Estimating prognosis at the time of repeat whole brain radiation therapy for multiple brain metastases: The reirradiation score

Logie, Natalie; Jimenez, Rachel; Pulenzas, Natalie; Linden, Kelly; Ciafone, Denise; Ghosh, Sunita; Xu, Yuhui; Lefresne, Shilo; Wong, Erin; Son, Christina H.; Shih, Helen A.; Wong, William W.; Tyldesley, Scott; Dennis, Kristopher; Chow, Edward; Fairchild, Alysa

doi:10.1016/j.adro.2017.05.010

Cited by 16 publications

(29 citation statements)

References 32 publications

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“…We also assessed the utility of the previously published ReRT score, which incorporates KPS <80, interval to ReRT < 9 months, uncontrolled primary, small cell histology, and presence of extracranial metastases, with 1 point given for each variable present. 8 ReRT score of 1 to 2 was associated with improved overall survival compared with a score of 3 to 4 with a median survival of 4.60 months (95% CI, 3.73-5.47 months) versus 2.86 months (95% CI, 0.86-4.86, P Z .01), thus validating the original study (Fig. 3).…”

Section: Resultssupporting

confidence: 76%

“…In terms of patient selection, validating the value of the ReRT score in this cohort suggests the validity of this tool in prognostication in this population. 8 Certainly, the characteristics of this cohort are quite different from the ReRT cohort, as the ReRT score was built from 5 significant findings on univariate analysis of KPS <80, interval <9 months, uncontrolled primary, small cell histology, and presence of extracranial metastases. We found that only KPS was associated with worse survival in our cohort.…”

Section: Discussionmentioning

confidence: 99%

“…Based on previously published series, a common technique is decreasing the total radiation dose or fraction size. 3 , 4 , 5 , 6 , 7 , 8 Other techniques involve blocking the optic nerve and chiasm via a so-called peninsula block . Finally, although not expressly pursued in ReRT, hippocampal sparing WBRT may represent a technique that can decrease late effects in patients treated with ReRT.…”

Section: Introductionmentioning

confidence: 99%

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Outcomes From Whole-Brain Reirradiation Using Pulsed Reduced Dose Rate Radiation Therapy

Burr

Robins

Bayliss

et al. 2020

Advances in Radiation Oncology

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Purpose Recurrent intracranial metastases after whole-brain irradiation pose a clinical challenge owing to the escalating morbidity associated with their treatment. Although stereotactic radiosurgery is increasingly being used, there are still situations in which whole-brain reirradiation (ReRT) continues to be appropriate. Here, we report our experience using whole-brain pulsed reduced dose rate radiation therapy (PRDR), a method that delivers radiation at a slower rate of 0.067 Gy/min to potentially increase sublethal damage repair and decrease toxicity. Methods and Materials Patients undergoing whole-brain ReRT with PRDR from January 1, 2001 to March 2019 were analyzed. The median PRDR ReRT dose was 26 Gy in 2 Gy fractions, resulting in a median total whole-brain dose of 59.5 Gy. Cox regression analysis was used for multivariate analysis. The Kaplan-Meier method was used for overall survival, progression free survival, and to evaluate the ReRT score. Binary logistic regression was employed to evaluate variables associated with rapid death. Results Seventy-five patients were treated with whole-brain PRDR radiation therapy. The median age was 54 (range, 26-72), the median Karnofsky performance status (KPS) was 80, and 86.7% had recursive partitioning analysis scores of 2. Thirty-two patients had over 10 metastases and 11 had leptomeningeal disease. The median overall survival was 4.1 months (range, 0.29-59.5 months) with a 1 year overall survival of 10.4%. Age, KPS, dexamethasone usage, and intracranial disease volume were significantly correlated with overall survival on multivariate analysis. A KPS ≤70 was associated with rapid death after radiation. The prognostic value of the ReRT score was validated. The most common acute toxicities were fatigue (23.1%) and headache (16.9%). Conclusions In this large cohort of patients with advanced intracranial metastases, PRDR achieves acceptable survival and may decrease toxicity associated with ReRT. PRDR is an easily implemented technique and is a viable treatment option for ReRT of brain metastases.

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Section: Resultssupporting

confidence: 76%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Outcomes From Whole-Brain Reirradiation Using Pulsed Reduced Dose Rate Radiation Therapy

Burr

Robins

Bayliss

et al. 2020

Advances in Radiation Oncology

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“…We found that there was no statistically significant difference in survival since re-WBRT between KPS > 70 and KPS < 70 at either initial presentation or at re-WBRT. We only found a single study evaluating the relation of RPA with post re-WBRT survival(22). They reported that median survival was better in patients with post re-WBRT RPA class I and this was in concordance with findings of our study.…”

Section: Discussionmentioning

confidence: 99%

Brain Re-Irradiation in Lung Cancer – Not an Exercise in Futility

Agarwal

Karmakar

Tibdewal

et al. 2020

Preprint

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BACKGROUND: Whole brain radiation therapy (WBRT) is an effective palliative measure and provides durable symptom relief in lung cancer patients with multiple brain metastases (BM). Clinico radiological progression of BM after WBRT is a common and challenging scenario; treatment is tailored, with various factors like driver mutation status, age, performance status, progression free interval and time since last irradiation influencing the treatment decision. Surgery or focal RT with stereotactic techniques may be an option for patients with oligometastases. However, they might not be a feasible option for patients with multiple BM. We aim to study the impact and outcome of patients with BM from lung cancer receiving reWBRT for clinico-radiological progression. MATERIALS AND METHODS: We retrospectively analyzed patients with BM from lung cancer who were registered at Tata Memorial Hospital, Mumbai, India between January 2016 to January 2019 and had undergone two courses of WBRT. Data of patients were retrieved from electronic medical records. Patients were treated using conventional or conformal technique with either telecobalt or Linear accelerator. RESULTS: Out of 446 patients with lung cancer, diagnosed and treated with WBRT for BM, 6% patients (n=28) received reWBRT. There were 16 men and 12 women with a median age of 53 years (range 30 to 70 years). Primary histology was adenocarcinoma in all except two patients who had small cell histology. Eighteen patients had driver mutation positive disease (11 with EGFR and 7 with ALK mutation) and a majority of patients (54%) had BM at presentation. Clinico-radiological progression was the commonest indication of re-WBRT. A majority of these patients had developed new symptoms while about 25% had recurrence of previous symptoms. Mean Karnofsky performance score (KPS) prior to re-WBRT was more than 70 in 13 patients (57%). Mean time interval between the two courses of WBRT were 16 months (range 5 to 37 months). Most patients received WBRT using a conventional technique (91%) and were treated in a telecobalt unit (83%). Re-WBRT fractionation schedule was 25 Gy in 10 fractions (n=17, 61%) or 20 Gy in 5 fractions (n=10, 36%). Mean biological effective dose (BED2Gy) for the first and second courses of WBRT were 63Gy and 56Gy respectively. The average cumulative BED2Gy was 118.91Gy (range 116.25 to 120Gy). Almost all patients received short acting steroids during the course of reWBRT. All patients except for one completed the course of treatment. At a median follow up of 2.5 years, median survival of patients after reWBRT was 5 months. Median survival since reWBRT was 8 months if pre first course of WBRT ds-GPA was 3.5-4 vs 1 month if it was 0-1 (p= 0.025). CONCLUSION: In lung cancer patients with symptomatic progression of multiple BM and good prognostic features (driver mutation positive, good performance status and long time interval since last WBRT), re-WBRT is safe and associated with better outcomes.

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“…Nevertheless, patients who have regional failure after WBRT can undergo effective salvage SRS with low morbidity and may have similar outcomes to those who experience first brain metastases with similar performance status. 6,[10][11][12][13][14][15] Local treatment should be evaluated for patients with multiple brain metastases and good performance status for whom salvages SRS is technically feasible.…”

Section: Discussionmentioning

confidence: 99%

Radiosurgery for multiple brain metastases: two cases reports

Caussa¹,

Davalos²,

O³

et al. 2018

JNSK

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Brain metastases are the most common intracranial tumors in the adult population and historically treated with whole brain radiation therapy (WBRT). However, as medical oncology advances improve life expectancy, stereotactic radiosurgery (SRS) has replaced WBRT as the standard for limited brain metastases,1-3 nevertheless has been less published in the case of multiple brain metastases. In these cases reports, we detail two patients at our institution that received SRS for multiple brain metastases and demonstrated acceptable tolerance and response. SRS is emerging as an acceptable alternative in multiple brain metastases and the decision to indicate it should be made with consideration of overall prognosis for each patient.

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Estimating prognosis at the time of repeat whole brain radiation therapy for multiple brain metastases: The reirradiation score

Cited by 16 publications

References 32 publications

Outcomes From Whole-Brain Reirradiation Using Pulsed Reduced Dose Rate Radiation Therapy

Outcomes From Whole-Brain Reirradiation Using Pulsed Reduced Dose Rate Radiation Therapy

Brain Re-Irradiation in Lung Cancer – Not an Exercise in Futility

Radiosurgery for multiple brain metastases: two cases reports

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