Stereotactic Radiosurgery for Brainstem Metastases: An International Cooperative Study to Define Response and Toxicity

Trifiletti, Daniel M.; Lee, Cheng‐Chia; Kano, Hideyuki; Cohen, Jonathan; Janopaul‐Naylor, James; Alonso‐Basanta, Michelle; Lee, John Y.K.; Šimonová, Gabriela; Liščák, Roman; Wolf, Amparo; Kvint, Svetlana; Grills, I.S.; Johnson, Matthew H.; Liu, Kang Du; Lin, Chung Jung; Mathieu, David; Silva, Danilo; Sharma, Mayur; Cifarelli, Christopher P.; Watson, Christopher N.; Hack, Joshua; Golfinos, John G.; Kondziolka, Douglas; Barnett, Gene H.; Lunsford, L. Dade; Sheehan, Jason P.

doi:10.1016/j.ijrobp.2016.06.009

Cited by 96 publications

(79 citation statements)

References 29 publications

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“…10 Higher doses of 15-20 Gy have been used in patients with other underlying conditions (for example, arteriovenous malformations or metastases) and conveyed a low rate of complications. 5,22 Regardless, further prospective data using modern radiosurgical planning systems and contouring will be required to determine the brainstem dose-volume constraints for single-session SRS cases. Finally, the current study does not address the use or value of hypofractionated SRS and its potential role in the management of complex skull base tumors including FMM.…”

Section: Study Limitationsmentioning

confidence: 99%

Outcomes of stereotactic radiosurgery for foramen magnum meningiomas: an international multicenter study

Mehta

Zenonos

Patibandla

et al. 2018

Journal of Neurosurgery

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OBJECTIVE Meningiomas are the most common benign extramedullary lesions of the foramen magnum; however, their optimal management remains undefined. Given their location, foramen magnum meningiomas (FMMs) can cause significant morbidity, and complete microsurgical removal can be challenging. Anterior and anterolateral FMMs carry greater risks with surgery, but they comprise the majority of these lesions. As an alternative to resection, stereotactic radiosurgery (SRS) has been used to treat FMMs in small case series. To more clearly define the outcomes of SRS and to delineate a rational management paradigm for these lesions, the authors analyzed the safety and efficacy of SRS for FMM in an international multicenter trial. METHODS Seven medical centers participating in the International Gamma Knife Research Foundation (IGKRF) provided data for this retrospective cohort study. Patients who were treated with Gamma Knife radiosurgery and whose clinical and radiological follow-up was longer than 6 months were eligible for study inclusion. Data from pre- and post-SRS radiological and clinical evaluations were analyzed. Stereotactic radiosurgery treatment variables were recorded. RESULTS Fifty-seven patients (39 females and 18 males, with a median age of 64 years) met the study inclusion criteria. Thirty-two percent had undergone prior microsurgical resection. Patients most frequently presented with cranial neuropathy (39%), headache (35%), numbness (32%), and ataxia (30%). Median pre-SRS tumor volume was 2.9 cm. Median SRS margin dose was 12.5 Gy (range 10-16 Gy). At the last follow-up after SRS, 49% of tumors were stable, 44% had regressed, and 7% had progressed. Progression-free survival rates at 5 and 10 years were each 92%. A greater margin dose was associated with a significantly increased likelihood of tumor regression, with 53% of tumors treated with > 12 Gy regressing. Fifty-two percent of symptomatic patients noted some clinical improvement. Adverse radiation effects were limited to hearing loss and numbness in 1 patient (2%). CONCLUSIONS Stereotactic radiosurgery for FMM frequently results in tumor control or tumor regression, as well as symptom improvement. Margin doses > 12 Gy were associated with increased rates of tumor regression. Stereotactic radiosurgery was generally safe and well tolerated. Given its risk-benefit profile, SRS may be particularly useful in the management of small- to moderate-volume anterior and anterolateral FMMs.

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Section: Study Limitationsmentioning

confidence: 99%

Outcomes of stereotactic radiosurgery for foramen magnum meningiomas: an international multicenter study

Mehta

Zenonos

Patibandla

et al. 2018

Journal of Neurosurgery

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“…Stereotactic radiosurgery (SRS) is a well‐established treatment modality (either alone or in combination with surgery/WBRT) in managing patients with single or multiple BMs with improved local control rates and minimal side effects . Also, SRS alone has been shown to have lesser cognitive decline with no difference in overall survival compared to SRS and WBRT at 3 months in patients with 1–3 BMs .…”

Section: Introductionmentioning

confidence: 99%

First follow‐up radiographic response is one of the predictors of local tumor progression and radiation necrosis after stereotactic radiosurgery for brain metastases

et al. 2017

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Local progression (LP) and radiation necrosis (RN) occur in >20% of cases following stereotactic radiosurgery (SRS) for brain metastases (BM). Expected outcomes following SRS for BM include tumor control/shrinkage, local progression and radiation necrosis. 1427 patients with 4283 BM lesions were treated using SRS at Cleveland Clinic from 2000 to 2012. Clinical, imaging and radiosurgery data were collected from the database. Local tumor progression and RN were the primary end points and correlated with patient and tumor‐related variables. 5.7% of lesions developed radiographic RN and 3.6% showed local progression at 6 months. Absence of new extracranial metastasis (P < 0.001), response to SRS at first follow‐up scan (local progression versus stable size (P < 0.001), partial resolution versus complete resolution at first follow up [P = 0.009]), prior SRS to the same lesion (P < 0.001), IDL% (≤55; P < 0.001), maximum tumor diameter (>0.9 cm; P < 0.001) and MD/PD gradient index (≤1.8, P < 0.001) were independent predictors of high risk of local tumor progression. Absence of systemic metastases (P = 0.029), good neurological function at 1st follow‐up (P ≤ 0.001), no prior SRS to other lesion (P = 0.024), low conformity index (≤1.9) (P = 0.009), large maximum target diameter (>0.9 cm) (P = 0.003) and response to SRS (tumor progression vs. stable size following SRS [P < 0.001]) were independent predictors of high risk of radiographic RN. Complete tumor response at first follow‐up, maximum tumor diameter <0.9 cm, tumor volume <2.4 cc and no prior SRS to the index lesion are good prognostic factors with reduced risk of LP following SRS. Complete tumor response to SRS, poor neurological function at first follow‐up, prior SRS to other lesions and high conformity index are favorable factors for not developing RN. Stable or partial response at first follow‐up after SRS have same impact on local progression and RN compared to those with complete resolution or progression.

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“…Survival is frequently used as the primary endpoint in brain metastasis studies. 17,18,20,22 Nevertheless, there has been increasing interest in QOL as an indicator of outcome in studies of advanced cancer patients. 2,18 In the EORTC (European Organisation for Research and Treatment of Cancer) phase III trial of adjuvant WBRT versus observation in patients with 1 to 3 brain metastases, healthrelated QOL (HRQOL) results were used as a secondary endpoint, and those patients in the observation-only arm (i.e., resection or SRS alone) demonstrated significantly higher HRQOL scores than did patients who underwent WBRT.…”

Section: Discussionmentioning

confidence: 99%

Quality of life outcomes for brain metastasis patients treated with stereotactic radiosurgery: pre-procedural predictive factors from a prospective national registry

Sheehan

Grills

Chiang

et al. 2019

Journal of Neurosurgery

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OBJECTIVEStereotactic radiosurgery (SRS) is increasingly used for the treatment of brain metastasis. To date, most studies have focused on survival, radiological response, or surrogate quality endpoints such as Karnofsky Performance Scale status or neurocognitive indices. The current study prospectively evaluated pre-procedural factors impacting quality of life in brain metastasis patients undergoing SRS.METHODSUsing a national, cloud-based platform, patients undergoing SRS for brain metastasis were accrued to the registry. Quality of life prior to SRS was assessed using the 5-level EQ-5D (EQ5D-L) validated tool; additionally, patient and treatment attributes were collected. Patient quality of life was assessed as part of routine follow-up after SRS. Factors predicting a difference in the aggregate EQ5D-L score or the subscores were evaluated. Pre-SRS covariates impacting changes in EQ5D-L were statistically evaluated. Statistical analyses were conducted using multivariate linear regression models.RESULTSEQ5D-L results were available for 116 patients. EQ5D-L improvement (average of 0.387) was noted in patients treated with earlier SRS (p = 0.000175). Worsening overall EQ5D-L (average of 0.052 per lesion) was associated with an increased number of brain metastases at the time of initial presentation (p = 0.0399). Male sex predicted a risk of worsening (average of 0.347) of the pain and discomfort subscore at last follow-up (p = 0.004205). Baseline subscores of pain/discomfort were not correlated with pain/discomfort subscores at follow-up (p = 0.604), whereas baseline subscores of anxiety/depression were strongly positively correlated with the anxiety/depression follow-up subscores (p = 0.0039).CONCLUSIONSAfter SRS, quality of life was likely to improve in patients treated early with SRS and worsen in those with a greater number of brain metastases. Sex differences appear to exist regarding pain and discomfort worsening after SRS. Those with high levels of anxiety and depression at SRS may benefit from medical treatment as this particular quality of life factor generally remains unchanged after SRS.

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Stereotactic Radiosurgery for Brainstem Metastases: An International Cooperative Study to Define Response and Toxicity

Cited by 96 publications

References 29 publications

Outcomes of stereotactic radiosurgery for foramen magnum meningiomas: an international multicenter study

Outcomes of stereotactic radiosurgery for foramen magnum meningiomas: an international multicenter study

First follow‐up radiographic response is one of the predictors of local tumor progression and radiation necrosis after stereotactic radiosurgery for brain metastases

Quality of life outcomes for brain metastasis patients treated with stereotactic radiosurgery: pre-procedural predictive factors from a prospective national registry

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