Tumor Bed Dynamics After Surgical Resection of Brain Metastases: Implications for Postoperative Radiosurgery

Jarvis, Lesley A.; Simmons, Nathan E.; Bellerive, Marc; Erkmen, Kadir; Eskey, Clifford J.; Gladstone, David J.; Hug, Eugen B.; Roberts, David W.; Hartford, Alan C.

doi:10.1016/j.ijrobp.2012.01.067

Cited by 88 publications

(60 citation statements)

References 11 publications

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“…Complicating the use of interstitial brachytherapy is the gradual shrinkage of the resection cavity, which is a poorly understood process that progressively moves the seeds closer together over time. 3,13,26,60 However, cavity shrinkage would likely result in pockets of higher dose delivery and higher rates of radiation necrosis, which we did not observe. We undertook several measures to decrease the degree of cavity shrinkage once the seeds were placed.…”

Section: Discussionmentioning

confidence: 52%

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

Wernicke¹,

Yondorf²,

Peng³

et al. 2014

JNS

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

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Section: Discussionmentioning

confidence: 52%

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

Wernicke¹,

Yondorf²,

Peng³

et al. 2014

JNS

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“…However, our own experience, and that of others, indicates that the cavity size in the early post-operative period is not constant 13 . Jarvis et al 13 recently reported on the dynamic nature of the post-operative resection cavity, and resulting implications on the timing of subsequent stereotactic radiosurgery. Their review included cases with gross total tumor resection as well as some cases with radiographic evidence for residual.…”

Section: Introductionmentioning

confidence: 54%

“…Therefore, metastases are usually confined to the area of T1 contrast-enhancement, which is removed during GTR. In cases with gross residual tumor following resection (not applicable to our study), mass effect and persistent edema from tumor progression can contrinute to collapse of the resection cavity 13 .…”

Section: Discussionmentioning

confidence: 91%

Change in Postsurgical Cavity Size Within the First 30 Days Correlates With Extent of Surrounding Edema

Ahmed

Hamilton

Colen

et al. 2014

Journal of Computer Assisted Tomography

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Objective Resection cavity diameter of <40 mm is required to be eligible for stereotactic radiosurgery (SRS), following gross total resection of brain metastasis at our institution. Our study evaluates the correlation between vasogenic edema and change in cavity size over 30 days. Methods Cavity size was measured on the post-operative and follow-up MRIs. Vasogenic edema was quantified as the largest axial measurement of T2 hyperintensity surrounding the resection cavity (post-operative MRI). Results Thirty-nine resection cavities (37 patients) were reviewed. There was statistically significant (Pearson coefficient=-0.35, P=0.02) negative correlation between edema and change in cavity size. An arbitrary cut-off value of 15 mm edema yielded a sensitivity of 96% and specificity of 65% (P<0.001) to predict 10% decrease in cavity size. Conclusions In patients with cavity size close to the size cutoff for SRS, rescanning closer to the date of SRS should be considered, especially if there is significant edema surrounding the cavity.

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“…Reported times from surgery to SRS span from 1 day to a month or more [14, 17, 19, 21-30, 32-37, 40]. It is not entirely clear how the postoperative cavity changes following surgical resection, and this has been the subject of a publication by at least two institutions [42,43]. Jarvis et al examined MR imaging of 41 patients before surgery, within 24 h after surgery, and at time of radiosurgery planning [43].…”

Section: Target Volumementioning

confidence: 99%

“…It is not entirely clear how the postoperative cavity changes following surgical resection, and this has been the subject of a publication by at least two institutions [42,43]. Jarvis et al examined MR imaging of 41 patients before surgery, within 24 h after surgery, and at time of radiosurgery planning [43]. They demonstrated that while tumor bed volumes change, most do not collapse, and approximately one-third increase in NR not reported, FX fractions, BM brain metastases, WBRT whole brain radiation therapy J Neurooncol size.…”

Section: Target Volumementioning

confidence: 99%

Tumor bed radiosurgery: an emerging treatment for brain metastases

2015

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While typically used for treating small intact brain metastases, an increasing body of literature examining tumor bed directed stereotactic radiosurgery (SRS) is emerging. There are now over 1000 published cases treated with this approach, and the first prospective trial was recently published. The ideal sequencing of tumor bed SRS is unclear. Current approaches include, a neoadjuvant treatment before resection, alone as an adjuvant after resection, and following surgery combined with whole brain radiotherapy either as an adjuvant or salvage treatment. Based on available evidence, adjuvant stereotactic radiosurgery improves local control following surgery, reduces the number of patients who require whole brain radiotherapy, and is well tolerated. While results from published series vary, heterogeneity in both patient populations and methods of reporting results make comparisons difficult. Additional prospective data, including randomized trials are needed to confirm equivalent outcomes to the current standard of care. We review the current literature, identify areas of ongoing contention, and highlight ongoing studies.

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Tumor Bed Dynamics After Surgical Resection of Brain Metastases: Implications for Postoperative Radiosurgery

Cited by 88 publications

References 11 publications

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

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

Change in Postsurgical Cavity Size Within the First 30 Days Correlates With Extent of Surrounding Edema

Tumor bed radiosurgery: an emerging treatment for brain metastases

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