The treatment of recurrent brain metastases with stereotactic radiosurgery

In Patients With Melanoma Brain Metastases, Is Combination Immune Checkpoint Inhibition a Safe and Effective First-Line Treatment? A Critically Appraised Topic

BACKGROUND

Combined PD-1/PD-L1 and CTLA-4 immune checkpoint inhibition for the has been shown to produce superior results in the treatment of malignant melanoma when compared to monotherapy. However, patients with intracranial disease were excluded from these studies given their poor prognosis.

OBJECTIVE

The objective of this study was to critically assess current evidence supporting the co-administration of PD-1/PD-L1 and CTLA-4 inhibitors in the treatment of melanoma brain metastases.

METHODS

The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and a content expert in the field of neuro-oncology.

RESULTS

A recent, open-label, non-comparative randomized phase II trial was selected for critical appraisal. This trial evaluated the efficacy and safety of nivolumab alone or in combination with ipilimumab in 79 adult patients with untreated, asymptomatic melanoma brain metastases. The rates of the primary outcome (intracranial response at ≥12 wk) in the primary endpoint cohort were 46% for cohort A (combination therapy) and 20% for cohort B (nivolumab monotherapy). No treatment related deaths were observed in the study. Grade 4 adverse events occurred in 9% of patients in cohort A and none in cohort B.

CONCLUSIONS

Co-administration of ipilimumab and nivolumab as first-line therapy is effective in the treatment of asymptomatic melanoma brain metastases, with an acceptable safety profile.

Combination Laser Interstitial Thermal Therapy Plus Stereotactic Radiotherapy (SRT) Increases Time to Progression for Biopsy-Proven Recurrent Brain Metastases

Background

Improved survival for patients with brain metastases has been accompanied by a rise in tumor recurrence after stereotactic radiotherapy (SRT). Laser interstitial thermal therapy (LITT) has emerged as an effective treatment for SRT failures as an alternative to open resection or repeat SRT. We aimed to evaluate the efficacy of LITT followed by SRT (LITT+SRT) in recurrent brain metastases.

Methods

A multicenter, retrospective study was performed of patients who underwent treatment for biopsy-proven brain metastasis recurrence after SRT at an academic medical center. Patients were stratified by “planned LITT+SRT” versus “LITT alone” versus “repeat SRT alone.” Index lesion progression was determined by modified Response Assessment in Neuro-Oncology Brain Metastases (RANO-BM) criteria.

Results

Fifty-five patients met inclusion criteria, with a median follow-up of 7.3 months (range: 1.0–30.5), age of 60 years (range: 37–86), Karnofsky Performance Status (KPS) of 80 (range: 60–100), and pre-LITT/biopsy contrast-enhancing volume of 5.7 cc (range: 0.7–19.4). Thirty-eight percent of patients underwent LITT+SRT, 45% LITT alone, and 16% SRT alone. Median time to index lesion progression (29.8, 7.5, and 3.7 months [P = .022]) was significantly improved with LITT+SRT. When controlling for age in a multivariate analysis, patients treated with LITT+SRT remained significantly less likely to have index lesion progression (P = .004).

Conclusions

These data suggest that LITT+SRT is superior to LITT or repeat SRT alone for treatment of biopsy-proven brain metastasis recurrence after SRT failure. Prospective trials are warranted to validate the efficacy of using combination LITT+SRT for treatment of recurrent brain metastases.

Developments in therapy for brain metastases in melanoma patients

Introduction: Cutaneous melanoma brain metastases (MBM) are a major cause of morbidity and mortality. While cytotoxic agents, interferon, or interleukin-2, have been used with some success in extracranial disease, limited efficacy is demonstrated in MBM. The rare patient with long-term survival presented with limited intracranial disease amenable to surgery or radiation therapy. However, the development of targeted therapy and immunotherapy over the last decade has significantly improved overall survival in this formerly devastating presentation of metastatic melanoma.Areas covered: This article reviews the mechanism of brain metastasis, challenges with treating the central nervous system, historical treatment of MBM, and outcomes in clinical trials with targeted therapy and immunotherapy.Expert opinion: The MBM patient population now, more than ever, requires a multidisciplinary approach with surgery, radiation therapy, and the use of newer systemic therapies such as immunotherapy agents and targeted therapy agents. MBM has traditionally been excluded from clinical trials for systemic therapy due to poor survival. However, recent data show overall survival rates have significantly improved, supporting the need for inclusion of MBM patients in systemic therapy clinical trials. Understanding the mechanisms of therapeutic activity in the brain, resistance  mechanisms, and the appropriate multi-modality treatment approach requires further investigation. Nevertheless, these therapies continue to give some hope to patients with historically poor survival.

Clinical Experience of Bevacizumab for Radiation Necrosis in Patients with Brain Metastasis

Background

As the application of radiotherapy to brain metastasis (BM) increases, the incidence of radiation necrosis (RN) as a late toxicity of radiotherapy also increases. However, no specific treatment for RN is indicated except long-term steroids. Here, we summarize the clinical results of bevacizumab (BEV) for RN.

Methods

Ten patients with RN who were treated with BEV monotherapy (7 mg/kg) were retrospectively reviewed. RN diagnosis was made using MRI with or without perfusion MRI. Radiological response was based on Response Assessment in Neuro-Oncology criteria for BM. The initial response was observed after 2 cycles every 2 weeks, and maintenance observed after 3 cycles every 3–6 weeks of increasing length intervals.

Results

The initial response of gadolinium (Gd) enhancement diameter maintained stable disease (SD) in 9 patients, and 1 patient showed partial response (PR). The initial fluid-attenuated inversion recovery (FLAIR) response showed PR in 4 patients and SD in 6 patients. The best radiological response was observed in 9 patients. Gd enhancement response was 6 PR and 3 SD between 15–43 weeks. Reduction of FLAIR showed PR in 5 patients and SD in 4 patients. Clinical improvement was observed in all but 1 patient. Five patients were maintained on protocol with durable response up to 23 cycles. However, 2 patients stopped treatment due to primary cancer progression, 1 patient received surgical removal from tumor recurrence, and 1 patient changed to systemic chemotherapy for new BM. Grade 3 intractable hypertension occurred in 1 patient who had already received antihypertensive medication.

Conclusion

BEV treatment for RN from BM radiotherapy resulted in favorable radiological (60%) and clinical responses (90%). Side effects were expectable and controllable. We anticipate prospective clinical trials to verify the effect of BEV monotherapy for RN.

Cerebral metastasis in recurrent squamous cell carcinoma of the vulva: case report and review of the literature

BACKGROUND

Distant metastases from squamous cell cancer of the vulva (VSCC) are encountered rarely and are associated with a poor prognosis. Cerebral metastases have only been described anecdotally.

CASE HISTORY

A 51-year old woman was diagnosed with hepatic metastases due to VSCC. Initial therapy comprised wide local excision of the primary tumor with inguino-femoral lymphadenectomy (LAE) followed by stereotactic radiation of the singular hepatic metastasis while adjuvant chemoradiation of the vulva and lymphatics was declined. 3 years later, she subsequently developed lung and cerebral metastases.

CONCLUSION

The course of metastatic disease in VSCC is poorly understood. Further knowledge of the metastatic patterns in vulvar cancer is required for guidance of future therapeutic interventions.

Predictors of radiation necrosis in long-term survivors after Gamma Knife stereotactic radiosurgery for brain metastases

Background

The long-term risk of necrosis after radiosurgery for brain metastases is uncertain. We aimed to investigate incidence and predictors of radiation necrosis for individuals with more than 1 year of survival after radiosurgery for brain metastases.

Methods

Patients who had a diagnosis of brain metastases treated between December 2006 and December 2014, who had at least 1 year of survival after first radiosurgery were retrospectively reviewed. Survival was analyzed using the Kaplan-Meier estimator, and the incidence of radiation necrosis was estimated with death or surgical resection as competing risks. Patient and treatment factors associated with radiation necrosis were also analyzed.

Results

A total of 198 patients with 732 lesions were analyzed. Thirty-four lesions required salvage radiosurgery and 10 required salvage surgical resection. Median follow-up was 24 months. The estimated median survival for this population was 25.4 months. The estimated per-lesion incidence of radiation necrosis at 4 years was 6.8%. Medical or surgical therapy was required for 60% of necrosis events. Tumor volume and male sex were significant factors associated with radiation necrosis. The per-lesions incidence of necrosis for patients undergoing repeat radiosurgery was 33.3% at 4 years.

Conclusions

In this large series of patients undergoing radiosurgery for brain metastases, patients continued to be at risk for radiation necrosis throughout their first 4 years of survival. Repeat radiosurgery of recurrent lesions greatly exacerbates the risk of radiation necrosis, whereas treatment of larger target volumes increases the risk modestly.

Re-Irradiation of Brain Metastases and Metastatic Spinal Cord Compression: Clinical Practice Suggestions

The recent improvements of therapeutic approaches in oncology have allowed a certain number of patients with advanced disease to survive much longer than in the past. So, the number of cases with brain metastases and metastatic spinal cord compression has increased, as has the possibility of developing a recurrence in areas of the central nervous system already treated with radiotherapy.

Clinicians are reluctant to perform re-irradiation of the brain, because of the risk of severe side effects. The tolerance dose for the brain to a single course of radiotherapy is 50–60 Gy in 2 Gy daily fractions. New metastases appear in 22–73% of the cases after whole brain radiotherapy, but the percentage of re-irradiated patients is 3–10%. An accurate selection must be made before giving an indication to re-irradiation. Patients with Karnofsky performance status >70, age <65 years, controlled primary and no extracranial metastases are those with the best prognosis. The absence of extracranial disease was the most significant factor in conditioning survival, and maximum tumor diameter was the only variable associated with an increased risk of unacceptable acute and/or chronic neurotoxicity. Re-treatment of brain metastases can be done with whole brain radiotherapy, stereotactic radiosurgery or fractionated stereotactic radiotherapy. Most patients had no relevant radiation-induced toxicity after a second course of whole brain radiotherapy or stereotactic radiosurgery. There are few data on fractionated stereotactic radiotherapy in the re-irradiation of brain metastases.

In general, the incidence of an “in-field” recurrence of spinal metastasis varies from 2.5–11% of cases and can occur 2–40 months after the first radiotherapy cycle. Radiation-induced myelopathy can occur months or years (6 months-7 years) after radiotherapy, and the pathogenesis remains obscure. Higher radiotherapy doses, larger doses per fraction, and previous exposure to radiation could be associated with a higher probability of developing radiation-induced myelopathy. Experimental data indicate that also the total dose of the first and second radiotherapy, interval to re-treatment, length of the irradiated spinal cord, and age of the treated animals influence the risk of radiation-induced myelopathy. An α/β ratio of 1.9–3 Gy could be generally the reference value for fractionated radiotherapy. However, when fraction sizes are up to 5 Gy, the linear-quadratic equation become a less valid model. The early diagnosis of relapse is crucial in conditioning response to re-treatment.

Cumulative Doses to Brain and Other Critical Structures After Multisession Gamma Knife Stereotactic Radiosurgery for Treatment of Multiple Metastatic Tumors

Purpose

Repeat stereotactic radiosurgery (SRS) is an attractive alternative to whole brain radiation therapy (WBRT) for treatment of recurrent brain metastases (BM). The purpose of this study is to determine the cumulative doses to the brain and critical normal structures in patients who underwent repeat courses of Gamma Knife (GK) SRS.

Materials and methods

We retrospectively identified ten patients who received at least three GK-SRS sessions for multiply recurrent BM at our institution from 2013 to 2016. We used Velocity™ 3.1.0 software to co-register the magnetic resonance imaging images and the dose data of all treatment sessions for each patient. The cumulative doses to brain, lenses, eyes, brainstem, optic nerves, chiasm, and hippocampi were calculated. Dose–volume histograms, as well as the mean, median and maximum doses of these structures, were analyzed.

Results

The median number of SRS was five sessions (range = 3–7 sessions) per patient over a median treatment span of 510 days (112–1,197 days), whereas the median number of metastatic tumors treated per patient was 25.0 (10–63). The median of the total tumor volume was 9.5 cc (2.3–75.9 cc). The median of the mean cumulative dose to the whole brain was 4.1 Gy (1.7–16.4 Gy). The medians of the maximum doses to the critical structures were as follows: brainstem, 6.1 Gy (2.2–28.9 Gy), chiasm, 3.9 Gy (1.8–10.8 Gy), right optic nerve, 2.9 Gy (1.2–9.0 Gy), and left optic nerve, 2.6 Gy (1.0–6.5 Gy). The medians of the mean and maximum cumulative doses to the hippocampi were 3.4 Gy (1.0–14.4 Gy) and 13.8 Gy (1.5–39.3 Gy), respectively. The median survival for the entire cohort was 26.7 months, and no patients developed radiation necrosis.

Conclusion

Our study demonstrated that multisession GKSRS could be delivered with low cumulative doses to critical normal structures. Further studies are required to fully establish its role as an alternative treatment strategy to WBRT for the treatment of multiply recurrent BM.

Efficacy, safety and outcome of frameless image-guided robotic radiosurgery for brain metastases after whole brain radiotherapy

Estimating efficacy, safety and outcome of frameless image-guided robotic radiosurgery for the treatment of recurrent brain metastases after whole brain radiotherapy (WBRT). We performed a retrospective single-center analysis including patients with recurrent brain metastases after WBRT, who have been treated with single session radiosurgery, using the CyberKnife® Radiosurgery System (CKRS) (Accuray Inc., CA) between 2011 and 2016. The primary end point was local tumor control, whereas secondary end points were distant tumor control, treatment-related toxicity and overall survival. 36 patients with 140 recurrent brain metastases underwent 46 single session CKRS treatments. Twenty one patients had multiple brain metastases (58%). The mean interval between WBRT and CKRS accounted for 2 years (range 0.2-7 years). The median number of treated metastases per treatment session was five (range 1-12) with a tumor volume of 1.26 ccm (mean) and a median tumor dose of 18 Gy prescribed to the 70% isodose line. Two patients experienced local tumor recurrence within the 1st year after treatment and 13 patients (36%) developed novel brain metastases. Nine of these patients underwent additional one to three CKRS treatments. Eight patients (22.2%) showed treatment-related radiation reactions on MRI, three with clinical symptoms. Median overall survival was 19 months after CKRS. The actuarial 1-year local control rate was 94.2%. CKRS has proven to be locally effective and safe due to high local tumor control rates and low toxicity. Thus CKRS offers a reliable salvage treatment option for recurrent brain metastases after WBRT.

Spinal Radiosurgery for Metastatic Disease of the Spine

Background

Metastatic tumor in the spinal column is common, causing symptomatic spinal cord compression in approximately 25,000 patients annually. Although surgical treatment of spinal metastases has become safer, less invasive, and more efficacious in recent years, there remains a subset of patients for whom other treatment modalities are needed. Stereotactic radiosurgery, which has long been used in the treatment of intracranial lesions, has recently been applied to the spine and enables the effective treatment of metastatic lesions.

Methods

We review the evolution of stereotactic radiosurgery and its applications in the spine, including a description of two commercially available systems.

Results

Although a relatively new technique, the use of stereotactic radiosurgery in the spine has advanced rapidly in the past decade. Spinal stereotactic radiosurgery is an effective and safe modality for the treatment of spinal metastatic disease.

Conclusions

Future challenges involve the refinement of noninvasive fiducial tracking systems and the discernment of optimal doses needed to treat various lesions. Additionally, dose-tolerance limits of normal structures need to be further developed. Increased experience will likely make stereotactic radiosurgery of the spine an important treatment modality for a variety of metastatic lesions.

Do Recent Advances in MR Technologies Contribute to Better Gamma Knife Radiosurgery Treatment Results for Brain Metastases?

The detection of intracerebral lesions has improved greatly with advancements in MR imaging, especially the greater sensitivity of the 1.5 Tesla unit versus the older 1.0 Tesla unit. We aimed to determine whether improvements in MR imaging have actually improved diagnostic capabilities and treatment outcomes in gamma knife radiosurgery (GKRS) for brain metastases (METs). Ours was a retrospective study of a consecutive series of 1179 patients (441 females, 738 males, mean age: 63 years, range: 19–92 years) with brain METs who underwent GKRS from 1998 to 2004. Our treatment policy was to irradiate all lesions visible on MR images during a single GKRS session. Mean and median tumor numbers were seven and three (range; 1–74). The 1179 patients were divided into two groups: a 1.0 T-group of 660 patients examined using a 1.0 Tesla MR unit before August, 2002, and a 1.5 T-group of 519 examined using a 1.5 Tesla MR unit after September 2002. In the 1.5 T-group, lesion volumes as small as 0.004 cc were detected with a 5 mm slice thickness. The corresponding lesion size was 0.013 cc in the 1.0 T-group. One or more lesions invisible on a 5 mm slice study were additionally detected on a 2 mm slice study in 47.8% of patients in the 1.0 T-group and 25.2% in the 1.5 T-group (p<.0001). The median survival time (MST) in the 1.5 T-group was significantly longer than that in the 1.0 T-group (8.4 vs. 6.3 months, p=.0004). Due to biases in patient numbers between the two groups, we analyzed subgroups with KPS of 80% or better, no neurological deficits, stable primary tumors, lung cancer, tumor numbers of four or less and tumor volumes of 10.0 cc or smaller. In every subgroup analysis, the MSTs of the 1.5-Tesla group were significantly longer than those of the 1.0-Tesla group. The prognosis of a cancer patient is undoubtedly influenced by multiple factors. Nevertheless, we conclude that application of the 1.5 Tesla MR unit has had a favorable impact on diagnosis and GKRS treatment results in patients with brain METs.

Lung cancer: Biology and treatment options

Lung cancer remains the leading cause of cancer mortality in men and women in the U.S. and worldwide. About 90% of lung cancer cases are caused by smoking and the use of tobacco products. However, other factors such as radon gas, asbestos, air pollution exposures, and chronic infections can contribute to lung carcinogenesis. In addition, multiple inherited and acquired mechanisms of susceptibility to lung cancer have been proposed. Lung cancer is divided into two broad histologic classes, which grow and spread differently: small-cell lung carcinomas (SCLCs) and non-small cell lung carcinomas (NSCLCs). Treatment options for lung cancer include surgery, radiation therapy, chemotherapy, and targeted therapy. Therapeutic-modalities recommendations depend on several factors, including the type and stage of cancer. Despite the improvements in diagnosis and therapy made during the past 25 years, the prognosis for patients with lung cancer is still unsatisfactory. The responses to current standard therapies are poor except for the most localized cancers. However, a better understanding of the biology pertinent to these challenging malignancies, might lead to the development of more efficacious and perhaps more specific drugs. The purpose of this review is to summarize the recent developments in lung cancer biology and its therapeutic strategies, and discuss the latest treatment advances including therapies currently under clinical investigation.

Photon Radiosurgery: A Clinical Review

The term radiosurgery has been used to describe a variety of radiotherapy techniques which deliver high doses of radiation to small, stereotactically defined intracranial targets in such a way that the dose fall-off outside the targeted volume is very sharp. Proton, charged particle, gamma unit, and linear accelerator-based techniques appear to be equivalent from the standpoint of accuracy, dose distributions, and clinical results. However, capital and operating costs associated with the use of linear accelerators in general clinical use are much lower. Radiosurgery has an established role in the treatment of arteriovenous malformations and acoustic neurinomas. Interest in these techniques is increasing in neurosurgical and radiation oncological communities, as radiosurgery is rapidly assuming a place in the management of several other conditions, including craniopharyngiomas, meningiomas, and selected malignant lesions.

Central nervous system cancers, version 2.2014. Featured updates to the NCCN Guidelines

The NCCN Guidelines for Central Nervous System Cancers provide multidisciplinary recommendations for the clinical management of patients with cancers of the central nervous system. These NCCN Guidelines Insights highlight recent updates regarding the management of metastatic brain tumors using radiation therapy. Use of stereotactic radiosurgery (SRS) is no longer limited to patients with 3 or fewer lesions, because data suggest that total disease burden, rather than number of lesions, is predictive of survival benefits associated with the technique. SRS is increasingly becoming an integral part of management of patients with controlled, low-volume brain metastases.

Feasibility and outcome of re-irradiation in the treatment of multiply recurrent pituitary adenomas

PURPOSE

This study evaluates the toxicity and outcomes of re-irradiation to the sella for pituitary adenomas.

METHODS

Patients diagnosed with a pituitary adenoma and treated with two or more courses of radiation treatment (RT) to the sella were retrospectively analyzed for: initial diagnosis, including histological type and functional status; RT modality, technique, dose, and fractionation; treatment with surgery, endocrine agents, and chemotherapy; toxicity of RT including radiation-induced optic neuropathy, radionecrosis, and radiation-induced neoplasms; and outcomes including local control, distant metastasis, biochemical control of functional tumors, and vital status at last follow-up.

RESULTS

We identified 15 patients with non-functioning pituitary adenoma (n = 6), Cushing's disease (CD) (n = 5), acromegaly (n = 3), and prolactinoma (n = 1). Initial RT was delivered using opposed lateral fields in 8 (53%), intensity-modulated radiation therapy (IMRT) in 4 (27%), fractionated stereotactic radiation therapy (FSRT) in 1 (6.7%), and stereotactic radiosurgery (SRS) in 2. The median dose was 49.5 Gy for fractionated RT and 15-25 Gy for SRS. Re-irradiation was performed a median of 5.8 years after initial RT, and delivered using lateral opposed beams (n = 1), IMRT (n = 4), linear-accelerator based SRS (n = 3), FSRT (n = 3), gamma knife surgery (n = 2), and yttrium-90 brachytherapy (n = 1). The median dose of re-irradiation was 45 Gy (range 27.9-54 Gy) for fractionated RT and 18 Gy for SRS. Radiation-induced optic neuropathy (RION) was observed in 2 (13.3%) patients, 6 months and 14 years after re-irradiation; the 5-year rate of RION was 9 %. Temporal lobe necrosis (TLN) occurred in two patients (13.3%), both of whom had received SRS. The 2- and 5-year rates of TLN were 10 and 28%. Actuarial local control rates at 2 and 5 years were 80 and 58%, respectively. Biochemical remission occurred in one of three patients with CD. Four patients (27%) ultimately developed pituitary carcinoma.

CONCLUSIONS

Re-irradiation is a feasible treatment option for local control in patients with recalcitrant pituitary adenomas, with acceptable rates of RION and TLN given the lack of options that may be available otherwise. Re-irradiation, however, did not control hormonal hypersecretion.

Stereotactic radiosurgery (SRS) for brain metastases: a systematic review

In many patients with brain metastases, the primary therapeutic aim is symptom palliation and maintenance of neurologic function, but in a subgroup, long-term survival is possible. Local control in the brain, and absent or controlled extracranial sites of disease are prerequisites for favorable survival. Stereotactic radiosurgery (SRS) is a focal, highly precise treatment option with a long track record. Its clinical development and implementation by several pioneering institutions eventually rendered possible cooperative group randomized trials. A systematic review of those studies and other landmark studies was undertaken. Most clinicians are aware of the potential benefits of SRS such as a short treatment time, a high probability of treated-lesion control and, when adhering to typical dose/volume recommendations, a low normal tissue complication probability. However, SRS as sole first-line treatment carries a risk of failure in non-treated brain regions, which has resulted in controversy around when to add whole-brain radiotherapy (WBRT). SRS might also be prescribed as salvage treatment in patients relapsing despite previous SRS and/or WBRT. An optimal balance between intracranial control and side effects requires continued research efforts.

Survival after surgery and stereotactic radiosurgery for patients with multiple intracranial metastases: results of a single-center retrospective study

OBJECTIVES

Patients with systemic cancer and a single brain metastasis who undergo treatment with resection plus radiotherapy live longer and have a better quality of life than those treated with radiotherapy alone. Historically, whole-brain radiotherapy (WBRT) has been the mainstay of radiation therapy; however, it is associated with significant delayed neurocognitive sequelae. In this study, the authors looked at survival in patients with single and multiple intracranial metastases who had undergone surgery and adjuvant stereotactic radiosurgery (SRS) to the tumor bed and synchronous lesions.

METHODS

The authors retrospectively reviewed the records from an 8-year period at a single institution for consecutive patients with brain metastases treated via complete resection of dominant lesions and adjuvant radiosurgery. The cohort was analyzed for time to local progression, synchronous lesion progression, new intracranial lesion development, systemic progression, and overall survival. The Kaplan-Meier method (stratified by age, sex, tumor histology, and number of intracranial lesions prior to surgery) was used to calculate both progression-free and overall survival. A Cox proportional-hazards regression model was also fitted with the number of intracranial lesions as the predictor and survival as the outcome controlling for disease severity, age, sex, and primary histology.

RESULTS

The median overall follow-up among the 150-person cohort eligible for analysis was 17 months. Patients had an average age of 46.2 years (range 16-82 years), and 62.7% were female. The mean (± standard deviation) number of intracranial lesions per patient was 2.5 ± 2.3. The mean time between surgery and stereotactic radiosurgery (SRS) was 3.2 ± 4.1 weeks. Primary cancers included lung cancer (43.3%), breast cancer (21.3%), melanoma (10.0%), renal cell carcinoma (6.7%), and colon cancer (6.7%). The average number of isocenters per treated lesion was 7.6 ± 6.6, and the average treatment dose was 17.8 ± 2.8 Gy. One-year survival for patients in this cohort was 52%, and the 1-year local control rate was 77%. The median (±standard error) overall survival was 13.2 ± 1.9 months. There was no difference in survival between patients with a single lesion and those with multiple lesions (p = 0.319) after controlling for age, sex, and histology of primary tumor. Patients with primary breast histology had the greatest overall median survival (22.9 ± 6.2 months); patients with colorectal cancer had the shortest overall median survival (5.3 ± 1.8 months). The most common cause of death in this series was systemic progression (79%).

CONCLUSIONS

These results confirm that 1-year survival for patients with multiple intracranial metastases treated with resection followed by SRS to both the tumor bed and synchronous lesions is similar to established outcomes for patients with a single intracranial metastasis.

Central nervous system cancers

Primary and metastatic tumors of the central nervous system are a heterogeneous group of neoplasms with varied outcomes and management strategies. Recently, improved survival observed in 2 randomized clinical trials established combined chemotherapy and radiation as the new standard for treating patients with pure or mixed anaplastic oligodendroglioma harboring the 1p/19q codeletion. For metastatic disease, increasing evidence supports the efficacy of stereotactic radiosurgery in treating patients with multiple metastatic lesions but low overall tumor volume. These guidelines provide recommendations on the diagnosis and management of this group of diseases based on clinical evidence and panel consensus. This version includes expert advice on the management of low-grade infiltrative astrocytomas, oligodendrogliomas, anaplastic gliomas, glioblastomas, medulloblastomas, supratentorial primitive neuroectodermal tumors, and brain metastases. The full online version, available at NCCN. org, contains recommendations on additional subtypes.

Cyberknife stereotactic radiosurgery for the re-irradiation of brain lesions: a single-centre experience

PURPOSE

The aim of our study was to retrospectively evaluate the feasibility and clinical benefit of cyberknife stereotactic radiosurgery (CSRS) in patients treated at Florence University for recurrent, pre-irradiated brain lesions.

MATERIALS AND METHODS

Thirteen patients were retreated with cyberknife. Mean age was 47.1 years (range 33-77 years). Karnofsky performance status ranged from 60 to 100 (median 80). Eleven (84.6%) out of 13 patients had metastatic lesions: four (36.4%) had primary lung, three (27.2%) had primary breast cancer and four (36.4%) other types of solid malignancies. Two (15.4%) out of 13 patients had recurrent of glioblastoma.

RESULTS

In terms of compliance with CSRS, the majority of patients did not develop any acute side effects. However, two (15.4%) out of 13 patients developed acute grade 2 toxicity requiring an increase of steroid medication. At the time of the last follow-up, response rates were as follows: complete response in one case (16.6%), partial response in three (50%) and stable disease in two (33.4%).

CONCLUSIONS

Re-irradiation with CSRS is a feasible and effective option for pre-irradiated, recurrent brain lesions to obtain clinical benefit without excessive acute toxicity.

Salvage stereotactic radiosurgery for brain metastases

Recurrent or progressive brain metastases after initial treatment represent a common clinical entity mainly due to increased survival of cancer patients. From the various available treatment modalities, salvage stereotactic radiosurgery seems to be the most commonly used. Many clinical studies of class of evidence III have demonstrated satisfied results concerning the local brain control and survival of patients with relapsing brain disease. Also stereotactic radiosurgery is considered a relatively safe modality with low incidence of brain toxicity side effects. It is obvious that well-designed, randomized, prospective studies are necessary for the evaluation of the stereotactic radiosurgery as salvage treatment and for the establishment of guidelines for the selection of patients most suitable for this treatment option. The increasing number of patients with relapsing brain metastatic disease will act as a pressure to this direction.

Surgery of recurrent brain metastases: retrospective analysis of 67 patients

OBJECTIVE

Treatment of patients with recurrent brain metastasis is one of the major challenges in neurooncology. Commonly, WBRT was applied after or as the initial treatment. Many patients received radiosurgery or their lesions were operated on. The question arises of what treatment modalities are appropriate and can be offered to the patients. In our retrospective analysis, we evaluated whether re-operation might be a useful measurement for the patients with respect to overall survival and quality of life.

METHODS

We included 67 patients who were treated between 1993 and 2008 in our department. The median age was 59 years. Metastases of 11 different primaries were diagnosed. The median OST was 7.5 months.

RESULTS

Statistically significant prognostic factors for OS were single lesions, completeness of resection, and time to recurrence, which was significantly influenced by WBRT after first operation. The one year survival rate correlated with the RPA classification: class I: 53.3 %, class II: 26.9 %, class III: 12.5 %. In 31.3 %, a second recurrence occurred which was treated by repeated surgery. Six patients survived as long-term survivors (25.7-132.2 months).

CONCLUSION

Surgery of recurrent brain metastasis is an important therapeutic option. A subgroup of patients, defined by prognostic factors, will profit with improvement of symptoms and prolongation of the overall survival time. Even long-term survivors can be expected.

Brain metastases research 1990-2010: pattern of citation and systematic review of highly cited articles

BACKGROUND

High and continuously increasing research activity related to different aspects of prevention, prediction, diagnosis and treatment of brain metastases has been performed between 1990 and 2010. One of the major databases contains 2695 scientific articles that were published during this time period. Different measures of impact, visibility, and quality of published research are available, each with its own pros and cons. For this overview, article citation rate was chosen.

RESULTS

Among the 10 most cited articles, 7 reported on randomized clinical trials. Nine covered surgical or radiosurgical approaches and the remaining one a widely adopted prognostic score. Overall, 30 randomized clinical trials were published between 1990 and 2010, including those with phase II design and excluding duplicate publications, for example, after longer followup or with focus on secondary endpoints. Twenty of these randomized clinical trials were published before 2008. Their median number of citations was 110, range 13-1013, compared to 5-6 citations for all types of publications. Annual citation rate appeared to gradually increase during the first 2-3 years after publication before reaching high levels.

CONCLUSIONS

A large variety of preclinical and clinical topics achieved high numbers of citations. However, areas such as quality of life, side effects, and end-of-life care were underrepresented. Efforts to increase their visibility might be warranted.

Radiation therapy for the treatment of recurrent glioblastoma: an overview

Despite the therapeutic advances in neuro-oncology, most patients with glioblastoma ultimately experience local progression/relapse. Re-irradiation has been poorly viewed in the past, mainly due to the overestimated risk of side effects using conventional radiotherapy. To date, thanks to the improvement of several delivery techniques, together with improved imaging capabilities, re-irradiation is a viable salvage treatment option to manage such clinical scenario. A literature overview on the feasibility and efficacy of the different irradiation modalities for recurrent glioblastoma along with considerations on areas of improvement are provided.

Iodine-125 brachytherapy for brain tumours--a review

Iodine-125 brachytherapy has been applied to brain tumours since 1979. Even though the physical and biological characteristics make these implants particularly attractive for minimal invasive treatment, the place for stereotactic brachytherapy is still poorly defined.An extensive review of the literature has been performed, especially concerning indications, results and complications. Iodine-125 seeds have been implanted in astrocytomas I-III, glioblastomas, metastases and several other tumour entities. Outcome data given in the literature are summarized. Complications are rare in carefully selected patients.All in all, for highly selected patients with newly diagnosed or recurrent primary or metastatic tumours, this method provides encouraging survival rates with relatively low complication rates and a good quality of life.

Management of melanoma brain metastases in the era of targeted therapy

Disseminated metastatic disease, including brain metastases, is commonly encountered in malignant melanoma. The classical treatment approach for melanoma brain metastases has been neurosurgical resection followed by whole brain radiotherapy. Traditionally, if lesions were either too numerous or surgical intervention would cause substantial neurologic deficits, patients were either treated with whole brain radiotherapy or referred to hospice and supportive care. Chemotherapy has not proven effective in treating brain metastases. Improvements in surgery, radiosurgery, and new drug discoveries have provided a wider range of treatment options. Additionally, recently discovered mutations in the melanoma genome have led to the development of "targeted therapy." These vastly improved options are resulting in novel treatment paradigms for approaching melanoma brain metastases in patients with and without systemic metastatic disease. It is therefore likely that improved survival can currently be achieved in at least a subset of melanoma patients with brain metastases.

Current standards in the management of cerebral metastases

The last 30 years have seen major changes in attitude toward patients with cerebral metastases. This paper aims to outline the major landmarks in this transition and the therapeutic strategies currently used. The controversies surrounding control of brain disease are discussed, and two emerging management trends are reviewed: tumor bed radiosurgery and salvage radiation.

Does the surgical resection of a brain metastasis alter the planning and subsequent local control achieved with radiosurgery prescribed for recurrence at the operated site?

Multiple treatments may be used in the management of patients with brain metastases including surgical resection or radiosurgery. In order to determine whether initial surgical resection in any way prejudices the subsequent efficacy of radiosurgery for recurrence at the operated site, a retrospective review of patients undergoing radiosurgery at the time of relapse was undertaken. All patients had previously received whole brain irradiation as part of initial management. A comparison of radiosurgical planning technique was made for recurrent brain metastases occurring at sites of a previous surgical resection versus unresected recurrences. Although recurrences of tumour at a resected site were more likely to be treated radiosurgically using larger and multiple collimators, there was no significant difference in subsequent local control. Assuming that the recurrence of a brain metastasis at a previously resected site is considered treatable radiosurgically, subsequent local control is no different from that achieved in previously unresected recurrences.

Clinical and pathological characteristics of brain metastasis resected after failed radiosurgery

OBJECTIVE

This study evaluates the tumor histopathology and clinical characteristics of patients who underwent resection of their brain metastasis after failed gamma knife radiosurgery.

METHODS

This study was a retrospective review from a prospective database. A total of 1200 brain metastases in 912 patients were treated by gamma knife radiosurgery during a 7-year period. Fifteen patients (1.6% of patients, 1.2% of all brain metastases) underwent resective surgery for either presumed tumor progression (6 patients) or worsening neurological symptoms associated with increased mass effect (9 patients). Radiographic imaging, radiosurgical and surgical treatment parameters, histopathological findings, and long-term outcomes were reviewed for all patients.

RESULTS

The mean age at the time of radiosurgery was 57 years (age range, 32-65 years). Initial pathological diagnoses included metastatic non-small cell lung carcinoma in 8 patients (53%), melanoma in 4 patients (27%), renal cell carcinoma in 2 patients (13%), and squamous cell carcinoma of the tongue in 1 patient (7%). The mean time interval between radiosurgery and surgical extirpation was 8.5 months (range, 3 weeks to 34 months). The mean treatment volume for the resected lesion at the time of radiosurgery was 4.4 cm(3) (range, 0.6-8.4 cm(3)). The mean dose to the tumor margin was 21Gy (range, 18-24 Gy). In addition to the 15 tumors that were eventually resected, a total of 32 other metastases were treated synchronously, with a 78% control rate. The mean volume immediately before surgery for the 15 resected lesions was 7.5 cm(3) (range, 3.8-10.2 cm(3)). Histological findings after radiosurgery varied from case to case and included viable tumor, necrotic tumor, vascular hyalinization, hemosiderin-laden macrophages, reactive gliosis in surrounding brain tissue, and an elevated MIB-1 proliferation index in cases with viable tumor. The mean survival for patients in whom viable tumor was identified (9.4 months) was significantly lower than that of patients in whom only necrosis was seen (15.1 months; Fisher's exact test, P < 0.05).

CONCLUSION

Radiation necrosis and tumor radioresistance are the most common causes precipitating a need for surgical resection after radiosurgery in patients with brain metastasis.

The role of retreatment in the management of recurrent/progressive brain metastases: a systematic review and evidence-based clinical practice guideline

QUESTION

What evidence is available regarding the use of whole brain radiation therapy (WBRT), stereotactic radiosurgery (SRS), surgical resection or chemotherapy for the treatment of recurrent/progressive brain metastases?

TARGET POPULATION

This recommendation applies to adults with recurrent/progressive brain metastases who have previously been treated with WBRT, surgical resection and/or radiosurgery. Recurrent/progressive brain metastases are defined as metastases that recur/progress anywhere in the brain (original and/or non-original sites) after initial therapy.

RECOMMENDATION

Level 3 Since there is insufficient evidence to make definitive treatment recommendations in patients with recurrent/progressive brain metastases, treatment should be individualized based on a patient's functional status, extent of disease, volume/number of metastases, recurrence or progression at original versus non-original site, previous treatment and type of primary cancer, and enrollment in clinical trials is encouraged. In this context, the following can be recommended depending on a patient's specific condition: no further treatment (supportive care), re-irradiation (either WBRT and/or SRS), surgical excision or, to a lesser extent, chemotherapy. Question If WBRT is used in the setting of recurrent/progressive brain metastases, what impact does tumor histopathology have on treatment outcomes? No studies were identified that met the eligibility criteria for this question.

Gamma Knife radiosurgery to the surgical cavity following resection of brain metastases

OBJECT

This study evaluated the efficacy of postoperative Gamma Knife surgery (GKS) to the tumor cavity following gross-total resection of a brain metastasis.

METHODS

A retrospective review was conducted of 700 patients who were treated for brain metastases using GKS. Forty-seven patients with pathologically confirmed metastatic disease underwent GKS to the postoperative resection cavity following gross-total resection of the tumor. Patients who underwent subtotal resection or who had visible tumor in the resection cavity on the postresection neuroimaging study (either CT or MR imaging with and without contrast administration) were excluded. Radiographic and clinical follow-up was assessed using clinic visits and MR imaging. The radiographic end point was defined as tumor growth control (no tumor growth regarding the resection cavity, and stable or decreasing tumor size for the other metastatic targets). Clinical end points were defined as functional status (assessed prospectively using the Karnofsky Performance Scale) and survival. Primary tumor pathology was consistent with lung cancer in 19 cases (40%), melanoma in 10 cases (21%), renal cell carcinoma in 7 cases (15%), breast cancer in 7 cases (15%), and gastrointestinal malignancies in 4 cases (9%). The mean duration between resection and radiosurgery was 15 days (range 2-115 days). The mean volume of the treated cavity was 10.5 cm3 (range 1.75-35.45 cm3), and the mean dose to the cavity margin was 19 Gy. In addition to the resection cavity, 34 patients (72%) underwent GKS for 116 synchronous metastases observed at the time of the initial radiosurgery.

RESULTS

The mean radiographic follow-up duration was 14 months (median 10 months, range 4-37 months). Local tumor control at the site of the surgical cavity was achieved in 44 patients (94%), and tumor recurrence at the surgical site was statistically related to the volume of the surgical cavity (p=0.04). During follow-up, 34 patients (72%) underwent additional radiosurgery for 140 new (metachronous) metastases. At the most recent follow-up evaluation, 11 patients (23%) were alive, whereas 36 patients had died (mean duration until death 12 months, median 10 months). Patients who showed good systemic control of their primary tumor tended to have longer survival durations than those who did not (p=0.004). At the last clinical follow-up evaluation, the mean Karnofsky Performance Scale score for the overall group was 78 (median 80, range 40-100).

CONCLUSION

Radiosurgery appears to be effective in terms of providing local tumor control at the resection cavity following resection of a brain metastasis, and in the treatment of synchronous and metachronous tumors. These data suggest that radiosurgery can be used to prevent recurrence following gross-total resection of a brain metastasis.

Relationship between volume, dose and local control in stereotactic radiosurgery of brain metastasis

The aim of this study is to analyse the efficacy of linear accelerator stereotactic radiosurgery (SRS) on prognostic factors, local control rate and survival in patients with brain metastasis. Patients with either a single metastasis or up to 4 multiple brain metastases with a maximum tumour diameter of 40 mm for each tumour and a Karnofsky Performance Status (KPS) > or = 70 were eligible for SRS. SRS was applied to 150 lesions in 86 consecutive patients with a median age of 60 years (median 1 and mean 1.7 lesions per patient, mean KPS 86). Median overall survival was 6.2 months after SRS and 9.7 months from diagnosis of brain metastasis. Multivariate analysis revealed that a KPS of 90 or more (p = 0.009) and female sex (p = 0.003) were associated with a longer survival. Radiation dose < or = 15 Gy (p = 0.017) and KPS < 90 (p = 0.013) were independent predictors of a shorter time to local failure. Five patients showed evidence of radionecrosis with a median survival of 14.8 months. Addition of WBRT neither led to improvement of survival nor to improvement of local control. Improved local control following SRS for brain metastases was associated with KPS > or =90, a radiation dose > 15 Gy and a PTV < 13 cc. The potential of hypofractionated stereotactic radiotherapy (SRT) for brain metastases of larger volume warrants further study.

Radiosurgery for recurrent brain metastases after whole-brain radiotherapy : factors affecting radiation-induced neurological dysfunction

OBJECTIVE

We retrospectively analyzed survival, local control rate, and incidence of radiation toxicities after radiosurgery for recurrent metastatic brain lesions whose initial metastases were treated with whole-brain radiotherapy. Various radiotherapeutical indices were examined to suggest predictors of radiation-related neurological dysfunction.

METHODS

In 46 patients, total 100 of recurrent metastases (mean 2.2, ranged 1-10) were treated by CyberKnife radiosurgery at average dose of 23.1 Gy in 1 to 3 fractions. The median prior radiation dose was 32.7 Gy, the median time since radiation was 5.0 months, and the mean tumor volume was 12.4 cm(3). Side effects were expressed in terms of radiation therapy oncology group (RTOG) neurotoxicity criteria.

RESULTS

Mass reduction was observed in 30 patients (65%) on MRI. After the salvage treatment, one-year progression-free survival rate was 57% and median survival was 10 months. Age (<60 years) and tumor volume affected survival rate (p=0.03, each). Acute (</=1 month) toxicity was observed in 22% of patients, subacute and chronic (>6 months) toxicity occurred in 21%, respectively. Less acute toxicity was observed with small tumors (<10 cm(3), p=0.03), and less chronic toxicity occurred at lower cumulative doses (<100 Gy, p=0.004). "Radiation toxicity factor" (cumulative dose times tumor volume of <1,000 Gyxcm(3)) was a significant predictor of both acute and chronic CNS toxicities.

CONCLUSION

Salvage CyberKnife radiosurgery is effective for recurrent brain metastases in previously irradiated patients, but careful evaluation is advised in patients with large tumors and high cumulative radiation doses to avoid toxicity.

Gamma knife radiosurgery for metastatic brain tumors from thyroid cancer

OBJECTIVE

We report our experience using gamma knife radiosurgery (GKR) for brain metastasis from thyroid cancer, which is extremely rare.

METHODS

Between 1995 and 2007, 9 patients with 26 metastatic brain tumor(s) from thyroid cancer underwent GKR. The mean patient age was 58 years (range: 10-78). Seven patients had metastases from papillary thyroid cancer, and two from medullary thyroid cancer. Five patients had solitary tumors, and four patients had multiple metastases. Three patients who had multiple metastases also underwent whole brain radiation therapy (WBRT). The mean tumor volume was 2.4 cc (range: 0.03-14.0). A median margin dose of 18.0 Gy (range: 12-20) was delivered to the tumor margin.

RESULTS

Tumor control was obtained in 25 out of 26 tumors (96%). The median progression-free period after GKR was 12 months (range: 4-53). The overall median survival after GKR was 33 months (range: 5-54). There were no procedure-related complications and six patients are still living 5-54 months after GKR.

CONCLUSIONS

Radiosurgery is an effective and minimally invasive strategy for management of brain metastases form thyroid cancer.

Salvage stereotactic radiosurgery effectively treats recurrences from whole-brain radiation therapy

BACKGROUND

The purpose of the current study was to examine overall survival (OS) and time to local failure (LF) in patients who received salvage stereotactic radiosurgery (SRS) for recurrent brain metastases (BM) after initial management that included whole-brain radiation therapy (WBRT).

METHODS

The records of 1789 BM patients from August 1989 to November 2004 were reviewed. Of these, 111 underwent WBRT as part of their initial management and SRS as salvage. Patients were stratified by Radiation Therapy Oncology Group (RTOG) recursive partitioning analysis class, primary disease, dimension of the largest metastases and number of BM at initial diagnosis, and time to first brain recurrence after WBRT. Overall survival, survival after SRS, and time to local and distant failure were analyzed.

RESULTS

The median OS from the initial diagnosis of BM was 17.7 months. Median survival after salvage SRS for the entire cohort was 9.9 months. Median survival after salvage SRS was 12.3 months in patients who had their first recurrence >6 months after WBRT versus 6.8 months for those who developed disease recurrence < or = 6 months after (P = .0061). Primary tumor site did not appear to affect survival after SRS. Twenty-eight patients (25%) developed local recurrence after their first SRS with a median time of 5.2 months. A dose <22 grays and lesion size >2 cm were found to be predictive of local failure.

CONCLUSIONS

In this study, patients who recurred after WBRT and were treated with salvage SRS were found to have good local control and survival after SRS. WBRT provided good initial control, as 45% of these patients failed >6 months after WBRT. Those with a longer time to failure after WBRT had significantly longer survival after SRS.

Factors influencing the time to development of brain metastases in breast cancer

This retrospective study analyzed risk factors influencing the time to development of brain metastases with the aim to facilitate the definition of a high-risk population among breast cancer patients. One hundred seventy-four breast cancer patients with brain metastases, treated with whole brain radiotherapy, were evaluated. Statistical analysis included hormone receptor status, HER2/neu status, tumour grading, tumour stage, young age at the time of diagnosis, adjuvant systemic treatment, palliative systemic treatment, metastatic sites (if brain metastases were not the first site of recurrence), and immunotherapy with trastuzumab. Time to development of brain metastases was significantly prolonged by systemic palliative treatment (p< or =0.0001) whereas high tumour grading (p< or =0.04) and trastuzumab therapy (p< or =0.04) significantly shortened this time span. Patients with the brain as first metastatic site, age>35 (p< or =0.001) and stage III (p< or =0.018) at the time of diagnosis had a significantly shorter time to development for brain lesions. These factors should be further validated by a prospective trial to identify a high-risk population amongst breast cancer patients and enable the development of screening programs for early detection.

[Current management of brain metastases]

INTRODUCTION

Cerebral metastases occur in 15 to 20% of cancers and their incidence is increasing. The majority occur at an advanced stage of the disease, but metastasis may be the inaugural sign of cancer. The aim of treatments, which are often palliative, is to preserve the neurological status of the patient with the best quality of life.

STATE OF ART

Corticosteroids are widely used for symptomatic palliation, requiring close monitoring and regular dose adaptation. Antiepileptic drugs should be given only for patients who have had a seizure. In case of multiple cerebral metastases occurring at an advanced stage of the disease, whole brain radiation is the most effective therapy for rapid symptom control. However, radiotherapy moderately improves overall survival, which often depends on the progression of disseminated systemic disease. On the contrary, surgery is indicated in case of a solitary metastasis, particularly when the patient is young (less than 65 years), with good general status (Karnofsky greater than 70), and when the systemic disease is under control. Radiosurgery offers an attractive alternative for these patients with good prognostic factors and a small number of cerebral metastases (< or = 4).

PERSPECTIVES

Chemotherapy, considered in the past as not effective, is taking on a more important place in patients with multiple nonthreatening metastases from chemosensitive cancers (breast, testes...). Radiosurgery and whole brain radiotherapy are complementary techniques. Their respective role in the management of multiple metastases (< 4) remains to be further investigated.

CONCLUSIONS

Therapeutic options are increasingly effective to improve the functional prognosis of patients with cerebral metastases. Ideally, a multidisciplinary assessment offers the best choice of therapeutic modalities.

Multidisciplinary management of brain metastases

Metastatic brain tumors are the most common intracranial neoplasms in adults. The incidence of brain metastases appears to be rising as a result of superior imaging modalities, earlier detection, and more effective treatment of systemic disease. Therapeutic approaches to brain metastases include surgery, whole brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), and chemotherapy. Treatment decisions must take into account clinical prognostic factors in order to maximize survival and neurologic function whilst avoiding unnecessary treatments. The goal of this article is to review important prognostic factors that may guide treatment selection, discuss the roles of surgery, radiation, and chemotherapy in the treatment of patients with brain metastases, and present new directions in brain metastasis therapy under active investigation. In the future, patients will benefit from a multidisciplinary approach focused on the integration of surgical, radiation, and chemotherapeutic options with the goal of prolonging survival, preserving neurologic and neurocognitive function, and maximizing quality of life.

Analysis of fiducial markers used for on-line verification in the external-beam radiotherapy of patients with cranial tumours

PURPOSE

Evaluate the fiducial marker-based position verification in the external-beam radiotherapy of patients with cranial tumour.

METHODS

Thirteen patients with intracranial tumours were treated with external- beam radiotherapy using 3 gold markers implanted in the skull. Before each fraction the patient was positioned on the treatment table and 2 orthogonal portal images were performed to localise the 3 gold seeds and the target position was calculated using a commercialised computer program (ISOLOC software, MEDTEC). This program provides the couch movements required to move the target to the isocentre.

RESULTS

When the set-up error was corrected using the coordinates of the 3 markers, the final movements were less than 2 mm in all cases: lateral, mean v., 1.21 mm; longitudinal, 1.23 mm; and anteroposterior, 1.18 mm. No serious complications related to the gold marker insertion were noted.

CONCLUSION

The use of 3 implanted fiducial seeds is an optimal technique for precise set-up in patients with brain tumours treated with external radiotherapy. This commercial system is highly suitable for fractionated stereotactic irradiation.

Trastuzumab prolongs overall survival in patients with brain metastases from Her2 positive breast cancer

BACKGROUND

Brain metastases are frequently encountered in Her2 positive advanced breast cancer. It is still not clear, if trastuzumab treatment should be continued following their diagnosis. In this analysis we evaluated if trastuzumab was able to influence time to in-brain progression (TTP) and overall survival (OS). For this reason, we compared patients who continued on trastuzumab with a historical control group.

PATIENTS AND METHODS

Seventeen Her2 positive patients receiving whole brain radiotherapy for brain metastases and continuing on trastuzumab were identified. As historical control group, thirty-six patients treated before 2002 were identified from a breast cancer database. We performed a multivariate analysis (Cox regression) to explore which factors were potentially able to significantly influence TTP and OS.

RESULTS

Median TTP was 6 months, range 1-33+ months. Median OS was 7 months, range 1-38 months. Seventeen patients received trastuzumab after WBRT. Factors associated with prolonged TTP were KPS (p = 0.001), and intensified local treatment (p = 0.004). A trend towards longer TTP was observed in patients treated with trastuzumab (p = 0.068). OS was significantly influenced by KPS (p < 0.001), and continued antibody therapy (p = 0.001).

CONCLUSION

Two parameters were significantly associated with prolonged OS: KPS and trastuzumab. While there was a trend towards prolonged TTP in patients with trastuzumab treatment after WBRT, this did not reach statistical significance. It appears therefore reasonable to suggest continuation of antibody therapy in patients with good performance status despite disease spreading to the brain. Concerning activity of trastuzumab in brain metastases themselves, no final conclusion is possible.

Surgical Therapies in Brain Metastasis

Brain metastases are the most common intracranial tumors in adults and source of the most common neurological complications of systemic cancer. The treatment approach to brain metastases differs essentially from treatment of systemic metastases due to the unique anatomical and physiological characteristics of the brain. Surgery and radiosurgery are important components in the complex treatment of brain metastases and can prolong survival and improve the quality of life (QOL). Aggressive intervention may be indicated for selected patients with well-controlled systemic cancer and good performance status in whom central nervous system (CNS) disease poses the greatest threat to functionality and survival. In this review the respective roles of surgery and radiosurgery, patient selection, general prognostic factors and tailoring of optimal surgical management strategies for cerebral metastases are discussed.

Radiation-induced necrosis deteriorating neurological symptoms and mimicking progression of brain metastasis after stereotactic-guided radiotherapy

PURPOSE

Although radiation-induced necrosis (RIN) is not a tumor in itself, the lesion progressively enlarges with mass effects and diffuse peritumoral edema in a way that resembles neoplasm. To identify the RIN that mimics progression of brain metastasis, we performed surgical resections of symptomatic RIN lesions.

MATERIALS AND METHODS

From June 2003 to December 2005, 7 patients received stereotactic-guided radiotherapy (SRT) for metastatic brain tumor, and they later underwent craniotomy and tumor resection due to the progressive mass effects and the peritumoral edema that caused focal neurological deficit. On MR imaging, a ring-like enhanced single lesion with massive peritumoral edema could not be distinguished from progression of brain metastasis.

RESULTS

Four patients had non-small cell lung cancer, 2 patients had colorectal cancer and 1 patient had renal cell carcinoma. The mean tumor volume was 8.7 ml (range: 3.0 approximately 20.7 ml). The prescribed dose of SRT was 30 Gy with 4 fractions for one patient, 18 Gy for two patients and 20 Gy for the other four patients. The four patients who received SRT with a dose of 20 Gy had RIN with or without microscopic residual tumor cells.

CONCLUSIONS

Early detection of recurrent disease after radiotherapy and identifying radiation-induced tissue damage are important for delivering adequate treatment. Therefore, specific diagnostic tools that can distinguish RIN from progression of metastatic brain tumor need to be developed.