Treatment of WHO Grade 2 Meningiomas With Stereotactic Radiosurgery: Identification of an Optimal Group for SRS Using RPA

Kowalchuk, Roman O.; Shepard, Matthew J.; Sheehan, Kimball; Sheehan, Darrah; Niranjan, Ajay; Kano, Hideyuki; Gurewitz, Jason; Bernstein, Kenneth; Guseynova, Khumar; Grills, I.S.; Parzen, Jacob S; Cifarelli, Christopher P.; Rehman, Azeem A.; Atik, Ahmet; Bakhsheshian, Joshua; Zada, Gabriel; Chang, Eric L.; Giannotta, Steven L.; Speckter, Herwin; Wu, Hsiu Mei; Kondziolka, Douglas; Mathieu, David; Lee, Cheng chia; Warnick, Ronald E.; Lunsford, L. Dade; Trifiletti, Daniel M.; Sheehan, Jason P.

doi:10.1016/j.ijrobp.2021.01.048

Cited by 29 publications

(16 citation statements)

References 41 publications

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“…Local control, progression-free survival, and overall survival rates were 82.2%, 84.1%, and 79%, respectively, for patients treated with adjuvant RT, and 71%, 71.9%, and 81.5%, respectively, for those not receiving the treatment. Lee et al [ 22 ] reported the outcome of 179 patients who underwent surveillance versus 51 patients who received postoperative adjuvant RT with photons (39%) or protons (57%) after resection of an atypical meningioma. Compared with patients who underwent surveillance, patients who received adjuvant RT showed better progression-free survival; 5-year and 10-year rates were 79% and 64%, respectively, in the adjuvant RT group, versus 62% and 54%, respectively, in the surveillance group (log-rank p =0.03).…”

Section: Radiation Therapy Outcomementioning

confidence: 99%

“…Kowalchuk et al [ 22 ] have recently reported the results of a large retrospective multicentric study of 233 atypical meningiomas treated with SRS. For high-risk grade 2 meningiomas, as defined by the RTOG 0539 study, the 3-year progression-free survival was 53.9%, being similar to the rate of 58.8% reported in the RTOG study.…”

Section: Radiation Therapy Outcomementioning

confidence: 99%

“…With regard to the timing of RT for atypical meningiomas, postoperative RT seems more effective when administered adjuvantly rather than at recurrence, and most authors recommend this approach [ 35 – 37 , 42 , 47 , 48 , 52 , 60 , 89 ]. In the study of Lee et al [ 22 ], adjuvant RT was associated with a longer time of tumor progression compared with salvage RT. For patients with unresectable and symptomatic meningioma or with imminent risk of symptomatology in case of further progression, there is a general consensus that RT should be initiated as soon as possible [ 6 ].…”

Section: Radiation Therapy Outcomementioning

confidence: 99%

“…A similar acceptable incidence of radiation-related toxicity has been reported in the majority of published studies of conventionally fractionated RT including either atypical or anaplastic meningiomas (Tables 1 and 2 ). For patients receiving SRS, neurological toxicity rates up to 26% have been reported in few studies [ 22 , 24 , 27 , 82 ], although it remains below 10% when limited volumes are treated [ 15 , 17 , 21 ]. Potential neurocognitive toxicity of adjuvant RT is a major cause that makes physicians hesitate to apply it to patients with an atypical meningioma after gross total resection.…”

Section: Radiation Therapy Outcomementioning

confidence: 99%

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Radiation therapy for atypical and anaplastic meningiomas: an overview of current results and controversial issues

et al. 2022

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Meningiomas are the most common intracranial tumors. Most meningiomas are WHO grade 1 tumors whereas less than one-quarter of all meningiomas are classified as atypical (WHO grade 2) and anaplastic (WHO grade 3) tumors, based on local invasiveness and cellular features of atypia. Surgical resection remains the cornerstone of meningioma therapy and represents the definitive treatment for the majority of patients; however, grade 2 and grade 3 meningiomas display more aggressive behavior and are difficult to treat. Several retrospective series have shown the efficacy and safety of postoperative adjuvant external beam radiation therapy (RT) for patients with atypical and anaplastic meningiomas. More recently, two phase II prospective trials by the Radiation Therapy Oncology Group (RTOG 0539) and the European Organisation for Research and Treatment of Cancer (EORTC 2042) have confirmed the potential benefits of fractionated RT for patients with intermediate and high-risk meningiomas; however, several issues remain a matter of debate. Controversial topics include the timing of radiation treatment in patients with totally resected atypical meningiomas, the optimal radiation technique, dose and fractionation, and treatment planning/target delineation. Ongoing randomized trials are evaluating the efficacy of early adjuvant RT over observation in patients undergoing gross total resection.

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Section: Radiation Therapy Outcomementioning

confidence: 99%

Section: Radiation Therapy Outcomementioning

confidence: 99%

Section: Radiation Therapy Outcomementioning

confidence: 99%

Section: Radiation Therapy Outcomementioning

confidence: 99%

See 2 more Smart Citations

Radiation therapy for atypical and anaplastic meningiomas: an overview of current results and controversial issues

et al. 2022

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“…However, several retrospective studies and single institution studies have demonstrated acceptable LC with margin doses of 12–20 Gy [ 46 , 47 , 48 , 49 ]. Additionally, there have been efforts to identify optimal subgroups of patients with higher grade tumors that may benefit from SRS [ 50 ]. While meningioma is generally considered a benign disease, there are certain subsets of tumors that appear to be more aggressive.…”

Section: Meningioma Treatmentmentioning

confidence: 99%

A Review of the Role of Stereotactic Radiosurgery and Immunotherapy in the Management of Primary Central Nervous System Tumors

et al. 2022

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Stereotactic radiosurgery (SRS) and immune checkpoint inhibitors (ICIs) are widely used in the management of brain metastases. These therapies are commonly administered concurrently; as SRS may enhance anti-tumor immunity and responsiveness to ICIs. However, the use of ICIs with and without SRS in the management of primary brain tumors remains a controversial topic. Meningiomas are the most common nonmalignant and extra-parenchymal brain tumor, which often respond well to surgery and radiotherapy. However, higher grade meningiomas tend to be resistant to these treatments, and the use of chemotherapy and targeted agents in this setting have yielded disappointing results. Thus, there is heightened interest in the utilization of ICIs. Glioblastoma is the most common malignant primary intraparenchymal brain tumor. It is associated with a grim prognosis with a median overall survival of approximately 20 months, despite optimal therapy. While SRS in the adjuvant setting, and ICI in the recurrent setting, have failed to demonstrate a survival benefit, SRS in the preoperative setting has the potential to enhance anti-tumor immunity and responsiveness to ICIs. Thus, these treatments represent an attractive option to add to the armamentarium of meningioma and glioblastoma management. In this review, we provide a detailed overview of the evidence supporting the use of ICIs and SRS in each of these settings.

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Development and Assessment of a Predictive Score for Vertebral Compression Fracture After Stereotactic Body Radiation Therapy for Spinal Metastases

et al. 2022

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IMPORTANCEVertebral compression fracture (VCF) is a potential adverse effect following treatment with stereotactic body radiation therapy (SBRT) for spinal metastases.OBJECTIVE To develop and assess a risk stratification model for VCF after SBRT. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study conducted at a high-volume referral center included 331 patients who had undergone 464 spine SBRT treatments from December 2007 through October 2019. Data analysis was conducted from November 1, 2020, to August 17, 2021. Exclusions included proton therapy, prior surgical intervention, vertebroplasty, or missing data.EXPOSURES One and 3 fraction spine SBRT treatments were most commonly delivered. Single-fraction treatments generally involved prescribed doses of 16 to 24 Gy (median, 20 Gy; range, 16-30 Gy) to gross disease compared with multifraction treatment that delivered a median of 30 Gy (range, 21-50 Gy). MAIN OUTCOMES AND MEASURESThe VCF and radiography components of the spinal instability neoplastic score were determined by a radiologist. Recursive partitioning analysis was conducted using separate training (70%), internal validation (15%), and test (15%) sets. The log-rank test was the criterion for node splitting. RESULTSOf the 331 participants, 88 were women (27%), and the mean (IQR) age was 63 (59-72) years. With a median follow-up of 21 months (IQR, 11-39 months), we identified 84 VCFs (18%), including 65 (77%) de novo and 19 (23%) progressive fractures. There was a median of 9 months (IQR, 3-21 months) to developing a VCF. From 15 candidate variables, 6 were identified using the backward selection method, feature importance testing, and a correlation heatmap. Four were selected via recursive partitioning analysis: epidural tumor extension, lumbar location, gross tumor volume of more than 10 cc, and a spinal instability neoplastic score of more than 6. One point was assigned to each variable, and the resulting multivariable Cox model had a concordance of 0.760. The hazard ratio per 1-point increase for VCF was 1.93 (95% CI, 1.62-2.30; P < .001). The cumulative incidence of VCF at 2 years (with death as a competing risk) was 6.7% (95% CI, 4.2%-10.7%) for low-risk (score, 0-1; 273 [58.3%]), 17.0% (95% CI, 10.8%-26.7%) for intermediate-risk (score, 2; 99 [21.3%]), and 35.4% (95% CI, 26.7%-46.9%) for high-risk cases (score, 3-4; 92 [19.8%]) (P < .001). Similar results were observed for freedom from VCF using stratification. CONCLUSIONS AND RELEVANCEThe results of this cohort study identify a subgroup of patients with high risk for VCF following treatment with SBRT who may potentially benefit from undergoing prophylactic spinal stabilization or vertebroplasty.

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Treatment of WHO Grade 2 Meningiomas With Stereotactic Radiosurgery: Identification of an Optimal Group for SRS Using RPA

Cited by 29 publications

References 41 publications

Radiation therapy for atypical and anaplastic meningiomas: an overview of current results and controversial issues

Radiation therapy for atypical and anaplastic meningiomas: an overview of current results and controversial issues

A Review of the Role of Stereotactic Radiosurgery and Immunotherapy in the Management of Primary Central Nervous System Tumors

Development and Assessment of a Predictive Score for Vertebral Compression Fracture After Stereotactic Body Radiation Therapy for Spinal Metastases

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