Comparing pre-operative versus post-operative single and multi-fraction stereotactic radiotherapy for patients with resectable brain metastases

Perlow, Haley K.; Ho, Cindy; Matsui, Jennifer K.; Prasad, Rahul N.; Klamer, Brett; Wang, Joshua; Damante, Mark; Upadhyay, Rituraj; Thomas, Evan M.; Blakaj, Dukagjin; Beyer, Sasha; Lonser, Russell R.; Hardesty, Douglas A.; Raval, Raju R.; Prabhu, Roshan S.; Elder, J. Bradley; Palmer, Joshua D.

doi:10.1016/j.ctro.2022.11.004

Cited by 6 publications

(4 citation statements)

References 19 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Lastly, a study investigated changes in the clinical target volume (CTV) and associated clinical implications of an MRL during hypofractionated SRT to resected brain metastases, finding statistically significant reductions in cavity CTV during SRT, which supports the use of MRgRT and treatment adaptation to mitigate toxicity [20]. Another potential application of MRgRT is in preoperative SRT, a modality which has recently gained traction, particularly for larger tumors [49]. Particularly in patients who may have symptomatic brain metastases, carefully planned use of MRgRT may expedite treatment and facilitate a shorter interval from diagnosis through resection.…”

Section: Stereotactic Radiation Therapy For Intracranial Tumorsmentioning

confidence: 95%

Treatment of Central Nervous System Tumors on Combination MR-Linear Accelerators: Review of Current Practice and Future Directions

Bryant,

Doniparthi,

Weygand

et al. 2023

Cancers

View full text Add to dashboard Cite

Magnetic resonance imaging (MRI) provides excellent visualization of central nervous system (CNS) tumors due to its superior soft tissue contrast. Magnetic resonance-guided radiotherapy (MRgRT) has historically been limited to use in the initial treatment planning stage due to cost and feasibility. MRI-guided linear accelerators (MRLs) allow clinicians to visualize tumors and organs at risk (OARs) directly before and during treatment, a process known as online MRgRT. This novel system permits adaptive treatment planning based on anatomical changes to ensure accurate dose delivery to the tumor while minimizing unnecessary toxicity to healthy tissue. These advancements are critical to treatment adaptation in the brain and spinal cord, where both preliminary MRI and daily CT guidance have typically had limited benefit. In this narrative review, we investigate the application of online MRgRT in the treatment of various CNS malignancies and any relevant ongoing clinical trials. Imaging of glioblastoma patients has shown significant changes in the gross tumor volume over a standard course of chemoradiotherapy. The use of adaptive online MRgRT in these patients demonstrated reduced target volumes with cavity shrinkage and a resulting reduction in radiation dose to uninvolved tissue. Dosimetric feasibility studies have shown MRL-guided stereotactic radiotherapy (SRT) for intracranial and spine tumors to have potential dosimetric advantages and reduced morbidity compared with conventional linear accelerators. Similarly, dosimetric feasibility studies have shown promise in hippocampal avoidance whole brain radiotherapy (HA-WBRT). Next, we explore the potential of MRL-based multiparametric MRI (mpMRI) and genomically informed radiotherapy to treat CNS disease with cutting-edge precision. Lastly, we explore the challenges of treating CNS malignancies and special limitations MRL systems face.

show abstract

Section: Stereotactic Radiation Therapy For Intracranial Tumorsmentioning

confidence: 95%

Treatment of Central Nervous System Tumors on Combination MR-Linear Accelerators: Review of Current Practice and Future Directions

Bryant,

Doniparthi,

Weygand

et al. 2023

Cancers

View full text Add to dashboard Cite

show abstract

“…However, post-operative SRS has been associated in some studies with radiation necrosis, leptomeningeal metastatic spread, and local failure at the SRS treatment site, thereby prompting the exploration of the use of pre-operative SRS [ 35 ]. One retrospective multi-institutional analysis of 279 patients found lower rates of radiation necrosis, leptomeningeal spread, and local failure in patients undergoing multimodal therapy for large BM with limited intracranial disease [ 36 ]. A recently initiated phase III trial is exploring the efficacy of pre-operative versus post-operative SRS for patients with surgically resected BM (NRG BN012; NCT05438212).…”

Section: Multi-disciplinary Clinical Management Of Brain Metastasesmentioning

confidence: 99%

Building Team Medicine in the Management of CNS Metastases

Baskaran

Buerki

Khan

et al. 2023

JCM

View full text Add to dashboard Cite

CNS metastases are often terminal for cancer patients and occur at an approximately 10-fold higher rate than primary CNS tumors. The incidence of these tumors is approximately 70,000–400,000 cases annually in the US. Advances that have occurred over the past two decades have led to more personalized treatment approaches. Newer surgical and radiation techniques, as well as targeted and immune therapies, have enanled patient to live longer, thus increasing the risk for the development of CNS, brain, and leptomeningeal metastases (BM and LM). Patients who develop CNS metastases have often been heavily treated, and options for future treatment could best be addressed by multidisciplinary teams. Studies have indicated that patients with brain metastases have improved survival outcomes when cared for in high-volume academic institutions using multidisciplinary teams. This manuscript discusses a multidisciplinary approach for both parenchymal brain metastases as well as leptomeningeal metastases implemented in three academic institutions. Additionally, with the increasing development of healthcare systems, we discuss optimizing the management of CNS metastases across healthcare systems and integrating basic and translational science into our clinical care to further improve outcomes. This paper summarizes the existing therapeutic approaches to the treatment of BM and LM and discusses novel and emerging approaches to optimizing access to neuro-oncologic care while simultaneously integrating multidisciplinary teams in the care of patients with BM and LM.

show abstract

“…12 Preoperative SRT is emerging as a neoadjuvant treatment option that may demonstrate an improved safety and toxicity profile compared with postoperative SRT. 13,14 For patients experiencing neurologic symptoms, initial treatment includes corticosteroids to manage vasogenic edema. 15 Steroid-sparing agents, such as the anti-VEGF antibody therapy bevacizumab, have also been studied for use in managing edema.…”

Section: Melanoma Brain Metastasesmentioning

confidence: 99%

BRAF/MEK Inhibition as a Bridge to Immunotherapy for Symptomatic BRAF V600 Melanoma Brain Metastases: A Case Series

Strelnikov,

Zhou,

Butt

et al. 2023

Journal of the National Comprehensive Cancer Network

View full text Add to dashboard Cite

Targeted and immune therapies have changed the paradigm of treatment for patients with metastatic melanoma. Treatment of patients with symptomatic melanoma brain metastases, however, is complicated by the frequent use of immune suppression for the management of vasogenic edema and the urgency in addressing disease burden. Use of BRAF/MEK inhibitors in patients with a corresponding BRAF V600 mutation often results in rapid response but is hindered by high rates of disease relapse and progression. Immunotherapy has higher durability of response, but the rate of response is slower and responses can be significantly diminished for patients on concurrent steroid therapy. Considering this gap in evidence-based guidance for optimal adjuvant therapy sequence in immunosuppressed patients with BRAF V600–mutant melanoma brain metastases, we report on 4 cases utilizing BRAF/MEK inhibitors as a bridging therapy for brain metastases management before initiation of immune checkpoint inhibitor therapy. Future prospective studies will be required to determine the optimal treatment sequencing for patients in this population with high unmet medical need.

show abstract

Comparing pre-operative versus post-operative single and multi-fraction stereotactic radiotherapy for patients with resectable brain metastases

Cited by 6 publications

References 19 publications

Treatment of Central Nervous System Tumors on Combination MR-Linear Accelerators: Review of Current Practice and Future Directions

Treatment of Central Nervous System Tumors on Combination MR-Linear Accelerators: Review of Current Practice and Future Directions

Building Team Medicine in the Management of CNS Metastases

BRAF/MEK Inhibition as a Bridge to Immunotherapy for Symptomatic BRAF V600 Melanoma Brain Metastases: A Case Series

Contact Info

Product

Resources

About