RADT-06. RADIOTHERAPY FOR BRAIN METASTASES FROM THYROID CANCER: A RETROSPECTIVE COHORT STUDY

2021 ◽  
Vol 23 (Supplement_6) ◽  
pp. vi42-vi42
Author(s):  
Erik Blomain ◽  
Scott Berta ◽  
Nicholas Hug ◽  
Duc Giao ◽  
Antonio Meola ◽  
...  
Keyword(s):  
Thyroid Cancer ◽  
Brain Metastases ◽  
Radiation Necrosis ◽  
Local Failure ◽  
Competing Risk ◽  
Treatment Modalities ◽  
Leptomeningeal Disease ◽  
Risk Of Death ◽  
Anaplastic Histology

Abstract PURPOSE/OBJECTIVE(S) Brain metastases from thyroid carcinoma are rare. Although stereotactic radiosurgery (SRS) is a standard of care for patients with brain metastases across many histologies, the current NCCN guidelines do not support a universal role for this modality in thyroid cancer. MATERIALS AND METHODS Thyroid cancer patients with brain metastases treated with radiotherapy at our institution from 2002-2020 were studied. Cumulative risk of local failure, distant intracranial failure and radiation necrosis were calculated using a competing risk of death analysis and censored at the last imaging follow-up. Overall survival was analyzed using Kaplan-Meier method. Stratified cox regression was used to study per-lesion outcomes. RESULTS We identified 34 patients with 203 treated brain metastases. 179 (88.2%) lesions were of differentiated histology; the remainder were anaplastic histology. Four patients received whole brain radiotherapy (WBRT) while 30 patients received SRS (SFED 22, interquartile (IQ) range 20-22). Of the patients receiving WBRT, one (25%) had anaplastic histology, and the median number of lesions was 15 (as compared to 2 for SRS). Median follow up among survivors was 32.3 months and median survival was 10.8 months. There were no observed failures (local or distant intracranial) observed at 1 year in the 24 metastases with anaplastic histology, although competing risk of death was high (91.7%). The 1 year cumulative incidences of local failure and distant intracranial failures were 9.8% (95CI 5.7%-13.9%) and 35.0% (95CI 29.0%-41.0%), respectively, in differentiated tumors. 6 (10.2%) of the distant intracranial failures were new cases of leptomeningeal disease. The 1 year risk of radiation necrosis was 15.5%. Of these cases, most were Grade 2 (57.1%); 3 (42.9%) were Grade 4 (there were no Grade 1 or 3 events). CONCLUSION In the largest known cohort of thyroid cancer brain metastasis patients, radiotherapy and SRS appear to be safe and effective treatment modalities.

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.

NCMP-03. ANATOMIC AND SURGICAL FACTORS PREDICT DEVELOPMENT OF LEPTOMENINGEAL DISEASE IN PATIENTS WITH METASTATIC MELANOMA

2021 ◽  
Vol 23 (Supplement_6) ◽  
pp. vi147-vi147
Author(s):  
Stephen Lowe ◽  
Christopher Wang ◽  
Amanda Brisco ◽  
John Arrington ◽  
Kamran Ahmed ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Primary Melanoma ◽  
Female Gender ◽  
Causative Factor ◽  
Leptomeningeal Disease ◽  
Melanoma Brain Metastases ◽  
Highly Correlated ◽  
Periventricular Lesions ◽  
Dural Metastasis

Abstract Leptomeningeal disease (LMD) is a devastating complication of systemic malignancy, portending a poor prognosis with an estimated median survival of 4-6 weeks if left untreated. Several reports have suggested surgical resection as a potential causative factor. Herein, we explore if surgical and anatomical factors are correlated with development of LMD in patients with melanoma brain metastases. METHODS: Patients treated at our institution between 1999-2019 for primary melanoma with brain metastasis were compiled into a database based on ICD9/10 coding. 1,079 patients with melanoma brain metastases and appropriate imaging were identified, and 834 patients with a minimum of 3 months’ follow up were included. Patients were dichotomized by development of LMD or lack thereof, and categorized into an overall cohort, and surgical and non-surgical cohorts. Anatomic factors and ventricular access during surgery were investigated as possible correlative factors for the development of LMD. RESULTS: In the overall cohort, female gender(p=0.033), presence of dural metastasis(p=0.018), presence of periventricular lesions(p< .001), presence of intraventricular lesions(p< .001), and ventricular access during surgery(p< .001) were significantly associated with LMD. Patients undergoing surgery, or those undergoing surgery without ventricular access, were not at higher risk of LMD. On multivariate analysis, female gender(p=.033), presence of periventricular lesions (p< .001), presence of intraventricular lesions(p< .002), and presence of dural metastasis(p=0.032) were significantly associated with development of LMD. In patients who had surgery, iatrogenic ventricular access(p< .001) was significantly correlated with LMD. In the group of patients without surgery, those with periventricular lesions had significantly higher odds of LMD(p< .001). CONCLUSIONS: In a retrospective cohort of patients with melanoma metastatic to the brain, surgical intervention does not increase odds of LMD; however, iatrogenic access to the CSF space during surgery is highly correlated with LMD development. Anatomic contact with the CSF space predicts LMD regardless of surgical status.

Healthcare (HC) utilization and costs in patients (pts) with newly diagnosed metastatic thyroid cancer (mTC)

2007 ◽  
Vol 25 (18_suppl) ◽  
pp. 17082-17082 ◽  
Author(s):  
A. Berger ◽  
J. Edelsberg ◽  
K. Chung ◽  
A. Ngyuyen ◽  
D. Stepan ◽  
...  
Keyword(s):  
Thyroid Cancer ◽  
Metastatic Disease ◽  
Index Date ◽  
Average Length ◽  
Treatment Strategies ◽  
Treatment Modalities ◽  
Newly Diagnosed ◽  
Office Visits ◽  
Antibody Testing

17082 Background: mTC is relatively rare and little is known about treatment patterns or HC costs in patients with newly diagnosed disease. Methods: Retrospective longitudinal cohort study. Using a large (∼14 million covered lives) US health-insurance claims database, we identified a cohort of pts with diagnoses of thyroid cancer (ICD-9-CM diagnosis codes 193.XX) and distant metastatic disease (197.XX-198.XX) between 1/1/2003 and 12/31/2005 (“study period”); the date of first mention of metastatic disease was designated the “index date”. All pts were required to be =18 years of age as of their index date and to have been continuously enrolled in the database for =6 months prior to this date. Pts were followed from their index date until health plan disenrollment (for any reason) or end of the study period, whichever occurred first. Utilization of HC services and costs (total reimbursed amount including pt liability) were then examined during each quarter of follow-up (eg, first 3 months of follow-up=Q1). Results: 183 pts met all study entry criteria. Mean (±SD) age was 51.5 (11.8) years; mean duration of follow-up was 344 days (median=275 days). Most common management/treatment strategies during Q1 included: imaging [eg, US/CT of the neck (49.7%)], thyroglobulin/thyroglobulin antibody testing (25.7%); radiation therapy (23.0%); I131 therapy (19.1%); thyroid surgery (12.6%); chemotherapy (10.9%); lymphadenectomy (8.7%); and bisphosphonate therapy (3.8%). In addition, during Q1, pts averaged 9.5 office visits (95% CI, 8.2, 10.9) and 0.6 hospitalizations (95% CI, 0.5, 0.7); for pts hospitalized during Q1, average length of stay was 6.6 (95% CI, 4.9, 8.4). Costs during the first 2 years of follow-up are presented in the table ; inpt care represented 43% of total HC costs. Conclusions: Many different treatment modalities are used in pts with newly diagnosed mTC; the cost of such care is substantial. [Table: see text] [Table: see text]

Impact of the radiosurgery prescription dose on the local control of small (2 cm or smaller) brain metastases

2017 ◽  
Vol 126 (3) ◽  
pp. 735-743 ◽  
Author(s):  
Alireza M. Mohammadi ◽  
Jason L. Schroeder ◽  
Lilyana Angelov ◽  
Samuel T. Chao ◽  
Erin S. Murphy ◽  
...  
Keyword(s):  
Lung Cancer ◽  
Prognostic Factors ◽  
Brain Metastases ◽  
Local Control ◽  
Radiation Necrosis ◽  
Small Cell ◽  
Small Cell Lung ◽  
Local Progression ◽  
Prescription Dose

OBJECTIVE The impact of the stereotactic radiosurgery (SRS) prescription dose (PD) on local progression and radiation necrosis for small (≤ 2 cm) brain metastases was evaluated. METHODS An institutional review board–approved retrospective review was performed on 896 patients with brain metastases ≤ 2 cm (3034 tumors) who were treated with 1229 SRS procedures between 2000 and 2012. Local progression and/or radiation necrosis were the primary end points. Each tumor was followed from the date of radiosurgery until one of the end points was reached or the last MRI follow-up. Various criteria were used to differentiate tumor progression and radiation necrosis, including the evaluation of serial MRIs, cerebral blood volume on perfusion MR, FDG-PET scans, and, in some cases, surgical pathology. The median radiographic follow-up per lesion was 6.2 months. RESULTS The median patient age was 56 years, and 56% of the patients were female. The most common primary pathology was non–small cell lung cancer (44%), followed by breast cancer (19%), renal cell carcinoma (14%), melanoma (11%), and small cell lung cancer (5%). The median tumor volume and median largest diameter were 0.16 cm3 and 0.8 cm, respectively. In total, 1018 lesions (34%) were larger than 1 cm in maximum diameter. The PD for 2410 tumors (80%) was 24 Gy, for 408 tumors (13%) it was 19 to 23 Gy, and for 216 tumors (7%) it was 15 to 18 Gy. In total, 87 patients (10%) had local progression of 104 tumors (3%), and 148 patients (17%) had at least radiographic evidence of radiation necrosis involving 199 tumors (7%; 4% were symptomatic). Univariate and multivariate analyses were performed for local progression and radiation necrosis. For local progression, tumors less than 1 cm (subhazard ratio [SHR] 2.32; p < 0.001), PD of 24 Gy (SHR 1.84; p = 0.01), and additional whole-brain radiation therapy (SHR 2.53; p = 0.001) were independently associated with better outcome. For the development of radiographic radiation necrosis, independent prognostic factors included size greater than 1 cm (SHR 2.13; p < 0.001), location in the corpus callosum (SHR 5.72; p < 0.001), and uncommon pathologies (SHR 1.65; p = 0.05). Size (SHR 4.78; p < 0.001) and location (SHR 7.62; p < 0.001)—but not uncommon pathologies—were independent prognostic factors for the subgroup with symptomatic radiation necrosis. CONCLUSIONS A PD of 24 Gy results in significantly better local control of metastases measuring < 2 cm than lower doses. In addition, tumor size is an independent prognostic factor for both local progression and radiation necrosis. Some tumor pathologies and locations may also contribute to an increased risk of radiation necrosis.

scholarly journals Utility of Inferior Vena Cava Filter in the Management of Venous Thromboembolism Among Patients with Brain Metastases: A Population-Based Study

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 47-48
Author(s):  
Vaibhav Kumar ◽  
Ann M Brunson ◽  
Anjlee Mahajan ◽  
Nigel S. Key ◽  
Ted Wun
Keyword(s):  
Brain Metastasis ◽  
Brain Metastases ◽  
Regression Model ◽  
Cox Regression ◽  
Vena Cava ◽  
Population Based ◽  
Population Based Study ◽  
Risk Of Death ◽  
Icd 10

Background: Brain metastases are a frequently occurring and devastating complication of solid organ malignancies. Individuals with brain metastases are noted to be high risk for venous thromboembolism (VTE) due to hypercoagulability from their malignancy, immobility, and need for cancer directed therapies. The management of VTE in patients with brain metastases is challenging due to the risk of intracranial hemorrhage (ICH) with therapeutic anticoagulation. Inferior vena cava filter (IVCF) are often used to mitigate the risk of ICH, however the utility of this practice and the impact on survival is not clear. Methods: We performed a retrospective cohort study using the linked California Cancer Registry (CCR) and California Patient Discharge Database (PDD) between 2005-2017 with follow up available to 2018. We identified individuals with breast and lung cancer (because they are common), and renal cell carcinoma and melanoma (because of bleeding tendency of brain metastases) who had an incident hospitalization with VTE (either pulmonary embolism, deep vein thrombosis or both). Brain metastasis were identified using the presence of International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) code 198.3 or ICD-10-CM code C79.31 present anytime in PDD and cases were classified as having brain metastases if the code was present prior to or at the time of the index VTE. Cases with multiple malignancies were excluded. ICD-9-CM code 38.7 and ICD-10-CM code 02HV was used to identify patients who received an IVCF. Univariate analysis was used to determine differences in baseline characteristics between those that did and did not receive an IVCF. A logistic regression model that included patient and index VTE hospital characteristics was used to develop a propensity score for IVCF placement. The primary outcomes were 30-day mortality and 180-day intracranial hemorrhage (ICH) determined by ICD codes. A Cox proportional hazards model, inverse propensity weighted for IVCF placement, was used to assess the effect of IVCF placement (as a time-dependent variable) on 30-day mortality. The effect of IVCF on ICH was assessed with a 1:3 propensity matched Fine-Gray model, accounting for the competing risk of death. Results: There were 17,182 patients with a diagnosis of VTE present on admission and an active first primary cancer diagnosis of interest, of these 3,309 (19.3%) had a diagnosis of brain metastasis with median follow-up of 96.8 months. The baseline characteristics of patients are summarized in Table 1. Among patients with brain metastases, 757 of 3309 (22.9%) had an IVCF inserted versus 1801 of 13873 (13.0%) in those without brain metastases (p&lt;0.001). In a multivariable logistic regression model the presence of brain metastasis was an independent predictor for the placement of IVCF (Odds Ratio (OR) 1.84 (95% CI 1.64-2.05). Using balanced (standardized mean difference less than 0.1 for all covariates included in the model) IPW-adjusted Cox regression model, the use of IVCF did not reduce the 30-day risk of death in those with acute VTE (Hazard Ratio (HR) 1.08 (95% CI 0.95-1.23). The presence of brain metastases was associated with a higher 30-day risk of death (HR 1.23 (95% CI 1.13- 1.35). Using IPW-adjusted Cox model restricted to those with brain metastasis, IVCF use was associated with a trend towards reduced 30-day risk of death (HR 0.86 (95% CI 0.73-1.01). In a propensity matched Cox regression competing risk model, the presence of brain metastases was significantly associated with an increased 180-day risk of ICH (HR 6.91 (95% CI 3.54-13.48), with no difference for those that received an IVCF (HR 1.31 (95% CI 0.85-2.01). When compared to breast cancer patients, those with lung cancer had lower risk of ICH (HR 0.28, CI 0.13-0.64), but melanoma and renal cell cancer did not have higher risk. Conclusions: This real-world retrospective population-based study demonstrated the use of IVCF was higher for patients with brain metastases among these four tumor types. There was a suggestion of reduced short-term mortality associated with IVCF placement in VTE patients and brain metastases, but this was not statistically significant. Although limited by the lack of data on anticoagulation use, there was no effect of IVCF placement on the risk of ICH. Randomized clinical trials are needed to determine the effect of IVCF on clinically relevant outcomes for VTE in patients with brain metastasis. Disclosures Key: Takeda: Research Funding; Grifols: Research Funding; Uniqure: Consultancy; Novo Nordisk: Other: Chair of Grants Committee. Wun:Glycomimetics, Inc.: Consultancy.

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 RADI-05. FRACTIONATED TREATMENT OF BRAIN METASTASES WITH GAMMA KNIFE ICON

2019 ◽  
Vol 1 (Supplement_1) ◽  
pp. i22-i22
Author(s):  
Jameson Mendel ◽  
Ankur Patel ◽  
Toral Patel ◽  
Robert Timmerman ◽  
Tu Dan ◽  
...  
Keyword(s):  
Brain Metastasis ◽  
Brain Metastases ◽  
Gamma Knife ◽  
Local Control ◽  
Stereotactic Radiotherapy ◽  
Tumor Volume ◽  
Univariate Analysis ◽  
Local Failure ◽  
Fractionated Stereotactic Radiotherapy

Abstract PURPOSE/OBJECTIVE(S): Stereotactic radiosurgery with Gamma Knife is a common treatment modality for patients with brain metastasis. The Gamma Knife ICON allows for immobilization with an aquaplast mask, permitting fractionated treatments. We describe one of the first experiences utilizing this technique with brain metastasis and evaluate outcomes. MATERIALS/METHODS: From June 2017 to November 2018, 29 patients with 43 separate intracranial lesions were treated with fractionated stereotactic radiotherapy using the gamma knife ICON at a single institution. Patients received between 20–30 Gy in 3–5 fractions with no margin over the course of 5 to 23 days. Local control was physician assessed. Local failure over time was modeled using cumulative incidence; lesions were censored at last radiographic follow up. RESULTS: Median tumor volume and prescription isodose was 7.7 cm3 (range 0.3–43.9) and 50% (range 40–65), respectively. Median radiographic follow-up was 7 months and median survival was 9 months. Radiation necrosis occurred in 3/3 patients treated with 27 Gy in 3 fractions, one requiring therapeutic resection. Incidence of local failure for all treated lesions was 9% at 1 year. Tumor volume &gt;7 cm3 was associated with local failure on univariate analysis (p=0.025). 100% (2/2) lesions treated with 20 Gy in 5 fractions developed local recurrence. CONCLUSION: Fractionated stereotactic radiotherapy with the Gamma Knife ICON provides excellent local control for small and large brain metastases with minimal toxicity. Tumors &gt;7 cm3 should receive at least 30 Gy in 5 fractions for optimal control. Treatment with 27 Gy in 3 fractions appears to have high rates of treatment related toxicity and should be avoided.

scholarly journals Predictors of leptomeningeal disease following hypofractionated stereotactic radiotherapy for intact and resected brain metastases

2019 ◽  
Vol 22 (1) ◽  
pp. 84-93 ◽  
Author(s):  
Timothy K Nguyen ◽  
Arjun Sahgal ◽  
Jay Detsky ◽  
Eshetu G Atenafu ◽  
Sten Myrehaug ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiotherapy ◽  
Median Overall Survival ◽  
Multivariable Analysis ◽  
Leptomeningeal Disease ◽  
Hypofractionated Stereotactic Radiotherapy ◽  
Increased Risk ◽  
Intact Brain ◽  
Intracranial Lesions

Abstract Background The objective was to evaluate the risk and predictors of developing leptomeningeal disease (LMD) in patients with brain metastases treated with 5-fraction hypofractionated stereotactic radiotherapy (HSRT). Methods Patients treated with HSRT for intact brain metastases and/or surgical cavities were reviewed from a prospectively maintained database. Radiographic patterns of LMD were classified as focal classical, diffuse classical, focal nodular, and diffuse nodular. Results HSRT was delivered, most commonly 30 Gy in 5 fractions, to 320 intracranial lesions (57% intact and 43% surgical cavities) in 235 patients. The median follow-up was 13.4 months (range, 0.8 to 60 mo). LMD developed in 19% of patients with a 1-year LMD rate of 12%. From the diagnosis of LMD, the median overall survival (OS) was 3.8 months (range, 2–20.8 mo). The most common LMD pattern was diffuse nodular (44%). No difference in OS was observed between LMD patterns (P = 0.203). Multivariable analysis identified surgical cavities at significantly higher risk of LMD compared with intact lesions (odds ratio [OR] = 2.30, 95% CI: 1.24, 4.29, P = 0.008). For cavities, radiosensitive tumors (OR = 2.35, 95% CI: 1.04, 5.35, P = 0.041) predicted for LMD, while, for intact metastases, patients receiving treatment with targeted agents or immunotherapy (TA/I) were at lower risk (OR = 0.178, 95% CI: 0.04, 0.79, P = 0.023). Conclusions Patients who had a brain metastasis resected were at an increased risk of LMD. OS was poor despite treatment of LMD, and no differences in OS based on the pattern of LMD was observed. Treatment with TA/I was observed to be protective against LMD and requires further study.

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 &gt; 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.

Effect of type and timing of systemic therapy on risk of radiation necrosis in patients with HER2+ breast cancer brain metastases.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e14002-e14002
Author(s):  
Christine Park ◽  
Evan Buckley ◽  
Amanda E.D. Van Swearingen ◽  
Will Giles ◽  
James Emmett Herndon ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Brain Metastases ◽  
Systemic Therapy ◽  
Radiation Necrosis ◽  
Treatment Modalities ◽  
Conformity Index ◽  
Her2 Breast Cancer ◽  
Breast Cancer Brain Metastasis ◽  
The Impact ◽  
Systemic Therapies

e14002 Background: It is estimated that 30% of patients with metastatic human epidermal growth factor receptor 2-positive (HER2+) breast cancer will develop brain metastases. Current standard of care options for HER2+ breast cancer brain metastasis (BCBrM) includes radiation therapy (stereotactic radiosurgery [SRS] or whole brain radiation), brain permeable systemic therapies, and in select cases, neurosurgical resection. A multimodal approach combining these different treatment modalities has improved the overall survival and functional outcomes of patients with BCBrM. Some HER2-directed systemic therapies, however, may increase the risk of radiation necrosis (RN), a longer-term consequence of SRS. This study explores the impact of timing and type of systemic therapies on the development of RN in patients treated with SRS for HER2+ BCBrM. Methods: This was a single-institution, retrospective study including patients ≥18 years of age with HER2+ BCBrM who received SRS between 2013 and 2018 at Duke University with at least 12-month post-SRS follow-up. Presence of RN was determined at one-year post-SRS. Demographics, radiotherapy parameters (total dose, fractions, clinical target volume [CTV], gross tumor volume [GTV], conformity index [CI], volume receiving 12 gray [V12Gy]), and timing (during [within 4 weeks of SRS] vs. not during SRS) and type of systemic therapy (HER2-directed therapy, mitosis inhibitors, DNA synthesis inhibitors, others) were evaluated. Results: Among 46 patients with HER2+ BCBrM who received SRS, 28 (60.9%) developed RN and 18 (39.1%) did not. Age at time of SRS did not differ between those who developed RN and those who did not (mean 53.3 vs 50.4 years, respectively). There was a higher percentage of African Americans in the RN group (28.6% vs 11.1%, p = 0.3). There were no significant differences between the measured radiotherapy parameters—including dose, fraction, CTV, GTV, CI, V12Gy—between the two groups (all p > 0.05). Receipt of any type of systemic therapy during SRS did not differ between patients who did or did not develop RN (60.7% vs 55.6%, p = 0.97). However, patients who developed RN more commonly received more than one line of HER2-directed therapy independent of SRS timing compared to those who did not develop RN (75.0% vs 44.4%, p = 0.08). In fact, a significantly higher proportion of those who developed RN received more than one line of HER2-directed therapy during SRS compared to those did not develop RN (35.7% vs 5.6%, p<0.05). Conclusions: Patients with HER2 BCBrM who receive multiple lines of HER2-directed therapy during SRS for BCBrM may be at higher risk of RN. This data supports a practice of holding HER2-directed therapy during SRS if medically acceptable. Further investigation of next generation HER2-directed therapies in a larger cohort of patients should be investigated to help guide best practice to minimize RN.

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