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Hippocampal sparing in patients receiving radiosurgery for ≥ 25 brain metastases

Kavi, Ami; Gurewitz, Jason; Benjamin, Carolina; Silverman, Joshua; Bernstein, Kenneth; Mureb, Monica; Oh, Cheongeun; Sulman, Erik P; Donahue, Bernadine; Kondziolka, Douglas
PURPOSE/OBJECTIVES/OBJECTIVE:To report our dosimetric analysis of the hippocampi (HC) and the incidence of perihippocampal tumor location in patients with≥25 brain metastases who received stereotactic radiosurgery (SRS) in single or multiple sessions. Materials/Methods Analysis of our prospective registry identified 89 patients treated with SRS for ≥ 25 brain metastases. HC avoidance regions (HA-region) were created on treatment planning MRIs by 5mm expansion of HC. Doses from each session were summed to calculate HC dose. The distribution of metastases relative to the HA-region and the HC was analyzed. RESULTS:Median number of tumors irradiated per patient was 33 (range 25-116) in a median of 3 (range1-12) sessions. Median bilateral HC Dmin (D100), D40, D50, Dmax, and Dmean (Gy) was 1.88, 3.94, 3.62, 16.6, and 3.97 for all patients, and 1.43, 2.99, 2.88, 5.64, and 3.07 for patients with tumors outside the HA-region. Multivariate linear regression showed that the median HC D40, D50, and Dmin were significantly correlated with the tumor number and tumor volume (p <0.001). Of the total3059 treated tumors,83 (2.7%) were located in the HA-region in 57% evaluable patients; 38 tumors (1.2%) abutted or involved the HC itself. CONCLUSIONS:Hippocampal dose, is higher in patients with tumors in the HA-region; however, even for patients with a high burden of intracranial disease and tumors located in the HA-regions, SRS affords hippocampal sparing. This is particularly relevant in light of our finding of eventual perihippocampal metastases in more than half of our patients.
PMID: 34052342
ISSN: 1879-0887
CID: 4890712

Treatment of sellar metastases with gamma knife radiosurgery in patients with advanced cancer

Benjamin, Carolina; Ashayeri, Kimberly; Golfinos, John G; Placantonakis, Dimitris G; Silverman, Joshua; Kondziolka, Douglas
PURPOSE/OBJECTIVE:Metastases should be considered in a patient with a cancer history and a sellar/suprasellar lesion, as this diagnosis can change the management strategy in such patients. Once the diagnosis is established, stereotactic radiosurgery (SRS) can be a safe and effective approach for these patients. METHODS:This case series describes five patients with pituitary metastases managed with GKRS at a single institution, taken from our prospective registry. All patients had SRS using the Gamma Knife Perfexion or Icon (Elekta), according to our standard institutional protocol. The optic nerves and chiasm were contoured, and the plan was adjusted to restrict dose to the optic apparatus as necessary. The tumor margin doses delivered were 11 Gy, 12 Gy, 14 Gy, 18 Gy (3 sessions of 6 Gy), and 12 Gy at the 50% isodose line. RESULTS:In this series, all sellar metastases were treated successfully with good radiographic and clinical response. The histology of the tumors included endometrial, gastrointestinal, and lung adenocarcinomas. Typically, histology is taken into consideration when choosing the treatment dose, along with size and location. In these patients, however, the dose used for the sellar metastases was chosen primarily for visual safety. This was typically lower than the dose for brain metastases in other locations. CONCLUSION/CONCLUSIONS:SRS provides an alternative treatment approach for sellar/suprasellar metastases with excellent local control, symptom improvement and maintenance of systemic therapy as desired. As such, CNS failure is rarely the proximate cause of demise in pituitary metastases provided that endocrinopathies are recognized and managed appropriately.
PMID: 32860552
ISSN: 1573-7403
CID: 4587032

Full automation of spinal stereotactic radiosurgery and stereotactic body radiation therapy treatment planning using Varian Eclipse scripting

Teruel, Jose R; Malin, Martha; Liu, Elisa K; McCarthy, Allison; Hu, Kenneth; Cooper, Bejamin T; Sulman, Erik P; Silverman, Joshua S; Barbee, David
The purpose of this feasibility study is to develop a fully automated procedure capable of generating treatment plans with multiple fractionation schemes to improve speed, robustness, and standardization of plan quality. A fully automated script was implemented for spinal stereotactic radiosurgery/stereotactic body radiation therapy (SRS/SBRT) plan generation using Eclipse v15.6 API. The script interface allows multiple dose/fractionation plan requests, planning target volume (PTV) expansions, as well as information regarding distance/overlap between spinal cord and targets to drive decision-making. For each requested plan, the script creates the course, plans, field arrangements, and automatically optimizes and calculates dose. The script was retrospectively applied to ten computed tomography (CT) scans of previous cervical, thoracic, and lumbar spine SBRT patients. Three plans were generated for each patient - simultaneous integrated boost (SIB) 1800/1600 cGy to gross tumor volume (GTV)/PTV in one fraction; SIB 2700/2100 cGy to GTV/PTV in three fractions; and 3000 cGy to PTV in five fractions. Plan complexity and deliverability patient-specific quality assurance (QA) was performed using ArcCHECK with an Exradin A16 chamber inserted. Dose objectives were met for all organs at risk (OARs) for each treatment plan. Median target coverage was GTV V100% = 87.3%, clinical target volume (CTV) V100% = 95.7% and PTV V100% = 88.0% for single fraction plans; GTV V100% = 95.6, CTV V100% = 99.6% and PTV V100% = 97.2% for three fraction plans; and GTV V100% = 99.6%, CTV V100% = 99.1% and PTV V100% = 97.2% for five fraction plans. All plans (n = 30) passed patient-specific QA (>90%) at 2%/2 mm global gamma. A16 chamber dose measured at isocenter agreed with planned dose within 3% for all cases. Automatic planning for spine SRS/SBRT through scripting increases efficiency, standardizes plan quality and approach, and provides a tool for target coverage comparison of different fractionation schemes without the need for additional resources.
PMID: 32965754
ISSN: 1526-9914
CID: 4605772

Evaluation of First-line Radiosurgery vs Whole-Brain Radiotherapy for Small Cell Lung Cancer Brain Metastases: The FIRE-SCLC Cohort Study

Rusthoven, Chad G; Yamamoto, Masaaki; Bernhardt, Denise; Smith, Derek E; Gao, Dexiang; Serizawa, Toru; Yomo, Shoji; Aiyama, Hitoshi; Higuchi, Yoshinori; Shuto, Takashi; Akabane, Atsuya; Sato, Yasunori; Niranjan, Ajay; Faramand, Andrew M; Lunsford, L Dade; McInerney, James; Tuanquin, Leonard C; Zacharia, Brad E; Chiang, Veronica; Singh, Charu; Yu, James B; Braunstein, Steve; Mathieu, David; Touchette, Charles J; Lee, Cheng-Chia; Yang, Huai-Che; Aizer, Ayal A; Cagney, Daniel N; Chan, Michael D; Kondziolka, Douglas; Bernstein, Kenneth; Silverman, Joshua S; Grills, Inga S; Siddiqui, Zaid A; Yuan, Justin C; Sheehan, Jason P; Cordeiro, Diogo; Nosaki, Kename; Seto, Takahashi; Deibert, Christopher P; Verma, Vivek; Day, Samuel; Halasz, Lia M; Warnick, Ronald E; Trifiletti, Daniel M; Palmer, Joshua D; Attia, Albert; Li, Benjamin; Cifarelli, Christopher P; Brown, Paul D; Vargo, John A; Combs, Stephanie; Kessel, Kerstin A; Rieken, Stefan; Patel, Samir; Guckenberger, Matthias; Andratschke, Nicolaus; Kavanagh, Brian D; Robin, Tyler P
Importance/UNASSIGNED:Although stereotactic radiosurgery (SRS) is preferred for limited brain metastases from most histologies, whole-brain radiotherapy (WBRT) has remained the standard of care for patients with small cell lung cancer. Data on SRS are limited. Objective/UNASSIGNED:To characterize and compare first-line SRS outcomes (without prior WBRT or prophylactic cranial irradiation) with those of first-line WBRT. Design, Setting, and Participants/UNASSIGNED:FIRE-SCLC (First-line Radiosurgery for Small-Cell Lung Cancer) was a multicenter cohort study that analyzed SRS outcomes from 28 centers and a single-arm trial and compared these data with outcomes from a first-line WBRT cohort. Data were collected from October 26, 2017, to August 15, 2019, and analyzed from August 16, 2019, to November 6, 2019. Interventions/UNASSIGNED:SRS and WBRT for small cell lung cancer brain metastases. Main Outcomes and Measures/UNASSIGNED:Overall survival, time to central nervous system progression (TTCP), and central nervous system (CNS) progression-free survival (PFS) after SRS were evaluated and compared with WBRT outcomes, with adjustment for performance status, number of brain metastases, synchronicity, age, sex, and treatment year in multivariable and propensity score-matched analyses. Results/UNASSIGNED:In total, 710 patients (median [interquartile range] age, 68.5 [62-74] years; 531 men [74.8%]) who received SRS between 1994 and 2018 were analyzed. The median overall survival was 8.5 months, the median TTCP was 8.1 months, and the median CNS PFS was 5.0 months. When stratified by the number of brain metastases treated, the median overall survival was 11.0 months (95% CI, 8.9-13.4) for 1 lesion, 8.7 months (95% CI, 7.7-10.4) for 2 to 4 lesions, 8.0 months (95% CI, 6.4-9.6) for 5 to 10 lesions, and 5.5 months (95% CI, 4.3-7.6) for 11 or more lesions. Competing risk estimates were 7.0% (95% CI, 4.9%-9.2%) for local failures at 12 months and 41.6% (95% CI, 37.6%-45.7%) for distant CNS failures at 12 months. Leptomeningeal progression (46 of 425 patients [10.8%] with available data) and neurological mortality (80 of 647 patients [12.4%] with available data) were uncommon. On propensity score-matched analyses comparing SRS with WBRT, WBRT was associated with improved TTCP (hazard ratio, 0.38; 95% CI, 0.26-0.55; P < .001), without an improvement in overall survival (median, 6.5 months [95% CI, 5.5-8.0] for SRS vs 5.2 months [95% CI, 4.4-6.7] for WBRT; P = .003) or CNS PFS (median, 4.0 months for SRS vs 3.8 months for WBRT; P = .79). Multivariable analyses comparing SRS and WBRT, including subset analyses controlling for extracranial metastases and extracranial disease control status, demonstrated similar results. Conclusions and Relevance/UNASSIGNED:Results of this study suggest that the primary trade-offs associated with SRS without WBRT, including a shorter TTCP without a decrease in overall survival, are similar to those observed in settings in which SRS is already established.
PMID: 32496550
ISSN: 2374-2445
CID: 4481022

Stereotactic Radiation for Treating Primary and Metastatic Neoplasms of the Spinal Cord

Liu, Elisa K; Silverman, Joshua S; Sulman, Erik P
Stereotactic radiation treatment can be used to treat spinal cord neoplasms in patients with either unresectable lesions or residual disease after surgical resection. While treatment guidelines have been suggested for epidural lesions, the utility of stereotactic radiation for intradural and intramedullary malignancies is still debated. Prior reports have suggested that stereotactic radiation approaches can be used for effective tumor control and symptom management. Treatment-related toxicity has been documented in rare subsets of patients, though the incidences of injury are not directly correlated with higher radiation doses. Further studies are needed to assess the factors that influence the risk of radiation-induced myelopathy when treating spinal cord neoplasms with stereotactic radiation, which can include, but may not be limited to, maximum dose, dose-fractionation, irradiated volume, tumor location, histology and treatment history. This review will discuss evidence for current treatment approaches.
PMID: 32582555
ISSN: 2234-943x
CID: 4493422

Endometrial adenocarcinoma presenting as a suprasellar mass: lessons to be learned [Case Report]

Granina, Evgenia; Fehniger, Julia; Kondziolka, Douglas; Silverman, Joshua; Downey, Andrea; Placantonakis, Dimitris; Muggia, Franco
A 66-year-old woman with a history of stage IA mixed endometrioid and serous endometrial cancer presented to our centre with 2 weeks of worsening headaches nearly 4 years after her initial surgery. At admission, she manifested bitemporal hemianopsia, difficulty walking and clinical and laboratory findings of panhypopituitarism, including diabetes insipidus. Magnetic resonance imaging of the brain revealed a 2.7 cm sellar/suprasellar mass compressing the optic chiasm and infiltrating the pituitary stalk. Computerised tomography documented mediastinal, lung, adrenal and liver involvement, including a 2.5 cm palpable left supraclavicular node that on excisional biopsy demonstrated metastatic endometrial adenocarcinoma. Due to the advanced stage of her cancer as well as the presence of multiple metastases, including lung and hepatic metastases causing post-obstructive pneumonia and coagulopathy, the sellar/suprasellar mass was treated with fractionated radiosurgery rather than surgical excision.
PMID: 32863877
ISSN: 1754-6605
CID: 4615322

How Many Lesions can be Treated With Radiosurgery? Whole Brain Dose from Radiosurgery of Multiple Targets [Meeting Abstract]

Becker, S. J.; Jozsef, G.; Molitoris, J. K.; Silverman, J. S.; Presser, J.; Kondziolka, D.
ISSN: 0360-3016
CID: 4686222

Hippocampal Dosimetry In Patients Receiving Radiosurgery For >= 25 Brain Metastases: Implications For HA-WBRT [Meeting Abstract]

Kavi, A.; Gurewitz, J.; Benjamin, C.; Bernstein, K.; Silverman, J. S.; Donahue, B. R.; Kondziolka, D.
ISSN: 0360-3016
CID: 4686332


Kurz, Sylvia; Zan, Elcin; Gurewitz, Jasone; Cordova, Christine; Troxel, Andrea B.; Sawaged, Zacharia; Sevillano-Torres, Hector; Silverman, Joshua S.; Snuderl, Matija; Zagzag, David; Golfinos, John; Kondziolka, Douglas; Sulman, Erik
ISSN: 1522-8517
CID: 4688132


Gurewitz, Jason; Donahue, Bernadine; Silverman, Joshua S.; Benjamin, Carolina; Bernstein, Kenneth; Kondziolka, Douglas
ISSN: 1522-8517
CID: 4688212