Background/Aim: Prolonged use of glucocorticoids (GC) in glioma treatment can lead to adrenal insufficiency (AI) and subsequent steroid dependence due to suppression of the hypothalamic-pituitary-adrenal (HPA) axis. This is challenging to diagnose due to its nonspecific clinical symptoms erroneously ascribed to treatment. This study aimed to evaluate the risk factors predisposing patients with gliomas to develop AI. Patients and Methods: Charts in the neurooncology clinic from July 2018 to March 2019 were reviewed. Inclusion criteria included >18 y/o with WHO Grade II-IV gliomas, and secondary AI. Demographic profile, tumor characteristics, and treatment profile were compared. Results: The majority of patients were started on high dose dexamethasone at >8 mg daily, and were on dexamethasone for 4-8 months. The minimum dose needed to prevent symptoms was 0.5 mg to 2 mg daily. The majority received standard radiation doses ranging from 54-60 Gy. Most patients had radiation exposure to the HPA axis within the prescription isodose levels. Conclusion: Prolonged steroid dependency can result from chronic GC use in patients with glioma. Dose and duration of GC are risk factors for its development. Radiation exposure to the HPA axis may also be a contributing factor.Glucocorticoids (GC) are a mainstay in the treatment of primary brain tumors. GC have been used for reducing vasogenic edema and improving symptoms related to swelling including: lethargy, headache, and nausea, among others. Dexamethasone is the commonly used GC for the treatment of central nervous system (CNS) tumors due to its potent anti-cerebral edema effects, long half-life, and low mineralocorticoid activity, hence minimizing fluid retention.Despite their benefits, prolonged use of GC can have a number of negative consequences. One of the most commonly unrecognized symptoms is the development of adrenal insufficiency (AI) and subsequent steroid dependence due to the suppression of the hypothalamicpituitary-adrenal (HPA) axis. Clinically, this can present with a wide range of signs and symptoms, including weakness/fatigue, malaise, nausea, vomiting, diarrhea, abdominal pain, headaches, fever, anorexia/weight loss, myalgia, arthralgia, as well as psychiatric symptoms (1). Screening for AI includes measuring early morning cortisol at 8:00 AM after GC dose has been tapered to a physiologic dose, and holding any oral GCs the evening and morning prior to the test. If the morning cortisol is normal but clinical suspicion for AI is high, an adrenocorticotrophic stimulating hormone (ACTH), cosyntropin stimulation, test can be performed to clarify the diagnosis (1).The challenge in diagnosing AI in glioma patients may stem from its nonspecific clinical presentation, and thus the tumor itself or the treatments (e.g. chemotherapy, radiation therapy) may be erroneously ascribed as the cause of these symptoms. Hence, GC use is often extended unnecessarily. In addition, there are no guidelines on the dosing, duration, and tapering of GC in neuro-oncologic patients, a...
216 Background: The importance of patient-reported outcomes (PROs) has been recognized and this data is increasingly being incorporated into modern radiotherapy (RT) trial design. Despite this, there is a lack of published data regarding collection and reporting of PRO data in the RT setting. We sought to systematically evaluate RT protocols to assess trends of PRO data collection and factors associated with reporting. Methods: We queried multi-institutional RT trials indexed on ClinicalTrials.gov, the Cochrane database, and MEDLINE and identified trials with full protocols available. We collected information in regards to study population, primary and secondary endpoints, quality of life measures, and PRO data. Descriptive and chi-squared analyses were employed to investigate trends and factors associated with PRO reporting. Results: 232 protocols were evaluable (1971-2014) from multiple cooperative groups. Of these, 198 were completed and 34 were in progress. Overall, only 41% of trials had protocol-specified collection of PROs. Of the 155 trials that had at least 1 published report, only 34 (22%) reported PRO data. All nine trials with PRO as a primary endpoint (9/9) had published reports with this information. Treatment era was associated with PRO collection, with 30% of trials collecting PRO data prior to 2005, 48% between 2006 and 2010, and 66% between 2011 and 2015 ( X2 [4, N = 232] = 15.79, p = 0.003). PROs were most likely to be collected in phase III trials ( X2 [4, N = 226] = 59.6, p < 0.0001). Conclusions: PROs are historically under collected and reported in cooperative group RT trials. Despite increasing PRO collection in modern trials, reporting remains suboptimal and may inaccurately inform survivorship issues. As digital literacy progresses, electronic PRO data may offer a potential avenue for improvement. Ultimately, PRO data will serve as a vital component to help define value in newly proposed payment models focused on improving quality of care while reducing cost of care.
INTRODUCTION: Brain metastases occur in 10 to 40% of cancer patients. In an effort to avoid the neurocognitive toxicities of whole brain radiation therapy, stereotactic radiosurgery (SRS) has become the preferred treatment option for most brain metastases. Many cancer patients will require several rounds of SRS during the course of their disease. Frame-based radiosurgery causes physical discomfort with each treatment session. We present our experience with frameless Gamma Knife radiosurgery (GKRS) and compare the clinical outcomes to frame-based treatments in the same patient cohort. METHODS: We evaluated all patients with brain metastases who underwent both frame-based and frameless SRS, using the Gamma Knife ICON, between January 2017 and November 2018. 11 patients with 110 unique lesions were included in this analysis. Clinical outcomes, including local control, were compared between the two treatment modalities. RESULTS: Mean patient age was 60.0 (range: 41 – 76) years. Median follow-up was 7.9 (range: 0 – 22.1) months. Median number of metastases treated was 4 (range: 1 – 9) per frame-based treatment and 3 (range: 1 – 10) per frameless treatment. Median number of frame-based and frameless procedures, per patient, was 1 (range: 1 – 3) and 1 (range: 1 – 2), respectively. Median tumor volume was 0.06 (range: 0.01 – 11.49) cm3 in the frame-based treatments and 0.14 (range: 0.01 – 4.22) cm3 in the frameless treatments. Median margin dose was 18 Gy for both the frame-based and frameless treatments. Local control was 86.5 and 91.5% at 6 and 9 months post-treatment, respectively in the frame-based treatments and 82.8 and 87.5% at 6 and 9 months post-treatment, respectively in the frameless treatments. CONCLUSIONS: Frameless GKRS results in similar rates of local control compared to frame-based GKRS. This treatment option should be considered in patients undergoing GKRS, as it balances clinical outcomes with patient comfort.
INTRODUCTION: Stereotactic radiosurgery (SRS) has excellent efficacy for patients with limited intracranial disease. Its use in patients with >10 brain metastases remains controversial. Nonetheless, cancer patients are living longer due to advancements in systemic therapeutics and avoiding the neurocognitive toxicities of whole brain radiation therapy is critical. Recent reports suggest that SRS may be effective in patients with ≥10 metastases. Treating large numbers of brain metastases in a single Gamma Knife radiosurgery (GKRS) treatment session poses several challenges. Treatment of metastases in close proximity to one another leads to an increased dose to normal brain, potentially increasing the risk of necrosis. Furthermore, single session treatment of multiple metastases may last several hours, causing significant patient discomfort. Here, we describe a novel treatment paradigm to address these issues: distributed frameless GKRS. Patients with ≥6 brain metastases undergo multi-session frameless GKRS with both temporal and spatial distribution over 2–5 sessions, decreasing treatment time per day and not treating adjacent metastases simultaneously. METHODS: We evaluated all patients with brain metastases who underwent distributed frameless SRS, using the Gamma Knife ICON, between January 2017 and November 2018. Fifty-one patients with 1097 unique lesions were included in this analysis. RESULTS: Mean patient age was 58.8 (range 29–89) years. Median follow-up was 4.1 (range: 0–20.4) months. The median number of metastases treated was 5 (range: 1–19) per treatment session and 11.5 (range: 3–82) per treatment course. The median number of treatment sessions per treatment course was 3 (range: 2–10). The median number of treatment courses, per patient, was 1 (range: 1–4). The median margin dose was 15 Gy. The median overall survival was 5.9 (range: 0.2–20.9) months. CONCLUSIONS: Distributed frameless Gamma Knife radiosurgery is technically feasible and should be considered in lieu of single session GKRS for patients with ≥6 brain metastases.
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