Staged Stereotactic Radiosurgery for Large Brain Metastases: Local Control and Clinical Outcomes of a One-Two Punch Technique

Dohm, Ammoren; McTyre, E.; Okoukoni, Catherine; Henson, Adrianna; Cramer, Christina K.; LeCompte, M.C.; Ruiz, Jimmy; Munley, Michael T.; Qasem, Shadi; Lo, Hui-Wen; Xing, Fei; Watabe, Kounosuke; Laxton, Adrian W.; Tatter, Stephen B.; Chan, Michael D.

doi:10.1093/neuros/nyx355

Cited by 54 publications

(42 citation statements)

References 22 publications

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“…Thus, staged SRS may be appropriate for tumors with a likelihood of rapid volume changes. The staged SRS technique was introduced for large metastatic brain tumors, in which the time interval between fractions ranged from 2 weeks to 1 month [16, 17]. This technique has the advantage of delivering the optimal dose to the target using interval imaging before each SRS as well as reducing the irradiated volume of the shrunken tumor after the first fraction.…”

Section: Discussionmentioning

confidence: 99%

Unexpected Daily Changes in Tumor Volume during Fractionated Gamma Knife Radiosurgery for Solitary Intraventricular Metastatic Renal Cell Carcinoma: A Case Report

Roh¹,

Kim²,

Chong³

et al. 2019

Stereotact Funct Neurosurg

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For most fractionated stereotactic radiosurgery treatment plans, daily imaging is not routinely performed, because there is little expectation that lesions will change significantly in the short term. However, here, we present the case of an abrupt increase and decrease in tumor volume during fractionated gamma knife radiosurgery (GKRS) for metastatic brain cancer. A 65-year-old man with a history of nephrectomy due to renal cell carcinoma was admitted to our hospital because of mild cognitive disorder and gait disturbance. An initial MRI of the brain demonstrated a 5 × 3 × 4.5 cm-sized, heterogeneously well-enhanced tumor with a large cystic component compressing the left thalamus and corpus callosum near the lateral ventricle. Owing to its large size and proximity to critical structures, we decided to perform 3 fractionated GKRSs over 3 consecutive days. After the first fraction of 9 Gy with 50% isodose, follow-up MRI the next day revealed an unexpected increase in tumor volume up to 30%. Therefore, the radiosurgical plan was adjusted, and GKRS was performed again using the same dose for the second fraction. The image taken on the third day showed rapid shrinkage of the tumor volume. This case shows that a tumor may change its shape and volume unexpectedly even during the short period of a fractionated GKRS session. Hence, for optimal fractionated GKRS treatment of tumors with the likelihood of an abrupt change in the short term, interval imaging should be considered.

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Section: Discussionmentioning

confidence: 99%

Unexpected Daily Changes in Tumor Volume during Fractionated Gamma Knife Radiosurgery for Solitary Intraventricular Metastatic Renal Cell Carcinoma: A Case Report

Roh¹,

Kim²,

Chong³

et al. 2019

Stereotact Funct Neurosurg

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“…As our main goal was to avoid surgery in symptomatic patients, we felt that Infini would be more suitable for obtaining a quicker tumor response that hopefully traduced in faster neurological improvement. Further studies are needed to compare multifraction LINAC versus multifraction Gamma Knife and the results provided by two-or three-session Gamma Knife in the treatment of large brain metastases [18][19][20]22,23].…”

Section: Discussionmentioning

confidence: 99%

“…Radiosurgery apparently enhances the effects of low-dose steroids (e.g., 0.5 mg dexamethasone), resulting in rapid patient improvement. Our neoadjuvant radiosurgery protocol was replaced by the present study of two-session radiosurgery, inspired by staged radiosurgery schemes described by others, but with the hope to benefit not only those unsuitable for surgery, but rather those who could be operated by current recommendations standards [22][23]. It was exactly this group of patients for whom we sought to provide an apparent non-inferior, safe, effective, noninvasive alternative means of radiosurgery for rapid tumor response and control.…”

Section: Discussionmentioning

confidence: 99%

“…These histology subtypes are considered more radioresistant than the histology here presented and thus may limit the extrapolation of the results here described. Several recent studies have described different fractionation schemes that are intended to safely increase the biologically effective dose to large lesions, thereby improving long-term local control and survival when compared with historical reports of tumor control at one year of 45 and 49% in patients that received a lower dose in a single fraction such as 15 and 18 Gy, respectively [14,[16][17][18][19][20][22][23]. Recent results suggest that the classical scheme of surgery followed by SRS may be comparable to staged (two-session) radiosurgery with local tumor failure rate at one year of 8% [26].…”

Section: Discussionmentioning

confidence: 99%

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Two-session Radiosurgery as Initial Treatment for Newly Diagnosed Large, Symptomatic Brain Metastases from Breast and Lung Histology

Lovo¹,

Torres²,

Campos³

et al. 2019

Cureus

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Introduction Surgery is considered the treatment of choice for patients with large, symptomatic brain metastases. This report describes a series of patients treated with upfront two-session radiosurgery rather than surgery for large brain metastases from breast and lung histology. Methods From October 2016 to January 2019, 10 consecutive patients with neurologic symptoms from large brain metastases producing mass effects underwent two sessions of radiosurgical treatments 30 days apart. The response was assessed by imaging and clinical evaluations. Results Ten patients had a total of 36 tumors; of these, 22 lesions with a mean volume of 12.3 ml (range, 7-78.4 ml) underwent two-session radiosurgery. The mean prescription dose for the first treatment was 13 Gy (range, 9-18 Gy) to the 50% isodose line, and the intratumoral mean dose was 17.9 Gy (12-22.9). All 10 patients had neurological symptoms, with a mean Karnofsky physical score (KPS) of 60 (range, 50-70) on the day of treatment. None of these patients required neurosurgical or emergency consultation related to worsening of neurological symptoms between the first and second treatments. At 30 days, the mean KPS was 80 and maintained at 80 at the last follow-up (range, 60-100; P=0.002), and mean lesion volume was 4.1 ml (range, 1.3-70 ml). The mean prescription dose for the second treatment was 12 Gy (range, 9-18 Gy) to the 50% isodose line, and the intratumoral mean dose was 17.9 Gy (11-22.4). The mean overall survival was 24 months (range, 3-32 months). At last follow-up, three patients (30%) had died, two of systemic progression and one of tumor progression, and at one year, local tumor control was 91% and 19 (86%) lesions showed documented local control at last follow up. In those tumors that progressed, the mean time to progression was eight months (range, 5-20 months), and the mean time to surgery was nine months (range, 5-32 months). Conclusion Two-session radiosurgery proved to be a safe treatment for patients with large, symptomatic metastases in this series. Neurological worsening after radiosurgery for large lesions of breast and lung histology may be an infrequent event. This strategy in radiosurgery may have neurological benefits for these patients providing adequate local tumor control while reducing the need of upfront surgery at diagnosis.

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“…The local recurrence rates in these studies ranged from 12.1% to 15.0% and complication incidences from 1.9% to 6.4%, results very similar to those obtained with 3-st-GK-Tx. 1,2,5 The next question is whether 3-st-GK-Tx or 2-st-GK-Tx is the better option in terms of patient outcomes. Very recently, Serizawa et al reported a multi-institutional retrospective study designed to compare the treatment results of these 2 protocols (i.e., 3-stage or 2-stage treatment).…”

Section: Discussionmentioning

confidence: 99%

Three-stage Gamma Knife treatment for metastatic brain tumors larger than 10 cm3: a 2-institute study including re-analyses of earlier results using competing risk analysis

Yamamoto

Higuchi

Serizawa

et al. 2018

Journal of Neurosurgery

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OBJECTIVEThe results of 3-stage Gamma Knife treatment (3-st-GK-Tx) for relatively large brain metastases have previously been reported for a series of patients in Chiba, Japan (referred to in this study as the C-series). In the current study, the authors reappraised, using a competing risk analysis, the efficacy and safety of 3-st-GK-Tx by comparing their experience with that of the C-series.METHODSThis was a retrospective cohort study. Among 1767 patients undergoing GK radiosurgery for brain metastases at Mito Gamma House during the 2005–2015 period, 78 (34 female, 44 male; mean age 65 years, range 35–86 years) whose largest tumor was > 10 cm3, treated with 3-st-GK-Tx, were studied (referred to in this study as the M-series). The target volumes were covered with a 50% isodose gradient and irradiated with a peripheral dose of 10 Gy at each procedure. The interval between procedures was 2 weeks. Because competing risk analysis had not been employed in the published C-series, the authors reanalyzed the previously published data using this method.RESULTSThe overall median survival time after 3-st-GK-Tx was 8.3 months (95% CI 5.6–12.0 months) in the M-series and 8.6 months (95% CI 5.5–10.6 months) in the C-series (p = 0.41). Actuarial survival rates at the 6th and 12th post–3-st-GK-Tx months were, respectively, 55.1% and 35.2% in the M-series and 62.5% and 26.4% in the C-series (HR 1.175, 95% CI 0.790–1.728, p = 0.42). Cumulative incidences at the 12th post–3-st-GK-Tx, determined by competing risk analyses, of neurological deterioration (14.2% in C-series vs 12.8% in M-series), neurological death (7.2% vs 7.7%), local recurrence (4.8% vs 6.2%), repeat SRS (25.9% vs 18.0%), and SRS-related complications (2.3% vs 5.1%) did not differ significantly between the 2 series.CONCLUSIONSThere were no significant differences in post–3-st-GK-Tx results between the 2 series in terms of overall survival times, neurological death, maintained neurological status, local control, repeat SRS, and SRS-related complications. The previously published results (C-series) are considered to be validated by the M-series results.

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Staged Stereotactic Radiosurgery for Large Brain Metastases: Local Control and Clinical Outcomes of a One-Two Punch Technique

Abstract: Staged radiosurgery is a safe and effective option for large, unresectable brain metastases. Prospective studies are required to validate the findings in this study.

Cited by 54 publications

References 22 publications

Unexpected Daily Changes in Tumor Volume during Fractionated Gamma Knife Radiosurgery for Solitary Intraventricular Metastatic Renal Cell Carcinoma: A Case Report

Unexpected Daily Changes in Tumor Volume during Fractionated Gamma Knife Radiosurgery for Solitary Intraventricular Metastatic Renal Cell Carcinoma: A Case Report

Two-session Radiosurgery as Initial Treatment for Newly Diagnosed Large, Symptomatic Brain Metastases from Breast and Lung Histology

Three-stage Gamma Knife treatment for metastatic brain tumors larger than 10 cm3: a 2-institute study including re-analyses of earlier results using competing risk analysis

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