Aims: To determine if multi-isocentric volumetric modulated arc radiotherapy for craniospinal irradiation (CSI-VMAT) can be implemented safely and accurately using robust optimisation in a commercially available treatment planning system. Our initial clinical experience is reported for the first 20 patients treated with the technique. Materials and methods: Patients received between 23.4 and 39.6 Gy (mode 23.4 Gy) in 13e22 fractions with CSI-VMAT. The heart mean dose was 4.2e10.3 Gy (median 5.3 Gy) for patients prescribed up to 24 Gy and 6.5e16.3 Gy (median 10.1 Gy) for patients receiving 35 Gy or more. The lung mean dose was 5.5e7.6 Gy (median 6.8 Gy) for patients prescribed up to 24 Gy and 6.9e11.1 Gy (median 10.0 Gy) for patients receiving 35 Gy or more. The robustness of the planning target volume D 0.1cm3 and D 99% to systematic errors in the isocentre superoinferior position of up to 5 mm was evaluated. These remained acceptable but were correlated to the length of the available beam overlap through the neck.Results: As of January 2021, one patient was deceased after 508 days and one patient was lost to follow-up after completing treatment. The median follow-up was 399 days (range 175e756 days) and progression-free survival was 131 days (34e490 days). Acute toxicities at Common Terminology Criteria for Adverse Events v5.0 grade 3þ included lowered white blood cell count (16/20), decreased platelet count (8/20), nausea (5/20), vomiting (2/20), pharyngeal mucositis (1/ 20) and oral mucositis (1/20). Three patients developed grade 4 neutropenia or decreased white blood cell count. Conclusions: CSI-VMAT can be implemented safely and accurately using robust optimisation functions in a commercially available treatment planning system.
INTRODUCTION Brain metastases (BM) are common in melanoma and historically associated with poor prognosis. Targeted systemic treatment have improved prognosis, and stereotactic radiosurgery (SRS) may offer an effective and less neurotoxic option. We evaluated the outcomes and potential prognostic factors of patients treated with SRS. METHODS Retrospective study of patients treated with linac-based SRS for BM from melanoma in a UK tertiary centre between August 2017-September 2021. Overall survival (OS), intracranial progression-free survival (IPFS), and prognostic factors were evaluated using Kaplan–Meier analysis, log-rank test, and Cox proportional-hazards model. RESULTS Median follow up was 32 months. 69 patients were included. Median age was 59 years old (range 30-93), and 63% were male. 99% had performance status of 0/1. 45% had BRAF mutation, and 68% had stable extracranial disease at SRS. 62 patients had first-line treatment with SRS. 133 BM were treated, with mean volume of 0.39 cm3(range 0.02-18.82). Median prescription dose was 23 Gy (range 14-24Gy), prescribed to 100% isodose. Median OS and IPFS from SRS was 18 months (95% CI 5-31), and 12 months (95% CI 6-18), respectively. 6 months and 1 year local control (LC) rate were 79% and 64 %, respectively. 91% had out-of-field recurrences. Patients with BRAF mutation had shorter IPFS compared to BRAF WT (7 months vs 18 months, HR 2, p=0.04). 36% were on BRAF inhibitors, and IPFS were longer for patients on immunotherapy within 3 months of SRS (15 months vs 4 months, HR 2.6, p=0.03). There was non-significant trend towards shorter OS and IPFS for patients who were male, ≥ 65 years old, BRAF mutant, progressive extracranial disease, > 4 BM, and total volume of ≥ 5cm3. CONCLUSION SRS demonstrates good OS and LC for treatment of BM from melanoma. Prospective studies should establish the synergistic effects between targeted treatment and SRS.
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