scholarly journals BIMG-19. 18F-FLUCICLOVINE PET/CT TO DISTINGUISH RADIATION NECROSIS FROM TUMOR PROGRESSION IN BRAIN METASTASES TREATED WITH STEREOTACTIC RADIOSURGERY: A PROSPECTIVE PILOT STUDY

2021 ◽  
Vol 3 (Supplement_1) ◽  
pp. i5-i5
Author(s):  
Martin Tom
Keyword(s):  
Brain Metastases ◽  
Radiation Necrosis ◽  
Normal Brain ◽  
Post Injection ◽  
Mr Perfusion ◽  
Mri Brain ◽  
Quantitative Metrics ◽  
Pet Ct ◽  
Normal Ratio

Abstract PURPOSE To estimate the accuracy of 18F-Fluciclovine PET/CT in distinguishing radiation necrosis (RN) from tumor progression (TP) among patients with brain metastases (BM) having undergone prior stereotactic radiosurgery (SRS) who presented with a follow-up MRI brain (with DSC-MR perfusion) which was equivocal for RN versus TP. METHODS Within 30 days of equivocal MRI brain, subjects underwent 18F-Fluciclovine PET/CT on a Siemens Biograph mCT scanner with a 10 mCi bolus dose immediately prior to PET. Data were collected in list mode for 25 minutes post-injection and were reconstructed as a static image of data 10–25 minutes post-injection, and as a dynamic series of four 5-minute frames between 5–25 minutes post-injection. Quantitative metrics for each lesion were documented including SUVmax, SUVmean, SUVpeak, and normal brain SUVmean. Lesion to normal brain ratios were calculated. The reference standard was clinical follow-up with MRI brain (with DSC-MR perfusion) every 2–4 months until multidisciplinary consensus (or tissue confirmation) for diagnosis of RN versus TP. RESULTS From 7/2019-11/2020, 16 of 16 planned subjects enrolled and underwent 18F-Fluciclovine PET/CT for evaluation of 21 brain lesions. Primary histology included NSCLC (n=7), breast (n=5), melanoma (n=3), and endometrial (n=1). Ranges of quantitative metrics were: SUVmax, 2.18–12.1; SUVmean, 1.16–7.37; SUVpeak, 1.06–5.14; normal brain SUVmean, 0.19–0.50; SUVmax/normal ratio, 7.5–45.4; SUVmean/normal ratio, 4.2–26.3; and SUVpeak/normal ratio, 3.9–26.4. Among the patients 10 patients with 12 lesions who completed follow up, estimates of the area under the receiver operating characteristic curve for SUVmax, SUVmean, and SUVpeak were: 0.93, 0.93, and 0.82, respectively. CONCLUSION In this population, 18F-Fluciclovine PET/CT favorably produces a wide range of lesion quantitative metric values, low uptake in the normal brain, and promising accuracy to distinguish RN from TP. Completion of follow-up for all patients is required. Phase II and III studies are under development.

scholarly journals NIMG-02. 18F-FLUCICLOVINE PET/CT TO DISTINGUISH RADIATION NECROSIS FROM TUMOR PROGRESSION IN BRAIN METASTASES TREATED WITH STEREOTACTIC RADIOSURGERY

2020 ◽  
Vol 22 (Supplement_2) ◽  
pp. ii146-ii147
Author(s):  
Martin Tom ◽  
Frank DiFilippo ◽  
Stephen Jones ◽  
John Suh ◽  
Erin Murphy ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Radiation Necrosis ◽  
Normal Brain ◽  
Post Injection ◽  
Mr Perfusion ◽  
Mri Brain ◽  
Quantitative Metrics ◽  
Pet Ct ◽  
Normal Ratio

Abstract PURPOSE/OBJECTIVE(S) To report descriptive updates of an ongoing pilot trial assessing whether 18F-Fluciclovine PET/CT, a widely available amino-acid radiotracer, is useful to distinguish radiation necrosis (RN) from tumor progression (TP) among patients with brain metastases. MATERIALS/METHODS The primary objective is to estimate the accuracy of 18F-Fluciclovine PET/CT in distinguishing RN from TP. We included adults with brain metastases who underwent prior stereotactic radiosurgery and presented with a follow-up MRI brain (with DSC-MR perfusion) which was equivocal for RN versus TP. Within 30 days of equivocal MRI, patients underwent 18F-Fluciclovine PET/CT on a Siemens Biograph mCT scanner with a 10 mCi bolus dose immediately prior to PET. PET data were collected in list-mode for 25 mins post-injection and were reconstructed as a static image of data 10-25 mins post-injection, and as a dynamic series of four 5-min frames between 5-25 mins post-injection. Quantitative metrics for each lesion were documented. Lesion to normal brain ratios were calculated. The reference standard was clinical follow-up with MRI brain (with DSC-MR perfusion) every 2-4 months until multidisciplinary consensus (or tissue confirmation) for diagnosis of RN versus TP. RESULTS From 7/2019-6/2020, 12 of 16 planned subjects with 17 lesions underwent 18F-Fluciclovine PET/CT. Primary histology was non-small cell lung cancer in 5 patients, breast in 4, melanoma in 2, and endometrial in 1. Among all 17 lesions, ranges of quantitative metrics were: SUVmax, 2.18-12.10; SUVmean, 1.16-7.37; SUVpeak, 1.06-4.45; normal brain SUVmean, 0.19-0.44; SUVmax/normal ratio, 7.50-45.40; SUVmean/normal ratio, 4.20-26.30; and SUVpeak/normal ratio, 3.90-26.40. Follow-up was completed for 5 patients (6 lesions). No adverse events have occurred. CONCLUSION In this population, 18F-Fluciclovine produces a wide range of lesion quantitative metric values and uniformly low uptake in normal brain, which may allow accurate discrimination. Ongoing additional accrual and follow up is required.

scholarly journals Long-term metabolic evolution of brain metastases with suspected radiation necrosis following stereotactic radiosurgery: longitudinal assessment by F-DOPA PET

2020 ◽  
Author(s):  
Francesco Cicone ◽  
Luciano Carideo ◽  
Claudia Scaringi ◽  
Andrea Romano ◽  
Marcelo Mamede ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Radiation Necrosis ◽  
Standardized Uptake Value ◽  
Longitudinal Assessment ◽  
Metabolic Evolution ◽  
Local Progression ◽  
Pet Ct

Abstract Background The evolution of radiation necrosis (RN) varies depending on the combination of radionecrotic tissue and active tumor cells. In this study, we characterized the long-term metabolic evolution of RN by sequential PET/CT imaging with 3,4-dihydroxy-6-[18F]-fluoro-l-phenylalanine (F-DOPA) in patients with brain metastases following stereotactic radiosurgery (SRS). Methods Thirty consecutive patients with 34 suspected radionecrotic brain metastases following SRS repeated F-DOPA PET/CT every 6 months or yearly in addition to standard MRI monitoring. Diagnoses of local progression (LP) or RN were confirmed histologically or by clinical follow-up. Semi-quantitative parameters of F-DOPA uptake were extracted at different time points, and their diagnostic performances were compared with those of corresponding contrast-enhanced MRI. Results Ninety-nine F-DOPA PET scans were acquired over a median period of 18 (range: 12–66) months. Median follow-up from the baseline F-DOPA PET/CT was 48 (range 21–95) months. Overall, 24 (70.6%) and 10 (29.4%) lesions were classified as RN and LP, respectively. LP occurred after a median of 18 (range: 12–30) months from baseline PET. F-DOPA tumor-to-brain ratio (TBR) and relative standardized uptake value (rSUV) increased significantly over time in LP lesions, while remaining stable in RN lesions. The parameter showing the best diagnostic performance was rSUV (accuracy = 94.1% for the optimal threshold of 1.92). In contrast, variations of the longest tumor dimension measured on contrast-enhancing MRI did not distinguish between RN and LP. Conclusion F-DOPA PET has a high diagnostic accuracy for assessing the long-term evolution of brain metastases following SRS.

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 CMET-37. CLINICAL UTILITY OF ENCYCLOPEDIC TUMOR ANALYSIS TO TREAT PATIENTS WITH BRAIN METASTASIS IN REFRACTORY CANCERS

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi59-vi60
Author(s):  
Timothy Crook ◽  
Darshana Patil ◽  
Dadasaheb Akolkar ◽  
Anantbhushan Ranade ◽  
Amit Bhatt ◽  
...  
Keyword(s):  
Brain Metastasis ◽  
Brain Metastases ◽  
Treatment Options ◽  
Brain Mri ◽  
Gene Mutations ◽  
Solid Organ ◽  
Pet Ct ◽  
The Impact

Abstract Brain metastasis in solid organ cancers is associated with adverse prognosis, which is further aggravated by limited systemic treatment options. Such patients are also often excluded from clinical trials since their poor prognosis is perceived to unfavorably impact trial outcomes and misrepresent efficacy data. We retrospectively evaluated the efficacy of treatment guided by Encyclopedic Tumor Analysis (ETA) in patients with advanced refractory malignancies and brain metastases to determine the impact on outcomes. Freshly biopsied tumor tissue (primary / lymph node / liver) and peripheral blood of patients were used for integrational multi-analyte investigations as part of ETA, which included gene mutations, gene expression, and in vitro chemosensitivity profiling of viable tumor cells. Based on ETA, patients received individualized therapy recommendations. All patients underwent a PET-CT scan as well as MRI scan prior to treatment start to determine extent of disease. All patients underwent follow-up PET-CT scans and brain MRI scans every 6–8 weeks. Of the ten patients with brain metastases, which were evaluated after receiving ETA-guided treatment, the median follow-up duration was 97 days (range 79 – 180 days) during which all ten patients remained progression-free. Median time to progression for these patients on the last (failed) line of treatment was 91 days (range 30 - 176 days). Five patients showed partial response and five patients showed stable disease while on ETA-guided treatment. During the follow-up period, all brain metastases were either stable (n=7) or had regressed (n=3), and none of the patients reported new brain lesions. Personalized ETA guided treatments imparted clinical benefit by halting disease progression in this cohort of high-risk patients who would have otherwise been considered for palliative regimens due to perceived unfavorable prognosis.

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.

scholarly journals Does immunotherapy increase the rate of radiation necrosis after radiosurgical treatment of brain metastases?

2016 ◽  
Vol 125 (1) ◽  
pp. 17-23 ◽  
Author(s):  
Rovel J. Colaco ◽  
Pierre Martin ◽  
Harriet M. Kluger ◽  
James B. Yu ◽  
Veronica L. Chiang
Keyword(s):  
Brain Metastases ◽  
Systemic Therapy ◽  
Lower Risk ◽  
Median Overall Survival ◽  
Radiation Necrosis ◽  
Cytotoxic Chemotherapy ◽  
High Dose ◽  
The Brain ◽  
Dose Radiation

OBJECT Radiation necrosis (RN), or its imaging equivalent, treatment-related imaging changes (TRIC), is an inflammatory reaction to high-dose radiation in the brain. The authors sought to investigate the hypothesis that immunotherapy increases the risk of developing RN/TRIC after stereotactic Gamma Knife (GK) radiosurgery for brain metastases. METHODS A total of 180 patients who underwent GK surgery for brain metastases between 2006 and 2012 were studied. The systemic therapy they received was classified as cytotoxic chemotherapy (CT), targeted therapy (TT), or immunotherapy (IT). The timing of systemic therapy in relation to GK treatment was also recorded. Logistic regression was used to calculate the odds of developing RN according to type of systemic therapy received. RESULTS The median follow-up time was 11.7 months. Of 180 patients, 39 (21.7%) developed RN/TRIC. RN/TRIC rates were 37.5% (12 of 32) in patients who received IT alone, 16.9% (14 of 83) in those who received CT only, and 25.0% (5 of 20) in those who received TT only. Median overall survival was significantly longer in patients who developed RN/TRIC (23.7 vs 9.9 months, respectively). The RN/TRIC rate was increased significantly in patients who received IT alone (OR 2.40 [95% CI 1.06–5.44]; p = 0.03), whereas receipt of any CT was associated with a lower risk of RN/TRIC (OR 0.38 [95% CI 0.18–0.78]; p = 0.01). The timing of development of RN/TRIC was not different between patients who received IT and those who received CT. CONCLUSIONS Patients who receive IT alone may have an increased rate of RN/TRIC compared with those who receive CT or TT alone after stereotactic radiosurgery, whereas receiving any CT may in fact be protective against RN/TRIC. As the use of immunotherapies increases, the rate of RN/TRIC may be expected to increase compared with rates in the chemotherapy era.

scholarly journals Predictors of radiation necrosis in long-term survivors after Gamma Knife stereotactic radiosurgery for brain metastases

2019 ◽  
Vol 7 (4) ◽  
pp. 400-408
Author(s):  
Zaid A Siddiqui ◽  
Bryan S Squires ◽  
Matt D Johnson ◽  
Andrew M Baschnagel ◽  
Peter Y Chen ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Surgical Resection ◽  
Radiation Necrosis ◽  
Factors Associated ◽  
Kaplan Meier ◽  
Target Volumes ◽  
Gamma Knife Stereotactic Radiosurgery ◽  
Long Term Survivors

Abstract Background The long-term risk of necrosis after radiosurgery for brain metastases is uncertain. We aimed to investigate incidence and predictors of radiation necrosis for individuals with more than 1 year of survival after radiosurgery for brain metastases. Methods Patients who had a diagnosis of brain metastases treated between December 2006 and December 2014, who had at least 1 year of survival after first radiosurgery were retrospectively reviewed. Survival was analyzed using the Kaplan-Meier estimator, and the incidence of radiation necrosis was estimated with death or surgical resection as competing risks. Patient and treatment factors associated with radiation necrosis were also analyzed. Results A total of 198 patients with 732 lesions were analyzed. Thirty-four lesions required salvage radiosurgery and 10 required salvage surgical resection. Median follow-up was 24 months. The estimated median survival for this population was 25.4 months. The estimated per-lesion incidence of radiation necrosis at 4 years was 6.8%. Medical or surgical therapy was required for 60% of necrosis events. Tumor volume and male sex were significant factors associated with radiation necrosis. The per-lesions incidence of necrosis for patients undergoing repeat radiosurgery was 33.3% at 4 years. Conclusions In this large series of patients undergoing radiosurgery for brain metastases, patients continued to be at risk for radiation necrosis throughout their first 4 years of survival. Repeat radiosurgery of recurrent lesions greatly exacerbates the risk of radiation necrosis, whereas treatment of larger target volumes increases the risk modestly.

scholarly journals SURG-03. COMBINATION LASER INTERSTITIAL THERMAL THERAPY PLUS SRS INCREASES TIME TO PROGRESSION FOR RECURRENT SRS-TREATED BRAIN METASTASES

2020 ◽  
Vol 22 (Supplement_2) ◽  
pp. ii203-ii203
Author(s):  
Matthew Grabowski ◽  
Eric Sankey ◽  
Ethan Srinivasan ◽  
Balint Otvos ◽  
Alex Scott ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Tumor Volume ◽  
Radiographic Progression ◽  
Radiation Necrosis ◽  
Thermal Therapy ◽  
Time To Progression ◽  
Index Lesion ◽  
Laser Interstitial Thermal Therapy ◽  
Prospective Trials

Abstract INTRODUCTION Laser interstitial thermal therapy (LITT) has evolved as an effective treatment for brain metastases (BM) failing stereotactic radiosurgery (SRS), and an alternative to open resection/repeat SRS. We sought to evaluate the efficacy of LITT+SRS in recurrent SRS-treated BM, and compare outcomes to LITT alone vs. repeat SRS. METHODS A multicenter, retrospective study was performed of patients with biopsy-proven BM recurrence after SRS. Patients were stratified by planned LITT+SRS vs. LITT alone vs. repeat SRS. Index lesion progression was determined by RANO criteria. RESULTS Forty-five patients fit inclusion, with a median follow-up of 7.3 months (range:1.1-30.5), age of 60 (range:37-86), KPS of 80 (range:60-100), and contrasted tumor volume (CTV) of 6.1cc (range:1.4-19.4). Histologies included NSCLC (44%), breast (24%), SCLC, melanoma, colon, and oroesophageal (&lt; 10% each). Sixty-three percent of patients underwent LITT alone, 18% had repeat SRS, while 27% had LITT+SRS (post-LITT SRS). Median time to index lesion progression was greatest in the LITT+SRS group compared to LITT alone or repeat SRS (&gt;23, 7.5, and 3.6 months, respectively [p=0.018]), as was overall survival (23.7, 5.9, and 7.0 months, respectively [p=0.023]). Age, sex, primary histology, CTV, and treatment strategy were univariate predictors of tumor progression; patients not treated with LITT+SRS were more likely to have index lesion progression (p=0.016). When controlling for histology and CTV in a multivariate model, patients not treated with LITT+SRS were significantly more likely to have progression (p=0.001). All LITT+SRS patients who experienced subsequent radiographic progression were diagnosed with recurrent tumor, while radiation necrosis incidence in the repeat SRS arm was 25%. CONCLUSION LITT+SRS appears superior to LITT alone or repeat SRS for treatment of biopsy-proven BM recurrence after SRS when controlling for other variables known to be predictive of progression. Prospective trials should be designed to validate the utility of combination LITT+SRS after SRS failure.

scholarly journals Negative 18F-FET PET/CT in brain metastasis recurrence: a teaching case report

2021 ◽  
Vol 5 (1) ◽  
Author(s):  
Samirah Alshehri ◽  
John Prior ◽  
Mohammed Moshebah ◽  
Luis Schiappacasse ◽  
Vincent Dunet
Keyword(s):  
Brain Metastasis ◽  
Radiation Necrosis ◽  
Brain Mri ◽  
False Negative ◽  
Therapy Outcomes ◽  
Fet Pet ◽  
Positron Emission ◽  
Pet Ct ◽  
Magnetic Resonance Imaging Mri

AbstractPositron emission tomography (PET) using O-(2-[18F]fluoroethyl)-L-tyrosine (18F-FET) PET has been shown to be a useful tool for differentiating radiation therapy outcomes, such as brain metastasis recurrence or radiation necrosis. We present the case of a female patient with brain metastases from pulmonary mucinous adenocarcinoma with suspicion of tumor recurrence on follow-up magnetic resonance imaging (MRI) after radiosurgery. 18F-FET PET/computed tomography (CT) was indicative of radiation necrosis. Due to the patient's medical history and the discrepancy between the brain MRI and PET/CT results, surgical biopsies were decided, which were positive for brain metastasis recurrence. The diagnosis of metastasis recurrence may also be challenging on 18F-FET PET/CT. In case of discrepancies between MRI and PET/CT results, false-negative 18F-FET PET/CT remains a possibility and requires careful follow-up or biopsy.

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