.012), suggesting that the physiological change occurs before the volumetric change. Also, K(trans) did not add significant discriminatory information for assessing response with respect to rCBV. CONCLUSION The physiological imaging-defined subvolumes of the tumors delineated by our method could be candidates for boost target, for which further development and evaluation is warranted.
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Affiliation(s)
- Reza Farjam
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
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Analysis of the layering pattern of the apparent diffusion coefficient (ADC) for differentiation of radiation necrosis from tumour progression. Eur Radiol 2012; 23:879-86. [PMID: 22903642 DOI: 10.1007/s00330-012-2638-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 07/17/2012] [Accepted: 08/01/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To evaluate the added value of diffusion-weighted imaging (DWI) to perfusion-weighted imaging (PWI) for differentiating tumour progression from radiation necrosis. METHODS Sixteen consecutive patients who underwent removal of a metastatic brain tumour that increased in size after stereotactic radiosurgery were retrospectively reviewed. The layering of the ADC was categorised into three patterns. ADC values were measured on each layer, and the maximum rCBV was measured. rCBV and the layering pattern of the ADC of radiation necrosis and tumour progression were compared. RESULTS Nine cases of radiation necrosis and seven cases of tumour progression were pathologically confirmed. Radiation necrosis (88.9 % vs. 14.3 %) showed a three-layer pattern of ADC with a middle layer of minimum ADC more frequently. If rCBV larger than 2.6 was used to differentiate radiation necrosis and tumour progression, the sensitivity was 100 % but specificity was 56 %. If the lesions with the three-layer pattern of ADC with moderately increased rCBV (2.6-4.1) were excluded from tumour progression, the sensitivity and specificity increased to 100 %. CONCLUSIONS The three-layer pattern of ADC shows high specificity in diagnosing radiation necrosis; therefore, combined analysis of the ADC pattern with rCBV may have added value in the correct differentiation of tumour progression from radiation necrosis.
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Zhang H, Zhang G, Oudkerk M. Brain Metastases from Different Primary Carcinomas: an Evaluation of DSC MRI Measurements. Neuroradiol J 2012; 25:67-75. [PMID: 24028878 DOI: 10.1177/197140091202500109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Accepted: 08/18/2011] [Indexed: 11/16/2022] Open
Abstract
This study evaluated the roles of different dynamic susceptibility contrast magnetic imaging (DSC MRI) measurements in discriminating between brain metastases derived from four common primary carcinomas. Thirty-seven patients with brain metastases were enrolled. Relative cerebral blood volume (rCBV), cerebral blood flow (rCBF) and relative mean transit time (rMTT) in both tumor and peritumoral edema were measured. Metastases were grouped by their primary tumor (lung, gastrointestinal, breast and renal cell carcinoma). DSC MRI measurements were compared between groups. Mean rCBV, rCBF, rMTT in tumor and peritumoral edema of all brain metastases (n=37) were 2.79 ± 1.73, 2.56 ± 2.11, 1.21 ± 0.48 and 1.05 ± 0.53, 0.86 ± 0.40, 1.99 ± 0.41, respectively. The tumoral rCBV (5.26 ± 1.89) and rCBF (5.32 ± 3.28) of renal metastases were greater than those of the other three metastases (P<0.05). The tumoral rMTT (1.58 ± 0.77) of breast metastases was statistically greater than that (0.96 ± 0.31) of gastrointestinal metastases (P=0.013). No statistical difference was found between peritumoral rCBV, rCBF and rMTT (P>0.05). Evaluating various DSC MRI measurements can provide complementary hemodynamic information on brain metastases. The tumoral rCBV, rCBF and likely rMTT can help discriminate between brain metastases originating from different primary carcinomas. The peritumoral DSC MRI measurements had limited value in discriminating between brain metastases.
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Affiliation(s)
- H Zhang
- Department of Radiology, Shanghai Jiaotong University Affiliated First People's Hospital; Shanghai, China -
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Patel TR, McHugh BJ, Bi WL, Minja FJ, Knisely JPS, Chiang VL. A comprehensive review of MR imaging changes following radiosurgery to 500 brain metastases. AJNR Am J Neuroradiol 2011; 32:1885-92. [PMID: 21920854 DOI: 10.3174/ajnr.a2668] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Stereotactic radiosurgery is known to control 85%-95% of intracranial metastatic lesions during a median survival of 6-8 months. However, with the advent of newer systemic cancer therapies, survival is improving; this change mandates a longitudinal quantitative analysis of the radiographic response of brain metastases to radiosurgery. MATERIALS AND METHODS MR imaging of 516 metastases in 120 patients treated with GK-SRS from June 2006 to December 2009 was retrospectively reviewed. Lesion volume at initial treatment and each follow-up was calculated by using the following formula: length × width × height / 2. Volume changes were correlated with patient demographics, histopathology, and radiation treatment variables. RESULTS Thirty-two percent of lesions increased in volume following radiosurgery. Clinically, this translated into 54% of patients having ≥1 of their lesions increase in size. This increase begins at 6 weeks and can last beyond 15 months' post-SRS. Male sex (P = .002), mean voxel dose <37 Gy (P = .009), and initial treatment volume >500 mm(3) (P < .001) are associated with posttreatment increases in tumor size. Median survival following radiosurgery was 9.5 months for patients with all lesions exhibiting stable/decreased volumes, >18.4 months for patients with all lesions exhibiting increased volumes, and 16.4 months for patients with mixed lesional responses. CONCLUSIONS Most metastatic lesions are stable or smaller in size during the first 36 months post-SRS. However, a transient increase in volume is seen in approximately one-third of lesions. Sex, treatment dose, initial lesion size, and histopathology all correlate with variations in lesion volume post-SRS. The longer the patient survives, the more likely an increase in lesion size will be seen on follow-up imaging.
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Affiliation(s)
- T R Patel
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut 06520, USA
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Abstract
Dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) and computed tomography (CT) scanning are emerging as valuable tools to quantitatively map the spatial distribution of vascular parameters, such as perfusion, vascular permeability, blood volume, and mean transit time in tumors and normal organs. DCE MRI/CT have shown prognostic and predictive value for response of certain cancers to chemotherapy and radiation therapy. DCE MRI/CT offer the promise of early assessment of tumor response to radiation therapy, opening a window for adaptively optimizing radiation therapy based upon functional alterations that occur earlier than morphologic changes. DCE MRI/CT has also shown the potential of mapping dose responses in normal organs and tissue for evaluation of individual sensitivity to radiation, providing additional opportunities to minimize risks of radiation injury. The evidence for potentially applying DCE MRI and CT for selection and delineation of radiation boost targets is growing. The clinical use of DCE MRI and CT scanning as a biomarker or even a surrogate endpoint for radiation therapy assessment of tumor and normal organs must consider technical validation issues, including standardization, reproducibility, accuracy and robustness, and clinical validation of the sensitivity and specificity for each specific problem of interest. Although holding great promise, to date, DCE MRI and CT scanning have not been qualified as a surrogate endpoint for radiation therapy assessment or for treatment modification in any prospective phase III clinical trial for any tumor site.
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Affiliation(s)
- Yue Cao
- Department of Radiation Oncology and Radiology, University of Michigan, Ann Arbor, MI 48103, USA.
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Ruge MI, Kickingereder P, Grau S, Hoevels M, Treuer H, Sturm V. Stereotactic biopsy combined with stereotactic (125)iodine brachytherapy for diagnosis and treatment of locally recurrent single brain metastases. J Neurooncol 2011; 105:109-18. [PMID: 21479963 DOI: 10.1007/s11060-011-0571-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Accepted: 03/26/2011] [Indexed: 10/18/2022]
Abstract
This paper reports on stereotactic biopsy combined with stereotactic (125)iodine brachytherapy (SBT) for locally recurrent, previously irradiated cerebral metastases, focusing on feasibility, complications, cerebral disease control, and survival. All patients with suspected locally recurrent metastases detected by MRI were selected for this combined procedure. After stereotactic biopsy, all patients with a verified vital tumor underwent SBT (50 Gy surface dose applied for 42 days) during the same surgical procedure. Histological results of biopsy, complications, treatment response, local and distant disease control, and survival were evaluated. Thirty patients underwent stereotactic biopsy, and 27 were treated with SBT for histologically proved tumor recurrence. There was no treatment-related mortality, and morbidity was transient and low (6.6%). Median survival was 14.8 months. After one year the actuarial incidence of local and distant relapse was 6.7 and 45.5%, respectively. There was no grade 3 or 4 CNS toxicity, even among the 18.5% of patients with tumors >30 mm. For these patients stereotactic biopsy seems to be a safe and valuable means of differentiating between radiation-induced tissue changes and tumor recurrence/progression. SBT is a safe, minimally invasive, and highly effective treatment option for cerebral disease control and survival. Furthermore, it can be performed during the same stereotactic operation.
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Affiliation(s)
- Maximilian I Ruge
- Department of Stereotactic and Functional Neurosurgery, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany.
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Stereotactic Interstitial Radiosurgery With the Photon Radiosurgery System (PRS) for Metastatic Brain Tumors: A Prospective Single-Center Clinical Trial. Int J Radiat Oncol Biol Phys 2009; 75:1392-400. [DOI: 10.1016/j.ijrobp.2009.01.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Revised: 01/09/2009] [Accepted: 01/13/2009] [Indexed: 11/18/2022]
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Goldman M, Boxerman JL, Rogg JM, Norén G. Utility of apparent diffusion coefficient in predicting the outcome of Gamma Knife-treated brain metastases prior to changes in tumor volume: a preliminary study. J Neurosurg 2009; 105 Suppl:175-82. [PMID: 18503353 DOI: 10.3171/sup.2006.105.7.175] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Gamma Knife surgery (GKS) is often the sole treatment for brain metastases. The authors hypothesized that early post-GKS measures of the relative apparent diffusion coefficient (rADC) could predict therapeutic response, recurrence, and radionecrosis prior to changes in tumor volume. METHODS Magnetic resonance (MR) images of 25 metastatic tumors in 15 patients were reviewed. Inclusion criteria included a history of surgery or GKS, a minimum tumor diameter of 5 mm at treatment, and a minimum of two follow-up MR images. Tumor volumes were normalized to baseline, and tumor ADC values were normalized to normal-appearing white matter (rADC). A successful therapeutic response (STR) was defined by a monotonically decreasing tumor volume throughout the follow-up period. Magnetic resonance spectroscopy was used to classify non-STRs as radionecrosis or tumor recurrence. All tumors exhibited a decreased normalized volume (mean 37%) at the first follow-up examination (range 33-124 days after GKS, mean 54 days), and three distinct rADC patterns subsequently evolved: Group 1 (STR [10 cases]), monotonically decreasing volume with gradually increasing rADC; Group 2 (radionecrosis [three cases]), initial volume reduction followed by gradual increase, with initial rapidly increasing rADC followed by more gradual increase or plateau; and Group 3 (recurrent tumor [12 cases]), initial volume decrease followed by increase, with a preceding gradual decrease in the rADC. CONCLUSIONS The rADC patterns outperform initial post-GKS tumor volume in predicting the long-term response to treatment. Decreasing tumor volume with an increasing rADC predicts an STR. For lesions with increasing volume, antecedent rADC reduction predicts recurrence, whereas a rapidly increasing rADC predicts radionecrosis. Evaluation of the rADC at the initial post-GKS follow-up examination appears to be a useful prognostic measure of metastatic tumor response.
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Affiliation(s)
- Marc Goldman
- Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island 02903, USA
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Hoefnagels FWA, Lagerwaard FJ, Sanchez E, Haasbeek CJA, Knol DL, Slotman BJ, Vandertop WP. Radiological progression of cerebral metastases after radiosurgery: assessment of perfusion MRI for differentiating between necrosis and recurrence. J Neurol 2009; 256:878-87. [PMID: 19274425 PMCID: PMC2698975 DOI: 10.1007/s00415-009-5034-5] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2008] [Revised: 11/03/2008] [Accepted: 11/19/2008] [Indexed: 11/29/2022]
Abstract
To assess the capability of perfusion MRI to differentiate between necrosis and tumor recurrence in patients showing radiological progression of cerebral metastases treated with stereotactic radiosurgery (SRS). From 2004 to 2006 dynamic susceptibility-weighted contrast-enhanced perfusion MRI scans were performed on patients with cerebral metastasis showing radiological progression after SRS during follow-up. Several perfusion MRI characteristics were examined: a subjective visual score of the relative cerebral blood volume (rCBV) map and quantitative rCBV measurements of the contrast-enhanced areas of maximal perfusion. For a total of 34 lesions in 31 patients a perfusion MRI was performed. Diagnoses were based on histology, definite radiological decrease or a combination of radiological and clinical follow-up. The diagnosis of tumor recurrence was obtained in 20 of 34 lesions, and tumor necrosis in 14 of 34. Regression analyses for all measures proved statistically significant (χ2 = 11.6–21.6, P < 0.001–0.0001). Visual inspection of the rCBV map yielded a sensitivity and specificity of 70.0 respectively 92.9%. The optimal cutoff point for maximal tumor rCBV relative to white matter was 2.00 (improving the sensibility to 85.0%) and 1.85 relative to grey matter (GM), improving the specificity to 100%, with a corresponding sensitivity of 70.0%. Perfusion MRI seems to be a useful tool in the differentiation of necrosis and tumor recurrence after SRS. For the patients displaying a rCBV-GM greater than 1.85, the diagnosis of necrosis was excluded. Salvage treatment can be initiated for these patients in an attempt to prolong survival.
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Affiliation(s)
- Friso W A Hoefnagels
- Department Neurosurgery, VU University Medical Centre, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
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Abstract
The goal of radiation therapy is to eradicate tumor stem cells while sparing healthy tissue. Therefore, the first aim must be to delineate tumor from healthy tissue. Advanced imaging techniques will enable one to reduce the uncertainty of microscopic extension of disease. Ultimately, advanced functional imaging systems correlated with image-registered pathological specimens will allow one to delineate disease extent from normal tissue at the tumor periphery. When it is not possible to determine the CTV margin with reasonable certainty, the margins must remain generous and conformal avoidance methodology could and should be deployed to spare critical normal structures. Of equal importance to defining the CTV is the need to guarantee that this target is indeed treated. For this purpose, image guidance using a variety of systems including portal images, ultrasound devices, and CT scanners at the time of treatment has been implemented. Some image-guided methods, portal images for instance, are more amenable for use with rigid structures such as encountered in the sinus whereas others like ultrasound or CT scanners are able to account for nonrigid setup variations. Several strategies for preventing organ motion from degrading the precision that radiotherapy offers have been described. In particular, a CT scan at the time of treatment delivery can also be used as the basis to reconstruct the dose received by the patient. Dose reconstruction will allow the dose just delivered to be superimposed on the pretreatment CT scan and will allow one to compare the reconstructed delivered dose distribution with the planned dose distribution to assess discrepancies between these. Furthermore, reconstruction of the delivered dose distributions holds the promise of allowing one to accumulate dose delivered to the tumor and normal structures on a fraction per fraction basis. This will ultimately allow for the determination of treatment-specific tumor control probabilities and normal tissue complication probabilities.
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Affiliation(s)
- Thomas Rockwell Mackie
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, USA
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Maldaun MVC, Aguiar PHP, Lang F, Suki D, Wildrick D, Sawaya R. Radiosurgery in the treatment of brain metastases: critical review regarding complications. Neurosurg Rev 2007; 31:1-8; discussion 8-9. [PMID: 17957397 DOI: 10.1007/s10143-007-0110-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2007] [Revised: 06/20/2007] [Accepted: 08/26/2007] [Indexed: 10/22/2022]
Abstract
Stereotactic radiosurgery (SRS) has been described as an effective treatment option for brain metastases. In general, SRS has been indicated for the treatment of lesions smaller than 3 cm in maximum diameter and for lesions considered not surgically treatable, owing to the patient's clinical status or because the lesion was located in or near eloquent brain areas. In several studies, SRS has been associated with clinical and radiographic improvement of the lesions and has been compared with surgery as the modality of choice for brain metastases. Beyond the high rate of local disease control with SRS, the few complications that have been described occurred mainly in the acute post treatment period. Most publications have addressed the outcome and effectiveness of this treatment modality but have not critically analyzed long-term complications, steroid dependency, or results relating to specific brain locations. It is important to understand the radiobiologic effects of a well-demarcated high dose of radiation on the brain lesion, controlling the tumor growth and not causing significant alteration of the related brain region, especially in an area controlling eloquent function.
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Affiliation(s)
- Marcos Vinícius Calfat Maldaun
- Division of Neurosurgery, Department of Neurology, São Paulo Medical School, Rua Barata Ribeiro, 414-Cj 63, 01308-000 São Paulo, SP, Brazil.
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Oh BC, Pagnini PG, Wang MY, Liu CY, Kim PE, Yu C, Apuzzo MLJ. Stereotactic radiosurgery: adjacent tissue injury and response after high-dose single fraction radiation: Part I--Histology, imaging, and molecular events. Neurosurgery 2007; 60:31-44; discussion 44-5. [PMID: 17228251 DOI: 10.1227/01.neu.0000249191.23162.d2] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Radiosurgery is now the preferred treatment modality for many intracranial disease processes. Although almost 50 years have passed since it was introduced as a tool to treat neurological disease, investigations into its effects on normal tissues of the central nervous system are still ongoing. The need for these continuing studies must be underscored. A fundamental understanding of the brain parenchymal response to radiosurgery would permit development of strategies that would enhance and potentiate the radiosurgical treatment effects on diseased tissue while mitigating injury to normal structures. To date, most studies on the response of the central nervous system to radiosurgery have been performed on brain tissue in the absence of pathological lesions, such as benign tumors or metastases. Although instructive, these investigations fail to emulate the majority of clinical scenarios that involve radiosurgical treatment of specific lesions surrounded by normal brain parenchyma. This article is the first in a two-part series that addresses the brain parenchyma's response to radiosurgery. This first article analyzes the histological, radiographic, and molecular data gathered regarding the brain parenchymal response to radiosurgery and aims to suggest future studies that could enhance our understanding of the topic. The second article in the series begins by discussing strategies for radiosurgical therapeutic enhancement. It concludes by focusing on strategies for mitigation and repair of radiation-induced brain injury.
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Affiliation(s)
- Bryan C Oh
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA
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Mayr NA, Lo SS, Grecula J, Wang J, Zhang H, Montebello J, Martin D, Yuh WT. Tumor imaging: radiation oncology perspective. Top Magn Reson Imaging 2006; 17:117-9. [PMID: 17198227 DOI: 10.1097/01.rmr.0000245462.28525.51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Affiliation(s)
- Nina A Mayr
- Radiation Medicine, The Ohio State University, Columbus, OH 43210, USA
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Underberg RWM, Lagerwaard FJ, van Tinteren H, Cuijpers JP, Slotman BJ, Senan S. Time trends in target volumes for stage I non-small-cell lung cancer after stereotactic radiotherapy. Int J Radiat Oncol Biol Phys 2006; 64:1221-8. [PMID: 16442240 DOI: 10.1016/j.ijrobp.2005.09.045] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2005] [Revised: 09/23/2005] [Accepted: 09/27/2005] [Indexed: 12/25/2022]
Abstract
PURPOSE To identify potential time trends in target volumes and tumor mobility after stereotactic radiotherapy (SRT) for Stage I non-small-cell lung cancer. PATIENTS AND METHODS Repeat planning computed tomography (CT) scans were performed for 40 tumors during fractionated SRT delivered in either three (n = 21), five (n = 14), or eight fractions (n = 5). The planning CT scans used to define internal target volumes (ITVs) consisted of either six multislice CT scans or a single four-dimensional CT scan. All repeat CT scans were coregistered with the initial (D0) scan to determine volumetric or spatial changes in target volume, and tumor mobility vectors were determined from each scan. RESULTS A significant decrease in target volumes (ITVs and gross tumor volumes) relative to baseline values was observed starting at the fourth week of SRT (p = 0.015). No trends in tumor mobility were detected during SRT. Significant positional shifts in the ITV, of more than 5 mm, were seen in 26-43% of patients at different times during SRT. CONCLUSION Significant changes in target volumes can occur during SRT for Stage I non-small-cell lung cancer. A failure to account for such changes e.g., by repeat CT planning or verification using on-board volumetric imaging can lead to inadequate target coverage.
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Affiliation(s)
- René W M Underberg
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
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Weber MA, Risse F, Giesel FL, Schad LR, Kauczor HU, Essig M. [Perfusion measurement using the T2* contrast media dynamics in neuro-oncology. Physical basics and clinical applications]. Radiologe 2005; 45:618-32. [PMID: 15098092 DOI: 10.1007/s00117-004-1048-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Perfusion imaging in the central nervous system (CNS) is mostly performed using the first-pass dynamic susceptibility-weighted contrast-enhanced (DSC) MRI. The first-pass of a contrast bolus in brain tissue is monitored by a series of T2*-weighted MR images. The susceptibility effect of the paramagnetic contrast agent leads to a signal loss that can be converted, using the principles of the indicator dilution theory, into an increase of the contrast agent concentration. From these data, parameter maps of cerebral blood volume (CBV) and flow (CBF) can be derived. Regional CBF and CBV values can be obtained by region-of-interest analysis. This review article describes physical basics of DSC MRI and summarizes the literature of DSC MRI in neurooncological issues.Studies, all with relatively limited patient numbers, report that DSC MRI is useful in the preoperative diagnosis of gliomas, CNS-lymphomas, and solitary metastases, as well as in the differentiation of these neoplastic lesions from infections and tumor-like manifestations of demyelinating disease. Additionally, DSC MRI is suitable for determining glioma grade and regions of active tumor growth which should be the target of stereotactic biopsy. After therapy, DSC MRI helps better assessing the tumor response to therapy, residual tumor after therapy, and possible treatment failure and therapy-related complications, such as radiation necrosis. The preliminary results show that DSC MRI is a diagnostic tool depicting regional variations in microvasculature of normal and diseased brains.
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Affiliation(s)
- M-A Weber
- Abteilung Radiologie, Deutsches Krebsforschungszentrum, Heidelberg.
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Soffietti R, Costanza A, Laguzzi E, Nobile M, Rudà R. Radiotherapy and chemotherapy of brain metastases. J Neurooncol 2005; 75:31-42. [PMID: 16215814 DOI: 10.1007/s11060-004-8096-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The authors have reviewed the results, the indications and the controversies regarding radiotherapy and chemotherapy of patients with newly diagnosed and recurrent brain metastases. Whole-brain radiotherapy, radiosurgery, hypofractionated stereotactic radiotherapy, brachytherapy and chemotherapy are the available options. New radiosensitizers and cytotoxic or cytostatic agents are being investigated. Adjuvant whole brain radiotherapy, either after surgery or radiosurgery, and prophylactic cranial irradiation in small-cell lung cancer are discussed, taking into account local control, survival, and risk of late neurotoxicity. Increasingly, the different treatments are tailored to the different prognostic subgroups, as defined by Radiation Therapy Oncology Group RPA Classes.
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Affiliation(s)
- R Soffietti
- Neuro-Oncology Service, Department of Neuroscience, University and Azienda Ospedaliera San Giovanni Battista, Torino, Italy.
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Warnick RE, Darakchiev BJ, Breneman JC. Stereotactic radiosurgery for patients with solid brain metastases: current status. J Neurooncol 2004; 69:125-37. [PMID: 15527085 DOI: 10.1023/b:neon.0000041876.90641.96] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The goal of this article is to provide a contemporary update on the use of stereotactic radiosurgery (SRS) for the treatment of intracranial metastatic disease. We discuss the rationale for employing SRS in brain metastases and describe the critical factors that predict outcome. We highlight the main clinical indications for SRS including treatment of recurrent brain metastases after previous whole brain radiation therapy (WBRT), as a boost after WBRT, and as sole therapy for newly diagnosed tumors. For each clinical scenario, we offer a treatment algorithm based on our clinical experience. The article also addresses the most common complications associated with SRS and their treatment.
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Affiliation(s)
- Ronald E Warnick
- Department of Neurosurgery, The Neuroscience Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267-0515, USA.
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Weber MA, Thilmann C, Lichy MP, Günther M, Delorme S, Zuna I, Bongers A, Schad LR, Debus J, Kauczor HU, Essig M, Schlemmer HP. Assessment of Irradiated Brain Metastases by Means of Arterial Spin-Labeling and Dynamic Susceptibility-Weighted Contrast-Enhanced Perfusion MRI. Invest Radiol 2004; 39:277-87. [PMID: 15087722 DOI: 10.1097/01.rli.0000119195.50515.04] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
RATIONALE AND OBJECTIVES To assess if preradiation and early follow-up measurements of relative regional cerebral blood flow (rrCBF) can predict treatment outcome in patients with cerebral metastases and to evaluate rrCBF changes in tumor and normal tissue after stereotactic radiosurgery using arterial spin-labeling (ASL) and first-pass dynamic susceptibility-weighted contrast-enhanced (DSC) perfusion MRI. METHODS In 25 patients with a total of 28 brain metastases, DSC MRI and ASL perfusion MRI using the Q2TIPS sequence were performed with a 1.5-T unit. Measurements were performed prior to and at 6 weeks, 12 weeks, and 24 weeks after stereotactic radiosurgery. Follow-up examinations were completely available in 25 patients for Q2TIPS and 17 patients with 18 metastases for DSC MRI. The rrCBF of the metastases and the normal brain tissue was determined by a region-of-interest analysis. rrCBF values were correlated with the treatment outcome that was classified according to tumor volume changes at 6 months. RESULTS The alteration of the rrCBF at the 6-week follow-up was highly predictive for treatment outcome. A decrease of the rrCBF value predicted tumor response correctly in all metastases for Q2TIPS and in 13 of 16 metastases for DSC MRI. The pretherapeutic rrCBF was not able to predict treatment outcome. The rrCBF values in normal brain tissue affected by radiation doses less than 0.5 Gy remained unchanged after therapy. CONCLUSION These preliminary results suggest that ASL and DSC MRI techniques determining rrCBF changes in brain metastases after stereotactic radiosurgery allow the prediction of treatment outcome.
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Affiliation(s)
- Marc-André Weber
- Division of Radiology, German Cancer Research Center, Im Neuenheimer Feld 280, D-69120 Heidelberg, Germany.
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Essig M, Waschkies M, Wenz F, Debus J, Hentrich HR, Knopp MV. Assessment of brain metastases with dynamic susceptibility-weighted contrast-enhanced MR imaging: initial results. Radiology 2003; 228:193-9. [PMID: 12832582 DOI: 10.1148/radiol.2281020298] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess if preradiation and early follow-up regional cerebral blood volume (CBV) measurements can help predict treatment outcome in patients with cerebral metastases and to evaluate regional CBV changes in tumor and normal tissue after radiosurgery. MATERIALS AND METHODS In 18 patients, dynamic susceptibility-weighted contrast material-enhanced magnetic resonance (MR) imaging was performed with a 1.5-T unit, which allowed an absolute quantification of the regional CBV. Measurements were performed prior to and at 6 weeks and 3 months after therapy. Treatment outcome was classified according to tumor volume changes at 6 months. The regional CBV of the metastases and the normal adjacent brain tissue were determined with a region-of-interest analysis. Regional CBV values were correlated with the patient outcome to assess the sensitivity and specificity of dynamic susceptibility-weighted contrast-enhanced MR imaging. RESULTS The pretherapeutic regional CBV was not able to help predict a treatment outcome; however, the method proved to be highly sensitive and specific for treatment outcome prediction at the 6-week follow-up. A decrease of the regional CBV value helped predict the treatment outcome with a sensitivity of more than 90%. The tumor volume change alone had a sensitivity of only 64%. The measured regional CBV values of normal brain tissue and their ratio were comparable to physiologic data and remained unchanged with therapy. CONCLUSION The results suggest that dynamic susceptibility-weighted contrast-enhanced MR imaging is a useful method for the assessment of radiosurgically treated brain metastases. The implemented technique with determination of the arterial input function enables an absolute quantification of the regional CBV and prediction of tumor response.
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Affiliation(s)
- Marco Essig
- Department of Radiology, German Cancer Research Center, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany.
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Mackie TR, Kapatoes J, Ruchala K, Lu W, Wu C, Olivera G, Forrest L, Tome W, Welsh J, Jeraj R, Harari P, Reckwerdt P, Paliwal B, Ritter M, Keller H, Fowler J, Mehta M. Image guidance for precise conformal radiotherapy. Int J Radiat Oncol Biol Phys 2003; 56:89-105. [PMID: 12694827 DOI: 10.1016/s0360-3016(03)00090-7] [Citation(s) in RCA: 344] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE To review the state of the art in image-guided precision conformal radiotherapy and to describe how helical tomotherapy compares with the image-guided practices being developed for conventional radiotherapy. MATERIALS AND METHODS Image guidance is beginning to be the fundamental basis for radiotherapy planning, delivery, and verification. Radiotherapy planning requires more precision in the extension and localization of disease. When greater precision is not possible, conformal avoidance methodology may be indicated whereby the margin of disease extension is generous, except where sensitive normal tissues exist. Radiotherapy delivery requires better precision in the definition of treatment volume, on a daily basis if necessary. Helical tomotherapy has been designed to use CT imaging technology to plan, deliver, and verify that the delivery has been carried out as planned. The image-guided processes of helical tomotherapy that enable this goal are described. RESULTS Examples of the results of helical tomotherapy processes for image-guided intensity-modulated radiotherapy are presented. These processes include megavoltage CT acquisition, automated segmentation of CT images, dose reconstruction using the CT image set, deformable registration of CT images, and reoptimization. CONCLUSIONS Image-guided precision conformal radiotherapy can be used as a tool to treat the tumor yet spare critical structures. Helical tomotherapy has been designed from the ground up as an integrated image-guided intensity-modulated radiotherapy system and allows new verification processes based on megavoltage CT images to be implemented.
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Abstract
The median survival after whole-brain irradiation of patients with brain metastases is 4 months. Because half the patients with brain metastases die of systemic cancer, for most the benefit of intensive local treatment (surgery or stereotactic radiosurgery) of brain metastases will be minimal. In particular, patients with controlled systemic disease and one to three brain metastases are candidates for intensive local treatments. Combined local treatment with whole-brain irradiation therapy improves the local control of brain metastases in comparison with whole-brain irradiation only. After the local treatment of brain metastases by either surgery or radiosurgery, overall survival is not adversely affected if whole-brain irradiation is only administered as salvage treatment at the time of relapse. New randomized trials are needed, however, to investigate this further. The response rate of brain metastases to chemotherapy is similar to the response rate of the primary tumour and non-cerebral metastases.
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Affiliation(s)
- M J van den Bent
- Department of Neuro-Oncology, Rotterdam Cancer Centre, University Hospital Rotterdam, PO Box 5201, 3008AE Rotterdam, the Netherlands.
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