scholarly journals Changing practice patterns of Gamma Knife versus linear accelerator-based stereotactic radiosurgery for brain metastases in the US

2016 ◽  
Vol 124 (4) ◽  
pp. 1018-1024 ◽  
Author(s):  
Henry S. Park ◽  
Elyn H. Wang ◽  
Charles E. Rutter ◽  
Christopher D. Corso ◽  
Veronica L. Chiang ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Gamma Knife ◽  
Linear Accelerator ◽  
Multivariable Analysis ◽  
Multivariable Logistic Regression Analysis ◽  
Single Fraction ◽  
Cancer Data ◽  
The Us ◽  
The Impact

OBJECT Single-fraction stereotactic radiosurgery (SRS) is a crucial component in the management of limited brain metastases from non-small cell lung cancer (NSCLC). Intracranial SRS has traditionally been delivered using a frame-based Gamma Knife (GK) platform, but stereotactic modifications to the linear accelerator (LINAC) have made an alternative approach possible. In the absence of definitive prospective trials comparing the efficacy and toxicities of treatment between the 2 techniques, nonclinical factors (such as technology accessibility, costs, and efficiency) may play a larger role in determining which radiosurgery system a facility may choose to install. To the authors’ knowledge, this study is the first to investigate national patterns of GK SRS versus LINAC SRS use and to determine which factors may be associated with the adoption of these radiosurgery systems. METHODS The National Cancer Data Base was used to identify patients > 18 years old with NSCLC who were treated with single-fraction SRS to the brain between 2003 and 2011. Patients who received “SRS not otherwise specified” or who did not receive a radiotherapy dose within the range of 12–24 Gy were excluded to reduce the potential for misclassification. The chi-square test, t-test, and multivariable logistic regression analysis were used to compare potential demographic, clinicopathologic, and health care system predictors of GK versus LINAC SRS use, when appropriate. RESULTS This study included 1780 patients, among whom 1371 (77.0%) received GK SRS and 409 (23.0%) underwent LINAC SRS. Over time, the proportion of patients undergoing LINAC SRS steadily increased, from 3.2% in 2003 to 30.8% in 2011 (p < 0.001). LINAC SRS was adopted more rapidly by community versus academic facilities (overall 29.2% vs 17.2%, p < 0.001). On multivariable analysis, 4 independent predictors of increased LINAC SRS use emerged, including year of diagnosis in 2008–2011 versus 2003–2007 (adjusted OR [AOR] 2.04, 95% CI 1.52–2.73, p < 0.001), community versus academic facility type (AOR 2.04, 95% CI 1.60–2.60, p < 0.001), non-West versus West geographic location (AOR 4.50, 95% CI 2.87–7.09, p < 0.001), and distance from cancer reporting facility of < 20 versus ≥ 20 miles (AOR 1.57, 95% CI 1.21–2.04, p = 0.001). CONCLUSIONS GK remains the most commonly used single-fraction SRS modality for NSCLC brain metastases in the US. However, LINAC-based SRS has been rapidly disseminating in the past decade, especially in the community setting. Wide geographic variation persists in the distribution of GK and LINAC SRS cases. Further comparative effectiveness research will be needed to evaluate the impact of these shifts on SRS-related toxicities, local control, and survival, as well as treatment costs and efficiency.

scholarly journals RTHP-06. IMPACT OF THE AMERICAN TAX PAYER RELIEF ACT ON STEREOTACTIC RADIOSURGERY UTILIZATION IN THE UNITED STATES

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi211-vi211
Author(s):  
Shearwood McClelland III ◽  
Catherine Degnin ◽  
Yiyi Chen ◽  
Gordon Watson ◽  
Jerry Jaboin
Keyword(s):  
United States ◽  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Gamma Knife ◽  
The United States ◽  
National Cancer Data Base ◽  
Federal Law ◽  
Cancer Data ◽  
Whole Brain Radiation ◽  
The Us

Abstract INTRODUCTION For brain metastases, single-fraction stereotactic radiosurgery (SRS) spares appropriately chosen patients from the invasiveness of operative intervention and the permanent cognitive morbidity of whole brain radiation. SRS is delivered predominantly via two modalities: Gamma Knife, and linear accelerator (LINAC). The implementation of the American Tax Payer Relief Act (ATRA) in 2013 represented the first time limitations specifically targeting SRS reimbursement were introduced into federal law. The subsequent impact of the ATRA on SRS utilization in the United States (US) has yet to be examined. METHODS The National Cancer Data Base (NCDB) from 2010–2016 identified brain metastases patients from non-small cell lung cancer (NSCLC) throughout the US having undergone SRS. Utilization between GKRS and LINAC was assessed before (2010–2012) versus after (2013–2016) ATRA implementation. Utilization was adjusted for several variables, including patient demographics and healthcare system characteristics. RESULTS From 2012 to 2013, there was a substantial decrease of LINAC SRS in favor of GKRS overall (37% to 28%) and individually in both academic and non-academic centers. Over the three-year span immediately preceding ATRA implementation, 65.8% received GKRS and the remaining 34.2% receiving LINAC. In the four years immediately following ATRA implementation 68.0% received GKRS compared with 32% receiving LINAC; these differences were not statistically significant. CONCLUSIONS ATRA implementation in 2013 caused an initial spike in Gamma Knife SRS utilization, followed by a steady decline, similar to rates prior to implementation. These findings are indicative that the ATRA provision mandating Medicare reduction of outpatient payment rates for Gamma Knife to be equivalent with those of LINAC SRS had a significant short-term impact on the radiosurgical treatment of metastatic brain disease throughout the US. Such findings should serve as a reminder of the importance and impact of public policy on treatment modality utilization by physicians and hospitals.

scholarly journals Gamma Knife versus Frameless Linear Accelerator Based Stereotactic Radiosurgery for Brain Metastases: Clinical Outcomes and Factors Associated with Local Failure and Radiation Necrosis

2021 ◽  
Author(s):  
Gregory S. Alexander ◽  
Jill S. Remick ◽  
Emily S. Kowalski ◽  
Kai Sun ◽  
Yannick Poirer ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Clinical Outcomes ◽  
Gamma Knife ◽  
Linear Accelerator ◽  
Radiation Necrosis ◽  
Univariate Analysis ◽  
Local Failure ◽  
Rank Test ◽  
Chi Square Analysis

Abstract BackgroundSingle-fraction stereotactic radiosurgery (SF-SRS) for the treatment of brain metastases can be delivered with either a Gamma-Knife platform (GK-SRS) or with a frameless linear accelerator (LA-SRS) which vary based on patterns of prescribing, patient setup and radiation delivery. Whether these differences affect clinical outcomes is unknown. MethodsPatients treated for metastatic brain cancer treated with SF-SRS from 2014-2020 were retrospectively reviewed and clinical outcomes were recorded on a per lesion basis. Covariates between groups were compared using a Chi-square analysis for dichotomous variables and t-test for continuous variables. Median follow up was calculated using the reverse Kaplan Meier (KM) method. Primary endpoints of local failure (LF) and symptomatic radiation necrosis (RN) were estimated using the KM method with salvage WBRT used as a censoring event. Outcome estimates were compared using the log-rank test. Multivariate analysis (MVA) and Cox proportional hazards modeling were used for statistical analyses. Propensity score (PS) adjustments were used to reduce the effects confounding variables.ResultsOverall, 119 patients with 287 lesions were included for analysis which included 57 patients (127 lesions) treated with LA-SRS compared to 62 patients (160 lesions) treated with GK-SRS. On both multivariate and univariate analysis, there was no statistically significant differences between GK-SRS and LA-SRS for LF, RN, or the combined endpoint of either LF or RN (multivariate p-value=0.17).ConclusionsIn our retrospective cohort, we found no statistically significant differences in the incidence of RN or LF in patients treated with GK-SRS when compared to LA-SRS.Trial Registration: Retrospectively registered

Single-fraction Stereotactic Radiosurgery Outcomes for Brain Metastases with Frameless Gamma Knife ICON Radiosurgery

2020 ◽  
Vol 108 (2) ◽  
pp. E29
Author(s):  
Elizabeth Buss ◽  
Horia Vulpe ◽  
Judith Jacobson ◽  
Akshay Save ◽  
Oscar Padilla ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Gamma Knife ◽  
Single Fraction

scholarly journals Three-staged stereotactic radiosurgery for brain metastases: a single institution experience

2021 ◽  
Vol 23 (Supplement_4) ◽  
pp. iv20-iv21
Author(s):  
Hamoun Rozati ◽  
Ian Paddick ◽  
Ian Sabin
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Correlation Coefficient ◽  
Gamma Knife ◽  
P Value ◽  
Percentage Reduction ◽  
Single Fraction ◽  
Mixed Response ◽  
Third Stage

Abstract Aims Stereotactic radiosurgery (SRS) using the Leksell Gamma Knife system is a commonly used modality for the treatment of brain metastases (BMs). As the size of the target volume (TV) increases, so too does the dose of radiation delivered to surrounding healthy tissue. Large BMs are therefore a contraindication to the use of SRS. Critical organs adjacent to the TV may also be a contraindication to SRS. Staged SRS was proposed as a novel method of delivering three SRS treatments at a reduced radiation dose with a gap of two weeks between each session as a way of shrinking the TV. This allows treatment of TVs otherwise considered untreatable with standard, single-fraction SRS. Little data exists in the literature as to its efficacy. The objective of this study was to evaluate the efficacy of this novel approach and to identify factors which may predict treatment failure. Method A retrospective analysis was undertaken at a single, tertiary Gamma Knife centre. All patients who underwent treatment of their BMs with three-staged Gamma Knife SRS from January 2014 to December 2020 were identified and included. Patient demographics and primary cancer status was ascertained. SRS treatment details for each lesion were collected, including TV, dose and dosimetric data. The percentage reduction in volume of the TVs between the first and second stage, the second and third stage and the first and third stage were calculated. Follow-up data was collected to include follow-up imaging, further intracranial treatments received and survival status. The percentage reduction in volume between each stage was demonstrated on box-and-whisker plots. Statistical significance in reduction in TV between each stage was ascertained by paired samples T-tests. Correlation between initial TV size and percentage reduction post-SRS was determined by a correlation coefficient. Differences were deemed significant with p-values &lt;0.05. Results 12 patients with 14 staged BMs were identified and included. The median age was 61.5 (range 45-79). Seven had a primary malignancy of breast cancer, five non-small cell lung cancer, one melanoma and one colorectal. Median follow-up was 140.5 days (range 10-821). Median TV was 7.44cc (range 1.14-21.53). All TVs received 10Gy at each stage. The median percentage reduction in size of the TV was 7.41% between 1st-2nd stage (range -16.0-42.49%, p-value 0.06), 19.47% between 2nd-3rd stage (range -5.38-53.53%, p-value &lt;0.01) and 24.25% between 1st-3rd stage (range 10.69-68.67%, p-value &lt;0.01). The correlation coefficient between initial TV size and percentage reduction post-SRS was -0.41 (p-value 0.07). 13/14 lesions showed a partial response on first follow-up scan post-SRS, 1/14 lesions showed a mixed response. One patient died 184 days from completion of treatment but without intracranial progression. Two patients had salvage intracranial surgery, 154 and 536 days from completion of treatment respectively. Conclusion Three-staged Gamma Knife is shown to be effective at shrinking the TV and can therefore be used to treat lesions otherwise considered unsuitable for SRS. The presence of extra-cranial metastases did not predict for poor outcomes. Though local control with SRS is thought to diminish with increasing TV size, all staged lesions showed a reduction in size between first and last treatment, and no significant effect was seen between initial TV size and percentage reduction in TV. No patients experienced disease progression on first follow up scan, with 13 of 14 lesions showing disease response. There were only two cases of intracranial progression, with one occurring 536 days post-SRS. Though limited by small numbers and short median follow up period, our data demonstrate encouraging results for three-stage SRS for lesions otherwise unsuitable for single fraction treatment, and should lead to further study.

scholarly journals Prognostic grading system specifically for elderly patients with brain metastases after stereotactic radiosurgery: a 2-institution study

2018 ◽  
Vol 129 (Suppl1) ◽  
pp. 95-102 ◽  
Author(s):  
Masaaki Yamamoto ◽  
Toru Serizawa ◽  
Yoshinori Higuchi ◽  
Osamu Nagano ◽  
Hitoshi Aiyama ◽  
...  
Keyword(s):  
Elderly Patients ◽  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Gamma Knife ◽  
Tumor Volume ◽  
Multivariable Analysis ◽  
Selection Procedure ◽  
Grading System ◽  
Survival Times ◽  
Related Factors

OBJECTIVEWith the aging of the population, increasing numbers of elderly patients with brain metastasis (BM) are undergoing stereotactic radiosurgery (SRS). Among recently reported prognostic grading indexes, only the basic score for brain metastases (BSBM) is applicable to patients 65 years or older. However, the major weakness of this system is that no BM-related factors are graded. This prompted the authors to develop a new grading system, the elderly-specific (ES)–BSBM.METHODSFor this IRB-approved, retrospective cohort study, the authors used their prospectively accumulated database comprising 3267 consecutive patients undergoing Gamma Knife SRS for BMs during the 1998–2016 period at the Mito GammaHouse. Among these 3267 patients, 1789 patients ≥ 65 years of age were studied (Yamamoto series [Y-series]). Another series of 1785 patients ≥ 65 years of age in whom Serizawa and colleagues performed Gamma Knife SRS during the same period (Serizawa series [S-series]) was used for validity testing of the ES-BSBM.RESULTSTwo factors were identified as strongly impacting longer survival after SRS by means of multivariable analysis using the Cox proportional hazard model with a stepwise selection procedure. These factors are the number of tumors (solitary vs multiple: HR 1.450, 95% CI 1.299–1.621; p < 0.0001) and cumulative tumor volume (≤ 15 cm3 vs > 15 cm3: HR 1.311, 95% CI 1.078–1.593; p = 0.0067). The new index is the addition of scores 0 and 1 for these 2 factors to the BSBM. The ES-BSBM system is based on categorization into 3 classes by adding these 2 scores to those of the original BSBM. Each ES-BSBM category has 2 possible scores. For the category ES-BSBM 4–5, the score is either 4 or 5; for ES-BSBM 2–3, the score is either 2 or 3; and for ES-BSBM 0–1, the score is either 0 or 1. In the Y-series, the median survival times (MSTs, months) after SRS were 17.5 (95% CI 15.4–19.3) in ES-BSBM 4–5, 6.9 (95% CI 6.4–7.4) in ES-BSBM 2–3, and 2.8 (95% CI 2.5–3.6) in ES-BSBM 0–1 (p < 0.0001). Also, in the S-series, MSTs were, respectively, 20.4 (95% CI 17.2–23.4), 7.9 (95% CI 7.4–8.5), and 3.2 (95% CI 2.8–3.6) (p < 0.0001). The ES-BSBM system was shown to be applicable to patients with all primary tumor types as well as to those 80 years or older.CONCLUSIONSThe authors found that the addition of the number of tumors and cumulative tumor volume as scoring factors to the BSBM system significantly improved the prognostic value of this index. The present study is strengthened by testing the ES-BSBM in a different patient group.

scholarly journals RTHP-12. NATIONWIDE DISTRIBUTION OF LINEAR ACCELERATOR VERSUS GAMMA KNIFE STEREOTACTIC RADIOSURGERY UTILIZATION FOR METASTATIC BRAIN DISEASE IN ACADEMIC VERSUS COMMUNITY HOSPITALS

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi212-vi212
Author(s):  
Shearwood McClelland III ◽  
Catherine Degnin ◽  
Yiyi Chen ◽  
Gordon Watson ◽  
Jerry Jaboin
Keyword(s):  
United States ◽  
Stereotactic Radiosurgery ◽  
Gamma Knife ◽  
Linear Accelerator ◽  
The United States ◽  
Brain Disease ◽  
Treatment Modalities ◽  
Academic Hospital ◽  
Cancer Data ◽  
Academic Hospitals

Abstract INTRODUCTION Single-fraction stereotactic radiosurgery (SRS) is often the preferred treatment modality for metastatic brain disease, particularly when patients have a small enough volume of disease to preclude whole brain radiation therapy and its associated permanent cognitive morbidity. The two predominant SRS treatment modalities are Gamma Knife and linear accelerator (LINAC). The recent impact of SRS modality in academic versus community hospital settings in the United States (US) since the 2013 implementation of the American Tax Payer Relief Act (ATRA) has yet to be examined. METHODS Brain metastases patients from non-small cell lung cancer (NSCLC) throughout the United States having undergone SRS were identified using the 2010–2016 National Cancer Data Base (NCDB). SRS utilization in academic versus community (non-academic) hospitals was identified and assessed. RESULTS Of the 4,012 SRS patients examined, the majority (64%) were treated at academic hospitals. Beginning in 2014, LINAC SRS rapidly increased in popularity compared to GKRS, reversing an annual decline in utilization originating from 2011. The 63% LINAC composition of SRS cases at non-academic centers in 2016 was an all-time high, a 12% increase from a year earlier. This was markedly different than SRS utilization at academic hospitals, where despite a steady increase in LINAC SRS since 2013, GKRS remained the predominant SRS modality, comprising 73% of cases in 2016. CONCLUSIONS The implementation of LINAC over Gamma Knife SRS in the non-academic hospital setting has markedly increased in the timespan since ATRA implementation, comprising more than 60% of SRS cases compared to only 27% of academic hospital SRS cases in 2016. These findings indicate that without the substantially increased Medicare reimbursement advantage formerly associated with Gamma Knife compared to LINAC prior to ATRA, the non-academic setting may be more sensitive than academic centers to conditions optimizing reimbursement.

scholarly journals RTHP-10. PREDICTORS OF LINEAR ACCELERATOR VERSUS GAMMA KNIFE STEREOTACTIC RADIOSURGERY USE FOR BRAIN METASTASES IN THE UNITED STATES

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi212-vi212
Author(s):  
Shearwood McClelland III ◽  
Catherine Degnin ◽  
Yiyi Chen ◽  
Gordon Watson ◽  
Jerry Jaboin
Keyword(s):  
United States ◽  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Gamma Knife ◽  
Linear Accelerator ◽  
Radiation Treatment ◽  
The United States ◽  
Treatment Facility ◽  
Southern Us ◽  
To Receive

Abstract INTRODUCTION Stereotactic radiosurgery (SRS) for brain metastases is predominantly delivered via single-fraction Gamma Knife SRS (GKRS) or linear accelerator (LINAC) in 1–5 fractions. Predictors of SRS modality have been sparsely examined on a nationwide level. METHODS The 2010–2016 National Cancer Database identified brain metastases patients from non-small cell lung cancer throughout the United States (US) having undergone SRS. A multivariable logistic regression model characterized SRS receipt, adjusting for patient age, dose, geographic location of treatment, facility type, and distance from treatment facility. RESULTS A total of 1,760 patients received GKRS, while 1,064 patients received LINAC SRS. Treatment at non-academic facilities was associated with increased LINAC SRS receipt, most prominently in the Midwestern (OR= 6.23; p< 0.001), Northeastern (OR= 4.42; p< 0.001), and Southern US (OR= 1.96;p< 0.001). Administered doses of 18–19 Gy (OR= 1.42;p= 0.025), 20–21 Gy (OR= 1.82;p< 0.001), and 22–24 Gy (OR= 3.11;p< 0.001) were associated with increased LINAC SRS receipt, as was patient location within 20 miles of a radiation treatment facility (OR= 1.27;p= 0.007). CONCLUSIONS Despite Gamma Knife being more prominently used over LINAC for SRS, patients treated at non-academic facilities outside of the Western US were substantially more likely to receive LINAC over Gamma Knife. Patients located in the Midwest were 523% more likely, Northeast 342% more likely, and South 96% more likely to receive LINAC when treated at a non-academic facility. Increasing dose independently predicted LINAC over GKRS, indicating that smaller tumors – particularly those less than two centimeters (consistent with RTOG 90-05 recommendations) – are being treated with LINAC. Finally, patients residing in close proximity to a treatment center were 27% more likely to receive LINAC, likely indicative of the increased geographic accessibility of LINAC compared with GKRS. These findings should result in hypothesis-generating questions to further explore predictors of LINAC versus GKRS.

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