Gamma Knife Radiosurgery For Brain Metastases Research Articles

Clinical outcomes of patients with multiple courses of radiosurgery for brain metastases from non-small cell lung cancer

We investigated the long-term clinical outcomes of patients who underwent multiple courses (≥ 5) of gamma knife radiosurgery (GKRS) due to recurrent brain metastases (BM) from non-small cell lung cancer (NSCLC). Between December 2001 and July 2019, consecutive 2571 patients underwent GKRS for BM from NSCLC. Clinical and radiological outcomes were investigated in 76 patients who underwent GKRS ≥ 5 times. The median follow-up period after the diagnosis of NSCLC was 54.6 months (range 14.5–159.1 months). The median number of GKRS procedures per patient was six (range 5–15). Actuarial post-GKRS survival rates at 1, 2, 3, 4, and 5 years following initial GKRS were 88.1%, 79.5%, 65.3%, 51.4%, and 37.3%, respectively. No significant difference in overall survival was observed between patients (n = 22) with whole-brain radiotherapy (WBRT) and patients (n = 54) without WBRT (p = 0.076). The incidence of radiation-induced leukoencephalopathy was 64% and 18% in patients with and without WBRT, respectively (p < 0.0001). Multiple courses of SRS are a tolerable and effective treatment option for recurrent BM from NSCLC. Repeat SRS may be an alternative treatment option to avoid or delay WBRT.

Brain Metastases in a Patient With Papillary Thyroid Carcinoma. Clinical Case Report

Introduction: Papillary thyroid carcinoma (PTC) is the most common neoplasm of the endocrine system and the least aggressive, representing between 70% and 80% of thyroid neoplasms. This is characterized by slow growth and a low risk of progression to metastasis. Brain Metastases (BM) associated with PTC occur with a incidence rate of 0.15%. Tyrosine kinase inhibitors (TKI) are a very promising alternative for managing these patients. Here is described the case of a patient with PTC with brain and lung metastases, her respective management and evolution. Clinical Case Report: A 64-year-old patient with a history of controlled hypothyroidism, who was recently diagnosed with high cell variant PTC, positive for BRAF V600E mutation. Neck CT revealed a thyroid mass extending to the superior mediastinum, with associated lung metastases. We started by suppressing TSH with levothyroxine. Brain MRI was done due to persistent and as safety precaution before starting thyrotropin alfa This showed multiple intra-parenchymal lesions compatible with BM. Patient received management with gamma Knife radiosurgery for BM and with lenvatinib 24mg day. The patient presented a decrease in tumor size by more than 50% in the neck, with disappearance of the majority of BM at 90 days. After 18 months of treatment, she was still alive. Discussion and Conclusion: PTC associated with BM has a very poor life expectancy, and there are not guidelines for its management and the treatment is based on case reports and expert opinions. Radiosurgery plus ITK combined therapy could provide better outcomes to these patients

The Effect of Epidermal Growth Factor Receptor Mutation on Intracranial Progression-Free Survival of Non-Small Cell Lung Cancer Patients with Brain Metastasis Underwent Gamma Knife Radiosurgery

BackgroundThe aim of this study was to survey prognostic factors, particularly those focusing on epidermal growth factor receptor (EGFR) mutations, of patients with non-small cell lung cancer (NSCLC) after Gamma Knife Radiosurgery (GKRS) for metastatic brain tumors.MethodsWe retrospectively reviewed the medical records of 98 patients with NSCLC who underwent GKRS for brain metastases from August 2010 to July 2017. The primary endpoint was progression-free survival (PFS) of the intracranial disease. We analyzed variables such as age, sex, Karnofsky Performance Status, recursive partitioning analysis (RPA) class, smoking status, primary cancer pathology, EGFR mutations, and time to brain metastases as prognostic factors.ResultsThe median overall survival (OS) of the patients was 16 months [95% confidence interval (CI), 13–21 months]. Median systemic PFS and intracranial PFS were 9 months (95% CI, 8–11 months) and 11 months (95% CI, 7–14 months), respectively. Kaplan-Meier survival analysis revealed that the patients with EGFR mutations had longer intracranial PFS than those without EGFR mutation (median intracranial PFS: 19 vs. 10 months with p=0.01) while they had no benefits in OS and systemic PFS. Furthermore, the patients harboring adenocarcinoma had longer OS (p<0.01) and intracranial PFS (p<0.01) and the patients with lower RPA class had longer OS (p=0.02) and intracranial PFS (p=0.03).ConclusionEGFR mutations, primary cancer pathology, and RPA class may be proposed as prognostic factors for intracranial PFS in NSCLC patients after GKRS for brain metastasis in this study.

EP-1186: Dosimetric comparison of planning modalities for GammaKnife radiosurgery of brain metastases

EP-1186: Dosimetric comparison of planning modalities for GammaKnife radiosurgery of brain metastases

Health State Utilities for Patients with Brain Metastases.

Purpose: Estimating the cost-effectiveness of whole-brain radiation therapy (WBRT) and stereotactic radiosurgery (SRS), including Gamma Knife radiosurgery (GKRS), requires the quantitative measurement of patients’ health states after treatment. We sought to quantify individuals’ preferences for the relevant health states after WBRT or GKRS for brain metastases on a 0 to 1 scale, where 1 is perfect health and 0 is death.Methods: We prospectively measured utilities in patients with brain metastases evaluated at Yale for consideration of WBRT and/or GKRS, as well as oncology nurses who had cared for patients with brain metastases before and after WBRT or GKRS, using the Standard Gamble (SG) technique. Demographic information was also collected. Nonparametric tests were used to compare potential differences in utility values and for subgroups based on demographic characteristics.Results: There were 24 patients and 31 nurses who completed the study between December 2013 and May 2015. Median utilities ranged from 0.85 for the status-post (S/P) GKRS state to 0.25 (for neurologic dying). The median utility of being S/P WBRT was 0.70 compared to 0.85 S/P GKRS (p < 0.001). The cognitive decline from WBRT was associated with a notably low utility score of 0.30. There were no statistically significant differences between patients’ and nurses’ median utility scores.Conclusions: These SG utilities provide unique insights into brain metastases-related health states from the patient and provider perspective. As perceived by individuals with direct knowledge of the health states in question, WBRT has a significantly lower utility compared to GKRS. Cognitive decline following WBRT is associated with significant perceived reduction in quality of life. Differences in the relative importance of overall survival and quality of life with treatment existed between patients with different stages of disease. These utilities can be used to calculate quality-adjusted life expectancy in cost-effectiveness evaluations of SRS and WBRT.

Outcomes of gamma knife radiosurgery, bi-modality & tri-modality treatment regimens for patients with one or multiple brain metastases: the Columbia University Medical Center experience.

Optimal treatment of brain metastases (BMs) is debatable. However, surgery or gamma knife radiosurgery (GKRS) improves survival when combined with whole brain radiotherapy (WBRT) versus WBRT alone. We retrospectively reviewed an institutional database of patients treated with GKRS for BMs from 1998 to 2013 to explore effects of single or multi-modality therapies on survival. There were 528 patients with median age 62 years. Histologies included 257 lung, 102 breast, 62 melanoma, 40 renal cell, 29 gastrointestinal, and 38 other primary cancers. Treatments included: 206 GKRS alone, 111 GKRS plus WBRT, 109 GKRS plus neurosurgical resection (NSG), and 102 all three modalities. Median overall survival (mOS) was 16.6 months. mOS among patients with one versus multiple metastasis was 17.2 versus 16.0 months respectively (p = 0.825). For patients with one BM, mOS following GKRS alone, GKRS plus WBRT, GKRS plus NSG, and all three modalities was 9.0, 19.1, 25.5, and 25.0 months, respectively, and for patients with multiple BMs, mOS was 8.6, 20.4, 20.7, 24.5 months for the respective groups. Among all patients, multivariate analysis confirmed that tri-modality group had the longest survival (HR 0.467; 95 % CI 0.350-0.623; p < 0.001) compared to GKRS alone; however, this was not significantly different than bi-modality approaches. Uncontrolled primary extra-CNS disease, age and KPS were also independent predictors of survival. Patients treated with GKRS plus NSG, GKRS plus WBRT, or all three modalities had improved OS versus GKRS alone. In our analysis, resection and GKRS allowed avoidance of WBRT without shortening survival.

Gamma knife radiosurgery for elderly patients with brain metastases: evaluation of scoring systems that predict survival.

BackgroundGamma knife radiosurgery (GKRS) has been increasingly employed for the treatment of elderly patients with brain metastases, mainly due to its demonstrated effectiveness and low complication rate. However, only a few studies have investigated the prognostic factors that influence the survival of elderly patients after GKRS. The purpose of this study was to identify a scoring system that is able to predict the survival of elderly patients undergoing GKRS using data obtained at the time of diagnosis for brain metastases.MethodsBetween 2004 and 2011, death was confirmed in 147 patients aged 70 years and older who had been treated with GKRS for brain metastases. Median age at the time of GKRS was 75.7 years (range, 70–86 years). The median tumor volume was 5.1 cm3 (range, 0.05–59.9 cm3). The median marginal prescription dose was 21.4 Gy (range, 14–25 Gy).ResultsThe median survival was 167 days. Overall survival rates at 6 months and 1 year were 60.4% and 29.4%, respectively. Among the patient characteristics pertaining to systemic cancer and brain metastasis for which data were obtained preoperatively, a multivariate analysis showed that low Karnofsky performance status (KPS ≤ 80, P = 0.047) and the presence of extracranial metastases (P = 0.014) detected at the time of brain metastasis diagnosis were independent prognostic factors for short survival. A high score index for radiosurgery (SIR score ≥ 4, P = 0.024) and a high graded prognostic assessment (GPA score ≥ 2, P = 0.004) were associated with longer survival. A multivariate analysis of the important characteristics of systemic cancer, and the scoring system evaluating survival duration showed that a low GPA score was the most powerful independent factor for predicting short survival (hazard ratio 1.756, 95% confidence interval 1.252–2.456, P = 0.001).ConclusionsGKRS is a safe approach to treat brain metastases in patients age 70 years and older. In this group, our study identified GPA score at the time of GKRS as a powerful prognostic factor for survival.

RT-39 * CONTROL OF BRAIN METASTASES FROM RADIORESISTANT TUMORS TREATED BY GAMMA KNIFE RADIOSURGERY

BACKGROUND: Renal cell carcinoma, sarcoma, and melanoma are considered to be “radioresistant” tumor histologies. Brain metastases (BM) from these tumors are unlikely to be controlled using the relatively low doses used in whole brain radiotherapy (WBRT). This study was designed to analyze the efficacy of Gamma Knife Radiosurgery (GKRS) on local control of BM from radioresistant primary tumors. METHODS: We reviewed all patients who received GKRS for BM at Columbia University Medical Center between January 2009 and April 2014. All patients were treated using the Gamma Knife Perfexion System. Dosimetric data was collected from treatment plans and metastases were categorized as radioresistant or not. Response was assessed by reviewing follow-up brain imaging studies and classified according to the Response Evaluation Criteria in Solid Tumors. Local control was calculated using the Kaplan-Meier method. RESULTS: In total, 373 tumors were analyzed. Of these, 49 (13.1%) originated from radioresistant cancers. Median follow up was 6 months in the radioresistant cohort and 5 months in the non-radioresistant cohort. The overall local control rate in the radioresistant cohort was 89.8% and 90.1% in the non-radioresistant cohort. Local control of radioresistant tumors at 6-, 12-, and 18- months was 97.2%, 91.5%, and 69.7%, respectively. Local control of non-radioresistant tumors at 6-, 12-, and 18- months was 94.2%, 83.0%, and 79.6%, respectively. Univariate and multivariate analyses demonstrated that radioresistance status of the primary tumor had no significant effect on local control with hazard ratios of 1.0 (p = 1.0, 95% CI: 0.388-2.576) and 0.954 (p = 0.926, 95% CI: 0.349-2.603) respectively. CONCLUSIONS: There was no significant difference in local control of BM from radioresistant and non-radioresistant primary tumors treated with GKRS. Both cohorts showed excellent response and local control, suggesting that GKRS upfront or in addition to WBRT may be an appropriate strategy in the treatment of BM from radioresistant cancers.

Gamma knife radiosurgery for breast cancer metastases to the brain: outcomes and prognostic factors from a large prospectively collected database

Background: To examine outcomes and prognostic factors in a large prospectively collected database of patients treated with Gamma Knife (GK) radiosurgery for breast cancer metastases to the brain. Methods: All patients were treated with GK radiosurgery for brain metastases from breast cancer between 1993 and 2009. Overall survival time was calculated from the time of GK radiosurgery to the time of death from any cause. Kaplan-Meier analysis was applied to calculate overall median time to failure and clinical and radiologic features of the study population. Multivariate analysis was performed using Cox Proportional Hazards regression analysis to calculate relative risk for mortality. Results: Two hundred and ninety-two patients with were analyzed over a median follow-up of 8.53 months (reverse Kaplan-Meier follow-up of 66.81 months). The median overall survival for the entire cohort from the time of GK radiosurgery was 9.08 months (95% CI, 7.86-10.63 months). There was a significantly greater median overall survival in patients that had KPS > 70, age 65) and multiple lesions (> 3 lesions) were independent predictors of poor prognosis. The risk of mortality in patients with low KPS, multiple lesions, and older age (as defined above) was 300%, 80%, 50% greater than their counterparts, respectively. Conclusion: Patients with poor performance status and multiple brain metastases from breast cancer have worse outcomes and may be candidates for conservative management. Categories: Radiation Oncology, Neurosurgery

Patterns of Failure in Patients Receiving Gamma Knife Radiosurgery for Breast Carcinoma to the Brain

Patterns of Failure in Patients Receiving Gamma Knife Radiosurgery for Breast Carcinoma to the Brain

Evaluation of the RTOG Recursive Partitioning Analysis (RPA) Classification for Brain Metastases Among Patients Treated With Gamma-Knife Radiosurgery for Brain Metastases

Evaluation of the RTOG Recursive Partitioning Analysis (RPA) Classification for Brain Metastases Among Patients Treated With Gamma-Knife Radiosurgery for Brain Metastases

Gamma-knife radiosurgery for brain metastases of renal cell carcinoma: results in 23 patients.

From Jan. 1993 to Sept. 1995 23 patients suffering from brain metastases from renal cell carcinoma were treated with the Leksell Gamma Knife at the University of Vienna. At the time of diagnosis 13 patients had single and 10 patients presented with multiple metastatic lesions with a total of 44 metastases in MRI scans. Median tumour volume was 5500 cmm (range 100-24000 cmm). Predominant neurological symptoms and signs were different forms of hemiparesis, focal and generalized seizures, cognitive deficit, headache, dizziness, ataxia and CN XII paresis. Fourteen patients received Gamma Knife Radiosurgery (GKRS) with a median dose of 22 Gy (range 8-30 Gy) at the tumour margin. Nine patients underwent a combined treatment of a radiosurgical boost with a median dose of 18 Gy (range 10-22 Gy) at the tumour margin followed by Whole Brain Radiotherapy (total dose 30 Gy/2 weeks). In 20 patients tumour volume reduction up to 30% of the primary tumour volume was found after 4 weeks, evaluated on CT or MRI. A total remission was seen in 4 cases 3 months after GKRS. We achieved a local tumour control of 96%. Rapid neurological improvement after GKRS was seen in 17 patients. The median survival time was 11 months; the one-year actual survival in this unselected group was 48%. Five long term survivors were still alive, 18 patients had subsequently died, 15 of them of general tumour progression. GKRS induces a significant tumour remission accompanied by rapid neurological improvement and therefore provides the opportunity for extended high quality survival. Neither local tumour control was improved nor CNS relapse free survival was prolonged significantly by additional WBRT.