Hemorrhagic and Cystic Brain Metastases Are Associated With an Increased Risk of Leptomeningeal Dissemination After Surgical Resection and Adjuvant Stereotactic Radiosurgery

Neurosurgery ◽  
2018 ◽  
Vol 85 (5) ◽  
pp. 632-641 ◽  
Author(s):  
Robert H Press ◽  
Chao Zhang ◽  
Mudit Chowdhary ◽  
Roshan S Prabhu ◽  
Matthew J Ferris ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Surgical Resection ◽  
Cumulative Incidence ◽  
Postoperative Radiotherapy ◽  
Multivariable Analysis ◽  
Treatment Strategies ◽  
Competing Risk ◽  
Leptomeningeal Dissemination ◽  
Increased Risk

Abstract BACKGROUND Brain metastases (BM) treated with surgical resection and focal postoperative radiotherapy have been associated with an increased risk of subsequent leptomeningeal dissemination (LMD). BMs with hemorrhagic and/or cystic features contain less solid components and may therefore be at higher risk for tumor spillage during resection. OBJECTIVE To investigate the association between hemorrhagic and cystic BMs treated with surgical resection and stereotactic radiosurgery and the risk of LMD. METHODS One hundred thirty-four consecutive patients with a single resected BM treated with adjuvant stereotactic radiosurgery from 2008 to 2016 were identified. Intracranial outcomes including LMD were calculated using the cumulative incidence model with death as a competing risk. Univariable analysis and multivariable analysis were assessed using the Fine & Gray model. Overall survival was analyzed using the Kaplan-Meier method. RESULTS Median imaging follow-up was 14.2 mo (range 2.5-132 mo). Hemorrhagic and cystic features were present in 46 (34%) and 32 (24%) patients, respectively. The overall 12- and 24-mo cumulative incidence of LMD with death as a competing risk was 11.0 and 22.4%, respectively. On multivariable analysis, hemorrhagic features (hazard ratio [HR] 2.34, P = .015), cystic features (HR 2.34, P = .013), breast histology (HR 3.23, P = .016), and number of brain metastases >1 (HR 2.09, P = .032) were independently associated with increased risk of LMD. CONCLUSION Hemorrhagic and cystic features were independently associated with increased risk for postoperative LMD. Patients with BMs containing these intralesion features may benefit from alternative treatment strategies to mitigate this risk.

scholarly journals CMET-38. HEMORRHAGIC BRAIN METASTASES UNDERGOING SURGICAL RESECTION ARE ASSOCIATED WITH INCREASED RISK OF LEPTOMENINGEAL DISSEMINATION

2017 ◽  
Vol 19 (suppl_6) ◽  
pp. vi47-vi47
Author(s):  
Robert Press ◽  
Chao Zhang ◽  
Mudit Chowdhary ◽  
Karen Xu ◽  
Roshan Prabhu ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Surgical Resection ◽  
Leptomeningeal Dissemination ◽  
Increased Risk

Preoperative Radiosurgery in Management of Brain Metastases

2020 ◽  
pp. 1-11
Author(s):  
Erkan Topkan ◽  
Ahmet Kucuk ◽  
Sukran Senyurek ◽  
Duygu Sezen ◽  
Nulifer Kilic Durankus ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Local Treatment ◽  
Treatment Strategies ◽  
Whole Brain Radiotherapy ◽  
Active Management ◽  
The Novel ◽  
Leptomeningeal Dissemination ◽  
Brain Radiotherapy ◽  
Increased Risk ◽  
Neurotoxic Effects

Brain metastases (BMs), the most frequent intracranial tumors, are diagnosed in approximately 30% of all adult patients over the span of planned treatment against a broad spectrum of solid cancers. The prognosis of patients presenting with BM is bleak with an expected median OS of only 4-7 months. However, some particular patients’ groups may enjoy longer survival durations with effective systemic and local therapies. At present, the feasible alternatives for active management of BMs typically include the whole-brain radiotherapy (WBRT), surgery, definitive SRS, postoperative SRS, systemic chemotherapy, targeted therapies, and their combination variants. Considering the local treatment, the severe neurotoxic effects of WBRT, and the increased risk for radionecrosis and leptomeningeal dissemination after postoperative SRS and together with the ineligibility of certain patients during the postoperative period prompted the energetic quest of alternative treatment strategies for such patients. In this respect, the novel preoperative SRS (PO-SRS) was proposed to provide at least equivalent local control rates with lesser radionecrosis and leptomeningeal dissemination risk. Respecting the scarcity of related literature, the present review aimed to meticulously detail theplausible rationale and accessible evidence for the novel PO-SRS in the management of patients presenting with BMs.

Tumor Progression in Patients Receiving Adjuvant Whole-Brain Radiotherapy vs Localized Radiotherapy After Surgical Resection of Brain Metastases

Neurosurgery ◽  
2015 ◽  
Vol 76 (4) ◽  
pp. 411-420 ◽  
Author(s):  
Jason Hsieh ◽  
Paul Elson ◽  
Balint Otvos ◽  
Jonathan Rose ◽  
Christopher Loftus ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Surgical Resection ◽  
Multivariable Analysis ◽  
Intraoperative Radiotherapy ◽  
Whole Brain Radiotherapy ◽  
Leptomeningeal Disease ◽  
Whole Brain ◽  
Brain Radiotherapy ◽  
Significant Difference

Abstract BACKGROUND: Surgery followed by adjuvant radiotherapy is a well-established treatment paradigm for brain metastases. OBJECTIVE: To examine the effect of postsurgical whole-brain radiotherapy (WBRT) or localized radiotherapy (LRT), including stereotactic radiosurgery and intraoperative radiotherapy, on the rate of recurrence both local and distal to the resection site in the treatment of brain metastases. METHODS: We retrospectively identified patients who underwent surgery for brain metastasis at the Cleveland Clinic between 2004 and 2012. Institutional review board-approved chart review was conducted, and patients who had radiation before surgery, who had nonmetastatic lesions, or who lacked postadjuvant imaging were excluded. RESULTS: The final analysis included 212 patients. One hundred fifty-six patients received WBRT, 37 received stereotactic radiosurgery only, and 19 received intraoperative radiotherapy. One hundred forty-six patients were deceased, of whom 60 (41%) died with no evidence of recurrence. Competing risks methodology was used to test the association between adjuvant modality and progression. Multivariable analysis revealed no significant difference in the rate of recurrence at the resection site (hazard ratio [HR] 1.46, P = .26) or of unresected, radiotherapy-treated lesions (HR 1.70, P = .41) for LRT vs WBRT. Patients treated with LRT had an increased hazard of the development of new lesions (HR 2.41, P < .001) and leptomeningeal disease (HR 2.45, P = .04). Median survival was 16.5 months and was not significantly different between groups. CONCLUSION: LRT as adjuvant treatment to surgical resection of brain metastases is associated with an increased rate of development of new distant metastases and leptomeningeal disease compared with WBRT, but not with recurrence at the resection site or of unresected lesions treated with radiation.

scholarly journals Melanoma Brain Metastases in the Era of Targeted Therapy and Checkpoint Inhibitor Therapy

Cancers ◽  
2021 ◽  
Vol 13 (7) ◽  
pp. 1489
Author(s):  
John M. Rieth ◽  
Umang Swami ◽  
Sarah L. Mott ◽  
Mario Zanaty ◽  
Michael D. Henry ◽  
...  
Keyword(s):  
Overall Survival ◽  
Brain Metastases ◽  
Checkpoint Inhibitor ◽  
Checkpoint Inhibitors ◽  
Performance Status ◽  
Multivariable Analysis ◽  
Treatment Strategies ◽  
Poor Performance Status ◽  
Poor Overall Survival ◽  
Melanoma Brain Metastases

Brain metastases commonly develop in melanoma and are associated with poor overall survival of about five to nine months. Fortunately, new therapies, including immune checkpoint inhibitors and BRAF/MEK inhibitors, have been developed. The aim of this study was to identify outcomes of different treatment strategies in patients with melanoma brain metastases in the era of checkpoint inhibitors. Patients with brain metastases secondary to melanoma were identified at a single institution. Univariate and multivariable analyses were performed to identify baseline and treatment factors, which correlated with progression-free and overall survival. A total of 209 patients with melanoma brain metastases were identified. The median overall survival of the cohort was 5.3 months. On multivariable analysis, the presence of non-cranial metastatic disease, poor performance status (ECOG 2–4), whole-brain radiation therapy, and older age at diagnosis of brain metastasis were associated with poorer overall survival. Craniotomy (HR 0.66, 95% CI 0.45–0.97) and treatment with a CTLA-4 checkpoint inhibitor (HR 0.55, 95% CI 0.32–0.94) were the only interventions associated with improved overall survival. Further studies with novel agents are needed to extend lifespan in patients with brain metastases in melanoma.

scholarly journals MRI Texture Analysis for the Prediction of Stereotactic Radiosurgery Outcomes in Brain Metastases from Lung Cancer

2021 ◽  
Vol 10 (2) ◽  
pp. 237
Author(s):  
Jung Hyun Park ◽  
Byung Se Choi ◽  
Jung Ho Han ◽  
Chae-Yong Kim ◽  
Jungheum Cho ◽  
...  
Keyword(s):  
Lung Cancer ◽  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Texture Analysis ◽  
Multivariable Analysis ◽  
Texture Features ◽  
Progression Free Survival ◽  
Clinical Parameter ◽  
Imaging Biomarker ◽  
Local Progression

This study aims to evaluate the utility of texture analysis in predicting the outcome of stereotactic radiosurgery (SRS) for brain metastases from lung cancer. From 83 patients with lung cancer who underwent SRS for brain metastasis, a total of 118 metastatic lesions were included. Two neuroradiologists independently performed magnetic resonance imaging (MRI)-based texture analysis using the Imaging Biomarker Explorer software. Inter-reader reliability as well as univariable and multivariable analyses were performed for texture features and clinical parameters to determine independent predictors for local progression-free survival (PFS) and overall survival (OS). Furthermore, Harrell’s concordance index (C-index) was used to assess the performance of the independent texture features. The primary tumor histology of small cell lung cancer (SCLC) was the only clinical parameter significantly associated with local PFS in multivariable analysis. Run-length non-uniformity (RLN) and short-run emphasis were the independent texture features associated with local PFS. In the non-SCLC (NSCLC) subgroup analysis, RLN and local range mean were associated with local PFS. The C-index of independent texture features was 0.79 for the all-patients group and 0.73 for the NSCLC subgroup. In conclusion, texture analysis on pre-treatment MRI of lung cancer patients with brain metastases may have a role in predicting SRS response.

161: Surgical Resection(S) Plus Stereotactic Radiosurgery (SRS) Versus SRS Alone for Large Brain Metastases: A Comparative Study

2021 ◽  
Vol 163 ◽  
pp. S68
Author(s):  
Barbara-Ann Millar ◽  
Normand Laperriere ◽  
Tatiana Conrad ◽  
Aristotelis Kalyvas ◽  
Gelareh Zadeh ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Comparative Study ◽  
Stereotactic Radiosurgery ◽  
Surgical Resection ◽  
Large Brain

scholarly journals CMET-41. OUTCOMES FOLLOWING STEREOTACTIC RADIOSURGERY (SRS) FOR LIMITED BRAIN METASTASES - AN AUSTRALIAN SINGLE INSTITUTIONAL EXPERIENCE

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi60-vi60
Author(s):  
Lilly Shen ◽  
Wee Loon Ong ◽  
Briana Farrugia ◽  
Anna Seeley ◽  
Carlos Augusto Gonzalvo ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Cumulative Incidence ◽  
Multivariate Analyses ◽  
Primary Lung Cancer ◽  
Factors Associated ◽  
Distant Failure ◽  
Kaplan Meier ◽  
Institutional Experience

Abstract INTRODUCTION Despite increasing use of stereotactic radiosurgery (SRS) for management of brain metastases (BM), published Australian data is scarce. We aim to report on the outcomes following SRS for limited BM in a single Australian institution. METHODS This is a retrospective cohort of patients with limited BM treated with SRS between August 2015 and March 2019. A dose of 24Gy/3# were prescribed to intact lesion, and 21Gy/3# to surgical cavity post-surgical resection. All patients were followed with 3-monthly surveillance MRI brain. Primary outcomes were: local failure (LF: increased in size of SRS-treated BM lesion/ recurrence in surgical cavity), distant failure (DF: intracranial progression outside of the SRS-treated lesion/ cavity), and overall survival (OS). LF, DF and OS were estimated using the Kaplan-Meier method. Multivariate Cox regressions were used to evaluate factors associated with outcomes of interest, with death as competing-risk events for LF and DF. RESULTS 76 courses of SRS were delivered in 65 patients (54 unresected BM lesions, and 22 surgical cavities). 43 (66%) patients were ECOG 0–1. 35 (54%) patients had solitary BM. 41 (63%) had symptomatic BM. Half of the patients had primary lung cancer. Median follow-up was 4.8 months (range:0.1–39 months). 10 LF were observed at a median of 3.5 month post-SRS, with 6- and 12-month LF cumulative incidence of 14% and 24% respectively. 30 DF were observed at a median of 3.3 months, with 6- and 12-month DF cumulative incidence of 38% and 63% respectively. The 12- and 24-month OS were 39% and 26% respectively. In multivariate analyses, better ECOG status, solitary BM lesion, resection of BM pre-SRS, and use of subsequent systemic therapy were independently associated with improved OS. CONCLUSION This is one of the few Australian series reporting on outcomes following SRS for limited BM, with comparable outcomes to published international series.

scholarly journals RTHP-42. OUTCOMES AFTER FRACTIONATED STEREOTACTIC RADIOSURGERY FOR BRAIN METASTASES

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi218-vi218
Author(s):  
Rebecca Anderson ◽  
Liberty Bonestroo ◽  
Christopher Spencer
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Surgical Resection ◽  
Metastatic Disease ◽  
Whole Brain Radiotherapy ◽  
Symptomatic Patient ◽  
Target Volume ◽  
Time To Death ◽  
Brain Radiotherapy ◽  
Fractionated Stereotactic Radiosurgery

Abstract PURPOSE To examine outcomes in patients undergoing linear accelerator (LINAC) based fractionated stereotactic radiosurgery (fSRS) to 30 Gy in 5 fractions. METHODS We completed a retrospective review of patients with brain metastases treated with 5-fraction LINAC fSRS at Phelps Health. All patients with CNS metastatic disease treated with fSRS were included in the study. Incidence of symptomatic radionecrosis (sRN), local brain failure (LBF), time to death, target volume and dose, prior whole brain radiotherapy (WBRT), prior surgical resection, and concurrent immunotherapy were assessed. sRN was defined as grade 2 or higher per CTCAE v4.0. RESULTS From 2016–2019, 28 patients and 60 lesions were treated. The most common metastasis histology was non-small cell lung cancer (n = 22), renal cell carcinoma (n = 12), and melanoma (n = 11). Median follow-up time was 6.49 months (range 0.33 – 23.96). Of 60 lesions, three lesions developed sRN and one asymptomatic patient developed radiographic evidence of radiation necrosis. Mean GTV was 1.03cm3 in patients with sRN. Of 57 lesions without sRN, median GTV was 1.45cm3 (range 0.11 - 20.1). Mean time to sRN was 3.17 months. Two symptomatic patients received prior WBRT. One symptomatic patient received concurrent immunotherapy. No symptomatic patients had surgical resection prior to fSRS. Among 24 lesions without prior radiation, 1 (4.2%) developed sRN. 10 lesions underwent surgical resection prior to fSRS with none developing sRN. 34 lesions were treated with concurrent immunotherapy and one developed sRN (2.9%). Local failure occurred in 9 lesions (15%). Median time to death for all patients was 4.50 months (range 1.02 - 19.40). CONCLUSIONS fSRS to 30 Gy in 5 fractions has promising efficacy with low incidence of sRN in treatment of CNS metastatic disease. Further investigation is required to determine predictors in patient outcome.

Stereotactic radiosurgery for brain metastases: a case-matched study comparing treatment results for patients 80 years of age or older versus patients 65–79 years of age

2014 ◽  
Vol 121 (5) ◽  
pp. 1148-1157 ◽  
Author(s):  
Shinya Watanabe ◽  
Masaaki Yamamoto ◽  
Yasunori Sato ◽  
Takuya Kawabe ◽  
Yoshinori Higuchi ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Statistical Significance ◽  
Disease Status ◽  
Competing Risk ◽  
Treatment Results ◽  
Number Of Patients ◽  
Group A ◽  
Group B ◽  
Matched Study

Object Recently, an increasing number of patients with brain metastases, even patients over 80 years of age, have been treated with stereotactic radiosurgery (SRS). However, there is little information on SRS treatment results for patients with brain metastases 80 years of age and older. The authors undertook this study to reappraise whether SRS treatment results for patients 80 years of age or older differ from those of patients who are 65–79 years old. Methods This was an institutional review board–approved, retrospective cohort study. Among 2552 consecutive brain metastasis patients who underwent SRS during the 1998–2011 period, we studied 165 who were 80 years of age or older (Group A) and 1181 who were age 65–79 years old (Group B). Because of the remarkable disproportion in patient numbers between the 2 groups and considerable differences in pre-SRS clinical factors, the authors conducted a case-matched study using the propensity score matching method. Ultimately, 330 patients (165 from each group, A and B) were selected. For time-to-event outcomes, the Kaplan-Meier method was used to estimate overall survival and competing risk analysis was used to estimate other study end points, as appropriate. Results Although the case-matched study showed that post-SRS median survival time (MST, months) was shorter in Group A patients (5.3 months, 95% CI 3.9–7.0 months) than in Group B patients (6.9 months, 95% CI 5.0–8.1 months), this difference was not statistically significant (HR 1.147, 95% CI 0.921–1.429, p = 0.22). Incidences of neurological death and deterioration were slightly lower in Group A than in Group B patients (6.3% vs 11.8% and 8.5% vs 13.9%), but these differences did not reach statistical significance (p = 0.11 and p = 0.16). Furthermore, competing risk analyses showed that the 2 groups did not differ significantly in cumulative incidence of local recurrence (HR 0.830, 95% CI 0.268–2.573, p = 0.75), rates of repeat SRS (HR 0.738, 95% CI 0.438–1.242, p = 0.25), or incidence of SRS-related complications (HR 0.616, 95% CI 0.152–2.495, p = 0.49). Among the Group A patients, post-SRS MSTs were 11.6 months (95% CI 7.8–19.6 months), 7.9 months (95% CI 5.2–10.9 months), and 2.8 months (95% CI; 2.4–4.6 months) in patients whose disease status was modified–recursive partitioning analysis (RPA) Class(es) I+IIa, IIb, and IIc+III, respectively (p < 0.001). Conclusions Our results suggest that patients 80 years of age or older are not unfavorable candidates for SRS as compared with those 65–79 years old. Particularly, even among patients 80 years and older, those with modified-RPA Class I+IIa or IIb disease are considered to be favorable candidates for more aggressive treatment of brain metastases.

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