P08.27 The role of supramarginal resection for single large brain metastases: feasibility, morbidity and local control evaluation

Abstract BACKGROUND: Optimal postoperative management paradigm for brain metastases remains controversial. OBJECTIVE: To conduct a systematic review of the literature to understand the role of postoperative stereotactic radiosurgery after resection of brain metastases. METHODS: We performed a MEDLINE search of the literature to identify series of patients with brain metastases treated with stereotactic radiosurgery after surgical resection. Outcomes including overall survival, local control, distant intracranial failure, and salvage therapy use were recorded. Patient, tumor, and treatment factors were correlated with outcomes through the use of the Pearson correlation and 2-way Student t test as appropriate. RESULTS: Fourteen studies involving 629 patients were included. Median survival for all studies was 14 months. Local control was correlated with the median volume treated with radiosurgery (r = −0.766, P < .05) and with the rate of gross total resection (r = .728, P < .03). Mean crude local control was 83%; 1-year local control was 85%. Distant intracranial failure occurred in 49% of cases, and salvage whole-brain radiation therapy was required in 29% of cases. Use of a radiosurgical margin did not lead to increased local control or overall survival. CONCLUSION: Our systematic review supports the use of radiosurgery as a safe and effective strategy for adjuvant treatment of brain metastases, particularly when gross total resection has been achieved. With all limitations of comparisons between studies, no increase in local recurrence or decrease in overall survival compared with rates with adjuvant whole-brain radiation therapy was found.

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The Judicious Use of Stereotactic Radiosurgery and Hypofractionated Stereotactic Radiotherapy in the Management of Large Brain Metastases

Cancers ◽

10.3390/cancers13010070 ◽

2020 ◽

Vol 13 (1) ◽

pp. 70

Author(s):

Tyler Gutschenritter ◽

Vyshak A. Venur ◽

Stephanie E. Combs ◽

Balamurugan Vellayappan ◽

Anoop P. Patel ◽

...

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Local Control ◽

Stereotactic Radiotherapy ◽

Leptomeningeal Disease ◽

Hypofractionated Stereotactic Radiotherapy ◽

Treatment Techniques ◽

Dose Volume ◽

Clinical Scenarios ◽

Large Brain

Brain metastases are the most common intracranial malignant tumor in adults and are a cause of significant morbidity and mortality for cancer patients. Large brain metastases, defined as tumors with a maximum dimension >2 cm, present a unique clinical challenge for the delivery of stereotactic radiosurgery (SRS) as patients often present with neurologic symptoms that require expeditious treatment that must also be balanced against the potential consequences of surgery and radiation therapy—namely, leptomeningeal disease (LMD) and radionecrosis (RN). Hypofractionated stereotactic radiotherapy (HSRT) and pre-operative SRS have emerged as novel treatment techniques to help improve local control rates and reduce rates of RN and LMD for this patient population commonly managed with post-operative SRS. Recent literature suggests that pre-operative SRS can potentially half the risk of LMD compared to post-operative SRS and that HSRT can improve risk of RN to less than 10% while improving local control when meeting the appropriate goals for biologically effective dose (BED) and dose-volume constraints. We recommend a 3- or 5-fraction regimen in lieu of SRS delivering 15 Gy or less for large metastases or resection cavities. We provide a table comparing the BED of commonly used SRS and HSRT regimens, and provide an algorithm to help guide the management of these challenging clinical scenarios.

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The Role of Tumor Size in the Radiosurgical Management of Patients with Ambiguous Brain Metastases

Neurosurgery ◽

10.1227/01.neu.0000073546.61154.9a ◽

2003 ◽

Vol 53 (2) ◽

pp. 272-281 ◽

Cited By ~ 69

Author(s):

Eric L. Chang ◽

Samuel J. Hassenbusch ◽

Almon S. Shiu ◽

Frederick F. Lang ◽

Pamela K. Allen ◽

...

Keyword(s):

Brain Metastasis ◽

Brain Metastases ◽

Local Control ◽

Medical Records ◽

Tumor Volume ◽

Unknown Primary ◽

Inclusion Criteria ◽

Peripheral Dose

Abstract OBJECTIVE To identify a size cutoff below which it is safe to observe obscure brain lesions suspected of being metastases so that treatment of nonmetastases can be avoided. METHODS Medical records from patients who underwent linear accelerator-based radiosurgery from August 1991 to October 2001 were reviewed. Inclusion criteria were defined as brain metastasis tumor volume less than 5 cm3 (diameter, ∼2.1 cm) treated with a dose of 20 Gy or more. One hundred thirty-five patients had 153 evaluable brain metastases with follow-up imaging that met inclusion criteria. Median age was 54 years (range, 18–79 yr). Lesion primaries were non-small-cell lung (n = 39), melanoma (n = 44), renal (n = 37), breast (n = 18), colon (n = 3), sarcoma (n = 5), other (n = 5), and unknown primary (n = 2). Median tumor volume was 0.67 cm3 (range, 0.06–4.58 cm3). The minimum peripheral dose was 20 Gy (n = 132) or 21 to 24 Gy (n = 21). At the time of analysis, the median follow-up for all patients was 10 months (range, 0.2–99 mo). RESULTS The 1- and 2-year actuarial local control rates for all of the lesions were 69 and 46%, respectively. For lesions of 1 cm (0.5 cm3) or less, the corresponding local control rates were 86 and 78%, respectively, which was significantly higher than the corresponding rates of 56 and 24%, respectively, for lesions larger than 1 cm (0.5 cm3) (P = 0.0016). CONCLUSION A convincing brain metastasis measuring less than 1 cm should be pursued aggressively. If the suspected brain metastasis is ambiguous, observation is proposed up to a diameter of 1 cm. This is the first study in the literature to identify a 1-cm cutoff for radiosurgical control of small brain metastases, and validation by additional studies is required.

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Postoperative Stereotactic Radiosurgery to the Resection Cavity for Large Brain Metastases

Neurosurgery ◽

10.1227/neu.0000000000000584 ◽

2014 ◽

Vol 76 (2) ◽

pp. 150-157 ◽

Cited By ~ 38

Author(s):

Diane C. Ling ◽

John A. Vargo ◽

Rodney E. Wegner ◽

John C. Flickinger ◽

Steven A. Burton ◽

...

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Local Control ◽

Systemic Disease ◽

Leptomeningeal Disease ◽

Resection Cavity ◽

Whole Brain Radiation ◽

Kaplan Meier ◽

Large Brain ◽

Patient Selection Criteria

ABSTRACT BACKGROUND: Postoperative stereotactic radiosurgery for brain metastases potentially offers similar local control rates and fewer long-term neurocognitive sequelae compared to whole brain radiation therapy, although patients remain at risk for distant brain failure (DBF). OBJECTIVE: To describe clinical outcomes of adjuvant stereotactic radiosurgery for large brain metastases and identify predictors of intracranial failure and their implications on optimal patient selection criteria. METHODS: We performed a retrospective review on 100 large (>3 cm) brain metastases in 99 patients managed by resection followed by postoperative stereotactic radiosurgery to a median dose of 22 Gy (range, 10–28) in 1 to 5 fractions (median, 3). Primary histology was nonsmall cell lung in 40%, breast cancer in 18%, and melanoma in 17%. Forty (40%) patients had uncontrolled systemic disease. RESULTS: With a median follow-up of 12.2 months (range, 0.6–87.4), the 1-year Kaplan-Meier local control was 72%, DBF 64%, and overall survival 55%. Nine patients (9%) developed evidence of radiation injury, and 6 (6%) developed leptomeningeal disease. Uncontrolled systemic disease (P = .03), melanoma histology (P = .04), and increasing number of brain metastases (P < .001) were significant predictors of DBF on Cox multivariate analysis. Patients with <4 metastases, controlled systemic disease, and nonmelanoma primary (n = 47) had a 1-year DBF of 48.6% vs 80.1% for all others (P = .01). CONCLUSION: Postoperative stereotactic radiosurgery to the resection cavity safely and effectively augments local control of large brain metastases. Patients with <4 metastases and controlled systemic disease have significantly lower rates of DBF and are ideal treatment candidates.

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The Expanding Role of Radiosurgery for Brain Metastases

10.20944/preprints201807.0455.v1 ◽

2018 ◽

Author(s):

Mark O'Beirn ◽

Helen Benghiat ◽

Sara Meade ◽

Geoff Heyes ◽

Vijay Sawlani ◽

...

Keyword(s):

Brain Metastases ◽

Local Control ◽

Systemic Disease ◽

Whole Brain Radiotherapy ◽

Targeted Agents ◽

Brain Radiotherapy ◽

Multiple Metastases ◽

Rising Incidence ◽

Molecular Information

Stereotactic radiosurgery (SRS) has become increasingly important in the management of brain metastases due to improving systemic disease control and rising incidence. Initial trials demonstrated SRS with whole brain radiotherapy (WBRT) improved local control rates versus WBRT alone. Concerns with WBRT associated neurocognitive toxicity have contributed to greater use of SRS alone, including for patients with multiple metastases and following surgical resection. Molecular information, targeted agents and immunotherapy have also altered the landscape for the management of brain metastases. This review summarises current and emerging data on the role of SRS in the management of brain metastases.

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The Role of Radio Surgery in Brain Metastases Treatment – Attaining Local Control

Cancer therapy & Oncology International Journal ◽

10.19080/ctoij.2016.01.555562 ◽

2016 ◽

Vol 1 (3) ◽

Author(s):

Or Cohen Inbar

Keyword(s):

Brain Metastases ◽

Local Control

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Staged radiosurgery in the managment of patients with brain metastases

Russian journal of neurosurgery ◽

10.17650/1683-3295-2021-23-1-26-37 ◽

2021 ◽

Vol 23 (1) ◽

pp. 26-37

Author(s):

I. K. Osinov ◽

A. V. Golanov ◽

S. M. Banov ◽

A. E. Artemenkova ◽

V. V. Kostuchenko ◽

...

Keyword(s):

Brain Metastases ◽

Local Control ◽

Progression Free Survival ◽

Antitumor Drug ◽

Neurological Deficits ◽

Study Objective ◽

Perifocal Edema ◽

Large Brain ◽

Grade Ii ◽

Post Radiation

The study objective is to present the results of the treatment of metastatic brain patients by the staged radiosurgery with the Gamma Knife.Materials and methods. The retrospective analysis included 31 patients (13 men and 18 women) with brain metastases, whose radiosurgery treatment was carried out in 2 sessions. The operation was contraindicated in all patients due to the risk of neurological deficits or due to the high anesthesiological risk.Results. Local control of metastases growth was achieved in 31 (96.9 %) of 32 foci 3 months after treatment, and in 92.5 and 83.8 %, after 6 and 12 months, respectively. The age <50 years were associated with higher progression-free survival respectively. The median time of grade I–II radiation complications was 3.0 months, complications were observed in 11 (45.8 %) of 24 patients. Radiation complications of grade II (perifocal edema) were observed in 8 (33.3 %) patients, grade III (radionecrosis) – in 2 (8.3 %) patients. Overall survival at 6 and 12 months was 55.6 and 40.8 %, respectively (median 6.9 months), in patients receiving antitumor drug treatment – 80.0 and 56.8 %, respectively. All patients who did not received antitumor drug therapy died within 6 months.Conclusion. Two-stage radiosurgery, carried out in 2 sessions with an interval of 2–4 weeks, provides satisfactory local control with an acceptable level of post-radiation complications. This method of treatment can be used in patients with large brain metastases who are not subject to surgical treatment.

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The Expanding Role of Radiosurgery for Brain Metastases

Medicines ◽

10.3390/medicines5030090 ◽

2018 ◽

Vol 5 (3) ◽

pp. 90 ◽

Cited By ~ 9

Author(s):

Mark O’Beirn ◽

Helen Benghiat ◽

Sara Meade ◽

Geoff Heyes ◽

Vijay Sawlani ◽

...

Keyword(s):

Brain Metastases ◽

Local Control ◽

Systemic Disease ◽

Whole Brain Radiotherapy ◽

Targeted Agents ◽

Brain Radiotherapy ◽

Multiple Metastases ◽

Rising Incidence ◽

Molecular Information

Stereotactic radiosurgery (SRS) has become increasingly important in the management of brain metastases due to improving systemic disease control and rising incidence. Initial trials demonstrated SRS with whole-brain radiotherapy (WBRT) improved local control rates compared with WBRT alone. Concerns with WBRT associated neurocognitive toxicity have contributed to a greater use of SRS alone, including for patients with multiple metastases and following surgical resection. Molecular information, targeted agents, and immunotherapy have also altered the landscape for the management of brain metastases. This review summarises current and emerging data on the role of SRS in the management of brain metastases.

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Dosimetric comparison of fractionated radiosurgery plans using frameless Gamma Knife ICON and CyberKnife systems with linear accelerator–based radiosurgery plans for multiple large brain metastases

Journal of Neurosurgery ◽

10.3171/2019.1.jns182769 ◽

2020 ◽

Vol 132 (5) ◽

pp. 1473-1479 ◽

Cited By ~ 5

Author(s):

Eun Young Han ◽

He Wang ◽

Dershan Luo ◽

Jing Li ◽

Xin Wang

Keyword(s):

Brain Metastases ◽

Gamma Knife ◽

Linear Accelerator ◽

Treatment Time ◽

Target Volume ◽

Planning System ◽

Treatment Planning System ◽

Normal Brain ◽

Large Brain ◽

The Mean

OBJECTIVEFor patients with multiple large brain metastases with at least 1 target volume larger than 10 cm3, multifractionated stereotactic radiosurgery (MF-SRS) has commonly been delivered with a linear accelerator (LINAC). Recent advances of Gamma Knife (GK) units with kilovolt cone-beam CT and CyberKnife (CK) units with multileaf collimators also make them attractive choices. The purpose of this study was to compare the dosimetry of MF-SRS plans deliverable on GK, CK, and LINAC and to discuss related clinical issues.METHODSTen patients with 2 or more large brain metastases who had been treated with MF-SRS on LINAC were identified. The median planning target volume was 18.31 cm3 (mean 21.31 cm3, range 3.42–49.97 cm3), and the median prescribed dose was 27.0 Gy (mean 26.7 Gy, range 21–30 Gy), administered in 3 to 5 fractions. Clinical LINAC treatment plans were generated using inverse planning with intensity modulation on a Pinnacle treatment planning system (version 9.10) for the Varian TrueBeam STx system. GK and CK planning were retrospectively performed using Leksell GammaPlan version 10.1 and Accuray Precision version 1.1.0.0 for the CK M6 system. Tumor coverage, Paddick conformity index (CI), gradient index (GI), and normal brain tissue receiving 4, 12, and 20 Gy were used to compare plan quality. Net beam-on time and approximate planning time were also collected for all cases.RESULTSPlans from all 3 modalities satisfied clinical requirements in target coverage and normal tissue sparing. The mean CI was comparable (0.79, 0.78, and 0.76) for the GK, CK, and LINAC plans. The mean GI was 3.1 for both the GK and the CK plans, whereas the mean GI of the LINAC plans was 4.1. The lower GI of the GK and CK plans would have resulted in significantly lower normal brain volumes receiving a medium or high dose. On average, GK and CK plans spared the normal brain volume receiving at least 12 Gy and 20 Gy by approximately 20% in comparison with the LINAC plans. However, the mean beam-on time of GK (∼ 64 minutes assuming a dose rate of 2.5 Gy/minute) plans was significantly longer than that of CK (∼ 31 minutes) or LINAC (∼ 4 minutes) plans.CONCLUSIONSAll 3 modalities are capable of treating multiple large brain lesions with MF-SRS. GK has the most flexible workflow and excellent dosimetry, but could be limited by the treatment time. CK has dosimetry comparable to that of GK with a consistent treatment time of approximately 30 minutes. LINAC has a much shorter treatment time, but residual rotational error could be a concern.

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