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

Neurosurgery ◽  
2003 ◽  
Vol 53 (2) ◽  
pp. 272-281 ◽  
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.

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 >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 >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 RADI-27. ROLE OF STEREOTACTIC RADIOSURGERY IN THE CARE OF PATIENTS WITH >/= 25 CUMULATIVE BRAIN METASTASES

2019 ◽  
Vol 1 (Supplement_1) ◽  
pp. i27-i27
Author(s):  
Carolina Benjamin ◽  
Monica Mureb ◽  
Bernadine Donahue ◽  
Erik Sulman ◽  
Joshua Silverman ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Tumor Volume ◽  
Median Number ◽  
Median Dose ◽  
Total Tumor Volume ◽  
Whole Brain Radiation ◽  
Brain Radiation

Abstract INTRODUCTION: Stereotactic radiosurgery (SRS) is an accepted treatment for multiple brain metastases. However, the upper limit of the number of brain metastases over the course of care suitable for this approach is controversial. METHODS: From a review of our prospective registry, 48 patients treated with SRS for ≥ 25 brain metastases in either single or multiple sessions between 2013 and 2019 were identified. Patient, tumor, and treatments characteristics were evaluated. Clinical outcomes and overall survival (OS) were analyzed. RESULTS: Thirty-one females (64.6%) and 17 males (35.4%) with a median age of 56 years (25–91) were included. Primary diagnoses included lung (n=23, 47.9%), breast (n=13, 27.1%), melanoma (n=8, 16.7%), and other (n=4, 8.33%). Initial median GPA index was 2 (0.5–3). Nine patients (18.8%) had received whole brain radiation therapy (WBRT) prior to first SRS treatment, with a median dose of 35Gy (30–40.5Gy). Ten patients (20.8%) received WBRT after initial SRS, with a median dose of 30Gy (20-30Gy). Thus, only 19 patients (40%) ever received WBRT. Median number of radiosurgeries per patient was 3 (1–12). Median number of cumulative tumors irradiated was 31 (25–110). Median number of tumors irradiated at first SRS was 10 (1–35). Median marginal dose for the largest tumor per session was 16Gy (10-21Gy). Median SRS total tumor volume was 6.8cc (0.8–23.4). Median follow-up since initial SRS was 16 months (1–71). At present, 21 (43.7%) are alive. Median OS from the diagnosis of brain metastases was 31 months (2–97), and OS from the time of first SRS, 22 months (1–70). Median KPS at first SRS and last follow-up was the same (90). Sixty-three percent did not require a corticosteroid course. CONCLUSION: In selected patients with a large number of cumulative brain metastases (≥ 25), SRS is effective and safe. Therefore, WBRT may not be required in this population.

The Volumetric Response of Brain Metastases After Stereotactic Radiosurgery and Its Post-treatment Implications

Neurosurgery ◽  
2013 ◽  
Vol 74 (1) ◽  
pp. 9-16 ◽  
Author(s):  
Suzanne R. Sharpton ◽  
Eric K. Oermann ◽  
Dominic T. Moore ◽  
Eric Schreiber ◽  
Riane Hoffman ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Local Control ◽  
Tumor Volume ◽  
Neurological Symptoms ◽  
Volume Reduction ◽  
Whole Brain Radiation ◽  
Local Progression ◽  
Tumor Volume Reduction

Abstract BACKGROUND: Changes in tumor volume are seen on magnetic resonance imaging within weeks after stereotactic radiosurgery (SRS), but it remains unclear what clinical outcomes early radiological changes portend. OBJECTIVE: We hypothesized that rapid, early reduction in tumor volume post-SRS is associated with prolonged local control and favorable clinical outcome. METHODS: A retrospective review of patients treated with CyberKnife SRS for brain metastases at the University of North Carolina from 2007 to 2009 was performed. Patients with at least 1 radiological follow-up, minimal initial tumor volume of 0.1 cm3, no previous focal radiation, and no recent whole-brain radiation therapy were eligible for inclusion. RESULTS: Fifty-two patients with 100 metastatic brain lesions were analyzed and had a median follow-up of 15.6 months (range, 2-33 months) and a median of 2 (range, 1–8) metastatic lesions. In treated metastases in which there was a significant tumor volume reduction by 6 or 12 weeks post-SRS, there was no local progression for the duration of the study. Furthermore, patients with metastases that did not reduce in volume by 6 or 12 weeks post-SRS were more likely to require corticosteroids (P = .01) and to experience progression of neurological symptoms (P = .003). CONCLUSION: Significant volume reductions of brain metastases measured at either 6 or 12 weeks post-SRS were strongly associated with prolonged local control. Furthermore, early volume reduction was associated with less corticosteroid use and stable neurological symptoms.

The Energy Index Does Not Affect Local Control of Brain Metastases Treated by Gamma Knife Stereotactic Radiosurgery

Neurosurgery ◽  
2015 ◽  
Vol 77 (1) ◽  
pp. 119-125 ◽  
Author(s):  
Ashish Jani ◽  
Tzlil Rozenblat ◽  
Andrew M. Yaeh ◽  
Tavish Nanda ◽  
Shumaila Saad ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Brain Metastases ◽  
Gamma Knife ◽  
Local Control ◽  
Tumor Volume ◽  
Complete Response ◽  
Local Failure ◽  
Energy Index ◽  
Prescription Dose

Abstract BACKGROUND: The energy index (EI) is a measure of dose homogeneity within a target volume calculated by the integral dose divided by the product of prescription dose and tumor volume. OBJECTIVE: To assess whether a higher EI is associated with greater local control for brain metastases (BMs) treated by Gamma Knife radiosurgery (GKRS). METHODS: We reviewed all patients treated with GKRS for BM at our institution between January 2009 and February 2014. Data on the prescription dose, prescription isodose line, minimum dose, mean dose, integral dose, tumor volume, and EI were collected. Tumor response was assessed by reviewing follow-up brain imaging studies and classified according to the Response Evaluation Criteria in Solid Tumors. Local control per lesion and dosimetric prognostic factors for local control were assessed by univariate and multivariate Cox proportional hazards regression analyses. RESULTS: Of 213 patients treated, 126 had follow-up imaging available with a median follow-up of 6 months. Three hundred seventy-three individual tumors were analyzed. Of these, 133 showed a complete response, 157 showed a partial response, 46 remained stable, and 37 developed local failure. Tumors with EI ≥1.6 mJ.mL−1.Gy−1 showed a higher rate of complete response. Local control rates at 6, 11, and 17 months were 95.4%, 86.5%, and 81.5%, respectively. On univariate analysis, the following factors were associated with higher rates of local failure: prescription doses of 16 and 18 Gy compared with a prescription dose of 20 Gy. The following factors were associated with a greater rate of local control: maximum dose and mean dose. On multivariate analysis, the only statistically significant factor associated with a greater rate of local failure was prescription dose of 16 Gy compared with 20 Gy. CONCLUSION: GKRS for BM results in a high rate of local control with an 11-month rate of 86.5%. A higher EI was not significantly associated with a higher rate of local control on multivariate analysis. Prescription dose was found to be the only significant predictor of local control on multivariate analysis.

scholarly journals SURG-10. The evolving role of neurosurgery for central nervous system metastases in the era of personalized medicine

2021 ◽  
Vol 3 (Supplement_3) ◽  
pp. iii25-iii25
Author(s):  
Philipp Karschnia ◽  
Emilie Le Rhun ◽  
Stefan J Grau ◽  
Matthias Preusser ◽  
Riccardo Soffietti ◽  
...  
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Personalized Medicine ◽  
Brain Metastasis ◽  
Brain Metastases ◽  
Surgical Resection ◽  
Current Status ◽  
Unknown Primary ◽  
Mixed Response

Abstract Background Novel therapies translating into improved survival of patients with advanced cancer have emerged. The number of metastases in the central nervous system is therefore seen to increase. Neurosurgery assumes an expanding role within multi-disciplinary care structures for such patients. Methods We performed a comprehensive literature review on the current status of neurosurgery for brain metastases patients. Based on the extracted data, we developed a review from experts in the field on the role of brain metastasis surgery in the era of personalized medicine. Results Traditionally, three metastases were considered the cutoff to offer surgical resection. With respect to the clinical status, the resection of a symptomatic mass may nowadays be considered even in presence of multiple tumors in a multimodal setting: surgical resection of brain metastasis provides immediate relief from mass effect-related symptoms and histology in case of unknown primary tumor; surgery may help stabilizing the disease, thus enabling further therapy; and in situations where immunotherapy is considered and non-surgical management would require long-term steroid administration, surgery may also provide expeditious relief of edema and reduction of needs for steroids. In patients with multiple brain metastasis and mixed response to non-surgical therapy, tumor resampling may allow tissue analysis for expression of molecular tumor targets. In patients with leptomeningeal dissemination and consecutive hydrocephalus, ventriculo-peritoneal shunting improves quality of life but also allows for time to administer more therapy thus prolonging survival. Addressing the limited efficacy of many oncological drugs for brain metastases, clinical trial protocols in which surgical specimens are analyzed for pre-surgically administered agents may offer pharmacodynamic insights. Conclusion Comprehensive neurosurgical care will have to be an integral element of multi-disciplinary oncological centres providing care to patients with brain metastases to improve on therapy and tumour biology research.

scholarly journals Prognostic Factors Influencing Outcomes of High Tibial Osteotomy in The Varus Knee: The Role of The Deformity

2020 ◽  
Vol 8 (7_suppl6) ◽  
pp. 2325967120S0046
Author(s):  
Carola Pilone ◽  
Federico Verdone ◽  
Roberto Rossi ◽  
Davide Bonasia ◽  
Federica Rosso
Keyword(s):  
Prognostic Factors ◽  
Regression Model ◽  
High Tibial Osteotomy ◽  
Womac Score ◽  
Tibial Osteotomy ◽  
Varus Knee ◽  
Inclusion Criteria ◽  
Opening Wedge

Objectives: High Tibial Osteotomy (HTO) is widely performed to treat early arthiritis in the varus knee. The aim of this prospective study is to evaluate different prognostic factors affecting the outcomes of HTO and, with special attention to the role of the site of deformity. Methods: 231 Opening Wedge HTO (OWHTO) were performed in 202 patients and included in the study. Inclusion criteria were: 1) age > 18 years, 2) no major associated procedures (i.e. ACL reconstruction, major cartilage procedure, 3) only OWHTO, 4) pre-operative complete clinical and radiological evaluation available. Patients were evaluated with (1) the Knee Society score (KSS), (2) the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, (3) another self-evaluation scale, (4) long-leg radiographs, and (5) plain radiographs. On the x-ray different angles were evaluated, including Join Line Congruence Angle. Furthermore, the location of deformity was established. Three main outcomes were identified: Indication to Total Knee Arthroplasty (TKA), KSS poor or fair and WOMAC < 76 points), and different prognostic factors were identified (Fig. 1). All the variables were firstly tested in a single regression model to evaluate the association with each outcome. All the variables with p<0.1 were re-tested in a multiple regression model. Results: 32 patients were lost to follow-up and 31 patients did not meet the inclusion criteria, leaving 139 patients (156 OWHTOs) for the study. The average age was 52.9 ± 9.6 years, and the average follow-up was 97.7 ± 42.8 months. Post-operatively there was a significant improvement in both the KSS and WOMAC score compared to the pre-operative period (p<0.0001). The only variable related to TKA indication was a pre-operative JLCA ≥5° (OR=24.3, p=0.0483). Conversely, different variables were related to a worse KSS, including pre-operative BMI >30 Kg/m2 (OR=78.9, p=0.0028), pre-operative ROM <120° of flexion (OR=40.8, p=0.0421), pre-operative mLDFA ≥91° (OR=36,6,p=0.0401) and femoral pre-operative CORA ≥3° of varus (OR=39,9 p=0.0269). Furthermore, a pre-operative BMI >30 Kg/m2 (OR=29,5, p=0.0314) was associated to a worse WOMAC score. Conversely, patients with a pre-operative mMPTA ≤84° had lower risk to obtain a worse KSS oe WOMAC score (respectively OR= 0,2 p=0.0364 and OR=0,3 p=0.0071). The cumulative survivorship was calculated with the Kaplan-Meier method, and it resulted equal to 98.6% at 5 years and decreased to 85.5% at 10 years. Conclusion: OWHTO is a good treatment for early arthritis in the varus knee if the correct indications are applied. The outcomes can be considered good, with 85% of 10-year survivorship. It is mandatory to correctly address the location of the deformity, because the presence of a femoral varus deformity is related to worse outcomes. Similarly, presence of a pre-operative JLCA ≥5° is the only factor associated to TKA indication. [Table: see text]

scholarly journals Selective dorsal rhizotomy for spasticity not associated with cerebral palsy: reconsideration of surgical inclusion criteria

2013 ◽  
Vol 35 (5) ◽  
pp. E6 ◽  
Author(s):  
William C. Gump ◽  
Ian S. Mutchnick ◽  
Thomas M. Moriarty
Keyword(s):  
Cerebral Palsy ◽  
Spinal Cord Injuries ◽  
Spastic Diplegia ◽  
Inclusion Criteria ◽  
Selective Dorsal Rhizotomy ◽  
Dorsal Rhizotomy ◽  
Common Diagnosis

Children with spastic diplegia from cerebral palsy (CP) experience measurable improvement in their spasticity and motor function following selective dorsal rhizotomy (SDR). The role of this operation in the treatment of other spasticity causes is less well defined. A literature review was undertaken to survey outcomes from SDRs performed outside the CP population. Multiple sclerosis was the most common diagnosis found, accounting for 74 of 145 patients described. Selective dorsal rhizotomies have also been reported in patients with traumatic brain and spinal cord injuries, ischemic and hemorrhagic stroke, neurodegenerative disease, hypoxic encephalopathy, and other causes of spasticity. Outcomes from surgery are generally described as favorable, although postoperative assessments and follow-up times are not standardized across reports. Long-term outcomes are sparsely reported. Larger numbers of patients and more detailed outcomes data have the potential to form a basis for expanding the inclusion criteria for SDR.

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

2016 ◽  
Vol 18 (suppl_4) ◽  
pp. iv46-iv47
Author(s):  
F. Pessina ◽  
P. Navarria ◽  
A. Ascolese ◽  
L. Cozzi ◽  
S. Tomatis ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Local Control ◽  
Large Brain ◽  
Control Evaluation ◽  
Supramarginal Resection

Stifle arthrodesis using a locking plate system in six dogs

2015 ◽  
Vol 28 (04) ◽  
pp. 288-293 ◽  
Author(s):  
T. Nicetto ◽  
M. Petazzoni
Keyword(s):  
Body Weight ◽  
Medical Records ◽  
Tibial Fracture ◽  
Locking Plate ◽  
Sagittal Plane ◽  
Inclusion Criteria ◽  
Radiographic Outcomes ◽  
Locking Plate System ◽  
Plate System

SummaryObjectives: To describe the use of the Fixin locking plate system for stifle arthrodesis in dogs and to retrospectively report the clinical and radiographic outcomes in six cases.[uni2028]Materials and methods: Medical records of dogs that had arthrodesis with the Fixin locking plate system were reviewed. For each patient, data pertaining to signalment and implant used were recorded. Plate series and thickness, number of screws placed, number of cortices engaged, and screw diameters were also recorded. The outcome was determined from clinical and radiographic followups. Radiographic outcomes assessed included the measurement of the postoperative femoral-tibial angle in the sagittal plane.Results: Six dogs met the inclusion criteria for the study. Mean body weight was 13 kg (range: 3 - 34 kg). Radiographic follow-up (mean: 32 weeks, range: 3 - 52 weeks) was available for all dogs. In one case, an intra-operative complication occurred. In another case, a tibial fracture occurred 20 days after surgery. All arthrodeses healed and no implant complication was detected although all cases had mechanical lameness.Clinical significance: Stifle arthrodesis can be performed successfully using a Fixin locking plate system.

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.

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