Feasibility of dose escalation using intraoperative radiotherapy following resection of large brain metastases compared to post-operative stereotactic radiosurgery

Vargo, John A.; Sparks, Kristie M.; Singh, Rahul; Jacobson, Geraldine M.; Hack, Joshua; Cifarelli, Christopher P.

doi:10.1007/s11060-018-2968-4

Cited by 21 publications

(21 citation statements)

References 25 publications

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“…After publication of the toxicity data of the INTRAGO phase1/2 study [25], we have increased dose stepwise and since 2016, all patients have been irradiated with 20 Gy. Other centers nowadays apply even higher doses [13,25,26]. However, with the reported outcome of our patients we do not see a necessity for further dose escalation currently.…”

Section: Discussionmentioning

confidence: 52%

Intraoperative radiotherapy with low energy x-rays after neurosurgical resection of brain metastases – Augsburg University Medical Center experience

Kahl

Balagiannis

Höck

et al. 2021

Preprint

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Purpose External beam radiotherapy (EBRT) is the predominant method for localized brain radiotherapy (LBRT) after resection of brain metastases (BM). Intraoperative radiotherapy (IORT) with 50kV x-rays is an alternative way to irradiate the resection cavity focally after BM surgery with the option to shorten the overall treatment time and limit normal tissue irradiation.Methods We retrospectively analyzed the outcomes of all patients who underwent neurosurgical resection of BM and 50kV x-ray IORT between 2013 and 2020 at Augsburg University Medical Center.Results We identified 40 patients with 44 resected BM treated with 50kV x-ray IORT. Median diameter of the resected metastases was 2.8 cm (range 1.5–5.9 cm). Median applied dose was 20 Gy. All patients received standardized follow-up (FU) including 3-monthly MRI of the brain. Mean FU was 14.4 months, with a median MRI FU for patients alive of 12.2 months. Median overall survival (OS) of all treated patients was 26.4 months (estimated 1-year OS 61.6%). The observed local control (LC) rate of the resection cavity was 88.6% (estimated 1-year LC 84.3%). Distant brain control (DC) was 47.5% (estimated 1-year DC 33.5%). Only 25% of all patients needed WBI in the further course of disease. The observed radionecrosis rate was 2.5%.Conclusion IORT with 50kV x-rays is a safe and appealing way to apply LBRT after neurosurgical resection of BM with low toxicity and excellent LC. Close MRI FU is paramount to detect distant brain failure (DBF) early.

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Section: Discussionmentioning

confidence: 52%

Intraoperative radiotherapy with low energy x-rays after neurosurgical resection of brain metastases – Augsburg University Medical Center experience

Kahl

Balagiannis

Höck

et al. 2021

Preprint

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“…Dosimetric comparisons have determined the feasibility of dose escalation with kilovoltage-IORT (kV-IORT), confirming a clear benefit in terms of healthy tissue sparing [ 10 ]. After these considerations, initial clinical experiences with kV-IORT have been reported during the last decade.…”

Section: Letter Bodymentioning

confidence: 99%

In regard to Minniti et al.: Current status and recent advances in resection cavity irradiation of brain metastases—roundup to cover all angles

2021

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We read with great interest the recent review, entitled “Current status and recent advances in resection cavity irradiation of brain metastases”. It is a comprehensive summary of currently available techniques for treatment of post-resection cavity in patients with this diagnosis. We would like to complement this manuscript by including intraoperative techniques as other viable approaches in the management of these patients.

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“…Conversely, larger cavities treated with intraoperative cesium-131 (Cs-131) implants have demonstrated excellent LC [17,19]. Previous trials with iodine-125 brachytherapy have also demonstrated very good LC in both large and small resected tumor cavities [37,38]. Interestingly, multidose SRS (9Gy x 3) has also shown good LC of 93% at one year for large (>3 cm) brain metastases [39], although this has not been commonly replicated.…”

Section: Reviewmentioning

confidence: 99%

“…Brachytherapy such as Cs-131 is also advantageous over SRS in cases of recurrent brain metastases in brains that have already been irradiated, as repeat irradiation greatly increases the risk of radiation necrosis [36]. This is because brachytherapy has the advantage of a steep dose fall-off outside of the immediate area of the resection cavity, leading to less irradiation of normal tissue [19,38]. Also, it has been hypothesized that immediate implantation of brachytherapy seeds may improve LC by counteracting the tumor-cell proliferation and dissemination caused by the surgical manipulation of the microenvironment during resection [38].…”

Section: Reviewmentioning

confidence: 99%

“…This is because brachytherapy has the advantage of a steep dose fall-off outside of the immediate area of the resection cavity, leading to less irradiation of normal tissue [19,38]. Also, it has been hypothesized that immediate implantation of brachytherapy seeds may improve LC by counteracting the tumor-cell proliferation and dissemination caused by the surgical manipulation of the microenvironment during resection [38]. We present an algorithm detailing situations in which different radiation techniques are preferable (Figure 2).…”

Section: Reviewmentioning

confidence: 99%

See 1 more Smart Citation

The Relationship Between Tumor Volume and Timing of Post-resection Stereotactic Radiosurgery to Maximize Local Control: A Critical Review

Yuan

Behrami

Pannullo

et al. 2019

Cureus

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After maximally safe neurosurgical resection of brain metastases, stereotactic radiosurgery (SRS) is now recommended as an alternative to whole-brain radiation therapy (WBRT), which has been associated with cognitive decline. One complicating factor associated with SRS is that postoperative cavity dynamics can change dramatically, creating significant variability in the recommended timing of SRS. While SRS has been shown to improve local control (LC) in smaller tumor cavities, achieving excellent LC rates still remains a challenge in larger ones. Furthermore, factors predicting the optimal timing of SRS in relation to the cavity size need to be defined and implemented. Variables such as the delay between postoperative MRI and treatment are critical but poorly understood. One potential treatment option that may improve outcomes is brachytherapy, but the widespread implementation of this technique has been slow. This critical review analyzes the relationship between preoperative tumor volume, resection cavity size, and timing of SRS and explores how these variables must be understood in order to achieve the highest LC possible.

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Feasibility of dose escalation using intraoperative radiotherapy following resection of large brain metastases compared to post-operative stereotactic radiosurgery

Cited by 21 publications

References 25 publications

Intraoperative radiotherapy with low energy x-rays after neurosurgical resection of brain metastases – Augsburg University Medical Center experience

Intraoperative radiotherapy with low energy x-rays after neurosurgical resection of brain metastases – Augsburg University Medical Center experience

In regard to Minniti et al.: Current status and recent advances in resection cavity irradiation of brain metastases—roundup to cover all angles

The Relationship Between Tumor Volume and Timing of Post-resection Stereotactic Radiosurgery to Maximize Local Control: A Critical Review

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