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Koori N, Kamekawa H, Mukawa N, Fuse H, Miyakawa S, Yasue K, Takahashi M, Yamada M, Henmi A, Kusumoto T, Kurata K. Relationship between imaging parameters and distortion in magnetic resonance images for gamma knife treatment planning. J Appl Clin Med Phys 2023; 24:e14205. [PMID: 37975638 PMCID: PMC10691626 DOI: 10.1002/acm2.14205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/27/2023] [Accepted: 10/23/2023] [Indexed: 11/19/2023] Open
Abstract
In magnetic resonance imaging (MRI), it is necessary to reduce image distortion as much as possible because it suppresses the increase in the planning target volume. This study investigated the relationship between imaging parameters and image distortion when using G-frames. The images were obtained using a 1.5-T MRI system with a 09-101 Pro-MRI phantom. Image distortion was measured by changing the RF pulse mode, gradient mode, asymmetric echo, and bandwidth (BW). The image distortion was increased in the high RF mode than in the Normal mode. The image distortion increased in the following order: Whisper ≦ Normal < Fast in the different gradient modes. The image distortion increased in the following order: Without ≦ Weak < Strong in the different asymmetric echo modes. The image distortion increased in the following order: 300 Hz/pixel > 670 Hz/pixel ≧ REF (150 Hz/pixel) in the different Bw. The relationship between parameters and image distortion was clarified in this study when G-frames were used for gamma knife therapy. There is had relationship between the parameters causing variation in the gradient magnetic field and image distortion. Therefore, these parameters should be adjusted to minimize distortion.
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Affiliation(s)
- Norikazu Koori
- School of Health SciencesIbaraki Prefectural University of Health SciencesAmiIbarakiJapan
- Division of Health SciencesKanazawa University Graduate School of Medical SciencesKanazawaIshikawaJapan
| | | | - Nanami Mukawa
- School of Health SciencesIbaraki Prefectural University of Health SciencesAmiIbarakiJapan
| | - Hiraku Fuse
- School of Health SciencesIbaraki Prefectural University of Health SciencesAmiIbarakiJapan
| | - Shin Miyakawa
- School of Health SciencesIbaraki Prefectural University of Health SciencesAmiIbarakiJapan
| | - Kenji Yasue
- School of Health SciencesIbaraki Prefectural University of Health SciencesAmiIbarakiJapan
| | - Masato Takahashi
- School of Health SciencesIbaraki Prefectural University of Health SciencesAmiIbarakiJapan
| | | | - Atsushi Henmi
- Department of RadiologyKomaki City HospitalKomakiAichiJapan
| | | | - Kazuma Kurata
- Department of RadiologyKomaki City HospitalKomakiAichiJapan
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Rostampour N, Rezaeian S, Sarbakhsh P, Meola A, Choupani J, Doosti-Irani A, Nemati H, Almasi T, Badrigilan S, Chang SD. Efficacy of Stereotactic Radiosurgery as Single or Combined Therapy for Brain Metastasis: A Systematic Review and Meta-Analysis. Crit Rev Oncol Hematol 2023; 186:104015. [PMID: 37146702 DOI: 10.1016/j.critrevonc.2023.104015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 03/22/2023] [Accepted: 05/01/2023] [Indexed: 05/07/2023] Open
Abstract
To determine the efficacy of stereotactic radiosurgery (SRS) in treating patients with brain metastases (BMs), a network meta-analysis (NMA) of randomized controlled trials (RCTs) and a direct comparison of cohort studies were performed. Relevant literature regarding the effectiveness of SRS alone and in combination with whole-brain radiotherapy (WBRT) and surgery was retrieved using systematic database searches up to April 2019. The patterns of overall survival (OS), one-year OS, progression-free survival (PFS), one-year local brain control (LBC), one-year distant brain control (DBC), neurological death (ND), and complication rate were analyzed. A total of 18 RCTs and 37 cohorts were included in the meta-analysis. Our data revealed that SRS carried a better OS than SRS+WBRT (p= 0.048) and WBRT (p= 0.041). Also, SRS+WBRT demonstrated a significantly improved PFS, LBC, and DBC compared to WBRT alone and SRS alone. Finally, SRS achieved the same LBC as high as surgery, but intracranial relapse occurred considerably more frequently in the absence of WBRT. However, there were not any significant differences in ND and toxicities between SRS and other groups. Therefore, SRS alone may be a better alternative since increased patient survival may outweigh the increased risk of brain tumor recurrence associated with it.
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Affiliation(s)
- Nima Rostampour
- Department of Medical Physics, School of Medcine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shahab Rezaeian
- Research Center for Environmental Determinants of Health (RCEDH), Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran; Epidemiology and Biostatistics Department, School of Public Health, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Parvin Sarbakhsh
- Research Center for Environmental Determinants of Health (RCEDH), Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Antonio Meola
- Depratment of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Jalal Choupani
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amin Doosti-Irani
- Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Hossein Nemati
- Department of Epidemiology, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Tinoosh Almasi
- Department of Medical Physics, School of Medcine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Samireh Badrigilan
- Department of Medical Physics, School of Medcine, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Steven D Chang
- Depratment of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
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Hasanov E, Yeboa DN, Tucker MD, Swanson TA, Beckham TH, Rini B, Ene CI, Hasanov M, Derks S, Smits M, Dudani S, Heng DYC, Brastianos PK, Bex A, Hanalioglu S, Weinberg JS, Hirsch L, Carlo MI, Aizer A, Brown PD, Bilen MA, Chang EL, Jaboin J, Brugarolas J, Choueiri TK, Atkins MB, McGregor BA, Halasz LM, Patel TR, Soltys SG, McDermott DF, Elder JB, Baskaya MK, Yu JB, Timmerman R, Kim MM, Mut M, Markert J, Beal K, Tannir NM, Samandouras G, Lang FF, Giles R, Jonasch E. An interdisciplinary consensus on the management of brain metastases in patients with renal cell carcinoma. CA Cancer J Clin 2022; 72:454-489. [PMID: 35708940 DOI: 10.3322/caac.21729] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/28/2022] [Accepted: 04/11/2022] [Indexed: 12/23/2022] Open
Abstract
Brain metastases are a challenging manifestation of renal cell carcinoma. We have a limited understanding of brain metastasis tumor and immune biology, drivers of resistance to systemic treatment, and their overall poor prognosis. Current data support a multimodal treatment strategy with radiation treatment and/or surgery. Nonetheless, the optimal approach for the management of brain metastases from renal cell carcinoma remains unclear. To improve patient care, the authors sought to standardize practical management strategies. They performed an unstructured literature review and elaborated on the current management strategies through an international group of experts from different disciplines assembled via the network of the International Kidney Cancer Coalition. Experts from different disciplines were administered a survey to answer questions related to current challenges and unmet patient needs. On the basis of the integrated approach of literature review and survey study results, the authors built algorithms for the management of single and multiple brain metastases in patients with renal cell carcinoma. The literature review, consensus statements, and algorithms presented in this report can serve as a framework guiding treatment decisions for patients. CA Cancer J Clin. 2022;72:454-489.
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Affiliation(s)
- Elshad Hasanov
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Debra Nana Yeboa
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mathew D Tucker
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd A Swanson
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas Hendrix Beckham
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brian Rini
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chibawanye I Ene
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Merve Hasanov
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sophie Derks
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marion Smits
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Shaan Dudani
- Division of Oncology/Hematology, William Osler Health System, Brampton, Ontario, Canada
| | - Daniel Y C Heng
- Tom Baker Cancer Center, University of Calgary, Calgary, Alberta, Canada
| | - Priscilla K Brastianos
- Division of Neuro-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Axel Bex
- The Royal Free London National Health Service Foundation Trust, London, United Kingdom
- University College London Division of Surgery and Interventional Science, London, United Kingdom
- Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Sahin Hanalioglu
- Department of Neurosurgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Jeffrey S Weinberg
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Laure Hirsch
- Department of Medical Oncology, Cochin University Hospital, Public Assistance Hospital of Paris, Paris, France
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Maria I Carlo
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ayal Aizer
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Paul David Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Mehmet Asim Bilen
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia
- Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Eric Lin Chang
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, California, Los Angeles
| | - Jerry Jaboin
- Department of Radiation Medicine, Oregon Health & Science University, Portland, Oregon
| | - James Brugarolas
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, Texas
- Division of Hematology/Oncology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Toni K Choueiri
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Michael B Atkins
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC
| | - Bradley A McGregor
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lia M Halasz
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Toral R Patel
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Neurosurgery, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California
| | - David F McDermott
- Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - James Bradley Elder
- Department of Neurological Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mustafa K Baskaya
- Department of Neurological Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin
| | - James B Yu
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Robert Timmerman
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michelle Miran Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Melike Mut
- Department of Neurosurgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - James Markert
- Department of Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nizar M Tannir
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - George Samandouras
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
- University College London Queen Square Institute of Neurology, University College London, Queen Square, London, United Kingdom
| | - Frederick F Lang
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rachel Giles
- International Kidney Cancer Coalition, Duivendrecht, the Netherlands
| | - Eric Jonasch
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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4
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Krist DT, Naik A, Thompson CM, Kwok SS, Janbahan M, Olivero WC, Hassaneen W. Management of Brain Metastasis. Surgical Resection versus Stereotactic Radiotherapy: A Meta-analysis. Neurooncol Adv 2022; 4:vdac033. [PMID: 35386568 PMCID: PMC8982204 DOI: 10.1093/noajnl/vdac033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Treatment of metastatic brain tumors often involves radiotherapy with or without surgical resection as the first step. However, the indications for when to use surgery are not clearly defined for certain tumor sizes and multiplicity. This study seeks to determine whether resection of brain metastases versus exclusive radiotherapy provided improved survival and local control in cases where metastases are limited in number and diameter.
Methods
According to PRISMA guidelines, this meta-analysis compares outcomes from treatment of a median number of brain metastases ≤4 with a median diameter ≤4 cm with exclusive radiotherapy versus surgery followed by radiotherapy. Four randomized control trials and 11 observational studies (1693 patients) met inclusion criteria. For analysis, studies were grouped based on whether radiation involved stereotactic radiosurgery (SRS) or whole-brain radiotherapy (WBRT).
Results
In both analyses, there was no difference in survival between surgery ±SRS versus SRS alone two years after treatment (OR 1.89 (95% CI: 0.47 - 7.55, p = 0.23) or surgery + WBRT versus radiotherapy alone (either WBRT and/or SRS) (OR 1.18 (95% CI: 0.76 – 1.84, p = 0.46). However, surgical patients demonstrated greater risk for local tumor recurrence compared to SRS alone (OR 2.20 (95% CI: 1.49 - 3.25, p < 0.0001)) and compared to WBRT/SRS (OR 2.93; 95% CI: 1.68 - 5.13, p = 0.0002).
Conclusion
The higher incidence of local tumor recurrence for surgical patients suggests that more prospective studies are needed to clarify outcomes for treatment of 1-4 metastasis less than 4 cm diameter.
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Affiliation(s)
- David T Krist
- Department of Neurosurgery, Carle Foundation Hospital, Urbana, IL
- Carle Illinois College of Medicine, Champaign, IL
| | - Anant Naik
- Department of Neurosurgery, Carle Foundation Hospital, Urbana, IL
- Carle Illinois College of Medicine, Champaign, IL
| | - Charee M Thompson
- Carle Illinois College of Medicine, Champaign, IL
- Department of Communication, University of Illinois at Urbana-Champaign, Urbana, IL
| | - Susanna S Kwok
- Department of Neurosurgery, Carle Foundation Hospital, Urbana, IL
- Carle Illinois College of Medicine, Champaign, IL
| | - Mika Janbahan
- Department of Neurosurgery, Carle Foundation Hospital, Urbana, IL
- Carle Illinois College of Medicine, Champaign, IL
| | - William C Olivero
- Department of Neurosurgery, Carle Foundation Hospital, Urbana, IL
- Carle Illinois College of Medicine, Champaign, IL
| | - Wael Hassaneen
- Department of Neurosurgery, Carle Foundation Hospital, Urbana, IL
- Carle Illinois College of Medicine, Champaign, IL
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Loo M, Clavier JB, Attal Khalifa J, Moyal E, Khalifa J. Dose-Response Effect and Dose-Toxicity in Stereotactic Radiotherapy for Brain Metastases: A Review. Cancers (Basel) 2021; 13:cancers13236086. [PMID: 34885193 PMCID: PMC8657210 DOI: 10.3390/cancers13236086] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022] Open
Abstract
Simple Summary Brain metastases are one of the most frequent complications for cancer patients. Stereotactic radiosurgery is considered a cornerstone treatment for patients with limited brain metastases and the ideal dose and fractionation schedule still remain unknown. The aim of this literature review is to discuss the dose-effect relation in brain metastases treated by stereotactic radiosurgery, accounting for fractionation and technical considerations. Abstract For more than two decades, stereotactic radiosurgery has been considered a cornerstone treatment for patients with limited brain metastases. Historically, radiosurgery in a single fraction has been the standard of care but recent technical advances have also enabled the delivery of hypofractionated stereotactic radiotherapy for dedicated situations. Only few studies have investigated the efficacy and toxicity profile of different hypofractionated schedules but, to date, the ideal dose and fractionation schedule still remains unknown. Moreover, the linear-quadratic model is being debated regarding high dose per fraction. Recent studies shown the radiation schedule is a critical factor in the immunomodulatory responses. The aim of this literature review was to discuss the dose–effect relation in brain metastases treated by stereotactic radiosurgery accounting for fractionation and technical considerations. Efficacy and toxicity data were analyzed in the light of recent published data. Only retrospective and heterogeneous data were available. We attempted to present the relevant data with caution. A BED10 of 40 to 50 Gy seems associated with a 12-month local control rate >70%. A BED10 of 50 to 60 Gy seems to achieve a 12-month local control rate at least of 80% at 12 months. In the brain metastases radiosurgery series, for single-fraction schedule, a V12 Gy < 5 to 10 cc was associated to 7.1–22.5% radionecrosis rate. For three-fractions schedule, V18 Gy < 26–30 cc, V21 Gy < 21 cc and V23 Gy < 5–7 cc were associated with about 0–14% radionecrosis rate. For five-fractions schedule, V30 Gy < 10–30 cc, V 28.8 Gy < 3–7 cc and V25 Gy < 16 cc were associated with about 2–14% symptomatic radionecrosis rate. There are still no prospective trials comparing radiosurgery to fractionated stereotactic irradiation.
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Affiliation(s)
- Maxime Loo
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
- Correspondence:
| | - Jean-Baptiste Clavier
- Radiotherapy Department, Strasbourg Europe Cancer Institute (ICANS), 67033 Strasbourg, France;
| | - Justine Attal Khalifa
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
| | - Elisabeth Moyal
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
| | - Jonathan Khalifa
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
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González L, Castro S, Villa E, Zomosa G. Surgical resection versus stereotactic radiosurgery on local recurrence and survival for patients with a single brain metastasis: a systematic review and meta-analysis. Br J Neurosurg 2021; 35:703-713. [PMID: 34431733 DOI: 10.1080/02688697.2021.1950623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Brain metastases (BM) are the most frequent intracranial tumours in adults. In patients with solitary BM, surgical resection (SR) or stereotactic radiosurgery (SRS) is performed. There is limited evidence comparing one treatment over the other. OBJECTIVE To compare SR versus SRS on patients with solitary BMs, regarding local recurrence (LR) and overall survival (OS) conducting a systematic review and meta-analysis. METHODS Systematic review of literature following PRISMA guidelines, using the databases of Medline, Clinicaltrials.gov, Embase, Web of Science, Sciencedirect, CINAHL, Wiley Online Library, Springerlink and LILACS. Following study selection based on inclusion and exclusion criteria, data extraction and a critical analysis of the literature was performed according to the GRADE scale. For quantitative analysis, a random effects model was used. Data were synthetized and evaluated on a forest plot and funnel plot. RESULTS Two randomized clinical trials, four cohort studies and one case-control studies met our inclusion criteria for the qualitative analysis. None was excluded subsequently. Overall, 614 patients with single metastasis were included. Studies had high heterogeneity. Multiple significant variables affecting the outcome were signalized. Meta-analysis showed no significant differences for survival (HR, 1.10; 95% CI, 0.75-1.45) or LR (HR, 0.81; 95% CI, 0.42-1.20). CONCLUSIONS According to current evidence, in patients with a single small metastasis there is no statistically significant difference in OS or LR among the chosen techniques (SR or SRS). Multiple significant co-variables may affect both outcomes. Different outcomes better than OS should be evaluated in further randomized studies.
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Affiliation(s)
- Lucas González
- Faculty of Medicine, University of Chile, Santiago, Chile
| | | | - Eduardo Villa
- Faculty of Medicine, University of Chile, Santiago, Chile
| | - Gustavo Zomosa
- Department of Neurology & Neurosurgery, Hospital Clinico Universidad de Chile, Santiago, Chile
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7
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Fuchs J, Früh M, Papachristofilou A, Bubendorf L, Häuptle P, Jost L, Zippelius A, Rothschild SI. Resection of isolated brain metastases in non-small cell lung cancer (NSCLC) patients - evaluation of outcome and prognostic factors: A retrospective multicenter study. PLoS One 2021; 16:e0253601. [PMID: 34181677 PMCID: PMC8238224 DOI: 10.1371/journal.pone.0253601] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 06/08/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Brain metastases occur in about 30% of all patients with non-small cell lung cancer (NSCLC). In selected patients, long-term survival can be achieved by resection of brain metastases. In this retrospective study, we investigate the prognosis of NSCLC patients with resected brain metastases and possible prognostic factors. METHODS In 119 patients with NSCLC and resected brain metastases, we report the following parameters: extent of resection, resection status, postoperative complications and overall survival (OS). We used the log-rank test to compare unadjusted survival probabilities and multivariable Cox regression to investigate potential prognostic factors with respect to OS. RESULTS A total of 146 brain metastases were resected in 119 patients. The median survival was 18.0 months. Postoperative cerebral radiotherapy was performed in 86% of patients. Patients with postoperative radiotherapy had significantly longer survival (median OS 20.2 vs. 9.0 months, p = 0.002). The presence of multiple brain metastases was a negative prognostic factor (median OS 13.5 vs. 19.5 months, p = 0.006). Survival of patients with extracerebral metastases of NSCLC was significantly shorter than in patients who had exclusively brain metastases (median OS 14.0 vs. 23.1 months, p = 0.005). Both of the latter factors were independent prognostic factors for worse outcome in multivariate analysis. CONCLUSIONS Based on these data, resection of solitary brain metastases in patients with NSCLC and controlled extracerebral tumor disease is safe and leads to an overall favorable outcome. Postoperative radiotherapy is recommended to improve prognosis.
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Affiliation(s)
- Julia Fuchs
- Medical Oncology, Department Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Martin Früh
- Department of Medical Oncology and Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Department of Medical Oncology, University Hospital Bern, Bern, Switzerland
| | - Alexandros Papachristofilou
- Lung Cancer Center Basel, Comprehensive Cancer Center, University Hospital Basel, Basel, Switzerland
- Department of Radiation Oncology, University Hospital Basel, Basel, Switzerland
| | - Lukas Bubendorf
- Institute of Pathology, University Hospital Basel, Basel, Switzerland
| | - Pirmin Häuptle
- Department Oncology, Hematology and Transfusion Medicine, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Lorenz Jost
- Medical Oncology, Cantonal Hospital Baselland, Bruderholz, Basel, Switzerland
| | - Alfred Zippelius
- Medical Oncology, Department Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Sacha I. Rothschild
- Medical Oncology, Department Internal Medicine, University Hospital Basel, Basel, Switzerland
- Lung Cancer Center Basel, Comprehensive Cancer Center, University Hospital Basel, Basel, Switzerland
- * E-mail:
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8
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Yu X, Sheng J, Pan G, Fan Y. Real-world utilization of EGFR TKIs and prognostic factors for survival in EGFR-mutated non-small cell lung cancer patients with brain metastases. Int J Cancer 2021; 149:1121-1128. [PMID: 33970485 DOI: 10.1002/ijc.33677] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 11/05/2022]
Abstract
Brain metastases (BMs) cause morbidity and mortality in patients with non-small cell lung cancer (NSCLC). The optimal management of epidermal growth factor receptor (EGFR)-mutated NSCLC with BM is debatable. We aimed to investigate the impact of different treatments among patients with EGFR-mutated NSCLC. A cohort of 2058 lung cancer patients with BM between 2013 and 2018 was retrospectively studied. A total of 571 patients with EGFR-mutated NSCLC and BM were enrolled. All patients had received EGFR tyrosine kinase inhibitors (TKIs). Overall survival (OS) was measured from the diagnosis of BM to death or last follow-up. With a median follow-up of 35.2 months (95% confidence interval [CI], 31.8-38.6), the median survival after BM was 21.3 months (95% CI, 19.0-23.6). Osimertinib resulted in significantly superior survival after resistance to front-line TKIs (P < 0.0035); the median OS reached 28.0 months (95% CI, 23.0-32.9), and the T790M status showed no difference in clinical effectiveness (P = 0.386). The combination of TKIs and chemotherapy/vascular endothelial growth factor (VEGF) inhibitors (anti-VEGF) tended to have longer OS (P = 0.271). Intracranial local radiotherapy significantly improved survival (P = 0.0008). In multivariable analysis, we noted that age, Karnofsky performance score, EGFR mutation type, number of BMs and the presence of extracranial metastasis were independent pretreatment prognostic factors. In conclusion, EGFR TKIs have a significant effect on patients with EGFR-mutant BM, and the application of osimertinib further improves survival outcomes regardless of T790M status. Patients who undergo intracranial local therapy can achieve a survival benefit.
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Affiliation(s)
- Xiaoqing Yu
- Department of Medical Oncology, Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Institute of Cancer Research and Basic Medical Sciences of Chinese Academy of Sciences, Hangzhou, China
| | - Jiamin Sheng
- Department of Medical Oncology, Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Institute of Cancer Research and Basic Medical Sciences of Chinese Academy of Sciences, Hangzhou, China
| | - Guoqiang Pan
- Department of Medical Oncology, Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Institute of Cancer Research and Basic Medical Sciences of Chinese Academy of Sciences, Hangzhou, China
| | - Yun Fan
- Department of Medical Oncology, Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Institute of Cancer Research and Basic Medical Sciences of Chinese Academy of Sciences, Hangzhou, China
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Socha J, Rychter A, Kepka L. Management of brain metastases in elderly patients with lung cancer. J Thorac Dis 2021; 13:3295-3307. [PMID: 34164222 PMCID: PMC8182516 DOI: 10.21037/jtd-2019-rbmlc-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The incidence of brain metastases (BM) is continuing to grow in the elderly population with lung cancer, but these patients are seriously under-represented in clinical trials. Thus, their treatment is not based on the evidence from randomized prospective studies. Age is a well recognized poor prognostic factor for survival in patients with BM from lung cancer, which is reflected in prognostic scales, but its impact on the patients' prognosis reflected by its value in gradually updated grading indices seems to decrease. The reason for poorer outcomes in the elderly is unknown—it may result from the influence of the age per se, simplified staging work-up and suboptimal treatment in this patient subgroup or the excess toxicity of the aggressive anticancer treatment secondary to the impaired physiological regulation mechanisms and comorbidities. The main goal of treatment of BM is to ameliorate neurological symptoms and delay neurological progression, with the focus on the improvement and maintenance of the patients’ quality of life. The possible treatment options for BM from lung cancer are whole-brain radiotherapy, stereotactic radiosurgery, surgery, chemotherapy, targeted therapies and best supportive care. The aim of this review is to summarize the problems related to the management of BM in elderly patients with lung cancer, to analyze the value of the above mentioned treatment options, and to provide an insight into the influence of age-related clinical factors on the patients’ outcomes.
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Affiliation(s)
- Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland.,Department of Radiotherapy, Regional Oncology Centre, Czestochowa, Poland
| | - Anna Rychter
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | - Lucyna Kepka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
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10
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Galanti D, Inno A, La Vecchia M, Borsellino N, Incorvaia L, Russo A, Gori S. Current treatment options for HER2-positive breast cancer patients with brain metastases. Crit Rev Oncol Hematol 2021; 161:103329. [PMID: 33862249 DOI: 10.1016/j.critrevonc.2021.103329] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 03/03/2021] [Accepted: 03/26/2021] [Indexed: 11/29/2022] Open
Abstract
Brain metastases (BMs) are frequently associated with HER2+ breast cancer (BC). Their management is based on a multi-modal strategy including both local treatment and systemic therapy. Despite therapeutic advance, BMs still have an adverse impact on survival and quality of life and the development of effective systemic therapy to prevent and treat BMs from HER2 + BC represents an unmet clinical need. Trastuzumab-based therapy has long been the mainstay of systemic therapy and over the last two decades other HER2-targeted agents including lapatinib, pertuzumab and trastuzumab emtansine, have been introduced in the clinical practice. More recently, novel agents such as neratinib, tucatinib and trastuzumab deruxtecan have been developed, with interesting activity against BMs. Further research is needed to better elucidate the best sequence of these agents and their combination with local treatment.
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Affiliation(s)
- Daniele Galanti
- Medical Oncology Unit, Buccheri La Ferla Fatebenefratelli Hospital, Palermo, Italy
| | - Alessandro Inno
- Medical Oncology Unit, IRCCS Sacro Cuore don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | | | - Nicolò Borsellino
- Medical Oncology Unit, Buccheri La Ferla Fatebenefratelli Hospital, Palermo, Italy
| | - Lorena Incorvaia
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), Section of Medical Oncology, University of Palermo, 90127, Palermo, Italy
| | - Antonio Russo
- Department of Surgical, Oncological & Oral Sciences, Section of Medical Oncology, University of Palermo, 90127, Palermo, Italy.
| | - Stefania Gori
- Medical Oncology Unit, Buccheri La Ferla Fatebenefratelli Hospital, Palermo, Italy
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11
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Liu Z, He S, Li L. Comparison of Surgical Resection and Stereotactic Radiosurgery in the Initial Treatment of Brain Metastasis. Stereotact Funct Neurosurg 2020; 98:404-415. [PMID: 32898850 DOI: 10.1159/000509319] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/09/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Brain metastasis (BM) is the most common brain malignancy and a common cause of death in cancer patients. However, the relative outcome-related advantages and disadvantages of surgical resection (SR) and stereotactic radiosurgery (SRS) in the initial treatment of BM are controversial. METHOD We systematically reviewed the English language literature up to March 2020 to compare the efficacy of SR and SRS in the initial treatment of BM. We identified cohort studies from the Cochrane Library, PubMed, and EMBASE databases and conducted a meta-analysis following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Twenty cohort studies involving 1,809 patients were included. Local control did not significantly differ between the SR and SRS groups overall (hazard ratio [HR] 1.02, 95% confidence interval (CI) 0.64-1.64, p = 0.92; I2 = 54%, p = 0.03) or in subgroup analyses of SR plus SRS vs. SRS alone, SR plus whole brain radiation therapy (WBRT) versus SRS plus WBRT, or SR plus WBRT versus SRS alone. Distant intracranial control did not significantly differ between the SR and SRS groups overall (HR 0.78, 95% CI 0.38-1.60, p = 0.49; I2 = 61%, p = 0.03) or in subgroup analyses of SR plus SRS versus SRS alone or SR plus WBRT versus SRS alone. In addition, overall survival (OS) did not significantly differ in the SR and SRS groups (HR 0.91, 95% CI 0.65-1.27, p = 0.57; I2 = 47%, p = 0.09) or in subgroup analyses of SR plus SRS versus SRS alone, SR plus WBRT versus SRS alone or SR plus WBRT versus SRS plus WBRT. CONCLUSION Initial treatment of BM with SRS may offer comparable local and distant intracranial control to SR in patients with single or solitary BM. OS did not significantly differ between the SR and SRS groups in people with single or solitary BM.
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Affiliation(s)
- Zhen Liu
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Shuting He
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Liang Li
- Department of Neurosurgery, Peking University First Hospital, Beijing, China,
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12
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Sankey EW, Tsvankin V, Grabowski MM, Nayar G, Batich KA, Risman A, Champion CD, Salama AKS, Goodwin CR, Fecci PE. Operative and peri-operative considerations in the management of brain metastasis. Cancer Med 2019; 8:6809-6831. [PMID: 31568689 PMCID: PMC6853809 DOI: 10.1002/cam4.2577] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 09/07/2019] [Accepted: 09/09/2019] [Indexed: 12/24/2022] Open
Abstract
The number of patients who develop metastatic brain lesions is increasing as the diagnosis and treatment of systemic cancers continues to improve, resulting in longer patient survival. The role of surgery in the management of brain metastasis (BM), particularly multiple and recurrent metastases, remains controversial and continues to evolve. However, with appropriate patient selection, outcomes after surgery are typically favorable. In addition, surgery is the only means to obtain a tissue diagnosis and is the only effective treatment modality to quickly relieve neurological complications or life-threatening symptoms related to significant mass effect, CSF obstruction, and peritumoral edema. As such, a thorough understanding of the role of surgery in patients with metastatic brain lesions, as well as the factors associated with surgical outcomes, is essential for the effective management of this unique and growing patient population.
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Affiliation(s)
- Eric W. Sankey
- Department of NeurosurgeryDuke University Medical CenterDurhamNCUSA
| | - Vadim Tsvankin
- Department of NeurosurgeryDuke University Medical CenterDurhamNCUSA
| | | | - Gautam Nayar
- Department of NeurosurgeryUniversity of Pittsburgh Medical CenterPittsburghPAUSA
| | | | - Aida Risman
- School of MedicineMedical College of GeorgiaAugustaGAUSA
| | | | | | - C. Rory Goodwin
- Department of NeurosurgeryDuke University Medical CenterDurhamNCUSA
| | - Peter E. Fecci
- Department of NeurosurgeryDuke University Medical CenterDurhamNCUSA
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13
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Sheppard JP, Prashant GN, Chen CHJ, Peeters S, Lagman C, Ong V, Udawatta M, Duong C, Nguyen T, Romiyo P, Gaonkar B, Yong WH, Kaprealian TB, Tenn S, Lee P, Yang I. Timing of adjuvant radiation therapy and survival outcomes after surgical resection of intracranial non-small cell lung cancer metastases. Clin Neurol Neurosurg 2019; 183:105389. [PMID: 31280101 DOI: 10.1016/j.clineuro.2019.105389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 05/14/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate if delay of adjuvant radiotherapy (ART) beyond 6 post-operative weeks affects survival outcomes in patients undergoing craniotomy or craniectomy for resection of non-small cell lung cancer (NSCLC) intracranial metastases. PATIENTS AND METHODS We performed a retrospective analysis of 28 patients undergoing resection of intracranial metastases and ART at our institution from 2001 to 2016. We assessed survival outcomes for patients who received delayed versus non-delayed ART, as well as associated risk factors. RESULTS Among 28 patients, 8 (29%) had delayed ART beyond 6 post-operative weeks. Fifteen received stereotactic radiotherapy (SRT), 8 (29%) received whole brain radiotherapy (WBRT), and 5 (18%) received combination WBRT + SRT. There were no significant differences in ART modality or dosing, age, sex, number of intracranial metastases, primary metastasis volume, rates of chemotherapy, extracranial metastases, or post-operative functional scores between groups. Expected post-operative survival was shorter with delayed ART (7 months versus 28 months, P = 0.01). The most common reason for delayed ART was complicated post-operative course (n = 3.38%). Significant risk factors for delayed ART included non-routine discharge (P = 0.01) and additional invasive procedures between surgery and ART start date (P = 0.02). CONCLUSIONS Our results suggest delayed ART in patients undergoing surgical resection of intracranial NSCLC metastases is associated with shorter overall survival. However, risk factors for delayed ART, including non-routine discharge and the need for additional invasive procedures, may have in themselves reflected poorer clinical courses that may have also contributed to the observed survival differences.
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Affiliation(s)
- John P Sheppard
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Giyarpuram N Prashant
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Cheng Hao Jacky Chen
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Sophie Peeters
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Carlito Lagman
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Vera Ong
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Methma Udawatta
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Courtney Duong
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Thien Nguyen
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Prasanth Romiyo
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Bilwaj Gaonkar
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - William H Yong
- Department of Pathology, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Tania B Kaprealian
- Department of Radiation Oncology, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Stephen Tenn
- Department of Radiation Oncology, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Percy Lee
- Department of Radiation Oncology, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Isaac Yang
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States; Department of Radiation Oncology, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States; Department of Head and Neck Surgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States; Department of UCLA Jonsson Comprehensive Cancer Center, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States; Department of Neurosurgery Harbor-UCLA Medical Center, Torrance, CA, United States; Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA, United States.
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14
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Protopapa M, Kouloulias V, Nikoloudi S, Papadimitriou C, Gogalis G, Zygogianni A. From Whole-Brain Radiotherapy to Immunotherapy: A Multidisciplinary Approach for Patients with Brain Metastases from NSCLC. JOURNAL OF ONCOLOGY 2019; 2019:3267409. [PMID: 30853981 PMCID: PMC6378013 DOI: 10.1155/2019/3267409] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 01/15/2019] [Indexed: 12/25/2022]
Abstract
Non-small cell lung cancer patients with brain metastases have a multitude of treatment options, but there is currently no international and multidisciplinary consensus concerning their optimal treatment. Local therapies have the principal role, especially in symptomatic patients. Advances in surgery and radiation therapy manage considerable local control. Systemic treatments have shown effect in clinical trials and in real life clinical settings; yet, at present, this is restricted to patients with asymptomatic or stable intracranial lesions. Targeted agents can have a benefit only in patients with EGFR mutations or ALK rearrangement. Immunotherapy has shown impressive results in patients with PD-L1 expression in tumor cells. Its effects can be further enhanced by a synergy with radiotherapy, possibly by increasing the percentage of responders. The present review summarizes the need for more effective systemic treatments, so that the increased intracranial control achieved by local treatments can be translated in an increase in overall survival.
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Affiliation(s)
- Maria Protopapa
- National and Kapodistrian University of Athens, Medical School, Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Greece
| | - Vassilis Kouloulias
- National and Kapodistrian University of Athens, Medical School, Radiation Oncology Unit, 2nd Department of Radiology, Attikon University General Hospital, Greece
| | - Styliani Nikoloudi
- National and Kapodistrian University of Athens, Medical School, Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Greece
| | - Christos Papadimitriou
- National and Kapodistrian University of Athens, Medical School, Medical Oncology Unit, 2nd Surgery Clinic, Aretaieion University Hospital of Athens, Greece
| | - Giannis Gogalis
- National and Kapodistrian University of Athens, Medical School, Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Greece
| | - Anna Zygogianni
- National and Kapodistrian University of Athens, Medical School, Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Greece
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15
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Fuentes R, Osorio D, Expósito Hernandez J, Simancas‐Racines D, Martinez‐Zapata MJ, Bonfill Cosp X. Surgery versus stereotactic radiotherapy for people with single or solitary brain metastasis. Cochrane Database Syst Rev 2018; 8:CD012086. [PMID: 30125049 PMCID: PMC6513097 DOI: 10.1002/14651858.cd012086.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Brain metastases occur when cancer cells spread from their original site to the brain and are a frequent cause of morbidity and death in people with cancer. They occur in 20% to 40% of people during the course of their disease. Brain metastases are also the most frequent type of brain malignancy. Single and solitary brain metastasis is infrequent and choosing the most appropriate treatment is a clinical challenge. Surgery and stereotactic radiotherapy are two options. For surgery, tumour resection is performed using microsurgical techniques, while in stereotactic radiotherapy, external ionising radiation beams are precisely focused on the brain metastasis. Stereotactic radiotherapy may be given as a single dose, also known as single dose radiosurgery, or in a number of fractions, also known as fractionated stereotactic radiotherapy. There is uncertainty regarding which treatment (surgery or stereotactic radiotherapy) is more effective for people with single or solitary brain metastasis. OBJECTIVES To assess the effectiveness and safety of surgery versus stereotactic radiotherapy for people with single or solitary brain metastasis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, March 2018), MEDLINE and Embase up to 25 March 2018 for relevant studies. We also searched trials databases, grey literature and handsearched relevant literature. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing surgery versus stereotactic radiotherapy, either a single fraction (stereotactic radiosurgery) or multiple fractions (fractionated stereotactic radiotherapy) for treatment of single or solitary brain metastasis. DATA COLLECTION AND ANALYSIS Two review authors screened all references, evaluated the quality of the included studies using the Cochrane tool for assessing risk of bias, and performed data extraction. The primary outcomes were overall survival and adverse events. Secondary outcomes included progression-free survival and quality of life . We analysed overall survival and progression-free survival as hazard ratios (HRs) with 95% confidence intervals (CIs), and analysed adverse events as risk ratios (RRs). For quality of life we used mean difference (MD). MAIN RESULTS Two RCTs including 85 participants met our inclusion criteria. One study included people with single untreated brain metastasis (n = 64), and the other included people with solitary brain metastasis (22 consented to randomisation and 21 were analysed). We identified a third trial reported as completed and pending results this may be included in future updates of this review. The two included studies were prematurely closed due to poor participant accrual. One study compared surgery plus whole brain radiotherapy (WBRT) versus stereotactic radiosurgery alone, and the second study compared surgery plus WBRT versus stereotactic radiosurgery plus WBRT. Meta-analysis was not possible due to clinical heterogeneity between trial interventions. The overall certainty of evidence was low or very low for all outcomes due to high risk of bias and imprecision.We found no difference in overall survival in either of the two comparisons. For the comparison of surgery plus WBRT versus stereotactic radiosurgery alone: HR 0.92, 95% CI 0.48 to 1.77; 64 participants, very low-certainty evidence. We downgraded the certainty of the evidence to very low due to risk of bias and imprecision. For the comparison of surgery plus WBRT versus stereotactic radiosurgery plus WBRT: HR 0.53, 95% CI 0.20 to 1.42; 21 participants, low-certainty evidence. We downgraded the certainty of the evidence to low due to imprecision. Adverse events were reported in both trial groups in the two studies, showing no differences for surgery plus WBRT versus stereotactic radiosurgery alone (RR 0.31, 95% CI 0.07 to 1.44; 64 participants) and for surgery plus WBRT versus stereotactic radiosurgery plus WBRT (RR 0.37, 95% CI 0.05 to 2.98; 21 participants). Most of the adverse events were related to radiation toxicities. We considered the certainty of the evidence from the two comparisons to be very low due to risk of bias and imprecision.There was no difference in progression-free survival in the study comparing surgery plus WBRT versus stereotactic radiosurgery plus WBRT (HR 0.55, 95% CI 0.22 to 1.38; 21 participants, low-certainty evidence). We downgraded the evidence to low certainty due to imprecision. This outcome was not clearly reported for the other comparison. In general, there were no differences in quality of life between the two studies. The study comparing surgery plus WBRT versus stereotactic radiosurgery plus WBRT found no differences after two months using the QLQ-C30 global scale (MD -10.80, 95% CI -44.67 to 23.07; 14 participants, very low-certainty evidence). We downgraded the certainty of evidence to very low due to risk of bias and imprecision. AUTHORS' CONCLUSIONS Currently, there is no definitive evidence regarding the effectiveness and safety of surgery versus stereotactic radiotherapy on overall survival, adverse events, progression-free survival and quality of life in people with single or solitary brain metastasis, and benefits must be decided on a case-by-case basis until well powered and designed trials are available. Given the difficulties in participant accrual, an international multicentred approach should be considered for future studies.
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Affiliation(s)
- Rafel Fuentes
- Institut Català d'OncologiaAvda França, s/nGironaSpain17007
| | - Dimelza Osorio
- Universidad Tecnológica EquinoccialCochrane Ecuador. Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC). Facultad de Ciencias de la Salud Eugenio EspejoQuitoEcuador
| | - José Expósito Hernandez
- Hospital Universitario Virgen de las NievesResearch UnitAvda. Fuerzas Armadas, 4GranadaSpain18014
| | - Daniel Simancas‐Racines
- Universidad Tecnológica EquinoccialCochrane Ecuador. Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC). Facultad de Ciencias de la Salud Eugenio EspejoQuitoEcuador
| | - Maria José Martinez‐Zapata
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 167Pavilion 18BarcelonaCatalunyaSpain08025
| | - Xavier Bonfill Cosp
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 167Pavilion 18BarcelonaCatalunyaSpain08025
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16
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Hatiboglu MA, Akdur K, Sawaya R. Neurosurgical management of patients with brain metastasis. Neurosurg Rev 2018; 43:483-495. [DOI: 10.1007/s10143-018-1013-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 06/19/2018] [Accepted: 07/15/2018] [Indexed: 12/18/2022]
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17
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Franchino F, Rudà R, Soffietti R. Mechanisms and Therapy for Cancer Metastasis to the Brain. Front Oncol 2018; 8:161. [PMID: 29881714 PMCID: PMC5976742 DOI: 10.3389/fonc.2018.00161] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/30/2018] [Indexed: 12/12/2022] Open
Abstract
Advances in chemotherapy and targeted therapies have improved survival in cancer patients with an increase of the incidence of newly diagnosed brain metastases (BMs). Intracranial metastases are symptomatic in 60–70% of patients. Magnetic resonance imaging (MRI) with gadolinium is more sensitive than computed tomography and advanced neuroimaging techniques have been increasingly used in the detection, treatment planning, and follow-up of BM. Apart from the morphological analysis, the most effective tool for characterizing BM is immunohistochemistry. Molecular alterations not always reflect those of the primary tumor. More sophisticated methods of tumor analysis detecting circulating biomarkers in fluids (liquid biopsy), including circulating DNA, circulating tumor cells, and extracellular vesicles, containing tumor DNA and macromolecules (microRNA), have shown promise regarding tumor treatment response and progression. The choice of therapeutic approaches is guided by prognostic scores (Recursive Partitioning Analysis and diagnostic-specific Graded Prognostic Assessment-DS-GPA). The survival benefit of surgical resection seems limited to the subgroup of patients with controlled systemic disease and good performance status. Leptomeningeal disease (LMD) can be a complication, especially in posterior fossa metastases undergoing a “piecemeal” resection. Radiosurgery of the resection cavity may offer comparable survival and local control as postoperative whole-brain radiotherapy (WBRT). WBRT alone is now the treatment of choice only for patients with single or multiple BMs not amenable to surgery or radiosurgery, or with poor prognostic factors. To reduce the neurocognitive sequelae of WBRT intensity modulated radiotherapy with hippocampal sparing, and pharmacological approaches (memantine and donepezil) have been investigated. In the last decade, a multitude of molecular abnormalities have been discovered. Approximately 33% of patients with non-small cell lung cancer (NSCLC) tumors and epidermal growth factor receptor mutations develop BMs, which are targetable with different generations of tyrosine kinase inhibitors (TKIs: gefitinib, erlotinib, afatinib, icotinib, and osimertinib). Other “druggable” alterations seen in up to 5% of NSCLC patients are the rearrangements of the “anaplastic lymphoma kinase” gene TKI (crizotinib, ceritinib, alectinib, brigatinib, and lorlatinib). In human epidermal growth factor receptor 2-positive, breast cancer targeted therapies have been widely used (trastuzumab, trastuzumab-emtansine, lapatinib-capecitabine, and neratinib). Novel targeted and immunotherapeutic agents have also revolutionized the systemic management of melanoma (ipilimumab, nivolumab, pembrolizumab, and BRAF inhibitors dabrafenib and vemurafenib).
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Affiliation(s)
- Federica Franchino
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
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18
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Koutras AK, Marangos M, Kourelis T, Partheni M, Dougenis D, Iconomou G, Vagenakis AG, Kalofonos HP. Surgical Management of Cerebral Metastases from Non-Small Cell Lung Cancer. TUMORI JOURNAL 2018; 89:292-7. [PMID: 12908786 DOI: 10.1177/030089160308900312] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and Background The objective of the study was to assess the efficacy of surgical resection of solitary brain metastasis in patients with non-small-cell lung cancer. Methods and Study Design We report a retrospective analysis of 32 patients with single brain metastasis surgically excised at our hospital. All but one patient underwent postoperative whole brain radiation therapy. Results The median survival of patients was 12.5 months postoperatively (mean, 17 months), and the overall 1-year survival was 53%. Thirteen patients had recurrence of brain metastasis: 6 of 13 underwent reoperation for the recurrent lesion, and 1 of the 6 patients had a third craniotomy. Baseline characteristics, which significantly influenced survival, included age less than 60 years, tumor histology (ie, adenocarcinoma), and treatment of the primary lung cancer. The analysis did not yield any significant differences between treatment modalities. Conclusions Our findings correspond well with those reported in the literature and suggest that surgical resection of single brain metastasis in patients with non-small cell lung cancer can improve survival over conservative management. Furthermore, surgical treatment of the primary tumor and the single brain metastasis, combined or not with radiotherapy and chemotherapy, represents an approach that merits further investigation with more patients and a prospective longitudinal design.
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Affiliation(s)
- Angelos K Koutras
- Division of Oncology, Department of Medicine, University Hospital, Patras Medical School, Rion, Greece
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19
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Frati A, Pesce A, D'Andrea G, Fraschetti F, Salvati M, Cimatti M, Esposito V, Raco A. A purely functional Imaging based approach for transcortical resection of lesion involving the dominant atrium: Towards safer, imaging-guided, tailored cortico-leucotomies. J Clin Neurosci 2018; 50:252-261. [PMID: 29429789 DOI: 10.1016/j.jocn.2018.01.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 01/08/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND STUDY OBJECT The Dominant Atrium (DA) is a crossroad of eloquent white matter bundles difficult to preserve with a standard "anatomical" approach. The aim of this work is to evaluate the results of a cohort of patients who underwent surgery with the aid of a purely functional MRI and DTI-based approach. MATERIALS AND METHODS 43 patients suffering from lesions involving the DA have been included in the final cohort and studied in regards to quality of life (KPS); a special attention was lent on the incidence of new or worsening of preexisting neurological deficits, with a focus on motor, visual and speech disturbances after the surgical treatment. Patient, surgery and lesion-related data were recorded to identify the relationships with outcome. Eloquent areas fMRI and the course of Arcuate Fasciculus (AF), Inferior frontooccipital fasciculus (IFOF), Optic radiation (OR) and corticospinal tract (CST) have been investigated with preoperative MRI sequences and DTI reconstruction. RESULTS The final cohort consisted of 43 patients, 19 males and 24 females; average age was 56.8 years. We recorded 9 transient and 3 permanent postoperative deficits, only one of those was caused by an edema interference with DTI reconstruction. Preoperative functional status, histology and volume of the lesion proved to be independent factors affecting results. CONCLUSIONS A purely functional surgical approach to the DA provided promising preliminary results. A direct DTI-fMRI visualization of the eloquent structures proximal to DA allows surgeon to conceive an ultra-precise and "tailored" cortico-leucotomy for an optimal exposure of the lesion.
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Affiliation(s)
- Alessandro Frati
- IRCCS "Neuromed" - Neurosurgery - "Sapienza" Univesity, Pozzilli (IS), Italy
| | - Alessandro Pesce
- NESMOS Department Neurosurgery Department "Sapienza" University, Roma, Italy; Azienda Ospedaliera Sant'Andrea, Roma, Italy
| | | | - Flavia Fraschetti
- NESMOS Department Neurosurgery Department "Sapienza" University, Roma, Italy; Azienda Ospedaliera Sant'Andrea, Roma, Italy.
| | - Maurizio Salvati
- IRCCS "Neuromed" - Neurosurgery - "Sapienza" Univesity, Pozzilli (IS), Italy
| | - Marco Cimatti
- NESMOS Department Neurosurgery Department "Sapienza" University, Roma, Italy; Azienda Ospedaliera Sant'Andrea, Roma, Italy
| | - Vincenzo Esposito
- IRCCS "Neuromed" - Neurosurgery - "Sapienza" Univesity, Pozzilli (IS), Italy
| | - Antonino Raco
- NESMOS Department Neurosurgery Department "Sapienza" University, Roma, Italy; Azienda Ospedaliera Sant'Andrea, Roma, Italy
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Dincoglan F, Beyzadeoglu M, Sager O, Oysul K, Sirin S, Surenkok S, Gamsiz H, Uysal B, Demiral S, Dirican B. Image-Guided Positioning in Intracranial Non-Invasive Stereotactic Radiosurgery for the Treatment of Brain Metastasis. TUMORI JOURNAL 2018; 98:630-5. [DOI: 10.1177/030089161209800514] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Aims and background The aim of the study was to examine the feasibility of non-invasive image-guided radiosurgery to improve patient comfort and quality of life in stereotactic radiosurgery planning and treatment of patients with brain metastasis. Precise immobilization is a rule of thumb for stereotactic radiosurgery. Non-invasive immobilization techniques have the potential of improved quality of life compared with invasive procedures. Methods and study design A total of 92 lesions from 42 patients with brain metastasis were included in the study. After immobilization with a thermoplastic mask and a bite-block unlike the invasive frame-based procedure, planning computed tomography images were acquired and fused with magnetic resonance images. After contouring, intensity-modulated stereotactic radiosurgery (IM-SRS) planning was done, and the patients were re-immobilized on the treatment couch for the therapy procedures. While patients were on the treatment couch, kilovoltage-cone beam computed tomography images were acquired to determine setup errors and achieve on-line correction and then repeated after on-line correction to confirm precise tumor localization. The patients then underwent single-fraction definitive treatment. Results For the 92 lesions treated, mean ± SD values of translational setup corrections in X (lateral), Y (longitudinal), and Z (vertical) dimensions were 0.7 ± 0.7 mm, 0.8 ± 0.7 mm, and 0.6 ± 0.5 mm, and rotational set-up corrections were 0.5 ± 1.1°, 0.06 ± 1.1°, and -0.1 ± 1.1° in X (pitch), Y (roll), and Z (yaw), respectively. The mean three-dimensional correction vector was 1.2 ± 1.1 mm. Conclusions Non-invasive image-guided radiosurgery for brain metastasis is feasible, and the non-invasive treatment approach can be routinely used in clinical practice to improve patientís quality of life.
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Affiliation(s)
- Ferrat Dincoglan
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Murat Beyzadeoglu
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Omer Sager
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Kaan Oysul
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Sait Sirin
- Neurosurgery Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Serdar Surenkok
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Hakan Gamsiz
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Bora Uysal
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Selcuk Demiral
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Bahar Dirican
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
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21
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González J, Gaynor JJ, Alameddine M, Esteban M, Ciancio G. Indications, complications, and outcomes following surgical management of locally advanced and metastatic renal cell carcinoma. Expert Rev Anticancer Ther 2018; 18:237-250. [PMID: 29353520 DOI: 10.1080/14737140.2018.1431530] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Surgery may set the basis for a potential cure or would provide the best achievable quality of life in locally advanced or metastatic renal cell carcinoma (mRCC). However, survival extension with this approach would be scarce and not exempt from adverse events, thus preventing its recommendation in an already frail patient. An evidence based analysis on the role of surgery in each of the possible clinical scenarios involved under this heading may provide a clear picture on this issue and would be of value in the decision making process. Areas covered: Current literature was queried in PubMed/Medline in a systematic fashion. Manuscripts included were selected according to the quality of the data provided. A narrative review strategy was adopted to summarize the evidence acquired. Expert commentary: A surgery-based multimodal treatment approach should be strongly considered after adequate counseling in locally advanced and mRCC, since it may provide for additional benefits in terms of survival. However, a critical reevaluation of its adequacy, optimal timing, and selection of ideal candidates is currently ongoing.
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Affiliation(s)
- Javier González
- a Servicio de Urología , Hospital Central de la Cruz Roja San José y Santa Adela , Madrid , Spain
| | - Jeffrey J Gaynor
- b Department of Surgery (Division of Transplantation), Department of Urology and the Miami Transplant Institute , University of Miami Miller School of Medicine, Jackson Memorial Hospital , Miami , FL , USA
| | - Mahmoud Alameddine
- b Department of Surgery (Division of Transplantation), Department of Urology and the Miami Transplant Institute , University of Miami Miller School of Medicine, Jackson Memorial Hospital , Miami , FL , USA
| | - Manuel Esteban
- c Servicio de Urología , Hospital Nacional de Parapléjicos , Toledo , Spain
| | - Gaetano Ciancio
- b Department of Surgery (Division of Transplantation), Department of Urology and the Miami Transplant Institute , University of Miami Miller School of Medicine, Jackson Memorial Hospital , Miami , FL , USA
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22
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Chen M, Chen D, Xu J, Xu M, Zhong P. Management of Solitary Intracranial Metastases of Differentiated Thyroid Carcinoma: 11 Pathologically Confirmed Cases and Systematic Literature Review. World Neurosurg 2018; 111:e888-e894. [PMID: 29317366 DOI: 10.1016/j.wneu.2017.12.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 12/27/2017] [Accepted: 12/30/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Solitary intracranial metastases of differentiated thyroid carcinoma (DTC) are rare, and their management is still controversial. This research aimed to seek suitable therapeutic methods for this disease. METHODS We retrospectively studied 11 pathologically confirmed cases of solitary intracranial metastases of DTC in a single institution from January 2000 to December 2016 and systematically reviewed 52 cases of this disease out of 416 cases described in the literature on PubMed. These 63 cases were analyzed by Kaplan-Meier analysis, Cox regression analysis, and post-hoc test. RESULTS The diameters of intracranial metastases in all 63 cases were greater than 2 cm. Lung metastases (P = 0.000) and neurosurgery (P = 0.014) were 2 independent prognostic factors of this disease. Only neurosurgery (P = 0.05) was an independent prognostic factor in the patients with lung metastases, and neurosurgery (P = 0.044) and whole brain radiotherapy (WBRT) (P = 0.041) were 2 independent factors in the patients without lung metastases. Longer overall survival (OS) was achieved in the gross total removal (GTR) and subtotal removal (STR) groups than in the no neurosurgery group (P = 0.015, P = 0.084, respectively), and there was no significance between the GTR and STR groups (P = 0.918). CONCLUSION The patients without lung metastases had a better prognosis than did the patients with lung metastases. Neurosurgery could obviously improve the prognosis, and if possible, GTR of metastases was supposed to be achieved; STR could be considered. WBRT was a suitable method after neurosurgery in the patients without lung metastases but could not prolong OS in the patients with lung metastases.
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Affiliation(s)
- Mingyu Chen
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Danqi Chen
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jian Xu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Ming Xu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Ping Zhong
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China.
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23
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Thon N, Kreth FW, Tonn JC. The role of surgery for brain metastases from solid tumors. HANDBOOK OF CLINICAL NEUROLOGY 2018; 149:113-121. [PMID: 29307348 DOI: 10.1016/b978-0-12-811161-1.00008-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Surgery, stereotactic radiosurgery, radiotherapy, and chemotherapy including novel targeted therapy strategies and any combination thereof as well as supportive care are the key elements for treatment of brain metastases. Goals of microsurgery are to obtain tissue samples for histologic diagnosis (particularly in case of uncertainty about the unknown primary tumor but also in the context of future targeted therapies), to relieve burden from space-occupying effects, to improve local tumor control, and to prolong overall survival. Complete surgical resection improves local tumor control and may even affect overall survival. Stereotactic radiosurgery is an equal effective alternative for metastases up to 3 cm in diameter, especially in highly eloquent or deep seated location. Gross total resection (as defined by immediate postoperative MRI) does not necessarily have to be combined with whole brain radiotherapy (WBRT), at least for patients with good performance status and controlled systemic disease. Particularly in cases of incomplete resections, focal irradiation or radiosurgery of the resection cavity or tumor remnant rather than WBRT may be attempted.
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Affiliation(s)
- Niklas Thon
- Department of Neurosurgery, University of Munich LMU, Munich, Germany
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24
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Abstract
Stereotactic radiosurgery has revolutionized the management of brain metastases. It delivers focused, highly conformal, ionizing radiation to a tumor delineated using high-resolution imaging, with low toxicity to adjacent brain structures. Randomized controlled and prospective trials have demonstrated a survival advantage and high local control rates after stereotactic radiosurgery for metastatic disease to the central nervous system, including for up to 10 brain metastases. Its minimal-access nature makes it an attractive alternative to surgical resection. Furthermore, in addition to chemotherapy, newer targeted therapies and immunotherapies with improved side-effect profiles allow for the concurrent delivery of systemic therapy with radiosurgery, with possible additive or synergistic effects, expediting the treatment of both extracranial and intracranial disease. The modern management of brain metastasis patients should include consideration of routine staging and surveillance magnetic resonance imaging scans in patients with higher-stage cancer to detect intracranial metastases earlier and treat promptly with radiosurgery in order to prevent the development of neurologic symptoms and the need for surgical resection.
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Affiliation(s)
- Amparo Wolf
- Department of Neurosurgery, Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York University, New York, NY, United States
| | - Douglas Kondziolka
- Department of Neurosurgery, Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York University, New York, NY, United States.
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25
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Kanazawa Y, Fujita I, Kakinuma D, Aoki Y, Kanno H, Arai H, Matsuno K, Shimoda T, Matsutani T, Hagiwara N, Nomura T, Yamada T, Kato S, Naito Z, Takasaki H, Uchida E. Five-year Survival After Surgical Removal and Gamma Knife Stereotactic Radiosurgery for a Cerebellar Metastasis from an Esophagogastric Junction Cancer: A Case Report and Literature Review. In Vivo 2017; 31:1209-1214. [PMID: 29102948 PMCID: PMC5756654 DOI: 10.21873/invivo.11192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 09/25/2017] [Accepted: 09/29/2017] [Indexed: 11/10/2022]
Abstract
Brain metastases originating from esophageal or gastric cancer are rare, accounting for 2.1-3.3% of all brain tumors registered in Japan. There are no established therapeutic measures for brain metastases, which accordingly have a poor prognosis. We present here a patient who survived for 5 years after surgery and gamma knife treatment of a cerebellar metastasis from esophagogastric adenocarcinoma. The primary gastric cancer was treated by laparotomy with total gastrectomy, splenectomy, and D2 lymphadenectomy. It was diagnosed as a esophagogastric junction Siewert type II tumor, type 3, tub1-2, pT3 (SS), pN1, and stage IIB on histopathological examination of the surgical specimen. Five months postoperatively, a solitary cerebellar metastasis was identified and surgically removed, followed by 20 Gy administered by gamma knife stereotactic radiosurgery; the patient received no subsequent treatment such as chemotherapy. Five years after the primary surgery, there have been no recurrences and the patient has a good quality of life. There are very few case reports of long-term survival after surgical treatment of cerebellar metastases from esophagogastric junction cancer. We report our experience and review published case reports of surgical treatment of brain metastases from gastric cancer.
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Affiliation(s)
- Yoshikazu Kanazawa
- Department of Gastrointestinal and Hepato-biliary-pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Itsuo Fujita
- Department of Gastrointestinal and Hepato-biliary-pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Daisuke Kakinuma
- Department of Gastrointestinal and Hepato-biliary-pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Yuto Aoki
- Department of Gastrointestinal and Hepato-biliary-pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Hitoshi Kanno
- Department of Gastrointestinal and Hepato-biliary-pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Hiroki Arai
- Department of Gastrointestinal and Hepato-biliary-pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Kunihiko Matsuno
- Department of Gastrointestinal and Hepato-biliary-pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Tomohiro Shimoda
- Department of Gastrointestinal and Hepato-biliary-pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Takeshi Matsutani
- Department of Gastrointestinal and Hepato-biliary-pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Nobutoshi Hagiwara
- Department of Gastrointestinal and Hepato-biliary-pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Tsutomu Nomura
- Department of Gastrointestinal and Hepato-biliary-pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Takeshi Yamada
- Department of Gastrointestinal and Hepato-biliary-pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Shunji Kato
- Department of Gastrointestinal and Hepato-biliary-pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Zenya Naito
- Department of Pathology, Nippon Medical School, Tokyo, Japan
| | | | - Eiji Uchida
- Department of Gastrointestinal and Hepato-biliary-pancreatic Surgery, Nippon Medical School, Tokyo, Japan
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26
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Soffietti R, Abacioglu U, Baumert B, Combs SE, Kinhult S, Kros JM, Marosi C, Metellus P, Radbruch A, Villa Freixa SS, Brada M, Carapella CM, Preusser M, Le Rhun E, Rudà R, Tonn JC, Weber DC, Weller M. Diagnosis and treatment of brain metastases from solid tumors: guidelines from the European Association of Neuro-Oncology (EANO). Neuro Oncol 2017; 19:162-174. [PMID: 28391295 DOI: 10.1093/neuonc/now241] [Citation(s) in RCA: 331] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The management of patients with brain metastases has become a major issue due to the increasing frequency and complexity of the diagnostic and therapeutic approaches. In 2014, the European Association of Neuro-Oncology (EANO) created a multidisciplinary Task Force to draw evidence-based guidelines for patients with brain metastases from solid tumors. Here, we present these guidelines, which provide a consensus review of evidence and recommendations for diagnosis by neuroimaging and neuropathology, staging, prognostic factors, and different treatment options. Specifically, we addressed options such as surgery, stereotactic radiosurgery/stereotactic fractionated radiotherapy, whole-brain radiotherapy, chemotherapy and targeted therapy (with particular attention to brain metastases from non-small cell lung cancer, melanoma and breast and renal cancer), and supportive care.
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Affiliation(s)
- Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Ufuk Abacioglu
- Department of Radiation Oncology, Neolife Medical Center, Istanbul, Turkey
| | - Brigitta Baumert
- Department of Radiation-Oncology, MediClin Robert-Janker-Klinik, Bonn, Germany
| | - Stephanie E Combs
- Department of Innovative Radiation Oncology and Radiation Sciences, Munich, Germany
| | - Sara Kinhult
- Department of Oncology, Skane University Hospital, Lund, Sweden
| | - Johan M Kros
- Department of Pathology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Christine Marosi
- Department of Internal Medicine, Division of Oncology, Medical University, Vienna, Austria
| | - Philippe Metellus
- Department of Internal Medicine, Division of Oncology, Medical University, Vienna, Austria.,Department of Neurosurgery, Clairval Hospital Center, Generale de Santé, Marseille, France
| | - Alexander Radbruch
- Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Salvador S Villa Freixa
- Department of Radiation Oncology, Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Michael Brada
- Department of Molecular and Clinical Cancer Medicine & Radiation Oncology, Liverpool, United Kingdom
| | - Carmine M Carapella
- Department of Neuroscience, Division of Neurosurgery, Regina Elena Nat Cancer Institute, Rome, Italy
| | - Matthias Preusser
- Department of Medicine I and Comprehensive Cancer Center CNS Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria
| | - Emilie Le Rhun
- Department of Neurosurgery, Neuro-oncology, University Hospital, Lille, France
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Joerg C Tonn
- Department of Neurosurgery, University of Munich LMU, Munich, Germany
| | - Damien C Weber
- Centre for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Michael Weller
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
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27
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Die deutsche S3-Leitlinie zum Nierenzellkarzinom. Strahlenther Onkol 2017; 194:1-8. [DOI: 10.1007/s00066-017-1185-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/30/2017] [Indexed: 10/19/2022]
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Khan M, Lin J, Liao G, Li R, Wang B, Xie G, Zheng J, Yuan Y. Comparison of WBRT alone, SRS alone, and their combination in the treatment of one or more brain metastases: Review and meta-analysis. Tumour Biol 2017; 39:1010428317702903. [PMID: 28675121 DOI: 10.1177/1010428317702903] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Whole brain radiotherapy has been a standard treatment of brain metastases. Stereotactic radiosurgery provides more focal and aggressive radiation and normal tissue sparing but worse local and distant control. This meta-analysis was performed to assess and compare the effectiveness of whole brain radiotherapy alone, stereotactic radiosurgery alone, and their combination in the treatment of brain metastases based on randomized controlled trial studies. Electronic databases (PubMed, MEDLINE, Embase, and Cochrane Library) were searched to identify randomized controlled trial studies that compared treatment outcome of whole brain radiotherapy and stereotactic radiosurgery. This meta-analysis was performed using the Review Manager (RevMan) software (version 5.2) that is provided by the Cochrane Collaboration. The data used were hazard ratios with 95% confidence intervals calculated for time-to-event data extracted from survival curves and local tumor control rate curves. Odds ratio with 95% confidence intervals were calculated for dichotomous data, while mean differences with 95% confidence intervals were calculated for continuous data. Fixed-effects or random-effects models were adopted according to heterogeneity. Five studies (n = 763) were included in this meta-analysis meeting the inclusion criteria. All the included studies were randomized controlled trials. The sample size ranged from 27 to 331. In total 202 (26%) patients with whole brain radiotherapy alone, 196 (26%) patients receiving stereotactic radiosurgery alone, and 365 (48%) patients were in whole brain radiotherapy plus stereotactic radiosurgery group. No significant survival benefit was observed for any treatment approach; hazard ratio was 1.19 (95% confidence interval: 0.96-1.43, p = 0.12) based on three randomized controlled trials for whole brain radiotherapy only compared to whole brain radiotherapy plus stereotactic radiosurgery and hazard ratio was 1.03 (95% confidence interval: 0.82-1.29, p = 0.81) for stereotactic radiosurgery only compared to combined approach. Local control was best achieved when whole brain radiotherapy was combined with stereotactic radiosurgery. Hazard ratio 2.05 (95% confidence interval: 1.36-3.09, p = 0.0006) and hazard ratio 1.84 (95% confidence interval: 1.26-2.70, p = 0.002) were obtained from comparing whole brain radiotherapy only and stereotactic radiosurgery only to whole brain radiotherapy + stereotactic radiosurgery, respectively. No difference in adverse events for treatment difference; odds ratio 1.16 (95% confidence interval: 0.77-1.76, p = 0.48) and odds ratio 0.92 (95% confidence interval: 0.59-1.42, p = 71) for whole brain radiotherapy + stereotactic radiosurgery versus whole brain radiotherapy only and whole brain radiotherapy + stereotactic radiosurgery versus stereotactic radiosurgery only, respectively. Adding stereotactic radiosurgery to whole brain radiotherapy provides better local control as compared to whole brain radiotherapy only and stereotactic radiosurgery only with no difference in radiation related toxicities.
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Affiliation(s)
- Muhammad Khan
- 1 Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China, 510515
| | - Jie Lin
- 2 Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, Guangdong Province, People's Republic of China, 510095
| | - Guixiang Liao
- 3 Department of Radiation Oncology, Shenzhen People's Hospital, Second Clinical Medicine College of Jinan University, China, 518020
| | - Rong Li
- 2 Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, Guangdong Province, People's Republic of China, 510095
| | - Baiyao Wang
- 1 Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China, 510515
| | - Guozhu Xie
- 1 Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China, 510515
| | - Jieling Zheng
- 1 Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China, 510515
| | - Yawei Yuan
- 1 Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China, 510515.,2 Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, Guangdong Province, People's Republic of China, 510095
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Tuleasca C, Negretti L, Faouzi M, Magaddino V, Gevaert T, von Elm E, Levivier M. Radiosurgery in the management of brain metastasis: a retrospective single-center study comparing Gamma Knife and LINAC treatment. J Neurosurg 2017; 128:352-361. [PMID: 28338441 DOI: 10.3171/2016.10.jns161480] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors present a retrospective analysis of a single-center experience with treatment of brain metastases using Gamma Knife (GK) and linear accelerator (LINAC)-based radiosurgery and compare the results. METHODS From July 2010 to July 2012, 63 patients with brain metastases were treated with radiosurgery. Among them, 28 (with 83 lesions) were treated with a GK unit and 35 (with 47 lesions) with a LINAC. The primary outcome was local progression-free survival (LPFS), evaluated on a per-lesion basis. The secondary outcome was overall survival (OS), evaluated per patient. Statistical analysis included standard tests and Cox regression with shared-frailty models to account for the within-patient correlation. RESULTS The mean follow-up period was 11.7 months (median 7.9 months, range 1.7-32 months) for GK and 18.1 months (median 17 months, range 7.5-28.7 months) for LINAC. The median number of lesions per patient was 2.5 (range 1-9) in the GK group and 1 (range 1-3) in the LINAC group (p < 0.01, 2-sample t-test). There were more radioresistant lesions (e.g., melanoma) and more lesions located in functional areas in the GK group. Additional technical reasons for choosing GK instead of LINAC were limitations of LINAC movements, especially if lesions were located in the lower posterior fossa or multiple lesions were close to highly functional areas (e.g., the brainstem), precluding optimal dosimetry with LINAC. The median marginal dose was 24 Gy with GK and 20 Gy with LINAC (p < 0.01, 2-sample t-test). For GK, the actuarial LPFS rate at 3, 6, 9, 12, and 17 months was 96.96%, 96.96%, 96.96%, 88.1%, and 81.5%, remaining stable until 32 months. For LINAC the rate at 3, 6, 12, 17, 24, and 33 months was 91.5%, 91.5%, 91.5%, 79.9%, 55.5%, and 17.1% (log-rank p = 0.03). In the Cox regression with shared-frailty model, the risk of local progression in the LINAC group was almost twice that of the GK group (HR 1.92, p > 0.05). The mean OS was 16.0 months (95% CI 11.2-20.9 months) in the GK group, compared with 20.9 months (95% CI 16.4-25.3 months) in the LINAC group. Univariate and multivariate analysis showed that a lower graded prognostic assessment (GPA) score, noncontrolled systemic status at last radiological assessment, and older age were associated with lower OS; after adjustment of these covariables by Cox regression, the OS was similar in the 2 groups. CONCLUSIONS In this retrospective study comparing GK and LINAC-based radiosurgery for brain metastases, patients with more severe disease were treated by GK, including those harboring lesions of greater number, of radioresistant type, or in highly functional areas. The risk of local progression for the LINAC group was almost twice that in the GK group, although the difference was not statistically significant. Importantly, the OS rates were similar for the 2 groups, although GK was used in patients with more complex brain metastatic disease and with no other therapeutic alternative.
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Affiliation(s)
- Constantin Tuleasca
- 1Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, and.,2Signal Processing Laboratory (LTS 5), Ecole Polytechnique Fédérale de Lausanne.,3Faculty of Biology and Medicine, University of Lausanne
| | | | - Mohamed Faouzi
- 3Faculty of Biology and Medicine, University of Lausanne.,5Institute of Social and Preventive Medicine, Lausanne University Hospital
| | - Vera Magaddino
- 6Institute of Radiation Physics, Lausanne,Switzerland; and
| | - Thierry Gevaert
- 7Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel,Belgium
| | - Erik von Elm
- 3Faculty of Biology and Medicine, University of Lausanne.,5Institute of Social and Preventive Medicine, Lausanne University Hospital
| | - Marc Levivier
- 1Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, and.,3Faculty of Biology and Medicine, University of Lausanne
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Shimony N, Shofty B, Harosh CB, Sitt R, Ram Z, Grossman R. Surgical Resection of Cerebral Metastases Leads to Faster Resolution of Peritumoral Edema than Stereotactic Radiosurgery: A Volumetric Analysis. Ann Surg Oncol 2016; 24:1392-1398. [PMID: 27896517 DOI: 10.1245/s10434-016-5709-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Surgical resection and stereotactic radiosurgery (SRS) are well-established treatment options for selected patients with oligo-brain metastases (BMs). The dynamics of edema resolution with each treatment method have not been well characterized. METHODS Of 389 patients treated for BMs between 2012 and 2014, this study retrospectively identified 107 patients (150 metastases) who underwent either surgery or SRS as a single treatment method for BMs. The two groups of patients were matched for clinical parameters. Volumetric assessments of the tumor and associated edema were performed before treatment and then 2-3 months after treatment. RESULTS In this study, 76 surgical cases were compared with 74 cases treated with SRS. The volume of the tumor and surrounding edema was significantly greater in the surgery group than in the SRS group. However, resolution of edema was significantly more rapid in the surgical group (p < 0.0001), accompanied by faster weaning from steroids. After a matching process based on the propensity of a patient to receive SRS, a subgroup cohort was analyzed (mean maximal diameter: 21 mm in the surgical group vs 20.8 mm in the SRS group; p = 0.9). At diagnosis, edema volume, but not tumor volume, was significantly greater in the surgical group. The resolution of edema 2-3 months after treatment was better in the surgical group than in the SRS group (89.6% vs 71.1% of baseline, respectively; p = 0.09), although this difference did not reach the level of significance. CONCLUSIONS Resolution of tumor-associated edema in BMs suitable for either surgery or SRS was significantly faster after surgical resection than after SRS. Accordingly, when both treatment options are suitable, surgery appears to induce faster resolution of the edema.
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Affiliation(s)
- Nir Shimony
- Department of Neurosurgery, Affiliated to the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Ben Shofty
- Department of Neurosurgery, Affiliated to the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Carmit Ben Harosh
- Department of Neurosurgery, Affiliated to the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Razi Sitt
- Department of Neurosurgery, Affiliated to the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Affiliated to the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Rachel Grossman
- Department of Neurosurgery, Affiliated to the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel.
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Abstract
The diagnosis of brain metastases is associated with a poor prognosis reflecting uncontrolled primary disease that has spread to the relative sanctuary of the central nervous system. 20 % of brain metastases occur in the posterior fossa and are associated with significant morbidity. The risk of acute hydrocephalus and potential for sudden death means these metastases are often dealt with as emergency cases. This approach means a full pre-operative assessment and staging of underlying disease may be neglected and a proportion of patients undergo comparatively high risk surgery with little or no survival benefit. This study aimed to assess outcomes in patients to identify factors that may assist in case selection. We report a retrospective case series of 92 consecutive patients operated for posterior fossa metastases between 2007 and 2012. Routine demographic data was collected plus data on performance status, primary cancer site, details of surgery, adjuvant treatment and survival. The only independent positive prognostic factors identified on multivariate analysis were good performance status (if Karnofsky performance score >70, hazard ratio (HR) for death 0.36, 95 % confidence interval (CI) 0.18–0.69), adjuvant whole brain radiotherapy (HR 0.37, 95 % CI 0.21–0.65) and adjuvant chemotherapy where there was extracranial disease and non-synchronous presentation (HR 0.51, 95 % CI 0.31–0.82). Patients presenting with posterior fossa metastases may not be investigated as thoroughly as those with supratentorial tumours. Staging and assessment is essential however, and in the meantime emergencies related to tumour mass effect should be managed with steroids and cerebrospinal fluid diversion as required.
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Shen CJ, Lim M, Kleinberg LR. Controversies in the Therapy of Brain Metastases: Shifting Paradigms in an Era of Effective Systemic Therapy and Longer-Term Survivorship. Curr Treat Options Oncol 2016; 17:46. [DOI: 10.1007/s11864-016-0423-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bai H, Xu J, Yang H, Jin B, Lou Y, Wu D, Han B. Survival prognostic factors for patients with synchronous brain oligometastatic non-small-cell lung carcinoma receiving local therapy. Onco Targets Ther 2016; 9:4207-13. [PMID: 27471395 PMCID: PMC4948689 DOI: 10.2147/ott.s106696] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Clinical evidence for patients with synchronous brain oligometastatic non-small-cell lung carcinoma is limited. We aimed to summarize the clinical data of these patients to explore the survival prognostic factors for this population. Methods From September 1995 to July 2011, patients with 1–3 synchronous brain oligometastases, who were treated with stereotactic radiosurgery (SRS) or surgical resection as the primary treatment, were identified at Shanghai Chest Hospital. Results A total of 76 patients (22 patients underwent brain surgery as primary treatment and 54 patients received SRS) were available for survival analysis. The overall survival (OS) for patients treated with SRS and brain surgery as the primary treatment were 12.6 months (95% confidence interval [CI] 10.3–14.9) and 16.4 months (95% CI 8.8–24.1), respectively (adjusted hazard ratio =0.59, 95% CI 0.33–1.07, P=0.08). Among 76 patients treated with SRS or brain surgery, 21 patients who underwent primary tumor resection did not experience a significantly improved OS (16.4 months, 95% CI 9.6–23.2), compared with those who did not undergo resection (11.9 months, 95% CI 9.7–14.0; adjusted hazard ratio =0.81, 95% CI 0.46–1.44, P=0.46). Factors associated with survival benefits included stage I–II of primary lung tumor and solitary brain metastasis. Conclusion There was no significant difference in OS for patients with synchronous brain oligometastasis receiving SRS or surgical resection. Among this population, the number of brain metastases and stage of primary lung disease were the factors associated with a survival benefit.
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Affiliation(s)
| | | | | | | | | | - Dan Wu
- Central Laboratory, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, People's Republic of China
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Shin HK, Kim JH, Lee DH, Cho YH, Kwon DH, Roh SW. Clinical Outcomes of Gamma Knife Radiosurgery for Metastatic Brain Tumors from Gynecologic Cancer : Prognostic Factors in Local Treatment Failure and Survival. J Korean Neurosurg Soc 2016; 59:392-9. [PMID: 27446522 PMCID: PMC4954889 DOI: 10.3340/jkns.2016.59.4.392] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 02/21/2016] [Accepted: 04/07/2016] [Indexed: 01/20/2023] Open
Abstract
Objective Brain metastases in gynecologic cancer (ovarian, endometrial, and cervical cancer) patients are rare, and the efficacy of Gamma Knife Radiosurgery (GKRS) to treat these had not been evaluated. We assessed the efficacy of GKRS and prognostic factors for tumor control and survival in brain metastasis from gynecologic cancers. Methods This retrospective study was approved by the institutional review board. From May 1995 to October 2012, 26 women (mean age 51.3 years, range 27–70 years) with metastatic brain tumors from gynecologic cancer were treated with GKRS. We reviewed their outcomes, radiological responses, and clinical status. Results In total 24 patients (59 lesions) were available for follow-up imaging. The median follow-up time was 9 months. The mean treated tumor volume at the time of GKRS was 8185 mm3 (range 10–19500 mm3), and the median dose delivered to the tumor margin was 25 Gy (range, 10–30 Gy). A local tumor control rate was 89.8% (53 of 59 tumors). The median overall survival was 9.5 months after GKRS (range, 1–102 months). Age-associated multivariate analysis indicated that the Karnofsky performance status (KPS), the recursive partitioning analysis (RPA) classification, and the number of treated lesions were significant prognostic factors for overall survival (HR=0.162, p=0.008, HR=0.107, p=0.038, and HR=2.897, p=0.045, respectively). Conclusion GKRS is safe and effective for the management of brain metastasis from gynecologic cancers. The clinical status of the patient is important in determining the overall survival time.
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Affiliation(s)
- Hong Kyung Shin
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Kim
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Heui Lee
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hyun Cho
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kwon
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Woo Roh
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Hayashi M, Yamamoto M, Nishimura C, Satoh H. Do Recent Advances in MR Technologies Contribute to Better Gamma Knife Radiosurgery Treatment Results for Brain Metastases? Neuroradiol J 2016; 20:481-90. [DOI: 10.1177/197140090702000501] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2007] [Accepted: 06/29/2007] [Indexed: 11/15/2022] Open
Abstract
The detection of intracerebral lesions has improved greatly with advancements in MR imaging, especially the greater sensitivity of the 1.5 Tesla unit versus the older 1.0 Tesla unit. We aimed to determine whether improvements in MR imaging have actually improved diagnostic capabilities and treatment outcomes in gamma knife radiosurgery (GKRS) for brain metastases (METs). Ours was a retrospective study of a consecutive series of 1179 patients (441 females, 738 males, mean age: 63 years, range: 19–92 years) with brain METs who underwent GKRS from 1998 to 2004. Our treatment policy was to irradiate all lesions visible on MR images during a single GKRS session. Mean and median tumor numbers were seven and three (range; 1–74). The 1179 patients were divided into two groups: a 1.0 T-group of 660 patients examined using a 1.0 Tesla MR unit before August, 2002, and a 1.5 T-group of 519 examined using a 1.5 Tesla MR unit after September 2002. In the 1.5 T-group, lesion volumes as small as 0.004 cc were detected with a 5 mm slice thickness. The corresponding lesion size was 0.013 cc in the 1.0 T-group. One or more lesions invisible on a 5 mm slice study were additionally detected on a 2 mm slice study in 47.8% of patients in the 1.0 T-group and 25.2% in the 1.5 T-group (p<.0001). The median survival time (MST) in the 1.5 T-group was significantly longer than that in the 1.0 T-group (8.4 vs. 6.3 months, p=.0004). Due to biases in patient numbers between the two groups, we analyzed subgroups with KPS of 80% or better, no neurological deficits, stable primary tumors, lung cancer, tumor numbers of four or less and tumor volumes of 10.0 cc or smaller. In every subgroup analysis, the MSTs of the 1.5-Tesla group were significantly longer than those of the 1.0-Tesla group. The prognosis of a cancer patient is undoubtedly influenced by multiple factors. Nevertheless, we conclude that application of the 1.5 Tesla MR unit has had a favorable impact on diagnosis and GKRS treatment results in patients with brain METs.
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Affiliation(s)
- M. Hayashi
- Department of Neurosurgery, Toho University Medical Center Ohashi Hospital, Japan
| | - M. Yamamoto
- Katsuta Hospital Mito GammaHouse; Ibaraki, Japan
| | - C. Nishimura
- Department of Medical Informatics, Toho University School of Medicine; Tokio, Japan
| | - H Satoh
- Katsuta Hospital Mito GammaHouse; Ibaraki, Japan
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Bex A, Larkin J, Voss M. Challenging the treatment paradigm for advanced renal cell carcinoma: a review of systemic and localized therapies. Am Soc Clin Oncol Educ Book 2016:e239-47. [PMID: 25993179 DOI: 10.14694/edbook_am.2015.35.e239] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The current standard of care for the management of advanced renal cell carcinoma (RCC) revolves around systemic therapy with molecularly targeted agents. Over the last decade, a total of seven targeted drugs have been approved but, altogether, only exploit two molecular targets in this disease: the vascular endothelial growth factor (VEGF) axis and the mammalian target of rapamycin (mTOR). Introduction of these agents has markedly improved outcomes compared with those in the cytokine era, yet comparatively little progress has been made since registration of the first targeted therapeutics occurred 10 years ago. In this article, we review efforts to improve on this current treatment paradigm. We discuss novel targets in this disease and corresponding new agents under investigation. The article dedicates particular attention to targeted immunotherapeutics, which are rapidly emerging as a new category of interest in this disease. Last, we review current data supporting the use of surgical interventions to improve outcomes in patients with metastatic disease.
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Affiliation(s)
- Axel Bex
- From the Netherlands Cancer Institute, Amsterdam, Netherlands; The Royal Marsden NHS Foundation Trust, London, United Kingdom; Memorial Sloan Kettering Cancer Center, New York, NY; Weill Cornell Medical College, New York, NY
| | - James Larkin
- From the Netherlands Cancer Institute, Amsterdam, Netherlands; The Royal Marsden NHS Foundation Trust, London, United Kingdom; Memorial Sloan Kettering Cancer Center, New York, NY; Weill Cornell Medical College, New York, NY
| | - Martin Voss
- From the Netherlands Cancer Institute, Amsterdam, Netherlands; The Royal Marsden NHS Foundation Trust, London, United Kingdom; Memorial Sloan Kettering Cancer Center, New York, NY; Weill Cornell Medical College, New York, NY
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Mehta MP, Ahluwalia MS. Whole-brain radiotherapy and stereotactic radiosurgery in brain metastases: what is the evidence? Am Soc Clin Oncol Educ Book 2016:e99-104. [PMID: 25993245 DOI: 10.14694/edbook_am.2015.35.e99] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The overall local treatment paradigm of brain metastases, which includes whole-brain radiotherapy (WBRT) and stereotactic radiosurgery (SRS), continues to evolve. Local therapies play an important role in the management of brain metastases. The choice of local therapy depends on factors that involve the patient (performance status, expected survival, and age), the prior treatment history, and the tumor (type and subtype, number, size, location of metastases, and extracranial disease status). Multidisciplinary collaboration is required to facilitate an individualized plan to improve the outcome of disease in patients with this life-limiting complication. There has been concern about the neurocognitive effects of WBRT. A number of approaches that mitigate cognitive dysfunction, such as pharmacologic intervention (memantine) or a hippocampal-sparing strategy, have been studied in a prospective manner with WBRT. Although there has been an increase in the use of SRS in the management of brain metastases in recent years, WBRT retains an important therapeutic role.
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Affiliation(s)
- Minesh P Mehta
- From the Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD; Burkhardt Brain Tumor Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Manmeet S Ahluwalia
- From the Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD; Burkhardt Brain Tumor Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
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Fuentes R, Osorio D, Expósito Hernandez J, Simancas-Racines D, Bonfill Cosp X. Surgery versus radiosurgery for people with single or solitary brain metastases. Hippokratia 2016. [DOI: 10.1002/14651858.cd012086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Rafel Fuentes
- Institut Català d'Oncologia; Avda França, s/n Girona Spain 17007
| | - Dimelza Osorio
- Universidad Tecnológica Equinoccial; Facultad de Ciencias de la Salud Eugenio Espejo; Avenida República de El Salvador 733 y Portugal Edificio Gabriela 3. Of. 403 Quito Ecuador Casilla Postal 17-17-525
| | - José Expósito Hernandez
- Hospital Universitario Virgen de las Nieves; Research Unit; Avda. Fuerzas Armadas, 4 Granada Spain 18014
| | - Daniel Simancas-Racines
- Universidad Tecnológica Equinoccial; Facultad de Ciencias de la Salud Eugenio Espejo; Avenida República de El Salvador 733 y Portugal Edificio Gabriela 3. Of. 403 Quito Ecuador Casilla Postal 17-17-525
| | - Xavier Bonfill Cosp
- CIBER Epidemiología y Salud Pública (CIBERESP); Iberoamerican Cochrane Centre - Biomedical Research Institute Sant Pau (IIB Sant Pau); Sant Antoni Maria Claret, 167 Pavilion 18 (D-13) Barcelona Catalunya Spain 08025
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Lee GS, Cho SJ, Kim JH, Park HK, Park SQ, Kim RS, Jang JC. Comparative Analysis of Efficacy and Safety of Multisession Radiosurgery to Single Dose Radiosurgery for Metastatic Brain Tumors. Brain Tumor Res Treat 2015; 3:95-102. [PMID: 26605264 PMCID: PMC4656902 DOI: 10.14791/btrt.2015.3.2.95] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 08/29/2015] [Accepted: 10/01/2015] [Indexed: 11/20/2022] Open
Abstract
Background The purpose of this study is to compare the efficacy and safety of multisession radiosurgery to those of single dose radiosurgery for metastatic brain tumors. Methods Between February 2008 and February 2012, 90 patients with 196 metastatic brain tumors were treated with cyberknife radiosurgery, and we reviewed these patients retrospectively. Among them, 57 patients underwent single dose radiosurgery, and 33 patients multisession radiosurgery. Tumors involving the eloquent area and large tumors (>5 cc) were treated with multisession radiosurgery. The median tumor volume and the median treatment dose of single dose radiosurgery were 2.05±0.72 cc and 19.76±1.54 Gy respectively, and in the case of multisession radiosurgery, 5.30±1.70 cc and 29.6±1.70 Gy respectively. The frequency of multisession dose was 3 to 5 times, on average 3.55 times, and 8.91 Gy were given per 1 session on average. Results The overall survival (OS) of multisession radiosurgery was 16.0 months, whereas that of single dose radiosurgery was 11.5 months. The radiologic tumor response rates were 90% in single dose radiosurgery and 95.4% in multisession radiosurgery, respectively. Over 6-month and 1-year periods, the OS rates of single dose radiosurgery were 71.4% and 44.9%, whereas those of multisession radiosurgery were 69.1% and 58.3%, respectively (p=0.83). Toxicities were seen in 18.1% in the single dose radiosurgery group versus 4% in the multisession radiosurgery group. The difference was significant (p<0.05). Conclusion In this study, the multisession radiosurgery group, despite the location and size constraints, did not differ from the single dose radiosurgery group when comparing the survival and recurrence rates, but complications and toxicity were lower. Thus, multisession radiosurgery is thought to be beneficial for treatment of large tumors and tumors located in the eloquent area.
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Affiliation(s)
- Gwang Soo Lee
- Department of Neurosurgery, Soonchunhyang University Hospital, Seoul, Korea
| | - Sung Jin Cho
- Department of Neurosurgery, Soonchunhyang University Hospital, Seoul, Korea
| | - Ji Hoon Kim
- Department of Neurosurgery, Soonchunhyang University Hospital, Seoul, Korea
| | - Hyung Ki Park
- Department of Neurosurgery, Soonchunhyang University Hospital, Seoul, Korea
| | - Suk Que Park
- Department of Neurosurgery, Soonchunhyang University Hospital, Seoul, Korea
| | - Ra Sun Kim
- Department of Neurosurgery, Soonchunhyang University Hospital, Seoul, Korea
| | - Jae Chil Jang
- Department of Neurosurgery, Soonchunhyang University Hospital, Seoul, Korea
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40
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Bex A. Integrating metastasectomy and stereotactic radiosurgery in the treatment of metastatic renal cell carcinoma. EJC Suppl 2015. [PMID: 26217128 PMCID: PMC4041303 DOI: 10.1016/j.ejcsup.2013.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Axel Bex
- The Netherlands Cancer Institute, Department of Urology, Amsterdam, The Netherlands
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41
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Kimmell KT, LaSota E, Weil RJ, Marko NF. Comparative Effectiveness Analysis of Treatment Options for Single Brain Metastasis. World Neurosurg 2015; 84:1316-32. [PMID: 26100168 DOI: 10.1016/j.wneu.2015.06.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 06/10/2015] [Accepted: 06/11/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Brain metastases (BMs) occur in up to 30% of patients with cancer. Treatments include surgery, whole-brain radiotherapy (WBRT), and stereotactic radiosurgery (SRS), alone or in combination. Although guidelines exist, data to inform individualized approaches to therapy remain sparse. We sought to compare semiquantitatively the effectiveness of various modalities in the treatment of single brain metastasis. METHODS We performed a comparative effectiveness analysis (CEA) that integrated efficacy, cost, and quality of life (QoL) data for alternate BM treatments. Efficacy data were obtained from a comprehensive review of current literature. Cost estimates were based on publicly available data. QoL data included the Karnofsky Performance Status (KPS) and other questionnaires. Six treatment strategies using combinations of surgery, WBRT, and SRS were compared with decision tree software. RESULTS The clinical efficacy, cost, and QoL effects of each strategy were scored semiquantitatively. We constructed a model to integrate individual preferences regarding the relative importance of efficacy, QoL, and cost to provide personalized rankings of the effectiveness of each strategy. CONCLUSION The choice of strategy must be individualized for patients with a single BM. Our CEA and decision model combines empirical data with patient priorities to produce a ranking of alternate management strategies.
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Affiliation(s)
- Kristopher T Kimmell
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA.
| | - Emily LaSota
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert J Weil
- Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania, USA
| | - Nicholas F Marko
- Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania, USA
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Kim M, Cheok S, Chung LK, Ung N, Thill K, Voth B, Kwon DH, Kim JH, Kim CJ, Tenn S, Lee P, Yang I. Characteristics and treatments of large cystic brain metastasis: radiosurgery and stereotactic aspiration. Brain Tumor Res Treat 2015; 3:1-7. [PMID: 25977901 PMCID: PMC4426272 DOI: 10.14791/btrt.2015.3.1.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 10/14/2014] [Accepted: 10/14/2014] [Indexed: 11/20/2022] Open
Abstract
Brain metastasis represents one of the most common causes of intracranial tumors in adults, and the incidence of brain metastasis continues to rise due to the increasing survival of cancer patients. Yet, the development of cystic brain metastasis remains a relatively rare occurrence. In this review, we describe the characteristics of cystic brain metastasis and evaluate the combined use of stereotactic aspiration and radiosurgery in treating large cystic brain metastasis. The results of several studies show that stereotactic radiosurgery produces comparable local tumor control and survival rates as other surgery protocols. When the size of the tumor interferes with radiosurgery, stereotactic aspiration of the metastasis should be considered to reduce the target volume as well as decreasing the chance of radiation induced necrosis and providing symptomatic relief from mass effect. The combined use of stereotactic aspiration and radiosurgery has strong implications in improving patient outcomes.
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Affiliation(s)
- Moinay Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Stephanie Cheok
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Lawrance K Chung
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Nolan Ung
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Kimberly Thill
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Brittany Voth
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Do Hoon Kwon
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Jin Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Stephen Tenn
- Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA, USA. ; Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Percy Lee
- Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA, USA. ; Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Isaac Yang
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA. ; Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA, USA
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To Remove or Not to Remove, that Is the Question? World Neurosurg 2015; 84:2-3. [PMID: 25841753 DOI: 10.1016/j.wneu.2015.03.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 03/30/2015] [Indexed: 11/20/2022]
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Optimal Timing of Whole-Brain Radiation Therapy Following Craniotomy for Cerebral Malignancies. World Neurosurg 2015; 84:412-9. [PMID: 25839399 DOI: 10.1016/j.wneu.2015.03.052] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 03/22/2015] [Accepted: 03/23/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND For patients with cerebral metastases that are limited in number, surgical resection followed by whole-brain radiation therapy is the standard of care. In addition, for high-grade gliomas, maximal surgical resection followed by local radiotherapy is considered the optimal treatment. Radiation is known to impair wound healing, including healing of surgical incisions. Radiotherapy shortly after surgical resection would be expected to minimize the opportunity for tumor regrowth or progression. Owing to these competing interests, the purpose of this study was to shed light on the optimal timing of radiotherapy after surgical resection of brain metastasis or high-grade gliomas. METHODS A review of the literature was conducted on the following topics: radiation and wound healing, corticosteroid use and wound healing, radiotherapy for tumor control for cerebral metastases and high-grade gliomas, and whole-brain radiation therapy or focal radiotherapy after craniotomy with focus on the timing of radiotherapy after surgery. RESULTS In animal models, wound integrity and healing was less impaired by radiotherapy administered 1 week after surgery. In humans, this timing would be expected to be significantly longer, on the order of several weeks. CONCLUSIONS Given the limited literature, insufficient conclusions can be drawn. However, animal data suggest a period of at least 1 week (but it is likely several weeks in humans) is necessary for reconstitution of wound strength before initiation of radiation therapy. A randomized prospective study is recommended to understand better the effect of the timing of radiation therapy following surgical intervention for brain metastasis or high-grade gliomas.
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Comparison Between Surgical Resection and Stereotactic Radiosurgery in Patients with a Single Brain Metastasis from Non-Small Cell Lung Cancer. World Neurosurg 2015; 83:900-6. [PMID: 25659803 DOI: 10.1016/j.wneu.2015.01.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 01/22/2015] [Accepted: 01/28/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND The management of patients with single brain metastasis (BM) from non-small cell lung cancer (NSCLC) is controversial. Surgical resection (SR) with adjuvant irradiation and stereotactic radiosurgery (SRS) are performed in the treatment of such lesions. This study compared both modalities in terms of tumor control and survival. METHODS During the period 2004-2011, 115 patients with single BM from NSCLC were treated with SR or SRS at our institution. Median patient age was 61 years. SR was performed in 43 patients, and SRS was performed in 72 patients. Most patients who underwent SR had adjuvant irradiation. Of patients, 63% in the SR group and 56% in the SRS group had synchronous presentation of BM and lung primary tumor. Thoracic disease was managed with curative intent in 60% of patients in the SR group compared with 50% of patients in the SRS group. RESULTS Median follow-up was 10.2 months. Local control was 72% in patients in the SR group and 79% in patients in the SRS group (P = 0.992). Median survival for patients in the SR group was 13.3 months, and median survival for patients in the SRS group was 7.8 months (P = 0.047). Multivariate analyses revealed aggressive treatment of the primary NSCLC as an independent factor associated with prolonged survival in patients undergoing SR. In the SRS group, patients with metachronous metastasis showed a better prognosis. Metachronous presentation was associated with more aggressive management of the primary tumor. CONCLUSIONS In this study, patients with single BM undergoing SR had a survival advantage. However, because SR and SRS achieved comparable local control of BM, patients receiving SRS should benefit from an equally aggressive treatment of the primary NSCLC, as thoracic management was the most important predictor of survival.
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Weil RJ, Mavinkurve GG, Chao ST, Vogelbaum MA, Suh JH, Kolar M, Toms SA. Intraoperative radiotherapy to treat newly diagnosed solitary brain metastasis: initial experience and long-term outcomes. J Neurosurg 2015; 122:825-32. [PMID: 25614945 DOI: 10.3171/2014.11.jns1449] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors assessed the feasibility of intraoperative radiotherapy (IORT) using a portable radiation source to treat newly diagnosed, surgically resected, solitary brain metastasis (BrM). METHODS In a nonrandomized prospective study, 23 patients with histologically confirmed BrM were treated with an Intrabeam device that delivered 14 Gy to a 2-mm depth to the resection cavity during surgery. RESULTS In a 5-year minimum follow-up period, progression-free survival from the time of surgery with simultaneous IORT averaged (± SD) 22 ± 33 months (range 1-96 months), with survival from the time of BrM treatment with surgery+IORT of 30 ± 32 months (range 1-96 months) and overall survival from the time of first cancer diagnosis of 71 ± 64 months (range 4-197 months). For the Graded Prognostic Assessment (GPA), patients with a score of 1.5-2.0 (n = 12) had an average posttreatment survival of 21 ± 26 months (range 1-96 months), those with a score of 2.5-3.0 (n = 7) had an average posttreatment survival of 52 ± 40 months (range 5-94 months), and those with a score of 3.5-4.0 (n = 4) had an average posttreatment survival of 17 ± 12 months (range 4-28 months). A BrM at the treatment site recurred in 7 patients 9 ± 6 months posttreatment, and 5 patients had new but distant BrM 17 ± 3 months after surgery+IORT. Six patients later received whole-brain radiation therapy, 7 patients received radiosurgery, and 2 patients received both treatments. The median Karnofsky Performance Scale scores before and 1 and 3 months after surgery were 80, 90, and 90, respectively; at the time of this writing, 3 patients remain alive with a CNS progression-free survival of > 90 months without additional BrM treatment. CONCLUSIONS The results of this study demonstrate the feasibility of resection combined with IORT at a dose of 14 Gy to a 2-mm peripheral margin to treat a solitary BrM. Local control, distant control, and long-term survival were comparable to those of other commonly used modalities. Surgery combined with IORT seems to be a potential adjunct to patient treatment for CNS involvement by systemic cancer.
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Affiliation(s)
- Robert J Weil
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center
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Qin H, Wang C, Jiang Y, Zhang X, Zhang Y, Ruan Z. Patients with single brain metastasis from non-small cell lung cancer equally benefit from stereotactic radiosurgery and surgery: a systematic review. Med Sci Monit 2015; 21:144-52. [PMID: 25579245 PMCID: PMC4299005 DOI: 10.12659/msm.892405] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background The appropriate treatment of non-small cell lung cancer (NSCLC) with single brain metastasis (SBM) is still controversial. A systematic review was designed to evaluate the effectiveness of neurosurgery and stereotactic radiosurgery (SRS) in patients with SBM from NSCLC. Material/Methods PUBMED, EMBASE, the Cochrane Library, Web of Knowledge, Current Controlled Trials, Clinical Trials, and 2 conference websites were searched to select NSCLC patients with only SBM who received brain surgery or SRS. SPSS 18.0 software was used to analyze the mean median survival time (MST) and Stata 11.0 software was used to calculate the overall survival (OS). Results A total of 18 trials including 713 patients were systematically reviewed. The MST of the patients was 12.7 months in surgery group and 14.85 months in SRS group, respectively. The 1, 2, and 5 years OS of the patients were 59%, 33%, and 19% in surgery group, and 62%, 33%, and 14% in SRS group, respectively. Furthermore, in the surgery group, the 1 and 3 years OS were 68% and 15% in patients with controlled primary tumors, and 50% and 13% in the other patients with uncontrolled primary tumors, respectively. Interestingly, the 5-year OS was up to 21% in patients with controlled primary tumors. Conclusions There was no significant difference in MST or OS between patients treated with neurosurgery and SRS. Patients with resectable lung tumors and SBM may benefit from the resection of both primary lesions and metastasis.
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Affiliation(s)
- Hong Qin
- Department of Oncology, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Cancan Wang
- Department of Oncology, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Yongyuan Jiang
- Department of Respiratory, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Xiaoli Zhang
- Department of Oncology, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Yao Zhang
- Department of Epidemiology, Third Military Medical University, Chongqing, China (mainland)
| | - Zhihua Ruan
- Department of Oncology, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
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Dabestani S, Bex A. Metastasectomy. KIDNEY CANCER 2015. [DOI: 10.1007/978-3-319-17903-2_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ahluwalia MS, Vogelbaum MV, Chao ST, Mehta MM. Brain metastasis and treatment. F1000PRIME REPORTS 2014; 6:114. [PMID: 25580268 PMCID: PMC4251415 DOI: 10.12703/p6-114] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Despite major therapeutic advances in the management of patients with systemic malignancies, management of brain metastases remains a significant challenge. These patients often require multidisciplinary care that includes surgical resection, radiation therapy, chemotherapy, and targeted therapies. Complex decisions about the sequencing of therapies to control extracranial and intracranial disease require input from neurosurgeons, radiation oncologists, and medical/neuro-oncologists. With advances in understanding of the biology of brain metastases, molecularly defined disease subsets and the advent of targeted therapy as well as immunotherapeutic agents offer promise. Future care of these patients will entail tailoring treatment based on host (performance status and age) and tumor (molecular cytogenetic characteristics, number of metastases, and extracranial disease status) factors. Considerable work involving preclinical models and better clinical trial designs that focus not only on effective control of tumor but also on quality of life and neurocognition needs to be done to improve the outcome of these patients.
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Affiliation(s)
- Manmeet S. Ahluwalia
- Burkhardt Brain Tumor Neuro-Oncology Center, Neurological InstituteCleveland Clinic, 9500 Euclid Avenue, Cleveland, OHUSA
| | - Michael V. Vogelbaum
- Burkhardt Brain Tumor Neuro-Oncology Center, Neurological InstituteCleveland Clinic, 9500 Euclid Avenue, Cleveland, OHUSA
| | - Samuel T. Chao
- Burkhardt Brain Tumor Neuro-Oncology Center, Neurological InstituteCleveland Clinic, 9500 Euclid Avenue, Cleveland, OHUSA
| | - Minesh M. Mehta
- Department of Radiation Oncology, University of Maryland School of MedicineBaltimore, MD 21201USA
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Management of Cerebral Brain Metastasis. CURRENT SURGERY REPORTS 2014. [DOI: 10.1007/s40137-014-0074-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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