Fractiona Stereotactic Radiotherapy for Malignant Glioma

Adult Supratentorial Ependymoma: The Mayo Clinic Experience

Objective To analyze the clinical efficacy of gamma-ray fractionated stereotactic radiotherapy (FSRT) in the treatment of intracranial metastatic polycystic tumors. Methods Forty cases with 61 metastatic polycystic tumors were selected from 189 patients with 373 intracranial metastatic tumors admitted to our hospital from 2013 to 2015. All cases received gamma-ray FSRT. The isodose line at 50% was defined as the prescription dose. The prescription dose was ranged from 40 to 48 Gy/10-12f. The survival rate was calculated by Kaplan-Meier method. The single factor analysis was performed by Log-rank method. Results The median follow-up time was 21months (range: 6-39 months). The median survival time was 15.3 months. The 6-month, 1-and 2-year local control rate was 93%, 82% and 79%, respectively. The 1-and 2-year survival rate was 63% and 30%. Single factor analysis demonstrated that the volume of cysts and the volume of lesions were not significantly correlated with local control rate (P=0.17 and 0.48). Conclusion Gamma-ray FSRT can be adopted to treat intracranial metastatic polycystic tumors, which yields similar clinical efficacy to metastatic solid tumors. It deserves wide application in clinical practice due to high local control rate and safety. Key words: Neoplasm, cystic brain metastasis/radiotherapy; Radiotherapy, gamma-ray stereotactic; Treatment outcome

Hypofractionated stereotactic radiotherapy combined with topotecan in recurrent malignant glioma

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

BACKGROUND: Despite the improved results of treatment of brain tumors achieved over the past decade, most patients experience relapses of the disease 1–2 years after treatment. Numerous clinical studies have made it possible to obtain standard protocols for the treatment of primary brain tumors; however, protocols for the treatment of recurrent tumors have not been developed. The choice of treatment usually includes reoperation, systemic chemotherapy, and reirradiation alone or in combination. However, the treatment of recurrent glial tumors is challenging given the lack of effective treatment options and the lack of randomized controlled trials on which to base therapy.
 AIM: To determine the most important prognostic factors, as well as the most effective treatment option in patients with continued growth of primary low-grade gliomas of the brain.
 METHODS: This study included 40 patients with a confirmed diagnosis of progression of low-malignant glial brain tumors, who underwent inpatient treatment at the Chelyabinsk Regional Clinical Center of Oncology and Nuclear Medicine from 2007 to 2022. The ratio of men and women: 1:1.5. The mean age was 45.6±11.5 years. Patients with grade I astrocytomas predominated (n=23), oligodendroglioma was diagnosed in 8 patients.
 Reoperation was performed in 11 patients as the first stage of progression treatment. In 7 cases, monochemotherapy with temozolomide was performed. Repeated radiation therapy was performed in 29 patients, of which: 9 patients received a course of combined photon-neutron therapy; 9 patients — stereotactic radiation therapy (was performed on the CyberKnife device); 11 patients — external beam radiation therapy.
 RESULTS: The median overall survival (OS) for all patients with continued growth of low-grade cerebral gliomas after treatment was 120 months. 1-year OS — 97.3%; 3-year — 86.8%; 5-year — 78.2%. Median OS after relapse treatment was 36 months. The median OS was higher in the age group under 50 compared to the older age group: 120 and 95 months (p 0.05).
 The best results of treatment were noted in patients who underwent reoperation followed by a course of radiation therapy or chemotherapy with temozolomide for 48 months and 36 months respectively (p 0.05). When analyzing the results of treatment after a course of repeated radiation therapy in an independent variant, there were undoubted advantages in patients who underwent stereotactic radiation therapy and photon-neutron therapy for 60 months and 24 months respectively (p 0.05).
 CONCLUSIONS: The optimal approach to the treatment of patients with continued growth of primary low-grade glioma brain tumors is to perform a second operation, followed by radiation therapy or chemotherapy. The method of choice for a repeat course of radiotherapy may be photon-neutron therapy or stereotactic radiation therapy.

Radiation Therapy for Intubated Patients With Malignant Airway Obstruction: Futile or Facilitating Extubation?

Objective To study the efficacy and prognostic factors of twenty patients diagnosed with non-small cell lung cancer (NSCLC) and 1-5 brain metastases (BM) with obvious peritumoral edema, undergoing whole brain radiation therapy (WBRT) plus stereotactic radiotherapy for tumors of 1-3 cm in size. Methods Twenty patents with NSCLC and 1-5 BM lesions as well as peritumoral edemas, undergoing WBRT followed by stereotactic radiotherapy within 3 to 6 months were enrolled. The overall survival was estimated by Kaplan-Meier analysis. The potential prognostic factors related to survival were evaluated. Results For all patients, the median survival time from the start of WBRT was 15.6 months. Univariate analysis showed that control of primary lesions in chest, extracranial metastasis, KPS score, GPA grade, targeted therapy, brain metastasis diameter and peritumoral edema band diameter were the independent prognostic factors affecting the survival of patients. Multivariate analysis showed that the prognostic factors affecting the survival of patients were control of primary thoracic lesions, extracranial metastasis, GPA classification, targeted therapy, the maximum diameter of tumors and the peritumoral edema band diameter. The survival time for patients with brain metastases larger than 2 cm in tumor diameter and 3 cm in peritumoral edema zone was shorter (P<0.05). The median progression-free survival time was 9.28 months, and the 6-month, 1-year and 2-year survival rates were 90%, 65% and 15%, respectively. Conclusions Control of primary thoracic lesions, extracranial metastasis, GPA classification, targeted therapy, the maximum diameter of tumors and the peritumoral edema band diameter were the independent predictive factors of survival. For NSCLC patients with 1-5 brain metastases and peritumoral edemas, a stereotactic radiotherapy dosage boost post WBRT edema relief resulted in a definite effect and prolonged survival. Key words: Non-small cell lung cancer; Brain metastasis; Stereotactic radiotherapy; Peritumoral edema zone; Prognostic factors

Impact of Facility Treatment Volume on Stereotactic Ablative Radiotherapy (SABR) Outcomes in Early-Stage Non-Small Cell Lung Cancer (NSCLC)

Introduction: Following the resection of brain metastases (BM), whole-brain radiotherapy (WBRT) is a long-established standard of care. Its position was recently challenged by the less toxic single-session radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT) of the resection cavity, reducing dose exposure of the healthy brain.Patients and Methods: We analyzed 101 patients treated with either SRS/FSRT (n = 50) or WBRT (n = 51) following BM resection over a 5-year period. Propensity score adjustment was done for age, total number of BM, timepoint of BM diagnosis, controlled primary and extracranial metastases. A Cox Proportional Hazards model with univariate and multivariate analysis was fitted for overall survival (OS), local control (LC) and distant brain control (DBC).Results: Median patient age was 61 (interquartile range, IQR: 56–67) years and the most common histology was non-small cell lung cancer, followed by breast cancer. 38% of the patients had additional unresected BM. Twenty-four patients received SRS, 26 patients received FSRT and 51 patients received WBRT. Median OS in the SRS/FSRT subgroup was not reached (IQR NA−16.7 months) vs. 12.6 months (IQR 21.3–4.4) in the WBRT subgroup (hazard ratio, HR 3.3, 95%-CI: [1.5; 7.2] p < 0.002). Twelve-months LC-probability was 94.9% (95%-CI: [88.3; 100.0]) in the SRS subgroup vs. 81.7% (95%-CI: [66.6; 100.0]) in the WBRT subgroup (HR 0.2, 95%-CI: [0.01; 0.9] p = 0.037). Twelve-months DBC-probabilities were 65.0% (95%-CI: [50.8; 83.0]) and 58.8% (95%-CI: [42.9; 80.7]), respectively (HR 1.4, 95%-CI: [0.7; 2.7] p = 0.401). In propensity score-adjusted multivariate analysis, incomplete resection negatively impacted OS (HR 3.9, 95%-CI: [2.0;7.4], p < 0.001) and LC (HR 5.4, 95%-CI: [1.3; 21.9], p = 0.018). Excellent clinical performance (HR 0.4, 95%-CI: [0.2; 0.9], p = 0.030) and better graded prognostic assessment (GPA) score (HR 0.4, 95%-CI: [0.2; 1.0], p = 0.040) were prognostic of superior OS. A higher number of BM was associated with a greater risk of developing new distant BM (HR 5.6, 95%-CI: [1.0; 30.4], p = 0.048). In subgroup analysis, larger cavity volume (HR 1.1, 95%-CI: [1.0; 1.3], p = 0.033) and incomplete resection (HR 12.0, 95%-CI: [1.2; 118.3], p = 0.033) were associated with inferior LC following SRS/FSRT.Conclusion: This is the first propensity score-adjusted direct comparison of SRS/FSRT and WBRT following the resection of BM. Patients receiving SRS/FSRT showed longer OS and LC compared to WBRT. Future analyses will address the optimal choice of safety margin, dose and fractionation for postoperative stereotactic RT of the resection cavity.

Radiation Dose, Technique and Use of Brain Radiation on Overall Survival in Patients with Limited-Stage Small Cell Lung Cancer

Radiation Therapy Alone for Imaging-Defined Meningiomas

5126 Background: The factors thought to influence overall survival (OS) and cause-specific survival (CSS) in patients treated for low and intermediate-risk prostate cancer (CaP) with brachytherapy (PI), external beam radiotherapy (RT), or radical prostatectomy (RP) were evaluated. Methods: From 1996 to 2003, 2285 patients with low or intermediate-risk CaP were treated at the Cleveland Clinic with either PI (n=662), RT (n=570), or RP (n=1053). Factors thought to influence OS and CSS were recorded. These factors included: Charlson score, age, socioeconomic status, race, body mass index (BMI), presence of coronary artery disease (CAD), presence of hypertension (HTN), presence of dyslipidemia (DL), initial prostate-specific antigen (iPSA), biopsy Gleason score (bGS), clinical stage, use of androgen deprivation (AD), AD duration, smoking history including pack-years, alcohol use, and cancer treatment modality (TX). Univariate and multivariate analyses were done using Cox proportional hazards regression. Results: The median follow-up is 59 months (range: 24–119 months). The 5- year OS rate is 96.0%, and the 8-year rate is 89.9%. Multivariate analysis revealed that Charlson score, age, smoking history, and TX were significantly associated with OS. Treatment with RT was independently associated with worse OS relative to PI and RP. CSS was grouped into 4 major categories: CAD, CaP, other cancer, and other. The only significant difference between these CSS categories and the treatment modalities was CaP. The percent of deaths due to CaP in the TX groups were: PI - 3.2%, RP - 9.7%, and RT - 24.5%. Conclusions: Charlson score, age, smoking history, and TX independently affect OS in patients treated for low and intermediate-risk CaP. The cause of the lower OS rate with RT may be related to an increased risk of death due to CaP. [Table: see text] No significant financial relationships to disclose.

Glioblastoma is the most aggressive and diffusely infiltrative primary brain tumor. Recurrence is almost universal even after all primary standard treatments. This article aims to review the literature and update the standard treatment strategies for patients with recurrent glioblastoma. A systematic search was performed with the phrase "recurrent glioblastoma and management" as a search term in PubMed central, Medline, and Embase databases to identify all the articles published on the subject till December 2020. The review included peer-reviewed original articles, clinical trials, review articles, and keywords in title and abstract. Out of 513 articles searched, 73 were included in this review after screening for eligibility. On analyzing the data, most of the studies report a median overall survival (OS) of 5.9 to 11.4 months after re-surgery and 4.7 to 7.6 months without re-surgery. Re-irradiation with stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) result in a median OS of 10.2 months (range: 7.0-12 months) and 9.8 months (ranged: 7.5-11.0 months), respectively. Radiation necrosis was found in 16.6% (range: 0-24.4%) after SRS. Chemotherapeutic agents like nitrosourea (carmustine), bevacizumab, and temozolomide (TMZ) rechallenge result in a median OS in the range of 5.1 to 7.5, 6.5 to 9.2, and 5.1-13.0 months and six months progression free survival (PFS-6) in the range of 13 to 17.5%, 25 to 42.6%, and 23 to 58.3%, respectively. Use of epithelial growth factor receptor (EGFR) inhibitors results in a median OS in the range of 2.0 to 3.0 months and PFS-6 in 13%. Although recurrent glioblastoma remains a fatal disease with universal mortality, the literature suggests that a subset of patients may benefit from maximal treatment efforts.

Growth hormone (GH)-secreting pituitary adenomas represent an uncommon subset of pituitary neoplasms. Stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) have been used as primary or adjuvant treatment. The purpose of this study is to report the long-term tumor control and toxicity from our institution and to perform a systematic literature review of acromegaly patients treated with FSRT. We retrospectively reviewed all patients treated with FSRT (median dose 50.4 Gray [Gy], range 50.4-54 Gy) between 2005 and 2012 who had: 1) GH-secreting adenoma with persistently elevated insulin growth factor-1 (IGF-1) despite medical therapy and 2) clinical follow up >3 years after FSRT. Patients were treated with modern FSRT planning techniques. Biochemical control was defined as IGF-1 normalization. Systematic review of the literature was performed for FSRT in acromegaly. With a median follow-up of 80 months, radiographic control was achieved in all 11 patients and overall survival was 100%. Long-term biochemical control was achieved in 10 patients (90.9%) with either FSRT alone (36.4%) or FSRT with continued medical management (45.5%). No patient experienced new hypopituitarism, cranial nerve dysfunctions, or visual deficits. Our systematic review found published rates of biochemical control and hypopituitarism vary, with uniformly good radiographic control and low incidence of visual changes. Adjuvant FSRT offered effective long-term biochemical control and radiographic control, and there was a lower rate of complications in this current series. Review of the literature shows variations in published rates of biochemical control after FSRT for acromegaly, but low incidence of serious toxicities.

We aimed to investigate several clinical and biochemical parameters, including palliative external beam radiation therapy (EBRT) to predict survival in patients with metastatic castrate-resistant prostate cancer (mCRPC) treated with radium-223 (223Ra). We tested known and possible prognostic parameters, including palliative EBRT, both prior and concurrent to 223Ra. Logrank test (Kaplan-Meier method) and Cox regression analysis were used to predict overall survival (OS). A total of 133 patients were treated with 223Ra; median age was 72 years. Median OS was 9.0 (95% confidence interval [CI] 7.4-10.6) months. By univariate analysis (log-rank test), baseline Eastern Cooperative Oncology Group performance status (ECOG PS) 0-1 (p=0.001), ≥5 cycles of 223Ra (p<0.001), baseline hemoglobin (Hb) ≥120 g/L (p <0.001), baseline total alkaline phosphatase (tALP) <110 U/L (p=0.001), and any prostate-specific antigen (PSA) decline at week 12 (p=0.013) were associated with increased OS. EBRT prior and/or concurrent to 223Ra showed a trend (p=0.051) towards inferior OS by univariate analysis only. By multivariate analysis, significant factors were PS 0-1 (hazard ratio [HR] 1.94, 95% CI 1.3-2.9, p=0.001), Hb ≥120 g/L (HR 0.5, 95% CI 0.3-0.9, p=0.011), and absence of docetaxel use prior to 223Ra (HR 1.86, 95% CI 1.08-3.22, p=0.026). With baseline Hb, tALP, and ECOG PS, we were able to divide patients into three groups with different median OS (months): 23.0 (95% CI 12.8-33.2), 8.0 (95% CI 6.7-9.3), and 5.0 (95% CI 3.1-6.9) for low-, intermediate-, and high-risk, respectively (p<0.001). We found that 223Ra therapy can result in an OS of close to two years in carefully selected patients. Earlier administration of 223Ra therapy to fitter patients with mCRPC should be tested.