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Surgical Resection and Brain Brachytherapy With Permanent Iodine-125 Seeds for Brain Metastases
Poster Viewing Abstracts S313
Volume 90 Number 1S Supplement 2014 Conclusions: Our results form a decision making-guideline for weighing the benefit of decreased dose to the hippocampi against the cost of decreased dose to potential brain metastases when deciding on a hippocampal-sparing WBI treatment approach. Author Disclosure: J. Chang: None. A. Perez-Andujar: None. S. Hossain: None. C. Higby: None. S. Ahmad: None. I.J. Barani: None. D.A. Larson: None. L. Ma: None.
2241 Outcomes Following Fractionated Stereotactic Radiation Therapy in the Management of Radioresistant and Radiosensitive Brain Metastases K.A. Ahmed,1 S. Sarangkasiri,1 P. Chinnaiyan,1 S. Sahebjam,1 H.M. Yu,2 A.B. Etame,1 and N.G. Rao1; 1H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, 2LifeBridge Health, Baltimore, MD Purpose/Objective(s): To evaluate the outcomes of patients treated with fractionated stereotactic radiation therapy (FSRT) for radiosensitive and radioresistant brain metastases. Materials/Methods: Between August 2006 and July 2013 a total of 56 consecutive, non-postoperative lesions in 44 patients with brain metastases were treated with FSRT. The reason for utilization of FSRT was primarily due to location in eloquent areas (n Z 25; 44.6%) or size (n Z 31; 55.4%). Twenty-three (41.1%) lesions were radioresistant. Treatment schedules were 25 Gy in 5 fractions for 27 lesions (48.2%), 30 Gy in 5 fractions in 19 lesions (33.9%), 20 Gy in 5 fractions for 6 lesions (10.7%), and 24 Gy in 3 fractions for 4 lesions (7.1%). Median planning target volume (PTV) was 6.18 cm3. The primary endpoint for this study was local control with secondary endpoints of overall survival (OS), distant failure, performance status, and treatment toxicity. Results: The majority of patients in this study had multiple brain metastases (61.4%) and did not have extracranial metastases (52.2%). The median follow-up for all patients was 5 months (range: 0.4 -58.3 months). Six and twelve month Kaplan-Meier (KM) estimates of local control for all lesions were 85.6% and 79.4%, respectively. Radioresistant tumors had a 6 and 12 month local control rate of 87.0% while radiosensitive tumors had a 6 and 12 month local control rate of 82.5% and 72.2%, respectively (p Z 0.41). Six and 12 month distant brain control rates for all lesions were 56.8% and 46.9%, respectively. Distant control rates at 6 and 12 months were 59.5% and 46.3% for radioresistant tumors and 53.7% and 46.9% for radiosensitive tumors (p Z 0.87). OS was significantly associated with recursive partitioning analysis (RPA) classes I, II, and III (p Z 0.0003) and graded prognostic assessment (GPA) score 2-3 and 1-1.5 (p Z 0.041). One case of radionecrosis was confirmed by surgical pathology. Conclusions: FSRT is a safe and feasible alternative to single session SRS for brain metastases. No difference was observed in local control rates between radioresistant and radiosensitive tumors. Author Disclosure: K.A. Ahmed: None. S. Sarangkasiri: None. P. Chinnaiyan: None. S. Sahebjam: None. H.M. Yu: None. A.B. Etame: None. N.G. Rao: None.
2242 Surgical Resection and Brain Brachytherapy With Permanent Iodine-125 Seeds for Brain Metastases Z.A. Seymour, M.W. McDermott, S.E. Fogh, M.K. Aghi, J. Pouliot, and P.K. Sneed; University of California - San Francisco, San Francisco, CA Purpose/Objective(s): To evaluate the efficacy and toxicity of surgical resection and permanent iodine-125 (I125) brachytherapy for brain metastases. Materials/Methods: A total of 96 patients with brain metastases treated with permanent I125 brachytherapy from 1997 to July 2013 were retrospectively reviewed, updating our prior report on 40 patients treated through 2003. The necrosis rate was 23% in the older series, prompting more consistent use of lower activity sources since 2005. Patients undergoing elective surgery for large or recurrent brain metastasis were
considered for brachytherapy. Any additional non-resected brain metastases at the time of the implant were treated with stereotactic radiosurgery (SRS). All patients were assessed for overall survival (OS), local freedom from progression (LFFP) and freedom from necrosis measured from the date of resection using Kaplan Meier methodology. Results: The median age at surgery was 59 yr with a median KPS of 80. The most common primary malignancies were lung (39%), melanoma (27%), and breast (23%). 13% of patients underwent SRS to additional lesions around the time of surgery. The median pre-surgical maximum dimension was 3.4 cm (range: 1.5-8.3 cm). Gross total, near gross total, and partial resection were achieved in 81, 17, and 2%. A median of 32 sources were implanted (range: 10-117) with a median source activity of 0.73 mCi (range: 0.34-1.32 mCi) and median total activity at implant of 24.0 mCi (range: 6.5-69.0 mCi). 51% of implants were for progressive or locally recurrent disease after prior radiation therapy or SRS. The median OS was 12.0 mo. The overall rate of local control was 91% by patient with a LFFP at 1 and 2 yr of 87% and 83%. LFFP was 90% and 82% for patients with recurrent disease versus 84% at 1 and 2 yr for patients with newly diagnosed brain metastases. Source activity and extent of resection were not associated with LFFP. The risks of wound complication and leptomeningeal disease were 6% and 9%. The overall risk of necrosis was 16%. Necrosis probabilities at 1 and 2 yr were 28% and 42% for recurrent lesions versus 5% and 14% for newly diagnosed lesions (p Z 0.059). If no prior SRS was done to the surgical site, the risk of necrosis was 8 and 17% compared to 29 and 44% at 1 and 2 yr for those with prior SRS. Excluding patients with prior SRS, the risk of necrosis was 0% at 1 and 2 yr for sources 0.73 mCi versus 14% and 29% for sources > 0.73 mCi. Maximal dimension, pre-surgical volume, and number of sources were not associated with necrosis or LFFP. Conclusions: Surgical resection with I125 brachytherapy is an option to provide good local control of large brain metastases. In spite of no statistical differences in local control with lower source activity or history of prior treatment at the surgical site, there was a trend towards reduced necrosis risk with source activity 0.73 mCi and for patients without prior radiation therapy or SRS. Author Disclosure: Z.A. Seymour: None. M.W. McDermott: None. S.E. Fogh: None. M.K. Aghi: None. J. Pouliot: None. P.K. Sneed: None.
2243 Randomized Trial of Whole-Brain Radiation Therapy in Melanoma Brain Metastases: First Interim Analysis G.B. Fogarty,1,2 A. Hong,2,3 K. Dolven-Jacobsen,4 C.H. Reisse,4 B. Burmeister,5,6 V. Steel,7 L. Haydu,2 H. Dhillon,8,9 B. Shivalingham,10 K. Drummond,11 J. Vardy,3,10 A. Nowak,12,13 G. Hruby,3,10 R. Scolyer,2,10 C. Mandel,14 and J.F. Thompson2,3; 1St. Vincent’s and Mater Hospitals, Department of Oncology, Sydney, Australia, 2Melanoma Institute Australia, Sydney, Australia, 3Sydney Medical School, University of Sydney, Sydney, Australia, 4The Radium Hospital, Oslo, Norway, 5Princess Alexandra Hospital, Brisbane, Australia, 6Trans-Tasman Radiation Oncology Group (TROG), Newcastle, Australia, 7Australia and New Zealand Melanoma Trials Group, Sydney, Australia, 8Centre for Medical Psychology & Evidence-based Decision-making, Sydney Medical School, University of Sydney, Sydney, Australia, 9Psycho-Oncology Co-Operative Research Group (PoCoG), School of Psychology, Faculty of Science, University of Sydney, Sydney, Australia, 10Sydney Cancer Centre, Royal Prince Alfred Hospital, Sydney, Australia, 11Royal Melbourne Hospital, Parkville, Australia, 12School of Medicine and Pharmacology, University of Western Australia, Crawley, Australia, 13Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, Australia, 14Peter MacCallum Cancer Centre East Melbourne & University of Melbourne, Parkville, Australia Purpose/Objective(s): Brain metastases are a common cause of death in melanoma. Immediate whole brain radiation therapy (WBRT) following local treatment of intracranial melanoma metastases with neurosurgery and/or stereotactic radiosurgery is controversial with limited evidence based practice to support or reject the use of this treatment. The Australia
Volume 90 Number 1S Supplement 2014 Conclusions: Our results form a decision making-guideline for weighing the benefit of decreased dose to the hippocampi against the cost of decreased dose to potential brain metastases when deciding on a hippocampal-sparing WBI treatment approach. Author Disclosure: J. Chang: None. A. Perez-Andujar: None. S. Hossain: None. C. Higby: None. S. Ahmad: None. I.J. Barani: None. D.A. Larson: None. L. Ma: None.
2241 Outcomes Following Fractionated Stereotactic Radiation Therapy in the Management of Radioresistant and Radiosensitive Brain Metastases K.A. Ahmed,1 S. Sarangkasiri,1 P. Chinnaiyan,1 S. Sahebjam,1 H.M. Yu,2 A.B. Etame,1 and N.G. Rao1; 1H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, 2LifeBridge Health, Baltimore, MD Purpose/Objective(s): To evaluate the outcomes of patients treated with fractionated stereotactic radiation therapy (FSRT) for radiosensitive and radioresistant brain metastases. Materials/Methods: Between August 2006 and July 2013 a total of 56 consecutive, non-postoperative lesions in 44 patients with brain metastases were treated with FSRT. The reason for utilization of FSRT was primarily due to location in eloquent areas (n Z 25; 44.6%) or size (n Z 31; 55.4%). Twenty-three (41.1%) lesions were radioresistant. Treatment schedules were 25 Gy in 5 fractions for 27 lesions (48.2%), 30 Gy in 5 fractions in 19 lesions (33.9%), 20 Gy in 5 fractions for 6 lesions (10.7%), and 24 Gy in 3 fractions for 4 lesions (7.1%). Median planning target volume (PTV) was 6.18 cm3. The primary endpoint for this study was local control with secondary endpoints of overall survival (OS), distant failure, performance status, and treatment toxicity. Results: The majority of patients in this study had multiple brain metastases (61.4%) and did not have extracranial metastases (52.2%). The median follow-up for all patients was 5 months (range: 0.4 -58.3 months). Six and twelve month Kaplan-Meier (KM) estimates of local control for all lesions were 85.6% and 79.4%, respectively. Radioresistant tumors had a 6 and 12 month local control rate of 87.0% while radiosensitive tumors had a 6 and 12 month local control rate of 82.5% and 72.2%, respectively (p Z 0.41). Six and 12 month distant brain control rates for all lesions were 56.8% and 46.9%, respectively. Distant control rates at 6 and 12 months were 59.5% and 46.3% for radioresistant tumors and 53.7% and 46.9% for radiosensitive tumors (p Z 0.87). OS was significantly associated with recursive partitioning analysis (RPA) classes I, II, and III (p Z 0.0003) and graded prognostic assessment (GPA) score 2-3 and 1-1.5 (p Z 0.041). One case of radionecrosis was confirmed by surgical pathology. Conclusions: FSRT is a safe and feasible alternative to single session SRS for brain metastases. No difference was observed in local control rates between radioresistant and radiosensitive tumors. Author Disclosure: K.A. Ahmed: None. S. Sarangkasiri: None. P. Chinnaiyan: None. S. Sahebjam: None. H.M. Yu: None. A.B. Etame: None. N.G. Rao: None.
2242 Surgical Resection and Brain Brachytherapy With Permanent Iodine-125 Seeds for Brain Metastases Z.A. Seymour, M.W. McDermott, S.E. Fogh, M.K. Aghi, J. Pouliot, and P.K. Sneed; University of California - San Francisco, San Francisco, CA Purpose/Objective(s): To evaluate the efficacy and toxicity of surgical resection and permanent iodine-125 (I125) brachytherapy for brain metastases. Materials/Methods: A total of 96 patients with brain metastases treated with permanent I125 brachytherapy from 1997 to July 2013 were retrospectively reviewed, updating our prior report on 40 patients treated through 2003. The necrosis rate was 23% in the older series, prompting more consistent use of lower activity sources since 2005. Patients undergoing elective surgery for large or recurrent brain metastasis were
considered for brachytherapy. Any additional non-resected brain metastases at the time of the implant were treated with stereotactic radiosurgery (SRS). All patients were assessed for overall survival (OS), local freedom from progression (LFFP) and freedom from necrosis measured from the date of resection using Kaplan Meier methodology. Results: The median age at surgery was 59 yr with a median KPS of 80. The most common primary malignancies were lung (39%), melanoma (27%), and breast (23%). 13% of patients underwent SRS to additional lesions around the time of surgery. The median pre-surgical maximum dimension was 3.4 cm (range: 1.5-8.3 cm). Gross total, near gross total, and partial resection were achieved in 81, 17, and 2%. A median of 32 sources were implanted (range: 10-117) with a median source activity of 0.73 mCi (range: 0.34-1.32 mCi) and median total activity at implant of 24.0 mCi (range: 6.5-69.0 mCi). 51% of implants were for progressive or locally recurrent disease after prior radiation therapy or SRS. The median OS was 12.0 mo. The overall rate of local control was 91% by patient with a LFFP at 1 and 2 yr of 87% and 83%. LFFP was 90% and 82% for patients with recurrent disease versus 84% at 1 and 2 yr for patients with newly diagnosed brain metastases. Source activity and extent of resection were not associated with LFFP. The risks of wound complication and leptomeningeal disease were 6% and 9%. The overall risk of necrosis was 16%. Necrosis probabilities at 1 and 2 yr were 28% and 42% for recurrent lesions versus 5% and 14% for newly diagnosed lesions (p Z 0.059). If no prior SRS was done to the surgical site, the risk of necrosis was 8 and 17% compared to 29 and 44% at 1 and 2 yr for those with prior SRS. Excluding patients with prior SRS, the risk of necrosis was 0% at 1 and 2 yr for sources 0.73 mCi versus 14% and 29% for sources > 0.73 mCi. Maximal dimension, pre-surgical volume, and number of sources were not associated with necrosis or LFFP. Conclusions: Surgical resection with I125 brachytherapy is an option to provide good local control of large brain metastases. In spite of no statistical differences in local control with lower source activity or history of prior treatment at the surgical site, there was a trend towards reduced necrosis risk with source activity 0.73 mCi and for patients without prior radiation therapy or SRS. Author Disclosure: Z.A. Seymour: None. M.W. McDermott: None. S.E. Fogh: None. M.K. Aghi: None. J. Pouliot: None. P.K. Sneed: None.
2243 Randomized Trial of Whole-Brain Radiation Therapy in Melanoma Brain Metastases: First Interim Analysis G.B. Fogarty,1,2 A. Hong,2,3 K. Dolven-Jacobsen,4 C.H. Reisse,4 B. Burmeister,5,6 V. Steel,7 L. Haydu,2 H. Dhillon,8,9 B. Shivalingham,10 K. Drummond,11 J. Vardy,3,10 A. Nowak,12,13 G. Hruby,3,10 R. Scolyer,2,10 C. Mandel,14 and J.F. Thompson2,3; 1St. Vincent’s and Mater Hospitals, Department of Oncology, Sydney, Australia, 2Melanoma Institute Australia, Sydney, Australia, 3Sydney Medical School, University of Sydney, Sydney, Australia, 4The Radium Hospital, Oslo, Norway, 5Princess Alexandra Hospital, Brisbane, Australia, 6Trans-Tasman Radiation Oncology Group (TROG), Newcastle, Australia, 7Australia and New Zealand Melanoma Trials Group, Sydney, Australia, 8Centre for Medical Psychology & Evidence-based Decision-making, Sydney Medical School, University of Sydney, Sydney, Australia, 9Psycho-Oncology Co-Operative Research Group (PoCoG), School of Psychology, Faculty of Science, University of Sydney, Sydney, Australia, 10Sydney Cancer Centre, Royal Prince Alfred Hospital, Sydney, Australia, 11Royal Melbourne Hospital, Parkville, Australia, 12School of Medicine and Pharmacology, University of Western Australia, Crawley, Australia, 13Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, Australia, 14Peter MacCallum Cancer Centre East Melbourne & University of Melbourne, Parkville, Australia Purpose/Objective(s): Brain metastases are a common cause of death in melanoma. Immediate whole brain radiation therapy (WBRT) following local treatment of intracranial melanoma metastases with neurosurgery and/or stereotactic radiosurgery is controversial with limited evidence based practice to support or reject the use of this treatment. The Australia