Resection and brain brachytherapy with permanent iodine-125 sources for brain metastasis

Abstract

OBJECTIVE Stereotactic radiosurgery (SRS) with or without whole-brain radiotherapy can be used to achieve local control (> 90%) for small brain metastases after resection. However, many brain metastases are unsuitable for SRS because of their size or previous treatment, and whole-brain radiotherapy is associated with significant neurocognitive morbidity. The purpose of this study was to investigate the efficacy and toxicity of surgery and iodine-125 (I) brachytherapy for brain metastases. METHODS A total of 95 consecutive patients treated for 105 brain metastases at a single institution between September 1997 and July 2013 were identified for this analysis retrospectively. Each patient underwent MRI followed by craniotomy with resection of metastasis and placement of I sources as permanent implants. The patients were followed with serial surveillance MRIs. The relationships among local control, overall survival, and necrosis were estimated by using the Kaplan-Meier method and compared with results of log-rank tests and multivariate regression models. RESULTS The median age at surgery was 59 years (range 29.9-81.6 years), 53% of the lesions had been treated previously, and the median preoperative metastasis volume was 13.5 cm (range 0.21-76.2 cm). Gross-total resection was achieved in 81% of the cases. The median number of I sources implanted per cavity was 28 (range 4-93), and the median activity was 0.73 mCi (range 0.34-1.3 mCi) per source. A total of 476 brain MRIs were analyzed (median MRIs per patient 3; range 0-22). Metastasis size was the strongest predictor of cavity volume and shrinkage (p< 0.0001). Multivariable regression modeling failed to predict the likelihood of local progression or necrosis according to metastasis volume, cavity volume, or the rate of cavity remodeling regardless of source activity or previous SRS. The median clinical follow-up time in living patients was 14.4 months (range 0.02-13.6 years), and crude local control was 90%. Median overall survival extended from 2.1 months in the shortest quartile to 62.3 months in the longest quartile (p < 0.0001). The overall risk of necrosis was 15% and increased significantly for lesions with a history of previous SRS (p < 0.05). CONCLUSIONS Therapeutic options for patients with large or recurrent brain metastases are limited. Data from this study suggest that resection with permanent I brachytherapy is an effective strategy for achieving local control of brain metastasis. Although metastasis volume significantly influences resection cavity size and remodeling, volumetric parameters do not seem to influence local control or necrosis. With careful patient selection, this treatment regimen is associated with minimal toxicity and can result in long-term survival for some patients. ▪ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: retrospective case series; evidence: Class IV.

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

“…A number of alternative techniques to low energy X-ray based IORT have been described for the treatment of brain metastases including permeant low dose rate brachytherapy with 125 I and 131 Cs as well as temporary implants with balloon based delivery of aqueous 125 I [6–8, 11, 12]. Low energy X-ray based IORT has advantages of avoiding concerns of seed migration, no need for special handling precautions of radioactive sources, and eliminates the complexity of seed placement thereby reducing anesthesia time and potential re-operation for seed removal in temporary brachytherapy implants.…”

“…Intraoperative radiotherapy (IORT) has been used as a potential alterative to SRS following resection of large brain tumors [6–12]. IORT has advantages of eliminating challenges in target definition, steep conformal dose delivery that may afford dose-escalation relative to SRS, and increased patient convenience by integrating resection and radiotherapy into 1 procedure.…”

“…IORT has advantages of eliminating challenges in target definition, steep conformal dose delivery that may afford dose-escalation relative to SRS, and increased patient convenience by integrating resection and radiotherapy into 1 procedure. A variety of techniques have been used for IORT in brain metastases including low-energy photons and permanent low dose rate brachytherapy with 131 Cs and 125 I [6–8, 11, 12]. However, dose selection for low energy photon based IORT in brain tumors remains largely empiric with doses ranging from 10 to 30 Gy in 1 fraction to varying prescription depths of 0–5 mm [6–10].…”

Oligorecurrence Non–small Cell Lung Cancer After Failure of First-Line Chemotherapy: Computed Tomography–Guided 125I Seed Implantation vs. Second-Line Chemotherapy

“…Recently, RIS implantation brachytherapy has been successfully used to treat diverse kinds of malignant tumors (17,(23)(24)(25)(26). A large quantity of studies on RIS implantation for NSCLC have been reported with promising results.…”

Editorial. Classes of evidence in neurosurgery

“…1,2 In this issue of the Journal of Neurosurgery, we introduce the classification of levels of evidence within select clinical research articles. 5,6,8 The designation of the level of evidence for each article is based on the data provided within the manuscript, and an analysis performed by Dr. Michael Glantz, Professor of Neurosurgery, Medicine, and Neurology at Penn State Hershey, who has had a longstanding interest in teaching statistics and statistical methods to neurosurgeons at our national meetings. Periodically, Dr. Glantz will review clinical research articles for the Journal and ascribe a level of evidence to each.…”