Predicting Tumor Control After Resection Bed Radiosurgery of Brain Metastases

Abstract BACKGROUND: Stereotactic radiosurgery (SRS) to the resection bed of a brain metastasis is an important treatment option. OBJECTIVE: To identify factors associated with tumor progression after SRS of the resection bed of a brain metastasis and to evaluate patterns of failure for patients who eventually had tumor progression. METHODS: We performed a retrospective analysis of 120 patients who underwent tumor bed radiosurgery after an initial gross total resection. The mean imaging follow-up time was 55 weeks. The median margin dose was 16 Gy. Forty-seven patients (39.2%) underwent whole-brain radiation therapy before or shortly after SRS. RESULTS: Local tumor control was achieved in 103 patients (85.8%). Progression-free survival was 96% at 6 months, 87% at 12 months, and 74% at 24 months. Recurrence most commonly occurred deep in the cavity (65%) outside the planned treatment volume (PTV) margin (53%). PTV, cavity diameter, and a margin dose < 16 Gy significantly correlated with local failure. For patients with PTVs ≥ 8.0 cm3, local progression-free survival declined to 93% at 6 months, 83% at 12 months, and 65% at 24 months. Development or progression of distant metastases occurred in 40% of patients. Whole-brain radiation therapy was not associated with improved local control. CONCLUSION: Resection bed SRS for brain metastases provided excellent local control. The cavity PTV is predictive of tumor control. Because failure usually occurs outside the PTV, inclusion of a judicious 2- to 3-mm margin beyond the area of postoperative enhancement may be prudent.

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The Role of Radiosurgery to the Tumor Bed After Resection of Brain Metastases

Neurosurgery ◽

10.1227/neu.0b013e31827fcd60 ◽

2012 ◽

Vol 72 (3) ◽

pp. 317-326 ◽

Cited By ~ 45

Author(s):

Jared H. Gans ◽

Daniel M.S. Raper ◽

Ashish H. Shah ◽

Amade Bregy ◽

Deborah Heros ◽

...

Keyword(s):

Systematic Review ◽

Overall Survival ◽

Radiation Therapy ◽

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Local Control ◽

Total Resection ◽

Whole Brain Radiation ◽

Brain Radiation

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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NCOG-05. MANAGEMENT OF BRAIN METASTASIS IN TRIPLE NEGATIVE BREAST CANCER

Neuro-Oncology ◽

10.1093/neuonc/noaa215.544 ◽

2020 ◽

Vol 22 (Supplement_2) ◽

pp. ii130-ii130

Author(s):

Ravi Medikonda ◽

Siddhartha Srivastava ◽

Timothy Kim ◽

Yuanxuan Xia ◽

Mira Patel ◽

...

Keyword(s):

Breast Cancer ◽

Overall Survival ◽

Radiation Therapy ◽

Brain Metastasis ◽

Brain Metastases ◽

Triple Negative Breast Cancer ◽

Triple Negative ◽

Whole Brain ◽

Whole Brain Radiation ◽

Brain Radiation

Abstract Brain metastasis is common in patients with breast cancer, and those with triple negative status have an even higher risk. Stereotactic radiosurgery (SRS) is preferred to whole brain radiation therapy (WBRT) in most patients. However, triple negative status is currently not considered when determining optimal radiation therapy. Given the aggressive nature of triple negative breast cancer, we evaluated a role for WBRT for all patients in this cohort. We conducted a single-institution retrospective cohort study to determine whether triple negative patients with brain metastases have a higher burden of intracranial disease and whether type of initial radiation therapy affects overall survival for this cohort of patients. 85 patients met the inclusion criteria for this study. 25% of patients had triple negative breast cancer, of which 91% received SRS and 53% of patients received WBRT. The average number of new brain metastases from time of initial brain imaging to radiation therapy was 0.67 (St.Dev:1.1) in the non-triple negative status patients and 2.6 (St. Dev:3.7) in the triple negative status patients (p=0.001). Using a cox proportional hazards model, it was found that whole brain radiotherapy does not significantly affect overall survival in patients with triple negative breast cancer (p = 0.96). Our findings highlight the highly aggressive intracranial nature of triple negative breast cancer. Indeed, the rate of increase in brain metastases is significantly higher for triple negative patients compared to non-triple negative patients. As a result, we evaluated whether triple negative patients would benefit from whole brain radiation regardless of findings on initial brain imaging. Despite 53% of patients receiving WBRT, our investigation found that there is no additional benefit to WBRT in triple negative breast cancer patients. These results suggest a need to re-evaluate the role of WBRT in the management of triple negative breast cancer.

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Results of Whole Brain Radiation Therapy in Patients with Brain Metastases from Colorectal Carcinoma

Tumori Journal ◽

10.1177/030089160509100211 ◽

2005 ◽

Vol 91 (2) ◽

pp. 163-167 ◽

Cited By ~ 22

Author(s):

Maurizio Amichetti ◽

Giancarlo Lay ◽

Marina Dessì ◽

Silvia Orrù ◽

Roberta Farigu ◽

...

Keyword(s):

Colorectal Cancer ◽

Radiation Therapy ◽

Brain Metastasis ◽

Brain Metastases ◽

Survival Time ◽

Whole Brain Radiation Therapy ◽

Whole Brain ◽

Whole Brain Radiation ◽

Brain Radiation ◽

The Brain

Aims and background Carcinoma of the colon-rectum is an infrequent cause of brain metastases, constituting 1-5% of all metastatic lesions to the brain. We reviewed our experience in the treatment of brain metastases from colorectal cancer to define the efficacy of whole brain radiation therapy as a palliative measure in this setting of patients. Methods Twenty-three consecutive cases of brain metastasis from colorectal cancer treated between 1999 and 2004 were identified in the files of the Division of Radiotherapy of the A Businco Regional Oncological Hospital, Cagliari. Their records were reviewed for patient and tumor characteristics and categorized according to the RTOG RPA classes. Results Fifteen patients (65%) had multiple metastases. Twenty-one patients (91%) showed extracranial metastases. Fourteen patients were classified as RTOG RPA class II and 9 class III. The median radiation dose delivered was 2000 cGy in 5 fractions in one week (range, 20-36 Gy). In 14 of 20 assessable patients (70%), symptomatic improvement was observed. The median follow-up and survival time for all the patients, 12 females and 11 males, was 3 months. In 3 patients only the cause of death was the brain metastasis. Conclusions Despite the disappointing survival time, external radiation therapy to the whole brain proved to be an efficacious palliative treatment for patients with multiple or inoperable brain metastasis from colorectal cancer.

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A Prospective Phase II Trial of Fractionated Stereotactic Intensity Modulated Radiotherapy With or Without Surgery in the Treatment of Patients With 1 to 3 Newly Diagnosed Symptomatic Brain Metastases

Neurosurgery ◽

10.1227/neu.0000000000000325 ◽

2014 ◽

Vol 74 (6) ◽

pp. 586-594 ◽

Cited By ~ 5

Author(s):

Mario Ammirati ◽

Varun R. Kshettry ◽

Tariq Lamki ◽

Lai Wei ◽

John C. Grecula

Keyword(s):

Overall Survival ◽

Confidence Interval ◽

Brain Metastases ◽

Phase Ii ◽

Progression Free Survival ◽

Newly Diagnosed ◽

Free Survival ◽

Intensity Modulated ◽

Whole Brain Radiation ◽

Brain Radiation

ABSTRACT BACKGROUND: Several studies have demonstrated that omitting the routine use of adjuvant whole-brain radiation therapy for patients with newly diagnosed brain metastases may be a reasonable first-line strategy. Retrospective evidence suggests that fractionated stereotactic radiotherapy (fSRT) may have a lower level of toxicity with equivalent efficacy in comparison with radiosurgery. OBJECTIVE: To study the phase II efficacy of using a focally directed treatment strategy for symptomatic brain metastases by the use of fSRT with or without surgery and omitting the routine use of adjuvant whole-brain radiation therapy. METHODS: We used a Fleming single-stage design of 40 patients. Patients were eligible if they presented with 1 to 3 newly diagnosed symptomatic brain metastases, Karnofsky performance scale (KPS) greater than 60, and histological confirmation of primary disease. Patients underwent fSRT with the use of a dose of 30 Gy in 5 intensity-modulated fractions as primary or adjuvant treatment after surgical resection. The primary end point was the proportion of patients who experienced neurological death. Secondary end points were overall survival, time to KPS <70, and progression-free survival. RESULTS: Of 40 patients accrued, 39 were eligible for analysis. The proportion of patients dying of neurological causes was 13% (5 patients), which includes 3 patients with an unknown cause of death. Median overall survival, time to KPS <70, and progression-free survival were 16 (95% confidence interval, 9-23), 14 (95% confidence interval, 7-20), and 11 (95% confidence interval, 4-21) months, respectively. CONCLUSION: A focally directed treatment strategy using fSRT with or without surgery appears to be an effective initial strategy. Based on the results of this phase II clinical trial, further study is warranted.

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Quality-of-life trajectories after stereotactic radiosurgery for brain metastases

Journal of Neurosurgery ◽

10.3171/2020.4.jns20788 ◽

2020 ◽

pp. 1-9

Author(s):

Adomas Bunevicius ◽

Karen Lavezzo ◽

Leah Shabo ◽

Jesse McClure ◽

Jason P. Sheehan

Keyword(s):

Quality Of Life ◽

Radiation Therapy ◽

Brain Metastasis ◽

Brain Metastases ◽

Cancer Patients ◽

Whole Brain Radiation ◽

Anxiety Depression ◽

Brain Radiation

OBJECTIVEQuality of life (QOL) is an important endpoint measure of cancer treatment. The authors’ goal was to evaluate QOL trajectories and prognostic value in cancer patients treated with stereotactic radiosurgery (SRS) for brain metastases.METHODSPatients who underwent Gamma Knife radiosurgery (GKRS) between January 2016 and November 2019 were prospectively evaluated for QOL using the EQ-5D-3L questionnaire before SRS and at follow-up visits. Only patients who had pre-SRS and at least 1 post-SRS QOL assessment were considered.RESULTSFifty-four cancer patients underwent 109 GKRS procedures. The first post-SRS visit was at a median of 2.59 months (range 0.13–21.08 months), and the last post-SRS visit was at 14.72 months (range 2.52–45.21 months) after SRS. There was no statistically significant change in the EQ-5D index score (p = 0.539) at the first compared with last post-SRS visit. The proportion of patients reporting some problems on the EQ-5D dimension of self-care increased during the course of follow-up from 9% (pre-SRS visit) to 18% (last post-SRS visit; p = 0.03). The proportion of patients reporting problems on the EQ-5D dimensions of mobility, usual activities, pain/discomfort, and anxiety/depression remained stable during the course of follow-up (p ≥ 0.106). After adjusting for clinical variables, a higher recursive partitioning analysis (RPA) class (i.e., worse prognostic category) was independently associated with greater odds for EQ-5D index score deterioration (p = 0.050). Upfront whole-brain radiation therapy predicted deterioration of the EQ-5D self-care (p = 0.03) and usual activities (p = 0.024) dimensions, while a greater number of lesions predicted deterioration of the EQ-5D anxiety/depression dimension (p = 0.008). A lower pre-SRS EQ-5D index was associated with shorter survival independently from clinical and demographic variables (OR 18.956, 95% CI 2.793–128.64; p = 0.003).CONCLUSIONSQOL is largely preserved in brain metastasis patients treated with SRS. Higher RPA class, upfront whole-brain radiation therapy, and greater intracranial disease burden are independent predictors of post-SRS QOL deterioration. Worse pre-SRS QOL predicts shorter survival. Assessment of QOL is recommended in brain metastasis patients managed with SRS.

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Results of Gamma Knife Surgery alone for Brain Metastases : Indications for and Limitations of Local Treatment Protocol without Prophylactic Whole Brain Radiation Therapy( Current Management of Brain Metastasis)

Japanese Journal of Neurosurgery ◽

10.7887/jcns.16.833 ◽

2007 ◽

Vol 16 (11) ◽

pp. 833-839

Author(s):

Toru Serizawa ◽

Osamu Nagano ◽

Yoshinori Higuchi ◽

Toshio Machida ◽

Koichi Okiyama ◽

...

Keyword(s):

Radiation Therapy ◽

Brain Metastasis ◽

Brain Metastases ◽

Gamma Knife ◽

Local Treatment ◽

Treatment Protocol ◽

Special Issue ◽

Current Management ◽

Whole Brain Radiation ◽

Brain Radiation

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Linear Accelerator Radiosurgery in the Treatment of Brain Metastases

Neurosurgery ◽

10.1227/01.neu.0000141084.28973.76 ◽

2004 ◽

Vol 55 (5) ◽

pp. 1076-1085 ◽

Cited By ~ 18

Author(s):

Arthur J. Ulm ◽

William A. Friedman ◽

Frank J. Bova ◽

Patrick Bradshaw ◽

Robert J. Amdur ◽

...

Keyword(s):

Radiation Therapy ◽

Brain Metastases ◽

Local Control ◽

Linear Accelerator ◽

Whole Brain Radiation Therapy ◽

Tumor Type ◽

Whole Brain ◽

Regional Control ◽

Whole Brain Radiation ◽

Brain Radiation

Abstract OBJECTIVE: To review a 12-year experience treating metastatic brain disease with linear accelerator-based stereotactic radiosurgery (SRS). METHODS: We performed a retrospective analysis of all patients treated between 1989 and 2001 with linear accelerator radiosurgery for brain metastases. Patients were followed up both clinically and with imaging studies to document local control, regional control, and survival. Demographic data, dosing parameters, number of lesions, histology, history of whole-brain radiation therapy, and other factors were obtained prospectively. Cox proportional-hazards regression with multivariate and univariate analysis was performed with Stata 8.0 software. RESULTS: A total of 383 patients received SRS for brain metastases during the study interval. Median survival was 9 months. Patients with tumor-type melanoma or multiple metastatic lesions had decreased survival. Actuarial 1-year local control was 75%. Differences in regional control rates were not statistically significant between patients treated with SRS and whole-brain radiation therapy versus SRS alone. CONCLUSION: Radiosurgery is an effective and safe method for treating selected patients with brain metastases.

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