scholarly journals Use of radiomics for the prediction of local control of brain metastases after stereotactic radiosurgery

2020 ◽  
Vol 22 (6) ◽  
pp. 797-805 ◽  
Author(s):  
Andrei Mouraviev ◽  
Jay Detsky ◽  
Arjun Sahgal ◽  
Mark Ruschin ◽  
Young K Lee ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Clinical Features ◽  
Characteristic Curve ◽  
Response Prediction ◽  
Response Assessment ◽  
Local Failure ◽  
Post Contrast ◽  
Axial Diameter ◽  
Fluid Attenuated Inversion Recovery

Abstract Background Local response prediction for brain metastases (BM) after stereotactic radiosurgery (SRS) is challenging, particularly for smaller BM, as existing criteria are based solely on unidimensional measurements. This investigation sought to determine whether radiomic features provide additional value to routinely available clinical and dosimetric variables to predict local recurrence following SRS. Methods Analyzed were 408 BM in 87 patients treated with SRS. A total of 440 radiomic features were extracted from the tumor core and the peritumoral regions, using the baseline pretreatment volumetric post-contrast T1 (T1c) and volumetric T2 fluid-attenuated inversion recovery (FLAIR) MRI sequences. Local tumor progression was determined based on Response Assessment in Neuro-Oncology‒BM criteria, with a maximum axial diameter growth of >20% on the follow-up T1c indicating local failure. The top radiomic features were determined based on resampled random forest (RF) feature importance. An RF classifier was trained using each set of features and evaluated using the area under the receiver operating characteristic curve (AUC). Results The addition of any one of the top 10 radiomic features to the set of clinical features resulted in a statistically significant (P < 0.001) increase in the AUC. An optimized combination of radiomic and clinical features resulted in a 19% higher resampled AUC (mean = 0.793; 95% CI = 0.792–0.795) than clinical features alone (0.669, 0.668–0.671). Conclusions The increase in AUC of the RF classifier, after incorporating radiomic features, suggests that quantitative characterization of tumor appearance on pretreatment T1c and FLAIR adds value to known clinical and dosimetric variables for predicting local failure.

scholarly journals Gamma Knife versus Frameless Linear Accelerator Based Stereotactic Radiosurgery for Brain Metastases: Clinical Outcomes and Factors Associated with Local Failure and Radiation Necrosis

2021 ◽  
Author(s):  
Gregory S. Alexander ◽  
Jill S. Remick ◽  
Emily S. Kowalski ◽  
Kai Sun ◽  
Yannick Poirer ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Clinical Outcomes ◽  
Gamma Knife ◽  
Linear Accelerator ◽  
Radiation Necrosis ◽  
Univariate Analysis ◽  
Local Failure ◽  
Rank Test ◽  
Chi Square Analysis

Abstract BackgroundSingle-fraction stereotactic radiosurgery (SF-SRS) for the treatment of brain metastases can be delivered with either a Gamma-Knife platform (GK-SRS) or with a frameless linear accelerator (LA-SRS) which vary based on patterns of prescribing, patient setup and radiation delivery. Whether these differences affect clinical outcomes is unknown. MethodsPatients treated for metastatic brain cancer treated with SF-SRS from 2014-2020 were retrospectively reviewed and clinical outcomes were recorded on a per lesion basis. Covariates between groups were compared using a Chi-square analysis for dichotomous variables and t-test for continuous variables. Median follow up was calculated using the reverse Kaplan Meier (KM) method. Primary endpoints of local failure (LF) and symptomatic radiation necrosis (RN) were estimated using the KM method with salvage WBRT used as a censoring event. Outcome estimates were compared using the log-rank test. Multivariate analysis (MVA) and Cox proportional hazards modeling were used for statistical analyses. Propensity score (PS) adjustments were used to reduce the effects confounding variables.ResultsOverall, 119 patients with 287 lesions were included for analysis which included 57 patients (127 lesions) treated with LA-SRS compared to 62 patients (160 lesions) treated with GK-SRS. On both multivariate and univariate analysis, there was no statistically significant differences between GK-SRS and LA-SRS for LF, RN, or the combined endpoint of either LF or RN (multivariate p-value=0.17).ConclusionsIn our retrospective cohort, we found no statistically significant differences in the incidence of RN or LF in patients treated with GK-SRS when compared to LA-SRS.Trial Registration: Retrospectively registered

scholarly journals Delayed contrast and multiparametric MRI for treatment response assessment in brain metastases following stereotactic radiosurgery

2021 ◽  
Vol 23 (Supplement_4) ◽  
pp. iv22-iv23
Author(s):  
Markand Patel ◽  
Dilina Rajapakse ◽  
Jian Ping Jen ◽  
Sara Meade ◽  
Helen Benghiat ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Treatment Response ◽  
Sensitivity And Specificity ◽  
Neuroendocrine Tumour ◽  
Response Assessment ◽  
Multiparametric Mri ◽  
Treatment Response Assessment ◽  
Measuring Signal

Abstract Aims Following stereotactic radiosurgery (SRS), brain metastases can increase in size in up to a third of cases. Conventional magnetic resonance imaging (MRI) has a limited role to distinguish between tumour recurrence and SRS-induced changes, which can impact patient management. Delayed contrast MRI treatment response assessment maps (TRAM) use the principle of contrast clearance seen in other tumours, where high vascularity shows a rapid rise in contrast as well as rapid clearance, whereas areas of damaged or low vascularity show accumulation of contrast. We aimed to assess the ability of delayed contrast MRI and multiparametric MRI techniques of diffusion-weighted imaging (DWI), perfusion-weighted imaging (PWI) and MR spectroscopy (MRS) to distinguish between radiation-related effects and tumour tissue, as these techniques assess tissue physiological and metabolic information. Method A retrospective review was performed on 23 patients who had delayed contrast and multiparametric MRI between October 2018 to April 2020. Studies were restricted to cases with brain metastases enlarging post-SRS with uncertainty at the MDT meeting regarding progression or treatment-related change, impacting the patient’s management. MRI was performed at 3T including DWI, PWI, MRS with short and intermediate echo times, and 3D T1 MPRAGE at 3-5, 20-30 and 70-90 minutes after administration of intravenous contrast. Contrast clearance analysis was performed by selecting an enhancing region of interest (ROI), measuring signal intensities at the three different timepoints and taking apparent diffusion coefficient (ADC) and relative cerebral blood volume (rCBV) values from the ROI. Choline/Creatine values were calculated from a single-voxel (10 mm isotropic) encompassing the entire contrast-enhancing lesion. Outcome was established from MRI follow-up at 6 months, with a stable or responding lesion considered treatment-related changes and increase considered progression. Results Across 23 patients, 24 metastases were assessed. Two patients were excluded as appropriate follow-up was not available. Sites of primary tumours included breast (n=8), lung (n=6), melanoma (n=4), neuroendocrine tumour from the lung (n=2) and renal cell carcinoma (n=2). Mean age was 56 years and 50% were female. In this cohort, 59% (n=13) were classified as having radiation-related changes on follow-up. Delayed MRI contrast clearance between the 3-5 and 70-90 minute imaging was significantly higher in cases of progression (23.6% vs. 2.5% decrease, p<0.05), as were the rCBV and Cho/Cr ratio (rCBV 3.1 vs. 1.5 and Cho/Cr ratio 2.3 vs. 1.4, p<0.05). Accuracy, sensitivity and specificity of using TRAM alone (contrast clearance decrease of >0%) for progression was 63%/100%/38%, PWI alone (rCBV cut-off 2.0) yielded results of 77%/75%/79% and for both Cho/Cr ratio alone (cut-off 1.8) and combined with TRAM, it was 90%/88%/92%. Neuroradiologist assessment of all techniques was 95%/100%/92%. Conclusion This study shows the effectiveness of delayed contrast and multiparametric MRI for treatment response assessment in patients with brain metastases treated by SRS in clinical practice. Although a delayed contrast MRI study is a very sensitive tool for detecting tumour progression, it lacks specificity. The accuracy of differentiating between tumour and treatment-related effects increases when delayed contrast MRI is used in combination with other advanced techniques such as MRS. By combining all these techniques, neuroradiologists had the highest accuracy, sensitivity and specificity for detecting progression in post-SRS brain metastases.

Staged Stereotactic Radiosurgery for Large Brain Metastases: Local Control and Clinical Outcomes of a One-Two Punch Technique

Neurosurgery ◽  
2017 ◽  
Vol 83 (1) ◽  
pp. 114-121 ◽  
Author(s):  
Ammoren Dohm ◽  
Emory R McTyre ◽  
Catherine Okoukoni ◽  
Adrianna Henson ◽  
Christina K Cramer ◽  
...  
Keyword(s):  
Overall Survival ◽  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Radiation Necrosis ◽  
Treatment Options ◽  
Radiation Therapy Oncology Group ◽  
Local Failure ◽  
Median Dose ◽  
Kaplan Meier ◽  
Dosimetric Analysis

Abstract BACKGROUND Treatment options are limited for large, unresectable brain metastases. OBJECTIVE To report a single institution series of staged stereotactic radiosurgery (SRS) that allows for tumor response between treatments in order to optimize the therapeutic ratio. METHODS Patients were treated with staged SRS separated by 1 mo with a median dose at first SRS of 15 Gy (range 10-21 Gy) and a median dose at second SRS of 14 Gy (range 10-18 Gy). Overall survival was evaluated using the Kaplan-Meier method. Cumulative incidences were estimated for neurological death, radiation necrosis, local failure (marginal or central), and distant brain failure. Absolute cumulative dose–volume histogram was created for each treated lesion. Logistic regression and competing risks regression were performed for each discrete dose received by a certain volume. RESULTS Thirty-three patients with 39 lesions were treated with staged radiosurgery. Overall survival at 6 and 12 mo was 65.0% and 60.0%, respectively. Cumulative incidence of local failure at 6 and 12 mo was 3.2% and 13.3%, respectively. Of the patients who received staged therapy, 4 of 33 experienced local failure. Radiation necrosis was seen in 4 of 39 lesions. Two of 33 patients experienced a Radiation Therapy Oncology Group toxicity grade > 2 (2 patients had grade 4 toxicities). Dosimetric analysis revealed that dose (Gy) received by volume of brain (ie, VDose(Gy)) was associated with radiation necrosis, including the range V44.5Gy to V87.8Gy. CONCLUSION Staged radiosurgery is a safe and effective option for large, unresectable brain metastases. Prospective studies are required to validate the findings in this study.

scholarly journals INNV-03. EFFICACY AND LONG-TERM OUTCOMES IN THE MANAGEMENT OF LARGE BRAIN METASTASIS (≥ 4 CM3) USING 2-STAGED STEREOTACTIC RADIOSURGERY (2-SSRS): AN INTERNATIONAL STUDY

2020 ◽  
Vol 22 (Supplement_2) ◽  
pp. ii117-ii117
Author(s):  
Yusuke Hori ◽  
Shoji Yomo ◽  
Wei Wei ◽  
Josue Avecillas-Chasin ◽  
Gene Barnett ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Cox Regression ◽  
Multivariable Analysis ◽  
International Study ◽  
Target Volume ◽  
Local Failure ◽  
Maximum Diameter ◽  
Large Brain

Abstract INTRODUCTION Stereotactic radiosurgery (SRS) for brain metastases results in time-to-local failure (TTLF) that significantly correlates with target volume and prescription dose. For large brain metastases (LBM), defined as ≥ 4 cm3, SRS monotherapy can result in < 40% local control (LC) rates. To overcome the TTLF limitations in the management of LBM, 2-staged SRS (2-SSRS) has demonstrated 6-month LC rates of 85–90%. This international multi-institutional study represents the largest series of patients with LBM managed with 2-SSRS. METHODS 181 patients with 218 LBM treated with 2-SSRS were retrospectively reviewed. Local failure (LF) was defined as ≥ 71.5% volumetric increase (equivalent to ≥ 20% increase in maximum diameter; RECIST criteria) from smallest volume date. Kaplan-Meier and log-rank tests were used to estimate and compare overall survival (OS) and TTLF; multivariable analysis was performed using Cox regression model. RESULTS Median age was 63 years (range: 29‒88), male sex was 50.3% with 34.8% of patients having non-small cell lung cancer. Median follow-up was 13.8 months (range:1.1‒49.4) and median OS was 14.6 months (95%CI: 12.6‒17.0). Median TTLF was 27.9 months (95%CI: 17.9‒NA) with a cumulative 6, 12 and 24-month LC of 91%, 81% and 71%, respectively. Using multivariable analysis, older age (≥ 65 years old; HR 1.58, 95%CI 1.06‒2.35, p=0.02) and larger total volume of concurrent small lesions (> 3 cm3; HR 2.05, 95%CI 1.25‒3.39, p=0.005) negatively impacted OS while younger age (< 65 years old; HR 2.60, 95%CI 1.26‒5.34, p=0.01) and RPA Class 3 (HR 3.10, 95%CI 1.26‒7.65, p=0.01) decreased TTLF. The number of concurrent LBM treated and total volume of the LBM were not significant factors. CONCLUSIONS This large multi-institutional dataset demonstrates excellent efficacy and long-term control of LBMs treated with 2-SSRS, which is independent of number or total volume of concurrent LBM.

scholarly journals The centrally restricted diffusion sign on MRI for assessment of radiation necrosis in metastases treated with stereotactic radiosurgery

2021 ◽  
Author(s):  
Nicolin Hainc ◽  
Noor Alsafwani ◽  
Andrew Gao ◽  
Philip J. O’Halloran ◽  
Paul Kongkham ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Tumor Progression ◽  
Stereotactic Radiosurgery ◽  
Interobserver Agreement ◽  
Radiation Necrosis ◽  
Restricted Diffusion ◽  
Post Contrast ◽  
Primary Tumors ◽  
Increased Susceptibility ◽  
Subsequent Intervention

Abstract Purpose Differentiation of radiation necrosis from tumor progression in brain metastases treated with stereotactic radiosurgery (SRS) is challenging. For this, we assessed the performance of the centrally restricted diffusion sign. Methods Patients with brain metastases treated with SRS who underwent a subsequent intervention (biopsy/resection) for a ring-enhancing lesion on preoperative MRI between 2000 and 2020 were included. Excluded were lesions containing increased susceptibility limiting assessment of DWI. Two neuroradiologists classified the location of the diffusion restriction with respect to the post-contrast T1 images as centrally within the ring-enhancement (the centrally restricted diffusion sign), peripherally correlating to the rim of contrast enhancement, both locations, or none. Measures of diagnostic accuracy and 95% CI were calculated for the centrally restricted diffusion sign. Cohen's kappa was calculated to identify the interobserver agreement. Results Fifty-nine patients (36 female; mean age 59, range 40 to 80) were included, 36 with tumor progression and 23 with radiation necrosis based on histopathology. Primary tumors included 34 lung, 12 breast, 5 melanoma, 3 colorectal, 2 esophagus, 1 head and neck, 1 endometrium, and 1 thyroid. The centrally restricted diffusion sign was seen in 19/23 radiation necrosis cases (sensitivity 83% (95% CI 63 to 93%), specificity 64% (95% CI 48 to 78%), PPV 59% (95% CI 42 to 74%), NPV 85% (95% CI 68 to 94%)) and 13/36 tumor progression cases (difference p < 0.001). Interobserver agreement was substantial, at 0.61 (95% CI 0.45 to 70.8). Conclusion We found a low probability of radiation necrosis in the absence of the centrally restricted diffusion sign.

Repeat stereotactic radiosurgery as salvage therapy for locally recurrent brain metastases previously treated with radiosurgery

2017 ◽  
Vol 127 (1) ◽  
pp. 148-156 ◽  
Author(s):  
Will H. McKay ◽  
Emory R. McTyre ◽  
Catherine Okoukoni ◽  
Natalie K. Alphonse-Sullivan ◽  
Jimmy Ruiz ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Local Control ◽  
Proportional Hazards ◽  
Radiation Necrosis ◽  
Disease Recurrence ◽  
Cox Proportional Hazards ◽  
Local Failure ◽  
Dose Volume Histograms ◽  
Dosimetric Data

OBJECTIVEThere are a variety of salvage options available for patients with brain metastases who experience local failure after stereotactic radiosurgery (SRS). These options include resection, whole-brain radiation therapy, laser thermoablation, and repeat SRS. There is little data on the safety and efficacy of repeat SRS following local failure of a prior radiosurgical procedure. This study evaluates the clinical outcomes and dosimetric characteristics of patients who experienced tumor recurrence and were subsequently treated with repeat SRS.METHODSBetween 2002 and 2015, 32 patients were treated with repeat SRS for local recurrence of ≥ 1 brain metastasis following initial SRS treatment. The Kaplan-Meier method was used to estimate time-to-event outcomes including overall survival (OS), local failure, and radiation necrosis. Cox proportional hazards analysis was performed for predictor variables of interest for each outcome. Composite dose-volume histograms were constructed for each reirradiated lesion, and these were then used to develop a predictive dosimetric model for radiation necrosis.RESULTSForty-six lesions in 32 patients were re-treated with a second course of SRS after local failure. A median dose of 20 Gy (range 14–22 Gy) was delivered to the tumor margin at the time of repeat SRS. Local control at 1 year was 79% (95% CI 67%–94%). Estimated 1-year OS was 70% (95% CI 55%–88%). Twelve patients had died at the most recent follow-up, with 8/12 patients experiencing neurological death (as described in Patchell et al.). Eleven of 46 (24%) lesions in 11 separate patients treated with repeat SRS were associated with symptomatic radiation necrosis. Freedom from radiation necrosis at 1 year was 71% (95% CI 57%–88%). Analysis of dosimetric data revealed that the volume of a lesion receiving 40 Gy (V40Gy) was the most predictive factor for the development of radiation necrosis (p = 0.003). The following V40Gy thresholds were associated with 10%, 20%, and 50% probabilities of radiation necrosis, respectively: 0.28 cm3 (95% CI 3%–28%), 0.76 cm3 (95% CI 9%–39%), 1.60 cm3 (95% CI 26%–74%).CONCLUSIONSRepeat SRS appears to be an effective salvage option for patients with brain metastases experiencing local failure following initial SRS treatment. This series demonstrates durable local control and, although rates of radiation necrosis are significant, repeat SRS may be indicated for select cases of local disease recurrence. Because the V40Gy is predictive of radiation necrosis, limiting this value during treatment planning may allow for a reduction in radiation necrosis rates.

Predicting Local Failure of Brain Metastases After Stereotactic Radiosurgery with Radiomics on Planning MR Images and Dose Maps

2021 ◽  
Author(s):  
Hesheng Wang ◽  
Jinyu Xue ◽  
Tanxia Qu ◽  
Kenneth Bernstein ◽  
Ting Chen ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Local Failure ◽  
Mr Images

scholarly journals Potential role for LINAC-based stereotactic radiosurgery for the treatment of 5 or more radioresistant melanoma brain metastases

2015 ◽  
Vol 123 (5) ◽  
pp. 1261-1267 ◽  
Author(s):  
Jessica M. Frakes ◽  
Nicholas D. Figura ◽  
Kamran A. Ahmed ◽  
Tzu-Hua Juan ◽  
Neha Patel ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Metastatic Melanoma ◽  
Stereotactic Radiosurgery ◽  
Proportional Hazards Model ◽  
Cox Proportional Hazards ◽  
Cox Proportional Hazards Model ◽  
Local Failure ◽  
Time To Failure ◽  
Kaplan Meier ◽  
Melanoma Brain Metastases

OBJECT Linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) is a treatment option for patients with melanoma in whom brain metastases have developed. Very limited data are available on treating patients with ≥ 5 lesions. The authors sought to determine the effectiveness of SRS in patients with ≥ 5 melanoma brain metastases. METHODS A retrospective analysis of metastatic melanoma treated with SRS in a single treatment session for ≥ 5 lesions was performed. Magnetic resonance imaging studies were reviewed post-SRS to evaluate local control (LC). Disease progression on imaging was defined using the 2009 Response Evaluation Criteria in Solid Tumors (RECIST). Survival curves were calculated from the date of brain metastases diagnosis or the date of SRS by using the Kaplan-Meier (KM) method. Univariate and multivariate analysis (UVA and MVA, respectively) were performed using the Cox proportional-hazards model. RESULTS The authors identified 149 metastatic brain lesions treated in 28 patients. The median patient age was 60.5 years (range 38–83 years), and the majority of patients (24 [85.7%]) had extracranial metastases. Four patients (14.3%) had received previous whole-brain radiotherapy (WBRT), and 11 (39.3%) had undergone previous SRS. The median planning target volume (PTV) was 0.34 cm3 (range 0.01–12.5 cm3). Median follow-up was 6.3 months (range 1–46 months). At the time of treatment, 7% of patients were categorized as recursive partitioning analysis (RPA) Class I, 89% as RPA Class II, and 4% as RPA Class III. The rate of local failure was 11.4%. Kaplan-Meier LC estimates at 6 and 12 months were 91.3% and 82.2%, respectively. A PTV volume ≥ 0.34 cm3 was a significant predictor of local failure on UVA (HR 16.1, 95% CI 3.2–292.6, p < 0.0001) and MVA (HR 14.8, 95% CI 3.0–268.5, p = 0.0002). Sixteen patients (57.1%) were noted to have distant failure in the brain with a median time to failure of 3 months (range 1–15 months). Nine patients with distant failures received WBRT, and 7 received additional SRS. Median overall survival (OS) was 9.4 and 7.6 months from the date of brain metastases diagnosis and the date of SRS, respectively. The KM OS estimates at 6 and 12 months were 57.8% and 28.2%, respectively, from the time of SRS treatment. The RPA class was a significant predictor of KM OS estimates from the date of treatment (p = 0.02). Patients who did not receive WBRT after SRS treatment had decreased OS on MVA (HR 3.5, 95% CI 1.1–12.0, p = 0.03), and patients who did not receive WBRT prior to SRS had improved OS (HR 0.11, 95% CI 0.02–0.53, p = 0.007). CONCLUSIONS Stereotactic radiosurgery for ≥ 5 lesions appears to be effective for selected patients with metastatic melanoma, offering excellent LC. This is particularly important for patients as new targeted systemic agents are improving outcomes but still have limited efficacy within the central nervous system.

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