scholarly journals Three-staged stereotactic radiosurgery for brain metastases: a single institution experience

2021 ◽  
Vol 23 (Supplement_4) ◽  
pp. iv20-iv21
Author(s):  
Hamoun Rozati ◽  
Ian Paddick ◽  
Ian Sabin
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Correlation Coefficient ◽  
Gamma Knife ◽  
P Value ◽  
Percentage Reduction ◽  
Single Fraction ◽  
Mixed Response ◽  
Third Stage

Abstract Aims Stereotactic radiosurgery (SRS) using the Leksell Gamma Knife system is a commonly used modality for the treatment of brain metastases (BMs). As the size of the target volume (TV) increases, so too does the dose of radiation delivered to surrounding healthy tissue. Large BMs are therefore a contraindication to the use of SRS. Critical organs adjacent to the TV may also be a contraindication to SRS. Staged SRS was proposed as a novel method of delivering three SRS treatments at a reduced radiation dose with a gap of two weeks between each session as a way of shrinking the TV. This allows treatment of TVs otherwise considered untreatable with standard, single-fraction SRS. Little data exists in the literature as to its efficacy. The objective of this study was to evaluate the efficacy of this novel approach and to identify factors which may predict treatment failure. Method A retrospective analysis was undertaken at a single, tertiary Gamma Knife centre. All patients who underwent treatment of their BMs with three-staged Gamma Knife SRS from January 2014 to December 2020 were identified and included. Patient demographics and primary cancer status was ascertained. SRS treatment details for each lesion were collected, including TV, dose and dosimetric data. The percentage reduction in volume of the TVs between the first and second stage, the second and third stage and the first and third stage were calculated. Follow-up data was collected to include follow-up imaging, further intracranial treatments received and survival status. The percentage reduction in volume between each stage was demonstrated on box-and-whisker plots. Statistical significance in reduction in TV between each stage was ascertained by paired samples T-tests. Correlation between initial TV size and percentage reduction post-SRS was determined by a correlation coefficient. Differences were deemed significant with p-values <0.05. Results 12 patients with 14 staged BMs were identified and included. The median age was 61.5 (range 45-79). Seven had a primary malignancy of breast cancer, five non-small cell lung cancer, one melanoma and one colorectal. Median follow-up was 140.5 days (range 10-821). Median TV was 7.44cc (range 1.14-21.53). All TVs received 10Gy at each stage. The median percentage reduction in size of the TV was 7.41% between 1st-2nd stage (range -16.0-42.49%, p-value 0.06), 19.47% between 2nd-3rd stage (range -5.38-53.53%, p-value <0.01) and 24.25% between 1st-3rd stage (range 10.69-68.67%, p-value <0.01). The correlation coefficient between initial TV size and percentage reduction post-SRS was -0.41 (p-value 0.07). 13/14 lesions showed a partial response on first follow-up scan post-SRS, 1/14 lesions showed a mixed response. One patient died 184 days from completion of treatment but without intracranial progression. Two patients had salvage intracranial surgery, 154 and 536 days from completion of treatment respectively. Conclusion Three-staged Gamma Knife is shown to be effective at shrinking the TV and can therefore be used to treat lesions otherwise considered unsuitable for SRS. The presence of extra-cranial metastases did not predict for poor outcomes. Though local control with SRS is thought to diminish with increasing TV size, all staged lesions showed a reduction in size between first and last treatment, and no significant effect was seen between initial TV size and percentage reduction in TV. No patients experienced disease progression on first follow up scan, with 13 of 14 lesions showing disease response. There were only two cases of intracranial progression, with one occurring 536 days post-SRS. Though limited by small numbers and short median follow up period, our data demonstrate encouraging results for three-stage SRS for lesions otherwise unsuitable for single fraction treatment, and should lead to further study.

Single-fraction Stereotactic Radiosurgery Outcomes for Brain Metastases with Frameless Gamma Knife ICON Radiosurgery

2020 ◽  
Vol 108 (2) ◽  
pp. E29
Author(s):  
Elizabeth Buss ◽  
Horia Vulpe ◽  
Judith Jacobson ◽  
Akshay Save ◽  
Oscar Padilla ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Gamma Knife ◽  
Single Fraction

Gamma Knife stereotactic radiosurgery in the treatment of brain metastases from breast cancer

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 10555-10555
Author(s):  
R. Gutt ◽  
S. Yovino ◽  
L. Chin ◽  
W. Regine ◽  
P. Amin ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Gamma Knife ◽  
Karnofsky Performance Status ◽  
Systemic Disease ◽  
Univariate Analysis ◽  
Complication Rates ◽  
Gamma Knife Stereotactic Radiosurgery

10555 Background: Outcomes of gamma knife stereotactic radiosurgery (GK-SRS) for patients with brain metastases specifically from breast cancer have not been well-defined. This study was undertaken to report the long-term experience with GK-SRS in this subset of patients. Methods: From 1995 to 2005, 75 patients with 162 brain lesions were treated with GK-SRS at the University of Maryland Medical Center. Complete follow-up data were available in 65 patients. Additional whole brain radiation therapy (WBRT) was administered to 53 (81.5%) patients. The median WBRT dose was 36.75 Gy (30.0–45.0 Gy). The median number of lesions treated with GK-SRS was 2 (1–8 lesions). The median follow-up, age, and KPS were 7.2 months (0.4–75.7 months), 53.5 years (23–81 years), and 90 (40–100), respectively. The factors included in the univariate and multivariate analyses for overall survival (OS) and progression free survival (PFS) were age, Karnofsky Performance Status (KPS), tumor histology, estrogen receptor status, Her-2-neu status, number of intracranial lesions, and presence of systemic disease. Results: Median PFS and OS from GK-SRS were 5.3 months (0.4–33.2 months) and 8.1 months (0.4–75.7 months), respectively. The 6, 12, and 24 month actuarial PFS were 47.8%, 24.9%, and 9.6% respectively. The 6, 12, and 24 month actuarial OS were 60.7%, 39.1%, and 18.1% respectively. The tumor local control after WBRT and GK-SRS was 87.7%. Radiation necrosis was a complication in 10.8% of patients. Forty-seven (72.3%) patients had neurological symptoms prior to gamma knife treatment. Seven (14.9%) and 9 (19.1%) of these patients experienced symptom resolution and significant symptomatic improvement, respectively. Multivariate and univariate analysis did not reveal any of the prognostic factors in question to be significantly associated with OS nor PFS. Conclusions: This relatively large cohort of patients experienced poor survival outcomes despite aggressive therapy with WBRT and GK-SRS. However, GK-SRS can provide significant symptomatic relief, with acceptable complication rates. More research is required to improve the survival of breast cancer patients with intracranial metastases. No significant financial relationships to disclose.

scholarly journals RADI-25. REPEAT STEREOTACTIC RADIOSURGERY FOR RECURRENT BRAIN METASTASES

2019 ◽  
Vol 1 (Supplement_1) ◽  
pp. i26-i26
Author(s):  
Daria Krivosheya ◽  
Hamid Borghei-Razavi ◽  
Matthew Grabowski ◽  
Lilyana Angelov ◽  
Gene Barnett ◽  
...  
Keyword(s):  
Radiation Dose ◽  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Radiation Necrosis ◽  
Gamma Knife Radiosurgery ◽  
Post Treatment ◽  
Average Dose ◽  
Single Fraction ◽  
Perfusion Studies

Abstract INTRODUCTION: Mainstream modality of treatment of oligo-metastatic disease is stereotactic radiosurgery (SRS). While the local control rate is nearing 90%, 7% of lesions and 10 to 15% of patients develop radiation necrosis post treatment. In the face of increasing lesion size and evidence of recurrence, re-treatment of the enlarging lesion with radiosurgery can be attempted. The aim of the project is to evaluate outcomes of lesions treated with repeat SRS. METHODS: We conducted a retrospective review of all patients that were treated with Gamma Knife radiosurgery at our institution from 2000 to 2018. Fifty-one lesions in 39 patients were identified that had recurrence during follow-up period and were treated with a second single-fraction SRS. RESULTS: A combination of imaging studies, such as PET and/or perfusion studies, lesion biopsy, and clinical course were used to make the diagnosis of lesion recurrence. The average radiation dose at first treatment was 21 Gy, and the average dose at second treatment was 19 Gy. The median time between treatments was 16.8 months, ranging from 2.5 to 75.3 months, and the median follow-up after second treatment was 10.2 months. Of 51 lesions that received two SRS treatments, 49% (25 lesions) continued to progress at a median interval of 4.8 months post treatment, of which 35% (18 lesions) were diagnosed as radiation necrosis based on biopsy results or advanced brain imaging. The overall rate of radiation necrosis post second SRS treatment was determined to be 16% per lesion and 21% per patient. CONCLUSION: Recurrent brain metastases that are re-treated with single fraction SRS are associated with a higher risk of radiation necrosis. Alternative treatment strategies, including fractionation of subsequent SRS treatments, radiation dose reduction, and combination with laser ablation could be considered to ensure symptom and disease control to reduce the rate of subsequent radiation necrosis.

scholarly journals Changing practice patterns of Gamma Knife versus linear accelerator-based stereotactic radiosurgery for brain metastases in the US

2016 ◽  
Vol 124 (4) ◽  
pp. 1018-1024 ◽  
Author(s):  
Henry S. Park ◽  
Elyn H. Wang ◽  
Charles E. Rutter ◽  
Christopher D. Corso ◽  
Veronica L. Chiang ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Gamma Knife ◽  
Linear Accelerator ◽  
Multivariable Analysis ◽  
Multivariable Logistic Regression Analysis ◽  
Single Fraction ◽  
Cancer Data ◽  
The Us ◽  
The Impact

OBJECT Single-fraction stereotactic radiosurgery (SRS) is a crucial component in the management of limited brain metastases from non-small cell lung cancer (NSCLC). Intracranial SRS has traditionally been delivered using a frame-based Gamma Knife (GK) platform, but stereotactic modifications to the linear accelerator (LINAC) have made an alternative approach possible. In the absence of definitive prospective trials comparing the efficacy and toxicities of treatment between the 2 techniques, nonclinical factors (such as technology accessibility, costs, and efficiency) may play a larger role in determining which radiosurgery system a facility may choose to install. To the authors’ knowledge, this study is the first to investigate national patterns of GK SRS versus LINAC SRS use and to determine which factors may be associated with the adoption of these radiosurgery systems. METHODS The National Cancer Data Base was used to identify patients > 18 years old with NSCLC who were treated with single-fraction SRS to the brain between 2003 and 2011. Patients who received “SRS not otherwise specified” or who did not receive a radiotherapy dose within the range of 12–24 Gy were excluded to reduce the potential for misclassification. The chi-square test, t-test, and multivariable logistic regression analysis were used to compare potential demographic, clinicopathologic, and health care system predictors of GK versus LINAC SRS use, when appropriate. RESULTS This study included 1780 patients, among whom 1371 (77.0%) received GK SRS and 409 (23.0%) underwent LINAC SRS. Over time, the proportion of patients undergoing LINAC SRS steadily increased, from 3.2% in 2003 to 30.8% in 2011 (p < 0.001). LINAC SRS was adopted more rapidly by community versus academic facilities (overall 29.2% vs 17.2%, p < 0.001). On multivariable analysis, 4 independent predictors of increased LINAC SRS use emerged, including year of diagnosis in 2008–2011 versus 2003–2007 (adjusted OR [AOR] 2.04, 95% CI 1.52–2.73, p < 0.001), community versus academic facility type (AOR 2.04, 95% CI 1.60–2.60, p < 0.001), non-West versus West geographic location (AOR 4.50, 95% CI 2.87–7.09, p < 0.001), and distance from cancer reporting facility of < 20 versus ≥ 20 miles (AOR 1.57, 95% CI 1.21–2.04, p = 0.001). CONCLUSIONS GK remains the most commonly used single-fraction SRS modality for NSCLC brain metastases in the US. However, LINAC-based SRS has been rapidly disseminating in the past decade, especially in the community setting. Wide geographic variation persists in the distribution of GK and LINAC SRS cases. Further comparative effectiveness research will be needed to evaluate the impact of these shifts on SRS-related toxicities, local control, and survival, as well as treatment costs and efficiency.

scholarly journals Biologically effective dose correlates with linear tumor volume changes after upfront single-fraction stereotactic radiosurgery for vestibular schwannomas

2021 ◽  
Author(s):  
Constantin Tuleasca ◽  
Mohamed Faouzi ◽  
Philippe Maeder ◽  
Raphael Maire ◽  
Jonathan Knisely ◽  
...  
Keyword(s):  
Standard Deviation ◽  
Effective Dose ◽  
Stereotactic Radiosurgery ◽  
Tumor Volume ◽  
Vestibular Schwannomas ◽  
Benign Tumors ◽  
Biologically Effective Dose ◽  
Volume Changes ◽  
Single Fraction

AbstractVestibular schwannomas (VSs) are benign, slow-growing tumors. Management options include observation, surgery, and radiation. In this retrospective trial, we aimed at evaluating whether biologically effective dose (BED) plays a role in tumor volume changes after single-fraction first intention stereotactic radiosurgery (SRS) for VS. We compiled a single-institution experience (n = 159, Lausanne University Hospital, Switzerland). The indication for SRS was decided after multidisciplinary discussion. Only cases with minimum 3 years follow-up were included. The Koos grading, a reliable method for tumor classification was used. Radiosurgery was performed using Gamma Knife (GK) and a uniform marginal prescription dose of 12 Gy. Mean BED was 66.3 Gy (standard deviation 3.8, range 54.1–73.9). The mean follow-up period was 5.1 years (standard deviation 1.7, range 3–9.2). The primary outcome was changes in 3D volumes after SRS as function of BED and of integral dose received by the VS. Random-effect linear regression model showed that tumor volume significantly and linearly decreased over time with higher BED (p < 0.0001). Changes in tumor volume were also significantly associated with age, sex, number of isocenters, gradient index, and Koos grade. However, the effect of BED on tumor volume change was moderated by time after SRS and Koos grade. Lower integral doses received by the VSs were inversely correlated with BED in relationship with tumor volume changes (p < 0.0001). Six (3.4%) patients needed further intervention. For patients having uniformly received the same marginal dose prescription, higher BED linearly and significantly correlated with tumor volume changes after SRS for VSs. BED could represent a potential new treatment paradigm for patients with benign tumors, such as VSs, for attaining a desired radiobiological effect. This could further increase the efficacy and decrease the toxicity of SRS not only in benign tumors but also in other SRS indications.

Incidence, timing, and treatment of new brain metastases after Gamma Knife surgery for limited brain disease: the case for reducing the use of whole-brain radiation therapy

2011 ◽  
Vol 115 (1) ◽  
pp. 37-48 ◽  
Author(s):  
Stephen Rush ◽  
Robert E. Elliott ◽  
Amr Morsi ◽  
Nisha Mehta ◽  
Jeri Spriet ◽  
...  
Keyword(s):  
Radiation Therapy ◽  
Brain Metastases ◽  
Gamma Knife ◽  
Gamma Knife Surgery ◽  
Whole Brain Radiation Therapy ◽  
Leptomeningeal Disease ◽  
Whole Brain ◽  
Whole Brain Radiation ◽  
Brain Radiation

Object In this paper, the authors' goal was to analyze the incidence, timing, and treatment of new metastases following initial treatment with 20-Gy Gamma Knife surgery (GKS) alone in patients with limited brain metastases without whole-brain radiation therapy (WBRT). Methods A retrospective analysis of 114 consecutive adults (75 women and 34 men; median age 61 years) with KPS scores of 60 or higher who received GKS for 1–3 brain metastases ≤ 2 cm was performed (median lesion volume 0.35 cm3). Five patients lacking follow-up data were excluded from analysis. After treatment, patients underwent MR imaging at 6 weeks and every 3 months thereafter. New metastases were preferentially treated with additional GKS. Indications for WBRT included development of numerous metastases, leptomeningeal disease, or diffuse surgical-site recurrence. Results The median overall survival from GKS was 13.8 months. Excluding the 3 patients who died before follow-up imaging, 12 patients (11.3%) experienced local failure at a median of 7.4 months. Fifty-three patients (50%) developed new metastases at a median of 5 months. Six (7%) of 86 instances of new lesions were symptomatic. Most patients (67%) with distant failures were successfully treated using salvage GKS alone. Whole-brain radiotherapy was indicated in 20 patients (18.3%). Thirteen patients (11.9%) died of neurological disease. Conclusions For patients with limited brain metastases and functional independence, 20-Gy GKS provides excellent disease control and high-functioning survival with minimal morbidity. New metastases developed in almost 50% of patients, but additional GKS was extremely effective in controlling disease. Using our algorithm, fewer than 20% of patients required WBRT, and only 12% died of progressive intracranial disease.

scholarly journals Intracranial Metastatic Neuroblastoma Treated with Gamma Knife Stereotactic Radiosurgery: Report of Two Novel Cases

2012 ◽  
Vol 2012 ◽  
pp. 1-4 ◽  
Author(s):  
Nathan C. Rowland ◽  
Jennifer Andrews ◽  
Daxa Patel ◽  
David V. LaBorde ◽  
Adam Nowlan ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Gamma Knife ◽  
Treatment Options ◽  
Tumor Burden ◽  
Poor Survival ◽  
Intracranial Metastasis ◽  
Temporary Reduction ◽  
Single Fraction ◽  
Curative Therapy ◽  
Gamma Knife Stereotactic Radiosurgery

Intracranial metastasis of neuroblastoma (IMN) is associated with poor survival. No curative therapy for the treatment of IMN currently exists. Unfractionated radiotherapy may be beneficial in the treatment of IMN given the known radiosensitivity of neuroblastoma as well as its proclivity to metastasize as discrete lesions. We present two patients with IMN treated with Gamma Knife stereotactic radiosurgery (SRS). Single-fraction radiotherapy yielded temporary reduction of tumor burden and stability of disease in both patients. SRS may be a useful palliative tool in the treatment of IMN and expands the overall treatment options for this disease.

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