Resection Followed by Stereotactic Radiosurgery to Resection Cavity for Intracranial Metastases

Do, Ly; Pezner, Richard D.; Radany, Eric H.; Liu, An; Staud, C.; Badie, Benham

doi:10.1016/j.ijrobp.2008.04.070

Cited by 111 publications

(63 citation statements)

References 17 publications

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“…Since this publication, authors from other institutions have published similar focused techniques with favorable outcomes. 5,8,22 This paper updates our experience using this treatment approach with additional patients and more mature follow-up.…”

mentioning

confidence: 76%

“…15,16 Utilizing a similar adjuvant SRS approach to the operative bed, Soltys et al 22 reported an overall local failure rate of 14% in 69 irradiated beds with 100% control achieved by adding a 2-mm margin around their resection cavities. Do et al 5 demonstrated a 12% local failure rate when using either adjuvant SRS or SRT to 33 resection cavities. Jagannathan et al 8 recently reported a 6% local recurrence rate in 47 patients who received adjuvant SRS, including 3 who received upfront WBRT.…”

Section: Discussionmentioning

confidence: 99%

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Stereotactic radiosurgery boost to the resection bed for oligometastatic brain disease: challenging the tradition of adjuvant whole-brain radiotherapy

Karlovits¹,

Quigley

Karlovits

et al. 2009

FOC

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Object Whole-brain radiation therapy (WBRT) has been the traditional approach to minimize the risk of intracranial recurrence following resection of brain metastases, despite its potential for late neurotoxicity. In 2007, the authors demonstrated an equivalent local recurrence rate to WBRT by using stereotactic radiosurgery (SRS) to the operative bed, sparing 72% of their patients WBRT. They now update their initial experience with additional patients and more mature follow-up. Methods The authors performed a retrospective review of all cases involving patients with limited intracranial metastatic disease (≤ 4 lesions) treated at their institution with SRS to the operative bed following resection. No patient had prior cranial radiation and WBRT was used only for salvage. Results From November 2000 to June 2009, 52 patients with a median age of 61 years met inclusion criteria. A single metastasis was resected in each patient. Thirty-four of the patients each had 1 lesion, 13 had 2 lesions, 3 had 3 lesions, and 2 had 4 lesions. A median dose of 1500 cGy (range 800–1800 cGy) was delivered to the resection bed targeting a median volume of 3.85 cm3 (range 0.08–22 cm3). With a median follow-up of 13 months, the median survival was 15.0 months. Four patients (7.7%) had a local recurrence within the surgical site. Twenty-three patients (44%) ultimately developed distant brain recurrences at a median of 16 months postresection, and 16 (30.7%) received salvage WBRT (8 for diffuse disease [> 3 lesions], 4 for local recurrence, and 4 for diffuse progression following salvage SRS). The median time to WBRT administration postresection was 8.7 months (range 2–43 months). On univariate analysis, patient factors of a solitary tumor (19.0 vs 12 months, p = 0.02), a recursive partitioning analysis (RPA) Class I (21 vs 13 months, p = 0.03), and no extracranial disease on presentation (22 vs 13 months, p = 0.01) were significantly associated with longer survival. Cox multivariate analysis showed a significant association with longer survival for the patient factors of no extracranial disease on presentation (p = 0.01) and solitary intracranial metastasis (p = 0.02). Among patients with no extracranial disease, a solitary intracranial metastasis conferred significant additional survival advantage (43 vs 10.5 months, p = 0.05, log-rank test). No factor (age, RPA class, tumor size or histological type, disease burden, extent of resection, or SRS dose or volume) was related to the need for salvage WBRT. Conclusions Adjuvant SRS to the metastatic intracranial operative bed results in a local recurrence rate equivalent to adjuvant WBRT. In combination with SRS for unresected lesions and routine imaging surveillance, this approach achieves robust overall survival (median 15 months) while sparing 70% of the patients WBRT and its potential acute and chronic toxicity.

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confidence: 76%

Section: Discussionmentioning

confidence: 99%

Stereotactic radiosurgery boost to the resection bed for oligometastatic brain disease: challenging the tradition of adjuvant whole-brain radiotherapy

Karlovits¹,

Quigley

Karlovits

et al. 2009

FOC

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“…12,16,23,29,34 Radiosurgical Instrumentation Gamma-unit devices have traditionally had significant advantages over LINAC devices in regard to simplicity of quality control and work flow speed. Linear accelerator devices employing cone-based collimation required more complex treatment planning and work flow.…”

Section: 33mentioning

confidence: 99%

Control of brain metastases using frameless image-guided radiosurgery

Chen

Bugoci

Girvigian

et al. 2009

FOC

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Object Radiosurgery is an important and well-accepted method in the management of brain metastases. Using conventional frame-based techniques, high lesional control rates are expected. The introduction of image-guided techniques allows for improved patient comfort and workflow. Some controversy exists as to the accuracy of imageguided techniques and consequently the impact they might have on control of brain metastases (as opposed to the level of control achieved with frame-based methods). The authors describe their initial 15-month experience with image-guided radiosurgery (IGRS) using Novalis with ExacTrac for management of brain metastases. Methods The authors reviewed the cases of brain metastasis treated by means of IGRS in their tertiary regional radiation oncology service over a 15-month period. During the study period 54 patients (median age 57.9 years) harboring 108 metastases were treated with IGRS. The median time from cancer diagnosis to development of brain metastasis was 12 months (range 0–144 months). The median tumor volume was 0.98 cm3 (range 0.03–19.07 cm3). The median prescribed dose was 18 Gy to the 80% isodose line (range 14–20 Gy). Lesions were followed with postradiosurgery MR imaging every 2–3 months following treatment. Results The median follow-up period was 9 months (range 0–20 months). Median actuarial survival was 8.6 months following IGRS. Eight patients with 18 lesions died within the first 2 months after the procedure, before scheduled follow-up imaging. Thus 90 lesions (in 46 patients) were followed up with imaging studies. Lesions that were unchanged or reduced in size were considered to be under control. The 6-month actuarial lesion control rate was 88%. Smaller lesions (< 1 cm3) had a statistically improved likelihood of complete imaging response (loss of all contrast-enhancement p = 0.01). Conclusions Image-guided radiosurgical treatment of brain metastases resulted in high rates of tumor control comparable to control rates reported for frame-based methods. High control rates were seen for small lesions in which spatial precision in dose delivery is critical. These data suggests that in regard to lesion control, IGRS using Novalis with ExacTrac is equivalent to frame-based radiosurgery methods.

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“…Stereotactic radiosurgery does not cause the long-term neurological deficits associated with whole-brain irradiation. 2,4,5,10,12 However, because SRS is a local therapy, it is important to avoid "missing" or inadequately treating metastases that could be detected and targeted during planned SRS.…”

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confidence: 99%

Time-delayed contrast-enhanced MRI improves detection of brain metastases and apparent treatment volumes

Kushnirsky

Nguyen

Katz

et al. 2016

JNS

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B rain metastases (BMs) are the most common intracranial tumors in adults, occurring in 20%-40% of cancer patients. 26 Their incidence has been increasing due to both prolonged systemic control and improved detection, making BMs a growing cause of mortality and morbidity.14,31 Magnetic resonance imaging is currently the standard of care for the diagnosis of BMs because its sensitivity is superior to CT,22,32 and refinements in MRI techniques allow the modality to detect metastases that are not seen with routine image-acquisition protocols. The abbreviatioNs BM = brain metastasis; GRE = gradient echo; SRS = stereotactic radiosurgery. obJective Contrast-enhanced MRI is the preeminent diagnostic test for brain metastasis (BM). Detection of BMs for stereotactic radiosurgery (SRS) planning may improve with a time delay following administration of a high-relaxivity agent for 1.5-T and 3-T imaging systems. Metastasis detection with time-delayed MRI was evaluated in this study. methods Fifty-three volumetric MRI studies from 38 patients undergoing SRS for BMs were evaluated. All studies used 0.1-mmol/kg gadobenate dimeglumine (MultiHance; Bracco Diagnostics) immediately after injection, followed by 2 more axial T1-weighted sequences after 5-minute intervals (final image acquisition commenced 15 minutes after contrast injection). Two studies were motion limited and excluded. Two hundred eighty-seven BMs were identified. The studies were randomized and examined separately by 3 radiologists, who were blinded to the temporal sequence. Each radiologist recorded the number of BMs detected per scan. A Wilcoxon signed-rank test compared BM numbers between scans. One radiologist determined the scan on which BMs were best defined. All confirmed, visible tumors were contoured using iPlan RT treatment planning software on each of the 3 MRI data sets. A linear mixed model was used to analyze volume changes. results The interclass correlations for Scans 1, 2, and 3 were 0.7392, 0.7951, and 0.7290, respectively, demonstrating excellent interrater reliability. At least 1 new lesion was detected in the second scan as compared with the first in 35.3% of subjects (95% CI 22.4%-49.9%). The increase in BM numbers between Scans 1 and 2 ranged from 1 to 10. At least 1 new lesion was detected in the third scan as compared with the second in 21.6% of subjects (95% CI 11.3%-35.3%). The increase in BM numbers between Scans 2 and 3 ranged from 1 to 9. Between Scans 1 and 3, additional tumors were seen on 43.1% of scans (increase ranged from 1 to 14). The median increase in tumor number for all comparisons was 1. There was a significant increase in number of BMs detected from Scan 1 to Scan 2 (p < 0.0367) and from Scan 1 to Scan 3 (p < 0.0264). In 34 of the 51 subjects (66.7%), the radiologist selected the third scan as the one providing the clearest tumor definition. There was an average 25.4% increase in BM volume between Scans 1 and 2 (p < 0.0001) and a 9% increase in BM volume between Scans 2 and 3 (p = 0.0001). coNclusioNs In patients who are ...

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Resection Followed by Stereotactic Radiosurgery to Resection Cavity for Intracranial Metastases

Cited by 111 publications

References 17 publications

Stereotactic radiosurgery boost to the resection bed for oligometastatic brain disease: challenging the tradition of adjuvant whole-brain radiotherapy

Stereotactic radiosurgery boost to the resection bed for oligometastatic brain disease: challenging the tradition of adjuvant whole-brain radiotherapy

Control of brain metastases using frameless image-guided radiosurgery

Time-delayed contrast-enhanced MRI improves detection of brain metastases and apparent treatment volumes

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