Stereotactic Radiotherapy Group Research Articles

Safety and efficacy of consolidative stereotactic radiotherapy for oligo-residual EGFR-mutant non-small cell lung cancer after first-line third-generation EGFR-tyrosine kinase inhibitors: a single-arm, phase 2 trial

Prospective data is limited on the efficacy and safety of consolidative stereotactic radiotherapy (SRT) in metastatic epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer (NSCLC) patients harboring oligo-residual disease (ORD) after first-line third-generation EGFR-tyrosine kinase inhibitors (TKIs). In this single-arm, phase II trial, 61 patients from two academic centers were enrolled from March 2021 to March 2023. All these patients had metastatic EGFR-mutant NSCLC and harbored ORD after first-line third-generation EGFR-TKIs. Consolidative SRT was performed and EGFR-TKIs were not held during SRT. The primary endpoint was progression-free survival (PFS) and the secondary endpoints included overall survival and treatment-related adverse events (TRAEs). A prespecified propensity score matched (PSM) comparison was conducted with a contemporary cohort of patients who developed ORD but received EGFR-TKIs alone. This trial was registered with ClinicalTrails.gov, NCT04764214. All patients received consolidative SRT. With a median follow-up of 21.1 months, the median PFS was 29.9 (80% CI 22.4-32.4) months and the lower boundary exceeded the predefined threshold, meeting the primary endpoint. TRAEs occurred in 43 (70%) patients, with pneumonitis (27.9%) and esophagitis (26.2%) being the most common toxicities. Four patients (6.6%) reported grade ≥3 TRAEs, each for pneumonitis, esophagitis, leukopenia, and cranial radiation necrosis. PSM analysis showed significantly prolonged PFS in EGFR-TKI+SRT group compared to EGFR-TKI group (HR 0.46, 80% CI 0.20-0.61; p=0.002). Consolidative SRT is associated with an encouraging PFS in first-line third-generation EGFR-TKI-treated metastatic NSCLC patients harboring ORD, with generally acceptable toxicities. Further confirmatory studies are warranted. Hui Lan Public Welfare and the Chinese Society of Clinical Oncology Foundation.

Stereotactic radiotherapy for neovascular age-related macular degeneration (STAR): a pivotal, randomised, double-masked, sham-controlled device trial

Neovascular age-related macular degeneration (nAMD) is a leading cause of blindness. The first-line therapy is anti-vascular endothelial growth factor (anti-VEGF) agents delivered by intravitreal injection. Ionising radiation mitigates key pathogenic processes underlying nAMD, and therefore has therapeutic potential. STAR aimed to assess whether stereotactic radiotherapy (SRT) reduces the number of anti-VEGF injections required, without sacrificing visual acuity. This pivotal, randomised, double-masked, sham-controlled trial enrolled participants with pretreated chronic active nAMD from 30 UK hospitals. Participants were randomly allocated in a 2:1 ratio to 16-Gray (Gy) SRT delivered using a robotically controlled device or sham SRT, stratified by treatment centre. Eligible participants were aged 50 years or older and had chronic active nAMD, with at least three previous anti-VEGF injections, including at least one in the last 4 months. Participants and all trial and image reading centre staff were masked to treatment allocation, except one unmasked statistician. The primary outcome was the number of intravitreal ranibizumab injections required over 2 years, tested for superiority (fewer injections). The main secondary outcome was Early Treatment Diabetic Retinopathy Study visual acuity at two years, tested for non-inferiority (five-letter margin). The primary analysis used the intention-to-treat principle, and safety was analysed per-protocol on participants with available data. The study is registered with ClinicalTrials.gov (NCT02243878) and is closed for recruitment. 411 participants enrolled between Jan 1, 2015, and Dec 27, 2019, and 274 were randomly allocated to the 16-Gy SRT group and 137 to the sham SRT group. 240 (58%) of all participants were female, and 171 (42%) of all participants were male. 241 participants in the 16-Gy SRT group and 118 participants in the sham group were included in the final analysis, and 409 patients were treated and formed the safety population, of whom two patients allocated to sham treatment erroneously received 16-Gy SRT. The SRT group received a mean of 10·7 injections (SD 6·3) over 2 years versus 13·3 injections (5·8) with sham, a reduction of 2·9 injections after adjusting for treatment centre (95% CI -4·2 to -1·6, p<0·0001). The SRT group best-corrected visual acuity change was non-inferior to sham (adjusted mean letter loss difference between groups, -1·7 letters [95% CI -4·2 to 0·8]). Adverse event rates were similar across groups, but reading centre-detected microvascular abnormalities occurred in 77 SRT-treated eyes (35%) and 13 (12%) sham-treated eyes. Overall, eyes with microvascular abnormalities tended to have better best-corrected visual acuity than those without. Fewer ranibizumab injections offset the cost of SRT, saving a mean of £565 per participant (95% CI -332 to 1483). SRT can reduce ranibizumab treatment burden without compromising vision. Medical Research Council and National Institute for Health and Care Research Efficacy and Mechanism Evaluation Programme.

Comparative Analysis of Stereotactic Radiation Therapy and Conventional Radiation Therapy in Cancer Pain Control: A Systematic Review and Meta-Analysis

AimsApproximately 55% of patients diagnosed with primary or metastatic cancer endure pain directly attributable to the disease. Consequently, it becomes imperative to address pain management through a comparative analysis of stereotactic radiotherapy (SRT) and conventional radiation therapy (CRT), especially in light of the less efficacious improvement achieved solely through pharmacological interventions. Materials and methodsA systematic exploration was undertaken on PubMed, the Cochrane Library, and Elsevier's ScienceDirect databases to identify studies that compare Stereotactic Radiotherapy to Conventional radiation therapy for pain management in individuals with metastatic bone cancer. The analyses were executed utilizing the random-effects model. ResultsA cohort of 1152 participants with metastatic bone cancer was analyzed, demonstrating significantly higher complete pain relief in the Stereotactic Radiotherapy group during both early and late follow-up (RR: 1.61; 95% CI: 1.17, 2.23, p-value: 0.004; I2: 0%). Stereotactic Radiotherapy also showed a non-significant increase in the incidence of partial pain relief (RR: 1.07; 95% CI: 0.85, 1.34, p-value: 0.56; I2: 18%). Furthermore, Stereotactic Radiotherapy was associated with a significantly reduced risk of stationary pain throughout follow-up (RR: 0.61; 95%CI: 0.48, 0.76, p-value: <0.0001; I2: 0. The incidence of progressive pain was non-significantly reduced with Stereotactic Radiotherapy during both early and late follow-up (RR: 0.77; 95% CI: 0.50, 1.17, p-value: 0.22; I2: 0%). Secondary outcomes exhibited a non-significant trend favoring Stereotactic Radiotherapy for dysphagia, esophagitis, pain, and radiodermatitis, while a non-significant increase was observed for nausea, fatigue, and vertebral compression fracture. ConclusionIn summary, stereotactic radiation therapy (SRT) has improved in achieving complete pain relief while exhibiting a decreased probability of delivering stationary pain compared to conventional radiation therapy (CRT). Nevertheless, it is crucial in future research to address a noteworthy limitation, specifically, the risk of vertebral compression fracture.

RADT-02. WHOLE-BRAIN RADIATION THERAPY WITH SIMULTANEOUS INTEGRATED BOOST VERSUS STEREOTACTIC RADIOTHERAPY FOR THE TREATMENT OF BRAIN METASTASIS FROM NON-SMALL CELL LUNG CANCER

Abstract OBJECTIVE To compare whole-brain radiotherapy with a simultaneous integrated boost (WBRT-SIB) to stereotactic radiotherapy (SRT) in treating non-small cell lung cancer (NSCLC) patients with brain metastases (BMs). METHODS Between April 2013 and June 2021, NSCLC patients receiving WBRT-SIB or SRT for 1-10 BMs were reviewed. Propensity score matching was carried out without replacement using a ratio of 1 WBRT-SIB: 1 SRT patient and a caliper width of 0.03 to yield sufficient power and homogeneity between treatment groups. Intracranial progression-free survival (iPFS), overall survival (OS), the cumulative incidence of local tumor progression, and intracranial distant tumor progression were compared between groups. Toxicities were assessed utilizing the National Cancer Institute Common Terminology Criteria for Adverse Events Version 5.0 (CTCAE 5.0). RESULTS A cohort of 181 patients with was included in this study. After propensity score matching, there were 37 patients in the WBRT-SIB and the SRT group, respectively. The WBRT-SIB group had a significantly longer median iPFS than the SRT group (10.8 months vs. 6.5 months, p = 0.018). The median OS (p = 0.861) and the cumulative incidence of local tumor progression (p = 0.437) were similar between the two groups. WBRT-SIB was associated with reduced intracranial distant tumor progression (p = 0.043). No toxicities higher than grade 3 were observed in both groups. KPS score was an independent prognostic factor of OS (HR 0.459, p = 0.032). CONCLUSIONS Compared to SRT, the iPFS of NSCLC patients with BMs was prolonged after WBRT-SIB, mainly related to better control of distant intracranial tumors. WBRT-SIB is safe and can be an alternative option for patients with BMs. We also found that the KPS score is an independent prognostic factor of OS.

Characteristics and outcomes for 61 cats that underwent either surgery or stereotactic radiotherapy as treatment for intracranial meningioma (2005-2017).

To report clinical features and outcomes of cats undergoing either stereotactic radiotherapy (SRT) or surgical excision for the treatment of intracranial meningioma. 61 client-owned cats. Medical records were retrospectively reviewed of cats with intracranial meningiomas that were treated with surgical removal and/or SRT between 2005 and 2017. Signalment, clinical signs, duration of clinical signs, diagnostic imaging reports, histopathology reports, treatment protocol, complications, recurrence or progression, and survival time were obtained from the medical record and through follow-up phone calls. Of the 61 patients, 46 had surgery, 14 had SRT, and 1 had surgery followed by SRT for initial treatment. Significantly more cats that underwent surgery had peritreatment complications compared to the SRT group (P < .0001). Cats that received surgery initially had a significantly longer median survival time (MST) of 1,345 days compared to the MST of 339 days for the SRT cats (P = .002). Fourteen (30%) cats in the surgery group and 4 cats in the SRT group (28%) had MRI- or CT-confirmed tumor regrowth or new tumor growth (P = 1.00). Five cases that had SRT for subsequent recurrence had an MST of 700 days (range, 335 to 1,460 days) after the last treatment. SRT proved to be a safe, alternative treatment option for feline patients with intracranial meningiomas; however, the survival times with surgery alone were significantly longer. SRT for the treatment of recurrence following initial surgery may show promising results.

Bevacizumab reduces peritumoral brain edema in lung cancer brain metastases after radiotherapy.

The aim of this study was to investigate the efficacy of bevacizumab (Bev) in reducing peritumoral brain edema (PTBE) after stereotactic radiotherapy (SRT) for lung cancer brain metastases. A retrospective analysis was conducted on 44 patients with lung cancer brain metastases (70 lesions) who were admitted to our oncology and Gamma Knife center from January 2020 to May 2022. All patients received intracranial SRT and had PTBE. Based on treatment with Bev, patients were categorized as SRT + Bev and SRT groups. Follow-up head magnetic resonance imaging was performed to calculate PTBE and tumor volume changes. The edema index (EI) was used to assess the severity of PTBE. Additionally, the extent of tumor reduction and intracranial progression-free survival (PFS) were compared between the two groups. The SRT + Bev group showed a statistically significant difference in EI values before and after radiotherapy (p = 0.0115), with lower values observed after treatment, but there was no difference in the SRT group (p = 0.4008). There was a difference in the distribution of EI grades in the SRT + Bev group (p = 0.0186), with an increased proportion of patients at grades 1-2 after radiotherapy, while there was no difference in the SRT group (p > 0.9999). Both groups demonstrated a significant reduction in tumor volume after radiotherapy (p < 0.05), but there was no difference in tumor volume changes between the two groups (p = 0.4089). There was no difference in intracranial PFS between the two groups (p = 0.1541). Bevacizumab significantly reduces the severity of PTBE after radiotherapy for lung cancer. However, its impact on tumor volume reduction and intracranial PFS does not reach statistical significance.

Optimizing treatment of brain metastases in an era of novel systemic treatments: a single center consecutive series

BackgroundThe multidisciplinary management of patients with brain metastases consists of surgical resection, radiation treatment and systemic treatment. Tailoring and timing these treatment modalities is challenging. This study presents real-world data from consecutively treated patients and assesses the impact of all treatment strategies and their relation with survival. The aim is to provide new insights to improve multidisciplinary decisions towards individualized treatment strategies in patients with brain metastases.MethodsA retrospective consecutive cohort study was performed. Patients with brain metastases were included between June 2018 and May 2020. Brain metastases of small cell lung carcinoma were excluded. Overall survival was analyzed in multivariable models.Results676 patients were included in the study, 596 (88%) received radiotherapy, 41 (6%) awaited the effect of newly started or switched systemic treatment and 39 (6%) received best supportive care. Overall survival in the stereotactic radiotherapy group was 14 months (IQR 5–32) and 32 months (IQR 11–43) in patients who started or switched systemic treatment and initially did not receive radiotherapy. In patients with brain metastases without options for local or systemic treatment best supportive care was provided, these patients had an overall survival of 0 months (IQR 0–1). Options for systemic treatment, Karnofsky Performance Score ≥ 70 and breast cancer were prognostic for a longer overall survival, while progressive extracranial metastases and whole-brain-radiotherapy were prognostic for shorter overall survival.ConclusionsAssessing prognosis in light of systemic treatment options is crucial after the diagnosis of brain metastasis for the consideration of radiotherapy versus best supportive care.Graphical

Single-fraction SRS and multiple-fraction SRT for brain metastases from colorectal cancer.

Brain metastasis from colorectal cancer (CRC) is rare. Although stereotactic radiotherapy (SRT) and stereotactic radiosurgery (SRS) are effective treatments for brain metastasis, reports on brain metastasis of CRC are limited. This study compared the efficacy of SRT and SRS for the treatment of brain metastases from CRC and analysed the related factors to reveal the specificity CRC-derived brain metastasis. A retrospective analysis of 116 patients with brain metastases from colorectal cancer was performed and included 56 patients in the SRT group and 60 patients in the SRS group. The clinical characteristics of the two groups were analysed, and the local tumour control rate, overall survival time and radiation-induced brain injury were compared between the two groups. The objective response rates of the SRT and SRS groups were 76.8% and 66.7%, respectively, while the local control rates at 6 months were 87.5% and 81.6%, respectively, and no significant differences were observed between the groups (P=0.295). The median overall survival time was 10.3 months for all patients and was 10.9 months in the SRT group and 9.8 months in the SRS group, with no significant difference between the groups (P=0.123). A multivariate analysis showed that the main factors of poor prognosis were low GPA score (P=0.002), KRAS mutation (P=0.035), extracranial metastasis (P=0.005) and no bevacizumab treatment (P=0.001). No significant difference was observed in the incidence of acute and late radiation-induced injury between the two groups. Both SRT and SRS are effective methods for the treatment of CRC-derived brain metastases. The simultaneous use of bevacizumab may be one of the most important factors that affects the survival of these patients.

Quality of life among patients with 4 to 10 brain metastases after treatment with whole-brain radiotherapy vs. stereotactic radiotherapy: a phase III, randomized, Dutch multicenter trial.

Stereotactic radiotherapy (SRT) is an attractive treatment option for patients with brain metastases (BM), sparing healthy brain tissue and likely controlling local tumors. Most previous studies have focused on radiological response or survival. Our randomized trial (NCT02353000) investigated whether quality of life (QoL) is better preserved using SRT than whole-brain radiotherapy (WBRT) for patients with multiple BM. Recently, we published our trial's primary endpoints. The current report discusses the study's secondary endpoints. Patients with 4 to 10 BM were randomly assigned to a standard-arm WBRT (20 Gy in 5 fractions) or SRT group (1 fraction of 15-24 Gy or 3 fractions of 8 Gy). QoL endpoints-such as EQ5D domains post-treatment, the Barthel index, the European Organisation for Research and Treatment of Cancer (EORTC) questionnaires, and the neurocognitive Hopkins Verbal Learning Test-were evaluated. Due to poor accrual resulting from patients' and referrers' preference for SRT, this study closed prematurely. The other endpoints' results were published recently. Twenty patients were available for analysis (n=10 vs. n=10 for the two groups, respectively). Significant differences were observed 3 months post-treatment for the mobility (P=0.041), self-care (P=0.028), and alopecia (P=0.014) EQ5D domains, favoring SRT. This self-care score also persisted compared to the baseline (P=0.025). Multiple EORTC categories reflected significant differences, favoring SRT-particularly physical functioning and social functioning. For patients with multiple BM, SRT alone led to persistently higher QoL than treatment with WBRT. ClinicalTrials.gov, NCT02353000.

A comparative study of treatment on portal vein tumor thrombosis in hepatocellular carcinoma with stereotactic radiotherapy versus three-dimensional conformal radiotherapy

Abstract Background: Portal venous tumor thrombosis (PVTT) in patients with hepatocellular carcinoma (HCC) is a poor prognostic factor, with median survival values ranging from 2 to 4 months, when untreated. Sorafenib has been used as a systemic therapy for advanced HCC patients with PVTT; however, its local effects are limited. We report the results of external beam radiotherapy for PVTT, including stereotactic radiotherapy. Methods: Fifty consecutive HCC patients with PVTT who underwent external beam radiotherapy were investigated at our institution between January 2004 and December 2019. Results: The median age of the patients was 71 years (range: 39–87). The patients were predominantly male (80%) who underwent three-dimensional conformal radiation therapy (82%). The Child-Pugh score was class A in 30(60%) patients and class B in 20(40%) patients. The median overall survival (OS) was 12.6 months (95% confidence interval [CI]: 7.2–18.2) and the 1-year overall survival rate for all patients was 52.3% (95% [CI]: 36.9 - 65.6). A favorable objective response rate was achieved in the stereotactic radiotherapy group (78%) compared to the three-dimensional conformal radiation therapy group (39%). Severe acute adverse events of grade 3 or higher were not observed. Conclusions: The present study demonstrated the feasibility and efficacy of external beam radiotherapy for PVTT in patients with HCC.

Overall survival after initial radiotherapy for brain metastases; a population based study of 2140 patients with non-small cell lung cancer

Background Brain metastases (BM) occur in about 30% of all patients with non-small cell lung cancer (NSCLC). BM treatment guidelines recommend more frequent use of stereotactic radiotherapy (SRT). Overall, studies report no difference in overall survival (OS) comparing SRT to whole-brain radiotherapy (WBRT). We examined survival after radiotherapy for BM in a population-based sample from the South-Eastern Norway Regional Health Authority treated 2006-2018. Methods We reviewed electronic medical records of 2140 NSCLC patients treated with SRT or WBRT for BM from 2006–2018. Overall survival (OS) was compared to predicted survival according to the prognostic systems DS-GPA and Lung-molGPA. Results Use of SRT increased during the period, from 19% (2006–2014) to 45% (2015–2018). Median OS for all patients was 3.0 months, increasing from 2.0 (2006) to 4.0 (2018). Median OS after SRT was 7.0 months (n = 435) and 3.0 months after WBRT (n = 1705). Twenty-seven percent of SRT patients and 50% of WBRT patients died within 90 days after start of RT. Age ≥70, male sex, KPS ≤70, non-adenocarcinoma histology, ECM present, multiple BM, and WBRT were associated with shorter survival (p < .001). Actual mOS corresponded best with predicted mOS by DS-GPA and Lung-molGPA for the SRT group. Conclusion Overall survival after radiotherapy (RT) for BM improved during the study period, but only for patients treated with SRT. Survival after WBRT remains poor; its use should be questioned. DS-GPA and Lung-molGPA seem most useful in predicting prognosis considered for SRT.

Combined Immunotherapy and Stereotactic Radiotherapy Improves Neurologic Outcomes in Patients with Non–small-cell Lung Cancer Brain Metastases

BackgroundThe purpose of this study was to compare the outcomes of patients with non-small cell lung cancer (NSCLC) brain metastases treated with stereotactic radiotherapy (SRT) alone versus SRT and immune checkpoint inhibitors (ICIs). Patients and MethodsPatients treated for their first diagnosis of intracranial metastases with SRT or SRT plus ICI were retrospectively identified. Overall survival (OS), local control (LC), distant brain failure (DBF), neurologic death, and rates of radiation necrosis were calculated. Univariate (UVA) and multivariable (MVA) analyses with competing risk analysis were performed. ResultsSeventy-seven patients with 132 lesions were analyzed, including 44 patients with 68 lesions in the SRT group and 33 patients with 64 lesions in the SRT plus ICI group. There were no differences in baseline factors between groups. Use of ICI predicted for decreased DBF (hazard ratio [HR], 0.45; 95% confidence interval [CI], 0.24-0.84; P = .01), decreased rates of neurologic death (HR, 0.29; 95% CI, 0.10-0.85; P = .02), and better OS (HR, 0.46; 95% CI, 0.23-0.91; P = .03). Two-year LC was 97% for the SRT + ICI group, and 86% for the SRT-alone group (P = .046). Actuarial 2-year DBF was 39% for the SRT + ICI group and 66% for the SRT alone group (P = .016). On MVA, ICI use persisted in predicting lower incidence of neurologic death (HR, 0.25; 95% CI, 0.09-0.72; P = .01) and DBF (HR, 0.47; 95% CI, 0.25-0.85; P = .01) when adjusted for competing risk of death. ConclusionIn this cohort of patients with NSCLC brain metastases, ICI use combined with SRT predicted for improved LC and OS and decreased DBF and risk of neurologic death.

Definitive Chemoradiotherapy Results in Synchronous Oligometastatic Non-Small Cell Lung Cancer Patients: Turkish Radiation Oncology Stereotactic Radiotherapy Group Study

Definitive Chemoradiotherapy Results in Synchronous Oligometastatic Non-Small Cell Lung Cancer Patients: Turkish Radiation Oncology Stereotactic Radiotherapy Group Study

Efficacy and Safety of Chemotherapy Combined with Stereotactic Radiotherapy in the Treatment of Nasopharyngeal Carcinoma.

BackgroundThe aim of this study was to investigate the efficacy and safety of chemotherapy (CT) combined with stereotactic radiotherapy (SRT) in the treatment of nasopharyngeal carcinoma (NPC).Material/MethodsA total of 329 NPC patients without any previous treatment were included in this study between January 2009 and November 2013. These patients were divided into three groups: CT group (n=114), SRT group (n=109), and CT + SRT group (n=106). Contrast-enhanced nasopharyngeal computed tomography (CT)/magnetic resonance (MR) scan was performed on the third month after treatment. Short-term efficacy was evaluated according to the Response Evaluation Criteria in Solid Tumors (RECIST). Toxicity was graded according to the Acute Radiation Morbidity Scoring Criteria (RTOG) and the World Health Organization (WHO) toxicity grading scale. Overall survival (OS), progression free survival (PFS), and incidence rate of acute toxicity (grade ≥3) were calculated after a 24 month follow-up.ResultsTotal response rate of all patients was 85.41%. Compared with the CT group and the SRT group, the CT + SRT group showed a substantially improved efficacy in NPC treatment. The incidence rate of the acute toxicity in the CT + SRT group was slightly higher than in the CT group and the SRT group, but the difference was not statistically significant. No treatment-related deaths were observed. The CT + SRT group had the highest two-year OS and PFS, followed by the CT group and the SRT group.ConclusionsIt was shown that NPC patients treated with CT + SRT had better short- and long-term efficacy than those treated with CT or SRT alone.

Therapeutic effect of stereotactic radiotherapy for brain metastases of non-small cell lung cancer

Objective To analyze the effect of stereotactic radiotherapy(SRT) with or without whole brain radiotherapy(WBRT) in the treatment of hmited number brain metastases of non-small cell lung cancer (NSGLC).Methods 75 NSCLC patients with brain metastases within 4 lesions were retrospectively analyzed.35cases were treated with SRT alone and 40 cases were treated with SRT + WBRT.The therapeutic effects,overall survival and radiotherapeufic side effects of the two groups were compared.Results The total effective rate of SRT group and WBRT + SRT group were 91.5％ and 87.5％ respectively.There was no significant difference between the two groups (P ＞0.05).For all the patients,the median overall survival time was 14.7 months.There was no difference between SRT alone group and SRT + WBRT group (13.7 months vs 15.4 months,P =0.180).There was no serious side effectin in two groups.Conclusions Stereotactic radiotherapy was an effective and safe treatment for limited number brain metastases of NSCLC.The patients who accepted SRT alone or SRT + WBRT had the similar overall survival time. Key words: Brain metastases; Non-small cell lung cancer; Whole brain radiotherapy; Stereotactic radiotherapy

Fifty percent patients avoid whole brain radiotherapy: stereotactic radiotherapy for multiple brain metastases. A retrospective analysis of a single center

To summarize the outcomes of stereotactic radiotherapy (SRT), with or without whole-brain radiotherapy (WBRT), in the treatment of multiple brain metastasis and to explore the status of WBRT and SRT in the management of multiple brain metastasis. From May 1995 to April 2010, 98 patients with newly diagnosed, multiple brain metastasis were treated in our center. Forty-four patients were treated with SRT alone for the initial treatment, and 54 were treated with SRT+WBRT. Kaplan-Meier and Cox proportional hazards regression analyses were used for the survival analysis. The median survival time (MST) was 13.5months. No difference was observed in MST between the SRT and the SRT+WBRT groups (p=0.578). The Karnofsky Performance Score at the time of treatment (p=0.025), the interval time between diagnosis of primary tumor and brain metastasis (P=0.012) and the situation of extracranial disease (p=0.018) were significant predictors of survival. The crude distant intracranial recurrence (DIR) rates were 47.7% in the SRT group and 24.1% in the SRT+WBRT group (p=0.018). In addition, 52.3% patients in the SRT group were free from DIR and did not require WBRT in their whole lives. Our data suggest that use of SRT as the initial treatment while reserving WBRT as the salvage therapy in case of distant intracranial recurrence made about 50% of the patients avoid WBRT throughout the course of their lives and may be another optional treatment modality for multiple brain metastases.

Whole-Brain Radiotherapy Combined with Surgery or Stereotactic Radiotherapy in Patients with Brain Oligometastases

To verify whether the treatment of brain oligometastases with whole-brain radiotherapy (WBRT) plus stereotactic radiotherapy (SRT) or surgical resection results in different outcomes. Files of patients affected by brain metastases submitted to surgical resection followed by WBRT (group A) or WBRT + SRT (group B) were retrospectively selected for this study. The two treatment groups were matched for the following potential prognostic factors: WBRT schedule, age, gender, performance status, tumor type, number of brain metastases, extra-cerebral metastases, and recursive partitioning analysis class (RPA). The outcomes of patients in both groups were evaluated in terms of toxicity, local control, and overall survival. Total of 97 patients were selected (56 male; 42 female) who were respectively submitted to surgical resection followed by WBRT (group A, n = 50 patients) or WBRT + SRT (Group B, n = 47 patients). Median follow-up was 95 months (range, 8-171 months). The 1-year local control rates were 46.0% and 69.0% respectively. No significant difference in local tumor control was observed between group A and B (p = 0.10). Median overall survival was 15 and 19 months in group A and B, respectively. One-year survival was 56.0% and 62%, respectively. No difference was observed in the two groups (p = 0.40). Surgery remains the main therapeutic approach in symptomatic patients; nevertheless, our data support the use of WBRT plus SRT in one or two brain metastases smaller than 3 cm.

Single Fraction Versus Fractionated Linac-Based Stereotactic Radiotherapy for Vestibular Schwannoma: A Single-Institution Experience

To evaluate and compare outcomes for patients with vestibular schwannoma (VS) treated in a single institution with linac-based stereotactic radiosurgery (SRS) or by fractionated stereotactic radiotherapy (SRT). One hundred and nineteen patients (SRS = 78, SRT = 41) were treated. For both SRS and SRT, beam shaping is performed by a mini-multileaf collimator. For SRS, a median single dose of 12.5 Gy (range, 11-14 Gy), prescribed to the 80% isodose line encompassing the target, was applied. Of the 42 SRT treatments, 32 treatments consisted of 10 fractions of 3-4 Gy, and 10 patients received 25 sessions of 2 Gy, prescribed to the 100% with the 95% isodose line encompassing the planning target volume. Mean largest tumor diameter was 16.6 mm in the SRS and 24.6 mm in the SRT group. Local tumor control, cranial nerve toxicity, and preservation of useful hearing were recorded. Any new treatment-induced cranial nerve neuropathy was scored as a complication. Median follow-up was 62 months (range, 6-136 months), 5 patients progressed, resulting in an overall 5-year local tumor control of 95%. The overall 5-year facial nerve preservation probability was 88% and facial nerve neuropathy was statistically significantly higher after SRS, after prior surgery, for larger tumors, and in Koos Grade ≥3. The overall 5-year trigeminal nerve preservation probability was 96%, not significantly influenced by any of the risk factors. The overall 4-year probability of preservation of useful hearing (Gardner-Robertson score 1 or 2) was 68%, not significantly different between SRS or SRT (59% vs. 82%, p = 0.089, log rank). Linac-based RT results in good local control and acceptable clinical outcome in small to medium-sized vestibular schwannomas (VSs). Radiosurgery for large VSs (Koos Grade ≥3) remains a challenge because of increased facial nerve neuropathy.

Excisional Biopsy followed by Intra-operative Seed Implant is a Promising Alternative to Stereotactic Radiotherapy (SRT) for Solitary Lung Cancer (SLC)

Obtaining tissue diagnosis is often challenging in patients with SLC who often have compromised pulmonary function. Percutaneous biopsy my cause pneumothorax and bleeding and pose a significant management dilemma. One option is to perform an excisional biopsy followed by IOSI once cancer diagnosis is confirmed. However, the clinical outcome of this approach has not been compared with SRT. This study was designed to compare IOSI and SRT. Forty four patients with SLC treated between 1999 and 2009 were evaluated. Twenty one patients received IOSI with I-125 seeds for 21 lesions and 23 patients received SRT to 24 lesions. The study subjects were evaluated for LC and distant metastasis (DM). Chi square test was employed to estimate significance. The median age of patients was 66 years and 76.5 years in IOSI and SRT group, respectively. In the IOSI group there were 90.4% patients with non–small cell lung cancer, 4.7% with small cell carcinoma and 4.7% with high-grade sarcoma. In the same group, 23.8% patients underwent lobectomy, 4.7% had a local excision of a sarcoma, and 57.1% underwent a wedge resection. The median number of I-125 seeds placed was 20.The median tumor size was 2.1 cm (range, 0.25–6 cm). The median activity of the seeds was 0.529mCi (range, 0.390–0.700mCi). The median follow-up was 7 months (range, 1–84 months). In the SRT group, 91.3% patients were non–small cell and 8.6% patients were metastatic carcinoma, 1 from an endometrial and 1 from parotid adenocarcinoma. The median tumor size in the SRT group was 1.5 cm (range, 0.3–4.8cm) and median follow-up was 12 months (Range, 2–72 months). SRT dose to 13/24 (54.1%) lesions was 30 Gy in 3 fractions, 4/24 (16.6%) lesions was 40 Gy in 4 fractions, 1/24 (4.1%) lesions was 50 Gy in 5 fractions, 1/24 (4.1%) lesions was 48 Gy in 4 fractions and 4/24 (16.6%) lesions was 60 Gy in 4 fractions. The LC in the IOSI group was 90.4% vs. 100% in the SRT group (p = 0.11). Distant failure as the first site of failure was observed in 4/23 (17.3%) patients in the IOSI group vs. 0/21 (0%) in the SRT group (p = 0.023). Four patients in the SRT group developed RTOG Grade II pneumonitis (RPN) (17.3%). No patients in the IOSI group developed RPN. There was 1 Grade II skin toxicity in the SRT group (4.3%). Both IOSI with I-125 seed implant and SRT produce high LC rates in patients with SLC. SRT resulted in fewer local recurrences (statistically non-significant) and fewer distant recurrences (statistically significant) when compared to IOSI. However, Patients undergoing SRT have a higher chance of developing Grade II pneumonitis and skin toxicity.

Treatment of juxtapapillary choroidal melanoma

Purpose: To compare different treatment for juxtapapillary choroidal melanomas. Methods: Retrospective study comparing recurrence, survival and complications in 14 patients treated with proton beam treatment, 11 patients treated with stereotactic radiotherapy and 28 patients treated with Ruthenium brachytherapy in combination with transpupillary thermotherapy. Results: Mean follow-up time was 45.3 months, in which 4 patients died due to their melanoma. There was a significant faster decrease of the tumour prominence in the Ruthenium group. Earlier radiation retinopathy (from 6 months onward) in the Ruthenium group, but no significant more radiation retinopathy after 5 years. The vision after 5 years was significant lower in the stereotactic radiotherapy group, but this was also due to the fact that there were more patients with a juxtapapillary melanoma on the macular side in this group. Conclusions: A prospective randomised study is neaded to determine which therapy is best in treating juxtapapillary melanomas. In this retrospective study, there was no difference in local recurrence or survival in the 3 treatment groups.