scholarly journals Cesium-131 brachytherapy for recurrent brain metastases: durable salvage treatment for previously irradiated metastatic disease

2017 ◽  
Vol 126 (4) ◽  
pp. 1212-1219 ◽  
Author(s):  
A. Gabriella Wernicke ◽  
Andrew W. Smith ◽  
Shoshana Taube ◽  
Menachem Z. Yondorf ◽  
Bhupesh Parashar ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Whole Brain Radiotherapy ◽  
Total Activity ◽  
Median Number ◽  
Salvage Treatment ◽  
Cavity Surface ◽  
Tumor Diameter ◽  
Resection Cavity ◽  
Brain Radiotherapy ◽  
Resected Tumor

OBJECTIVE Managing patients whose intraparenchymal brain metastases recur after radiotherapy remains a challenge. Intraoperative cesium-131 (Cs-131) brachytherapy performed at the time of neurosurgical resection may represent an excellent salvage treatment option. The authors evaluated the outcomes of this novel treatment with permanent intraoperative Cs-131 brachytherapy. METHODS Thirteen patients with 15 metastases to the brain that recurred after stereotactic radiosurgery and/or whole brain radiotherapy were treated between 2010 and 2015. Stranded Cs-131 seeds were placed as a permanent volume implant. Prescription dose was 80 Gy at 5-mm depth from the resection cavity surface. The primary end point was resection cavity freedom from progression (FFP). Resection cavity freedom from progression (FFP), regional FFP, distant FFP, median survival, overall survival (OS), and toxicity were assessed. RESULTS The median duration of follow-up after salvage treatment was 5 months (range 0.5–18 months). The patients' median age was 64 years (range 51–74 years). The median resected tumor diameter was 2.9 cm (range 1.0–5.6 cm). The median number of seeds implanted was 19 (range 10–40), with a median activity per seed of 2.25 U (range 1.98–3.01 U) and median total activity of 39.6 U (range 20.0–95.2 U). The 1-year actuarial local FFP was 83.3%. The median OS was 7 months, and 1-year OS was 24.7%. Complications included infection (3), pseudomeningocele (1), seizure (1), and asymptomatic radionecrosis (RN) (1). CONCLUSIONS After failure of prior irradiation of brain metastases, re-irradiation with intraoperative Cs-131 brachytherapy implants provides durable local control and limits the risk of RN. The authors' initial experience demonstrates that this treatment approach is well tolerated and safe for patients with previously irradiated tumors after failure of more than 1 radiotherapy regimen and that it results in excellent response rates and minimal toxicity.

scholarly journals RADI-21. STEREOTACTIC RADIOSURGERY FOR 10 OR MORE BRAIN METASTASES PROVIDES EXCELLENT RATES OF INTRACRANIAL DISEASE CONTROL WITH SUPERIOR HIPPOCAMPAL SPARING

2019 ◽  
Vol 1 (Supplement_1) ◽  
pp. i25-i26
Author(s):  
Matthew Susko ◽  
Michael Garcia ◽  
Lijun Ma ◽  
Jean Nakamura ◽  
David Raleigh ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Radiation Effect ◽  
Whole Brain Radiotherapy ◽  
Median Number ◽  
Salvage Treatment ◽  
Single Institution ◽  
Brain Radiotherapy ◽  
Metastatic Lesions ◽  
Hippocampal Sparing

Abstract BACKGROUND: Recent evidence supports hippocampal sparing during whole brain radiotherapy (HS-WBRT) to improve neurocognitive outcomes in patients with brain metastases (BM). This study sought to quantify the hippocampal dosimetry and treatment efficacy of stereotactic radiosurgery (SRS) to 10 or greater BM to clarify the roles of SRS and WBRT. METHODS: Patients at a single institution treated with SRS to 10 or more BM without WBRT from 1999 to 2016 were retrospectively reviewed. Treatment-related outcomes including overall survival (OS), freedom from progression (FFP), freedom from new metastases (FFNM), and adverse radiation effect (ARE) were quantified. Hippocampal volumes were retrospectively delineated and dosimetry was evaluated in patients treated with upfront SRS. RESULTS: 143 patients with a total of 2198 lesions met criteria for inclusion with 75 patients treated with upfront SRS and 68 treated as salvage from prior WBRT. Median age was 57 (IQR: 46–65) and median KPS 80 (IQR: 70–90). Histologies included breast (n=52), lung (n=49), melanoma (n=30), and other (n=12). Median number of lesions per patient was 13 (IQR 11–17) with median total volume of treatment of 4.1 cc (IQR 2.0–9.9). 12-month FFP per lesion for upfront and salvage treatment was 96.8% (95% CI: 95.5–98.1) and 83.6% (95% CI: 79.9–87.5) respectively (p < 0.001). 12-month FFNM for upfront and salvage FFSRS was 18.8% (95% CI: 10.9–32.3) versus 19.2% (95% CI: 9.7–37.8) respectively (p = 0.90). Mean hippocampal dose was 150 cGy (IQR 100–202). Symptomatic ARE was observed in 2% of patients or 1% of treated lesions. CONCLUSIONS: High rates of local control can be achieved when treating patients with greater than 10 BM with hippocampal doses that are dramatically lower than for HS-WBRT. Hippocampal sparing is readily achievable with expected rates of new metastatic lesions developing in treated patients with low rates of symptomatic ARE.

scholarly journals Phase I/II study of resection and intraoperative cesium-131 radioisotope brachytherapy in patients with newly diagnosed brain metastases

2014 ◽  
Vol 121 (2) ◽  
pp. 338-348 ◽  
Author(s):  
A. Gabriella Wernicke ◽  
Menachem Z. Yondorf ◽  
Luke Peng ◽  
Samuel Trichter ◽  
Lucy Nedialkova ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Radiation Treatment ◽  
Radiation Necrosis ◽  
High Response Rate ◽  
High Rate ◽  
Csf Leak ◽  
Cavity Surface ◽  
Newly Diagnosed ◽  
Resection Cavity ◽  
Resected Tumor

Object Resected brain metastases have a high rate of local recurrence without adjuvant therapy. Adjuvant whole-brain radiotherapy (WBRT) remains the standard of care with a local control rate > 90%. However, WBRT is delivered over 10–15 days, which can delay other therapy and is associated with acute and long-term toxicities. Permanent cesium-131 (131Cs) implants can be used at the time of metastatic resection, thereby avoiding the need for any additional therapy. The authors evaluated the safety, feasibility, and efficacy of a novel therapeutic approach with permanent 131Cs brachytherapy at the resection for brain metastases. Methods After institutional review board approval was obtained, 24 patients with a newly diagnosed metastasis to the brain were accrued to a prospective protocol between 2010 and 2012. There were 10 frontal, 7 parietal, 4 cerebellar, 2 occipital, and 1 temporal metastases. Histology included lung cancer (16), breast cancer (2), kidney cancer (2), melanoma (2), colon cancer (1), and cervical cancer (1). Stranded 131Cs seeds were placed as permanent volume implants. The prescription dose was 80 Gy at a 5-mm depth from the resection cavity surface. Distant metastases were treated with stereotactic radiosurgery (SRS) or WBRT, depending on the number of lesions. The primary end point was local (resection cavity) freedom from progression (FFP). Secondary end points included regional FFP, distant FFP, median survival, overall survival (OS), and toxicity. Results The median follow-up was 19.3 months (range 12.89–29.57 months). The median age was 65 years (range 45–84 years). The median size of resected tumor was 2.7 cm (range 1.5–5.5 cm), and the median volume of resected tumor was 10.31 cm3 (range 1.77–87.11 cm3). The median number of seeds used was 12 (range 4–35), with a median activity of 3.82 mCi per seed (range 3.31–4.83 mCi) and total activity of 46.91 mCi (range 15.31–130.70 mCi). Local FFP was 100%. There was 1 adjacent leptomeningeal recurrence, resulting in a 1-year regional FFP of 93.8% (95% CI 63.2%–99.1%). One-year distant FFP was 48.4% (95% CI 26.3%–67.4%). Median OS was 9.9 months (95% CI 4.8 months, upper limit not estimated) and 1-year OS was 50.0% (95% CI 29.1%–67.8%). Complications included CSF leak (1), seizure (1), and infection (1). There was no radiation necrosis. Conclusions The use of postresection permanent 131Cs brachytherapy implants resulted in no local recurrences and no radiation necrosis. This treatment was safe, well tolerated, and convenient for patients, resulting in a short radiation treatment course, high response rate, and minimal toxicity. These findings merit further study with a multicenter trial.

Evaluation of Stereotactic Radiotherapy of the Resection Cavity After Surgery of Brain Metastases Compared to Postoperative Whole-Brain Radiotherapy (ESTRON)—A Single-Center Prospective Randomized Trial

Neurosurgery ◽  
2018 ◽  
Vol 83 (3) ◽  
pp. 566-573 ◽  
Author(s):  
Rami A El Shafie ◽  
Angela Paul ◽  
Denise Bernhardt ◽  
Henrik Hauswald ◽  
Thomas Welzel ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiotherapy ◽  
Randomized Study ◽  
Whole Brain Radiotherapy ◽  
Progression Free Survival ◽  
Locoregional Control ◽  
Single Center ◽  
Whole Brain ◽  
Resection Cavity ◽  
Brain Radiotherapy

Abstract BACKGROUND Neurosurgical resection is recommended for symptomatic brain metastases, in oligometastatic patients or for histology acquisition. Without adjuvant radiotherapy, roughly two-thirds of the patients relapse at the resection site within 24 mo, while the risk of new metastases in the untreated brain is around 50%. Adjuvant whole-brain radiotherapy (WBRT) can reduce the risk of both scenarios of recurrence significantly, although the associated neurocognitive toxicity is substantial, while stereotactic radiotherapy (SRT) improves local control at comparably low toxicity. OBJECTIVE To compare locoregional control and treatment-associated toxicity for postoperative SRT and WBRT after the resection of 1 brain metastasis in a single-center prospective randomized study. METHODS Fifty patients will be randomized to receive either hypofractionated SRT of the resection cavity and single- or multisession SRT of all unresected brain metastases (up to 10 lesions) or WBRT. Patients will be followed-up regularly and the primary endpoint of neurological progression-free survival will be assessed by magnetic resonance imaging (MRI). Quality of life and neurocognition will be assessed in 3-mo intervals using standardized tests and EORTC questionnaires. EXPECTED OUTCOMES We expect to show that postoperative SRT of the resection cavity and further unresected brain metastases is a valid means of improving locoregional control over observation at less neurocognitive toxicity than caused by WBRT. DISCUSSION The present study is the first to compare locoregional control as well as neurocognitive toxicity for postoperative SRT and WBRT in patients with up to 10 metastases, while utilizing a highly sensitive and standardized MRI protocol for treatment planning and follow-up.

scholarly journals Is local radiotherapy a viable option for patients with an opening of the ventricles during surgical resection of brain metastases?

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Sophia Scharl ◽  
Kerstin A. Kessel ◽  
Christian Diehl ◽  
Jens Gempt ◽  
Bernhard Meyer ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Surgical Resection ◽  
Local Treatment ◽  
Whole Brain Radiotherapy ◽  
Standard Of Care ◽  
Neurological Impairment ◽  
Distant Recurrence ◽  
Tumor Bed ◽  
Resection Cavity ◽  
Brain Radiotherapy

Abstract Background Local hypofractionated stereotactic radiotherapy (HFSRT) of the resection cavity is emerging as the standard of care in the treatment of patients with a limited number of brain metastases as it warrants less neurological impairment compared to whole brain radiotherapy. In periventricular metastases surgical resection can lead to an opening of the ventricles and subsequently carries a potential risk of cerebrospinal tumour cell dissemination. The aim of this study was to assess whether local radiotherapy of the resection cavity is viable in these cases. Methods From our institutional database we analyzed the data of 125 consecutive patients with resected brain metastases treated in our institution with HFSRT between 2009 and 2017. The incidence of LMD, overall survival (OS), local recurrence (LC) and distant recurrence were evaluated depending on ventricular opening (VO) during surgery. Results From all 125 patients, the ventricles were opened during surgery in 14 cases (11.2%). None of the patients with VO and 7 patients without VO during surgery developed LMD (p = 0.371). OS (p = 0.817), LC (p = 0.524) and distant recurrence (p = 0.488) did not differ in relation to VO during surgical resection. However, the incidence of distant intraventricular recurrence was slightly increased in patients with VO (14.3% vs. 2.7%, p < 0.01). Conclusion VO during neurosurgical resection did not affect the outcome after HFSRT of the resection cavity in patients with brain metastases. Particularly, the incidence of LMD was not increased in patients receiving local HFSRT after VO. HFSRT can therefore be offered independently of VO as a local treatment of tumor bed after resection of brain metastases.

Poor prognostic indicators for patients treated with radiosurgery for brain metastases.

2016 ◽  
Vol 34 (26_suppl) ◽  
pp. 32-32 ◽  
Author(s):  
Michael A Garcia ◽  
Wendy Anderson ◽  
Shannon E. Fogh ◽  
Jean L. Nakamura ◽  
Philip Theodosopoulos ◽  
...  
Keyword(s):  
Brain Metastases ◽  
San Francisco ◽  
Karnofsky Performance Status ◽  
Performance Status ◽  
Whole Brain Radiotherapy ◽  
Median Number ◽  
Prognostic Indicators ◽  
Imaging Data ◽  
Primary Tumors ◽  
Brain Radiotherapy

32 Background: Radiosurgery (SRS) is a standard palliative treatment for patients with limited number of brain metastases. Growing evidence supports the use of SRS for more extensive disease. As SRS is increasingly used in advanced cancer, we sought to identify predictors of survival after SRS to help better inform patients about prognosis. Methods: We reviewed patients treated with SRS for brain metastases at the University of California, San Francisco (UCSF) from Jan 2010-Dec 2013. Before SRS, all patients were screened for appropriateness of SRS at a multidisciplinary conference. Post-SRS overall survival (OS) was estimated by Kaplan-Meier method and compared by log-rank tests. Frequencies of death within 30 days of SRS were compared by chi-squared tests. Results: Demographic and imaging data was available for 326 SRS patients. At SRS consult, 90% patients were Karnofsky Performance Status (KPS) ≥ 70. Median number of brain metastases at consult was 2 (range 1-37). Median follow up was 13 months. Median OS after SRS was 11 months. Median OS was shorter for patients with KPS < 70 (4 months) compared to those with KPS ≥ 70 (12 months) (p < 0.001). Overall, frequency of death within 30 days of SRS was 5.4%. Within 30 days of SRS, 13% of patients with KPS < 70 died compared to 3.8% with KPS ≥ 70 (p = 0.03). Death within 30 days of SRS was more common among patients with uncontrolled (10%) versus controlled primary tumors (3%) (p = 0.02). Both uncontrolled primary tumor and KPS < 70% were associated with death within 30 days of SRS on multivariate analysis (p = 0.02 and p = 0.03, respectively). Patients with both KPS < 70 and uncontrolled primary tumors had frequency of death within 30 days of 29%. Factors not associated with death within 30 days were age, extracranial metastatic disease burden, histology, number of brain metastases, prior whole brain radiotherapy, SRS, or neurosurgery. Conclusions: Death within 30 days of SRS within the UCSF cohort is uncommon, likely due to multidisciplinary screening for patients expected to live long enough to benefit from SRS. Most patients who die within 30 days of SRS have both KPS < 70 and uncontrolled primary tumors. The potential for poor prognosis should be discussed with these patients during shared-decision making.

scholarly journals Incidence of Hippocampal Metastases: Laterality and Implications for Unilateral Hippocampal Avoiding Whole Brain Radiotherapy

2018 ◽  
Vol 2018 ◽  
pp. 1-7 ◽  
Author(s):  
Tomas Kazda ◽  
Adela Misove ◽  
Petr Burkon ◽  
Petr Pospisil ◽  
Ludmila Hynkova ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Verbal Memory ◽  
Statistical Significance ◽  
Primary Tumour ◽  
Whole Brain Radiotherapy ◽  
Median Number ◽  
Whole Brain ◽  
Brain Radiotherapy ◽  
Significant Difference ◽  
Left And Right

Introduction. Hippocampi sparing whole brain radiotherapy (WBRT) is an evolving approach in the treatment of patients with multiple brain metastases, pursuing mitigation of verbal memory decline as a consequence of hippocampal radiation injury. Accumulating data are showing different postradiotherapy changes in the left and right hippocampus with a theoretical proposal of only unilateral (dominant, left) hippocampal sparing during WBRT. Method. The aim of this retrospective study is to describe spatial distribution of brain metastases on MRI in a cohort of 260 patients (2595 metastases) and to evaluate distribution separately in the left and right hippocampus and in respective hippocampal avoiding zones (HAZ, region with subtherapeutic radiation dose), including evaluation of location of metastatic mass centre. Results. The median number of brain metastases was three, with lung cancer being the most common type of primary tumour; 36% had single metastasis. Almost 8% of patients had metastasis within hippocampus (1.1% of all metastases) and 18.1% of patients within HAZ (3.3% of all metastases). No statistically significant difference was observed in the laterality of hippocampal involvement, also when the location of centre of metastases was analyzed. There were more patients presenting the centre of metastasis within left (15) versus right (6) HAZ approaching the borderline of statistical significance. Conclusion. No significant difference in the laterality of BM seeding within hippocampal structures was observed. The hypothesized unilateral sparing WBRT would have theoretical advantage in about 50% reduction in the risk of subsequent recurrence within spared regions.

Prognostic factors and survival after whole-brain radiotherapy for initial brain metastases arising from non-small cell lung cancer

2021 ◽  
pp. 1-6
Author(s):  
Yukinori Okada ◽  
Mariko Kobayashi ◽  
Mio Shinozaki ◽  
Tatsuyuki Abe ◽  
Naoki Nakamura
Keyword(s):  
Prognostic Factors ◽  
Brain Metastasis ◽  
Brain Metastases ◽  
Gene Mutation ◽  
Stage Iv ◽  
Whole Brain Radiotherapy ◽  
Hazard Ratio ◽  
Small Cell Lung ◽  
Mutation Status ◽  
Brain Radiotherapy

Abstract Aim: To identify prognostic factors and investigate patient survival after whole-brain radiotherapy (WBRT) for initial brain metastases arising from non-small cell lung cancer (NSCLC). Methods: Patients diagnosed with NSCLC between 1 January 2010 and 30 September 2019, and who received WBRT upon first developing a brain metastasis, were investigated. Overall survival was determined as related to age, sex, duration between initial examination and brain metastasis detection, stage at the first examination, presence of metastases outside the brain, blood analysis findings, brain metastasis symptoms, radiotherapy dose and completion, imaging findings, therapeutic course of chemotherapy and/or radiation therapy, histological type, and gene mutation status. Results: Thirty-one consecutive patients (20 men and 11 women) with a mean age of 63·8 years and median survival of 129 days were included. Multivariate analysis with stepwise testing was performed to investigate differences in survival according to gene mutation status, lactate dehydrogenase (LDH) level, irradiation dose, WBRT completion and Stage status. Of these, a statistically significant difference in survival was observed in patients with gene mutation status (hazard ratio: 0·31, 95% CI: 0·11–0·86, p = 0·025), LDH levels <230 vs. ≥230 IU/L (hazard ratio: 4·08, 95% CI: 1·45–11·5, p < 0·01) received 30 Gy, 30 Gy/10 fractions to 35 Gy/14 fractions, and 37·5 Gy/15 fractions (hazard ratio: 0·26, 95% CI: 0·09–0·71, p < 0·01), and stage IV versus non-stage IV (hazard ratio: 0·13, 95 CI:0·02–0·64, p < 0·01) Findings: Gene mutation, LDH, radiation dose and Stage are prognostic factors for patients with initial brain metastases who are treated with WBRT.

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