RADI-23. Exploring the optimal timing of routine initial surveillance MRI following treatment of brain metastases with stereotactic radiosurgery: a comparison of two approaches

Abstract Purpose To measure the value of early initial surveillance MRI scans in patients with brain metastases undergoing stereotactic radiosurgery (SRS), as MRI scans are a significant cost and patient stressor. Methods We identified a retrospective cohort of patients with brain metastases treated with SRS and followed at a single institution with scheduled 6-week or 12-week initial surveillance MRI. Imaging interval was based on policy of different providers. Outcome measures included new/progressive lesions, salvage treatment, detection of new lesions before symptoms, and use of surgical resection. Results Two hundred patients were included: 100 consecutive patients scanned with 6-week and 12-week imaging. Eighty-seven and 74 patients in each group had available follow-up imaging and were analyzed. Median time to MRI was 6.7 weeks and 13.5 (p<.001). No difference in primary site, prior SRS, number of treated brain metastases, or use of targeted therapy/immune checkpoint inhibitors was detected. A lower percentage of patients with 6-week MRI had controlled extracranial disease at initial treatment (30% vs 47%,p=.003). Twenty-eight percent with 6-week MRI had findings concerning for new/progressive disease, compared to 47% with 3-month MRI (p=0.01). Fifteen percent (10/87) with 6-week MRI underwent intervention (i.e. SRS, whole brain radiotherapy, or surgery) compared to 34% (20/74) with 12-week MRI (p=0.004). Of patients receiving SRS, a higher percentage had new/worsening neurologic symptoms (45% vs 30%) at follow-up although a lower percentage had new lesions >1cm (20% vs 50%) when discovered. One patient in each group underwent surgical salvage. Conclusion While shorter 6-week interval MRI surveillance post-SRS may detect new/progressive disease less frequently than 12-week MRI surveillance intervals, short interval MRI may be more likely to detect new/progressive lesions before symptoms develop. Surgical salvage was uncommon with either schedule. Further study may identify a high-risk subgroup who would benefit from early surveillance.

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

Neuro-Oncology ◽

10.1093/neuonc/noz175.242 ◽

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.

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Acute and subacute prostate MRI findings after MRI-guided transurethral ultrasound ablation of prostate cancer

Acta Radiologica ◽

10.1177/0284185120976931 ◽

2020 ◽

pp. 028418512097693

Author(s):

Pietari Mäkelä ◽

Mikael Anttinen ◽

Visa Suomi ◽

Aida Steiner ◽

Jani Saunavaara ◽

...

Keyword(s):

Prostate Cancer ◽

Diagnostic Value ◽

Optimal Timing ◽

Mri Findings ◽

Apparent Diffusion Coefficient Values ◽

Mri Scans ◽

Ultrasound Ablation ◽

Mri Guided ◽

Transurethral Ultrasound

Background Magnetic resonance imaging (MRI)-guided transurethral ultrasound ablation (TULSA) is an emerging method for treatment of localized prostate cancer (PCa). TULSA-related subacute MRI findings have not been previously characterized. Purpose To evaluate acute and subacute MRI findings after TULSA treatment in a treat-and-resect setting. Material and Methods Six men with newly diagnosed MRI-visible and biopsy-concordant clinically significant PCa were enrolled and completed the study. Eight lesions classified as PI-RADS 3–5 were focally ablated using TULSA. One- and three-week follow-up MRI scans were performed between TULSA and robot-assisted laparoscopic prostatectomy. Results TULSA-related hemorrhage was detected as a subtle T1 hyperintensity and more apparent T2 hypointensity in the MRI. Both prostate volume and non-perfused volume (NPV) markedly increased after TULSA at one week and three weeks after treatment, respectively. Lesion apparent diffusion coefficient values increased one week after treatment and decreased nearing the baseline values at the three-week MRI follow-up. Conclusion The optimal timing of MRI follow-up seems to be at the earliest at three weeks after treatment, when the post-procedural edema has decreased and the NPV has matured. Diffusion-weighted imaging has little or no added diagnostic value in the subacute setting.

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Survival of melanoma patients with brain metastases treated with ipilimumab combined with stereotactic radiosurgery.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.e20019 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. e20019-e20019

Author(s):

Karim Tazi ◽

Cody Chiuzan ◽

Keisuke Shirai

Keyword(s):

Overall Survival ◽

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Performance Status ◽

Survival Rates ◽

Stage Iv ◽

Rank Test ◽

Group A ◽

Stage Iv Melanoma

e20019 Background: Historically, melanoma with brain metastases has a poor prognosis and is a major contributor to patient morbidity and mortality. Recently, the use of ipilimumab has improved overall survival in stage IV melanoma; however, the outcome of patients with brain metastases remains unclear. In this retrospective medical record review, we report the outcome of patients with stage IV melanoma with brain metastases treated with ipilimumab and brain stereotactic radiosurgery (SRS). Methods: All patients with metastatic melanoma treated with ipilimumab from April 2010 to March 2012 were identified and stratified by presence (A) or absence (B) of brain metastases. All patients with brain metastases received SRS. Performance status, dates of stage IV diagnosis, brain SRS and cycle 1 of ipilimumab administration were recorded. We used the Disease Specific Graded Prognostic Assessment (DS-GPA) to estimate the predicted survival. Overall survival was defined as time (months) from the date of the stage IV diagnosis and the time of ipilimumab administration to death or last follow-up. Survival curves were estimated using the Kaplan-Meier method, and compared using a two-tailed log-rank test. Results: Twelve of 30 patients treated with ipilimumab had brain metastases. Median age was 66 years. Median DS-GPA score was 3 (estimated mean survival of 8.7 months). Four patients (33%) in group A and 6 patients (33%) in group B died as of last follow-up. Median number of SRS treatment was 1 (1 to 4), and median total treated lesions were 3 (1-14). Median survivals from date of Stage IV for A and B were 29.1 and 32.9 months, respectively (p=0.67). The estimated 2 year survival rates from date of cycle 1 ipilimumab administration for A and B were 58% (95% CI: 32-100%) and 55% (95% CI: 32-93%), respectively. Ten out of 12 patients in group A maintained an ECOG PS of 0-1 as of last follow-up. Conclusions: Survival of patients with melanoma brain metastases treated with ipilimumab combined with SRS may be comparable to patients without brain metastases. Ipilimumab and SRS do not seem to adversely impact quality of life.

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Limited Utility of Routine Surveillance MRI Following Chemoradiation for Advanced-Stage Oropharynx Carcinoma

International Journal of Otolaryngology ◽

10.1155/2010/904297 ◽

2010 ◽

Vol 2010 ◽

pp. 1-5 ◽

Cited By ~ 11

Author(s):

Gerald T. Kangelaris ◽

Sue S. Yom ◽

Kim Huang ◽

Steven J. Wang

Keyword(s):

Recurrent Disease ◽

Clinical Signs ◽

Surveillance Program ◽

Advanced Stage ◽

Asymptomatic Patients ◽

Routine Surveillance ◽

Oropharynx Carcinoma ◽

Mri Scans ◽

Mri Surveillance

Objectives. To determine the utility of routine surveillance MRI in detecting locoregional recurrence following definitive chemoradiation in advanced-stage oropharynx carcinoma.Methods. We identified patients with Stage III-IV oropharynx carcinoma who were treated with chemoradiation between April 2000 and September 2004 and underwent longitudinal followup care at our institution. Patient charts were retrospectively reviewed for findings on MRI surveillance imaging, clinical signs and symptoms, and recurrence.Results. Forty patients received a total of 229 surveillance MRI scans with a minimum follow-up of three years (mean of 5.6 scans per patient). Six patients experienced false-positive surveillance studies that resulted in intervention. Four patients experienced recurrent disease, two of whom had new symptoms or exam findings that preceded radiographic identification of disease. Surveillance MRI scans identified recurrent disease in two asymptomatic patients who were salvaged, one of whom remains free of disease at follow-up. The overall sensitivity and specificity of the MRI surveillance program were 50 and 83 percent, respectively. The mean charge to each patient for the surveillance program was approximately $10,000 annually.Conclusion. In oropharyngeal cancer patients who have been treated with chemoradiation, an imaging surveillance program utilizing MRI produces limited opportunity for successful salvage.

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Long-term Survival After Stereotactic Radiosurgery of Brain Metastases: A Case Series with 10-year Follow-up

Anticancer Research ◽

10.21873/anticanres.11930 ◽

2017 ◽

Vol 37 (9) ◽

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Case Series ◽

Term Survival ◽

Long Term Survival

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Stereotactic Radiosurgery for Recursive Partitioning Analysis Class II / III Lung Cancer Patients with Brain Metastases in the Modern Treatment Era

10.20944/preprints201809.0103.v1 ◽

2018 ◽

Author(s):

In Bong Ha ◽

Jin Ho Song ◽

Bae Kwon Jeong ◽

Hojin Jeong ◽

Yun Hee Lee ◽

...

Keyword(s):

Lung Cancer ◽

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Cancer Patients ◽

Recursive Partitioning ◽

Class Ii ◽

Lung Cancer Patients ◽

Primary Disease ◽

Modern Treatment

Stereotactic radiosurgery (SRS) is considered the initial treatment for lung cancer patients with small-sized and limited number of brain metastases. The objective of this study was to assess clinical outcomes of SRS treatment using CyberKnife (CK) for recursive partitioning analysis (RPA) class II/III patients with one to three brain metastases from lung cancer and identify which patients in the high RPA class could benefit from SRS. A total of 48 lung cancer patients who received CK-based SRS for their metastatic brain lesions from 2010 to 2017 were retrospectively analyzed. Radiographic response was evaluated during follow-up period. Overall survival (OS) and intracranial progression-free survival (IPFS) were calculated and prognostic variables associated with OS and IPFS were evaluated. Median follow-up time was 6.6 months. Local control rates at 6 months and 1-year following SRS were 98% and 92%, respectively. The median OS of all patients was 8 months. One-year and 2-year OS rates were 40.8% and 20.9%, respectively. In multivariate analysis, uncontrolled primary disease (p = 0.008) and ECOG performance status of 2 or 3 (p = 0.001) were independent prognostic factors for inferior OS. These two factors were also significantly associated with inferior IPFS. In subgroup analysis according to RPA class, primary disease status was the only prognostic factor, showing statistically significant OS differences in both RPA class II and III (controlled vs. uncontrolled: 41.1 vs. 12.3 months in RPA class II, p = 0.031; 26.9 vs. 4.1 months in RPA class III, p = 0.011). Our results indicated that SRS could be an effective treatment option for RPA class II/III patients with brain metastases from lung cancer in the modern treatment era. SRS might be particularly considered for patients with controlled primary disease.

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Delayed contrast and multiparametric MRI for treatment response assessment in brain metastases following stereotactic radiosurgery

Neuro-Oncology ◽

10.1093/neuonc/noab195.056 ◽

2021 ◽

Vol 23 (Supplement_4) ◽

pp. iv22-iv23

Author(s):

Markand Patel ◽

Dilina Rajapakse ◽

Jian Ping Jen ◽

Sara Meade ◽

Helen Benghiat ◽

...

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Treatment Response ◽

Sensitivity And Specificity ◽

Neuroendocrine Tumour ◽

Response Assessment ◽

Multiparametric Mri ◽

Treatment Response Assessment ◽

Measuring Signal

Abstract Aims Following stereotactic radiosurgery (SRS), brain metastases can increase in size in up to a third of cases. Conventional magnetic resonance imaging (MRI) has a limited role to distinguish between tumour recurrence and SRS-induced changes, which can impact patient management. Delayed contrast MRI treatment response assessment maps (TRAM) use the principle of contrast clearance seen in other tumours, where high vascularity shows a rapid rise in contrast as well as rapid clearance, whereas areas of damaged or low vascularity show accumulation of contrast. We aimed to assess the ability of delayed contrast MRI and multiparametric MRI techniques of diffusion-weighted imaging (DWI), perfusion-weighted imaging (PWI) and MR spectroscopy (MRS) to distinguish between radiation-related effects and tumour tissue, as these techniques assess tissue physiological and metabolic information. Method A retrospective review was performed on 23 patients who had delayed contrast and multiparametric MRI between October 2018 to April 2020. Studies were restricted to cases with brain metastases enlarging post-SRS with uncertainty at the MDT meeting regarding progression or treatment-related change, impacting the patient’s management. MRI was performed at 3T including DWI, PWI, MRS with short and intermediate echo times, and 3D T1 MPRAGE at 3-5, 20-30 and 70-90 minutes after administration of intravenous contrast. Contrast clearance analysis was performed by selecting an enhancing region of interest (ROI), measuring signal intensities at the three different timepoints and taking apparent diffusion coefficient (ADC) and relative cerebral blood volume (rCBV) values from the ROI. Choline/Creatine values were calculated from a single-voxel (10 mm isotropic) encompassing the entire contrast-enhancing lesion. Outcome was established from MRI follow-up at 6 months, with a stable or responding lesion considered treatment-related changes and increase considered progression. Results Across 23 patients, 24 metastases were assessed. Two patients were excluded as appropriate follow-up was not available. Sites of primary tumours included breast (n=8), lung (n=6), melanoma (n=4), neuroendocrine tumour from the lung (n=2) and renal cell carcinoma (n=2). Mean age was 56 years and 50% were female. In this cohort, 59% (n=13) were classified as having radiation-related changes on follow-up. Delayed MRI contrast clearance between the 3-5 and 70-90 minute imaging was significantly higher in cases of progression (23.6% vs. 2.5% decrease, p<0.05), as were the rCBV and Cho/Cr ratio (rCBV 3.1 vs. 1.5 and Cho/Cr ratio 2.3 vs. 1.4, p<0.05). Accuracy, sensitivity and specificity of using TRAM alone (contrast clearance decrease of >0%) for progression was 63%/100%/38%, PWI alone (rCBV cut-off 2.0) yielded results of 77%/75%/79% and for both Cho/Cr ratio alone (cut-off 1.8) and combined with TRAM, it was 90%/88%/92%. Neuroradiologist assessment of all techniques was 95%/100%/92%. Conclusion This study shows the effectiveness of delayed contrast and multiparametric MRI for treatment response assessment in patients with brain metastases treated by SRS in clinical practice. Although a delayed contrast MRI study is a very sensitive tool for detecting tumour progression, it lacks specificity. The accuracy of differentiating between tumour and treatment-related effects increases when delayed contrast MRI is used in combination with other advanced techniques such as MRS. By combining all these techniques, neuroradiologists had the highest accuracy, sensitivity and specificity for detecting progression in post-SRS brain metastases.

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RADI-32. INTRACRANIAL CONTROL AND RADIONECROSIS IN MELANOMA PATIENTS WITH BRAIN METASTASES TREATED WITH STEREOTACTIC RADIOSURGERY

Neuro-Oncology Advances ◽

10.1093/noajnl/vdz014.124 ◽

2019 ◽

Vol 1 (Supplement_1) ◽

pp. i28-i28

Author(s):

Michael Tjong ◽

Fabio Moraes ◽

David Shultz

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Local Control ◽

Brain Mri ◽

Lesion Size ◽

Kaplan Meier ◽

Prescription Dose ◽

Melanoma Patients ◽

The Brain

Abstract PURPOSE/OBJECTIVE(S): Melanoma commonly metastasizes to the brain and is radioresistant. Stereotactic radiosurgery (SRS) confers durable local control of brain metastases (BM) while maintaining neurocognitive function. These advantages are increasingly important as survival among these patients improves secondary to advances in systemic therapies. This study investigated the local control (LC), intracranial PFS (iPFS), freedom from radionecrosis (FFRN), and overall survival (OS) among melanoma patients receiving SRS for BM. MATERIALS/METHODS: We retrospectively reviewed clinical outcomes of melanoma patients with brain metastases treated with SRS between October 2008 and January 2017 in a large academic centre. Post-SRS, patients were followed in a multidisciplinary clinic with clinical examination and brain MRI every 3 months. Survival outcomes were estimated using the Kaplan-Meier method. RESULTS: In total, 97 patients with 283 brain metastases (including 12 surgical cavities) treated with SRS were identified. Median age was 60.5 (24.4–90.7). Median follow-up was 9.6 (2.2–74.7) months after first SRS. Median prescription dose was 21 (10–24) Gy delivered in a single fraction. Thirty (30.9%) patients had WBRT post-SRS, 36 (37.1%) patients had BRAF-positive disease. Per lesion (N=283), 1-year LC and FFRN were 84.4%, and 90.1%, respectively; medians were not achieved for either LC or FFRN. Radionecrosis (RN) occurred in 20 (7.1%) lesions. Per patient (N=97), median OS and iPFS were 16.0 and 5.3 months, respectively; 1-year OS and iPFS rates were 62.0%, and 30.1%, respectively. CONCLUSION: SRS resulted in excellent rates of LC, with a low risk of RN. However, most patients developed intracranial progression within 1 year. Further analyses to establish correlates (lesion size, SRS dose, and molecular status) to LC, FFRN, OS, and iPFS will be performed prior to the final presentation.

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