- Email: [email protected]
Outcomes From First 3 Years of Frameless Stereotactic Radiosurgery in Treating Brain Metastases
S322
International Journal of Radiation Oncology Biology Physics
location (p Z 0.025 for OS, p Z 0.009 for PFS), KPS at initial RT consult (p Z 0.026, p Z 0.019), use of adjuvant chemotherapy (p Z 0.012, p Z 0.0213), and postponement of RT during treatment (p Z 0.006, p Z 0.0073). Gender appeared to affect PFS, with females doing better (p Z 0.008). Not completing planned chemotherapy approached significance for OS (p Z 0.057). Conclusions: Adult medulloblastoma patients treated with radiation therapy did not have different rates of recurrence with the use of high or low dose CSI. GTR, age, and VP shunt may impact recurrence. AR adult medulloblastoma may be treated with low dose CSI with the use of adjuvant chemotherapy. If patient is anticipated not to be able to complete chemotherapy, high dose CSI may be favored for AR. Author Disclosure: A.J. Song: None. A. Kumar: A. Employee; Cleveland Clinic. E.S. Murphy: A. Employee; Cleveland Clinic. T. Tekautz: A. Employee; Cleveland Clinic. M. Ahluwalia: A. Employee; Cleveland Clinic. D. Peereboom: A. Employee; Cleveland Clinic. G. Stevens: A. Employee; Cleveland Clinic. J.H. Suh: A. Employee; Cleveland Clinic. S.T. Chao: A. Employee; Cleveland Clinic.
and allow flexibility in scheduling radiosurgery delivery. Previous case series have low patient numbers or short follow-up. In this study we report clinical outcomes and our center’s experience with SRS in treating newly diagnosed brain metastases. Materials/Methods: We reviewed electronic charts of all patients undergoing SRS at the institution between June 2010 and September 2013. A total of 235 lesions in 120 patients were treated in 130 SRS sessions. Median age of patients undergoing SRS was 58.5 years (range 26-81). Median Karnofsky Performance Status (KPS) was 80 (range 60-100). Patients had non-small cell lung cancer (51), breast cancer (21), melanoma (20), renal cell carcinoma (10), colorectal cancer (7) and others (13). Number of lesions treated in a single session ranged from one to four. Results: Median follow-up was 12.7 months (range 0-60). Overall median survival from the time of brain mets diagnosis was 18.2 months (95% CI Z 14-22 months) and 10.4 months from time of SRS (95% CI Z 7-13 months). Seventy four (62%) patients received whole brain radiation therapy (WBRT) prior to SRS. Median survival from the time of brain mets diagnosis was 22.3 months for patients treated with WBRT plus SRS versus 9.3 months for patients treated with SRS (95% CI Z 14-30 months and 1-17 months respectively). Overall, fifty percent of patients received palliative chemotherapy after SRS (55% if KPS 80; 33% if KPS 70; no difference if prior WBRT). Median survival for patient who received chemotherapy was 22.3 months versus 12.3 months who did not. We identified local failure rate (within SRS site) of 11%, whereas 38% of patients had distant intracranial relapse; there was no difference between those who did or did not receive WBRT prior to SRS. Radionecrosis was identified in 8% of treated lesions. Conclusions: This is so far the largest frameless SRS series. Our results are comparable if not better than previously reported. Frameless SRS is an effective, non-invasive option for patients with less than four metastatic lesions as well as patients with residual or growing lesions post WBRT. Patients who underwent chemotherapy post SRS had better overall survival regardless of WBRT prior to SRS or number of lesions treated with SRS. Author Disclosure: A. Taggar: None. H. Lau: None. G. Lim: None. R. Nordal: None. R. Khan: None. K. Breitman: None. A. Hudson: None. D. Spencer: None. J. Voroney: None.
2264 Use of CT Cisternograms in Target Definition for Trigeminal Neuralgia Radiosurgery S.A. Althaqfi; The Ottawa Hospital Cancer Center, Ottawa, ON, Canada Purpose/Objective(s): Radiosurgery (RS) is an effective treatment for trigeminal neuralgia (TG). RS provides effective pain relief in 60 to 80 % of pts. For RS planning it is critical to identify the trigeminal nerve to ensure safe and effective RS. We describe the use of CT Cisternograms (CS) to help define RS target in patients with contraindication to MRI or where the nerve is difficult to visualize because of patient and anatomic factors. Materials/Methods: Three patients with TG underwent CT cisternogram as preparation for radiosurgery planning. Two of the patients had received prior RS for TG. 1 patient had a pacemaker as contraindication to MRI. In the other 2 cases the TG nerve was difficult to visualize on MRI because of disrupted anatomy from prior micro-vascular decompression surgery. CS procedure was performed by a neuro-radiologist. 10 cc of Isovue-300 contrast was injected into the thecal sac under fluoroscopic guidance at L3L4 level. Patient is maintained in a Trendelenburg position and transferred to the diagnostic CT scanner. One mm axial images were obtained through the brain. CS was imported into the RS planning system and fused with the CT simulation scan for targeting. Results: There were no peri-procedural or post-procedural complications following CS. There was excellent visualization of CSF spaces and cranial nerves involving the basal cisterns. The Trigeminal Nerve was easily visualized in the cisternal portion by 3 RS physicians. The Nerve was targeted adjacent to the root entry zone. For 2 patients being retreated 50 Gy was prescribed to the 80 % isodose line. The 3rd pt was treated with 60 Gy prescribed to 80 isodose line. All patients had complete pain relief with no complications to date from RS. Conclusions: CT Cisternogram is a safe and effective technique to visualize the cisternal portion of the trigeminal nerve for RS. CS can be used in pts who have contra-indications to MRI or for cases in which MRI is insufficient for identifying the trigeminal nerve. Author Disclosure: S.A. Althaqfi: None.
2265 Outcomes From First 3 Years of Frameless Stereotactic Radiosurgery in Treating Brain Metastases A. Taggar, H. Lau, G. Lim, R. Nordal, R. Khan, K. Breitman, A. Hudson, D. Spencer, and J. Voroney; Tom Baker Cancer Centre, Calgary, AB, Canada Purpose/Objective(s): Stereotactic radiosurgery (SRS) is an important tool in management of brain metastases. Frameless SRS uses image guidance to deliver high dose radiation to the target volume, while being minimally invasive. Frameless techniques have improved patient comfort
2266 Stereotactic Radiation Therapy for Brain Metastases From Advanced Non-Small Cell Lung Cancer With or Without Endothelial Growth Factor Receptor (EGFR) Mutations: Influence of Gefitinib Treatment T. Murai,1 K. Yamada,2 F. Oshita,2 K. Sato,3 K. Tatewaki,4 N. Yokota,5 S. Ohta,6 H. Iwata,7 M. Iwabuchi,8 S. Sadao,9 and Y. Shibamoto8; 1Nagoya City university, Nagoya, Japan, 2Department of Thoracic Oncology, Kanagawa Cancer Center Hospital, Yokohama, Japan, 3Japanese Red Cross Medical Center, Tokyo, Japan, 4Yokohama CyberKnife Center, Yokohama, Japan, 5Suzukake Central Hospital, Hamamatsu, Japan, 6 Yokohama CyberKnife Center, Yokohama, Japan, 7Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Japan, 8 Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan, 9Department of Public Health, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan Purpose/Objective(s): Gefitinib is a tyrosine kinase inhibitor of EGFR that have shown efficacy against non-small cell lung cancer (NSCLC) with EGFR mutations. This agent can also pass through the blood-brain barrier and is expected to be effective against brain metastases (BM). The purpose of this study is to examine the relationship between gefitinib treatment and outcome of stereotactic radiation therapy (SRT) against BM. Materials/Methods: Patients with BM from NSCLC were treated with SRT (22 Gy/1 fx or 35 Gy/3 fx) as a first-line therapy for BM between 2007 and 2011. After the treatment, patients were evaluated at 2- to 3month intervals using contrast-enhanced magnetic resonance imaging. When new BM developed, they were treated again with SRT or whole brain radiation therapy. Regarding systemic therapy, our policy was as
International Journal of Radiation Oncology Biology Physics
location (p Z 0.025 for OS, p Z 0.009 for PFS), KPS at initial RT consult (p Z 0.026, p Z 0.019), use of adjuvant chemotherapy (p Z 0.012, p Z 0.0213), and postponement of RT during treatment (p Z 0.006, p Z 0.0073). Gender appeared to affect PFS, with females doing better (p Z 0.008). Not completing planned chemotherapy approached significance for OS (p Z 0.057). Conclusions: Adult medulloblastoma patients treated with radiation therapy did not have different rates of recurrence with the use of high or low dose CSI. GTR, age, and VP shunt may impact recurrence. AR adult medulloblastoma may be treated with low dose CSI with the use of adjuvant chemotherapy. If patient is anticipated not to be able to complete chemotherapy, high dose CSI may be favored for AR. Author Disclosure: A.J. Song: None. A. Kumar: A. Employee; Cleveland Clinic. E.S. Murphy: A. Employee; Cleveland Clinic. T. Tekautz: A. Employee; Cleveland Clinic. M. Ahluwalia: A. Employee; Cleveland Clinic. D. Peereboom: A. Employee; Cleveland Clinic. G. Stevens: A. Employee; Cleveland Clinic. J.H. Suh: A. Employee; Cleveland Clinic. S.T. Chao: A. Employee; Cleveland Clinic.
and allow flexibility in scheduling radiosurgery delivery. Previous case series have low patient numbers or short follow-up. In this study we report clinical outcomes and our center’s experience with SRS in treating newly diagnosed brain metastases. Materials/Methods: We reviewed electronic charts of all patients undergoing SRS at the institution between June 2010 and September 2013. A total of 235 lesions in 120 patients were treated in 130 SRS sessions. Median age of patients undergoing SRS was 58.5 years (range 26-81). Median Karnofsky Performance Status (KPS) was 80 (range 60-100). Patients had non-small cell lung cancer (51), breast cancer (21), melanoma (20), renal cell carcinoma (10), colorectal cancer (7) and others (13). Number of lesions treated in a single session ranged from one to four. Results: Median follow-up was 12.7 months (range 0-60). Overall median survival from the time of brain mets diagnosis was 18.2 months (95% CI Z 14-22 months) and 10.4 months from time of SRS (95% CI Z 7-13 months). Seventy four (62%) patients received whole brain radiation therapy (WBRT) prior to SRS. Median survival from the time of brain mets diagnosis was 22.3 months for patients treated with WBRT plus SRS versus 9.3 months for patients treated with SRS (95% CI Z 14-30 months and 1-17 months respectively). Overall, fifty percent of patients received palliative chemotherapy after SRS (55% if KPS 80; 33% if KPS 70; no difference if prior WBRT). Median survival for patient who received chemotherapy was 22.3 months versus 12.3 months who did not. We identified local failure rate (within SRS site) of 11%, whereas 38% of patients had distant intracranial relapse; there was no difference between those who did or did not receive WBRT prior to SRS. Radionecrosis was identified in 8% of treated lesions. Conclusions: This is so far the largest frameless SRS series. Our results are comparable if not better than previously reported. Frameless SRS is an effective, non-invasive option for patients with less than four metastatic lesions as well as patients with residual or growing lesions post WBRT. Patients who underwent chemotherapy post SRS had better overall survival regardless of WBRT prior to SRS or number of lesions treated with SRS. Author Disclosure: A. Taggar: None. H. Lau: None. G. Lim: None. R. Nordal: None. R. Khan: None. K. Breitman: None. A. Hudson: None. D. Spencer: None. J. Voroney: None.
2264 Use of CT Cisternograms in Target Definition for Trigeminal Neuralgia Radiosurgery S.A. Althaqfi; The Ottawa Hospital Cancer Center, Ottawa, ON, Canada Purpose/Objective(s): Radiosurgery (RS) is an effective treatment for trigeminal neuralgia (TG). RS provides effective pain relief in 60 to 80 % of pts. For RS planning it is critical to identify the trigeminal nerve to ensure safe and effective RS. We describe the use of CT Cisternograms (CS) to help define RS target in patients with contraindication to MRI or where the nerve is difficult to visualize because of patient and anatomic factors. Materials/Methods: Three patients with TG underwent CT cisternogram as preparation for radiosurgery planning. Two of the patients had received prior RS for TG. 1 patient had a pacemaker as contraindication to MRI. In the other 2 cases the TG nerve was difficult to visualize on MRI because of disrupted anatomy from prior micro-vascular decompression surgery. CS procedure was performed by a neuro-radiologist. 10 cc of Isovue-300 contrast was injected into the thecal sac under fluoroscopic guidance at L3L4 level. Patient is maintained in a Trendelenburg position and transferred to the diagnostic CT scanner. One mm axial images were obtained through the brain. CS was imported into the RS planning system and fused with the CT simulation scan for targeting. Results: There were no peri-procedural or post-procedural complications following CS. There was excellent visualization of CSF spaces and cranial nerves involving the basal cisterns. The Trigeminal Nerve was easily visualized in the cisternal portion by 3 RS physicians. The Nerve was targeted adjacent to the root entry zone. For 2 patients being retreated 50 Gy was prescribed to the 80 % isodose line. The 3rd pt was treated with 60 Gy prescribed to 80 isodose line. All patients had complete pain relief with no complications to date from RS. Conclusions: CT Cisternogram is a safe and effective technique to visualize the cisternal portion of the trigeminal nerve for RS. CS can be used in pts who have contra-indications to MRI or for cases in which MRI is insufficient for identifying the trigeminal nerve. Author Disclosure: S.A. Althaqfi: None.
2265 Outcomes From First 3 Years of Frameless Stereotactic Radiosurgery in Treating Brain Metastases A. Taggar, H. Lau, G. Lim, R. Nordal, R. Khan, K. Breitman, A. Hudson, D. Spencer, and J. Voroney; Tom Baker Cancer Centre, Calgary, AB, Canada Purpose/Objective(s): Stereotactic radiosurgery (SRS) is an important tool in management of brain metastases. Frameless SRS uses image guidance to deliver high dose radiation to the target volume, while being minimally invasive. Frameless techniques have improved patient comfort
2266 Stereotactic Radiation Therapy for Brain Metastases From Advanced Non-Small Cell Lung Cancer With or Without Endothelial Growth Factor Receptor (EGFR) Mutations: Influence of Gefitinib Treatment T. Murai,1 K. Yamada,2 F. Oshita,2 K. Sato,3 K. Tatewaki,4 N. Yokota,5 S. Ohta,6 H. Iwata,7 M. Iwabuchi,8 S. Sadao,9 and Y. Shibamoto8; 1Nagoya City university, Nagoya, Japan, 2Department of Thoracic Oncology, Kanagawa Cancer Center Hospital, Yokohama, Japan, 3Japanese Red Cross Medical Center, Tokyo, Japan, 4Yokohama CyberKnife Center, Yokohama, Japan, 5Suzukake Central Hospital, Hamamatsu, Japan, 6 Yokohama CyberKnife Center, Yokohama, Japan, 7Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Japan, 8 Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan, 9Department of Public Health, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan Purpose/Objective(s): Gefitinib is a tyrosine kinase inhibitor of EGFR that have shown efficacy against non-small cell lung cancer (NSCLC) with EGFR mutations. This agent can also pass through the blood-brain barrier and is expected to be effective against brain metastases (BM). The purpose of this study is to examine the relationship between gefitinib treatment and outcome of stereotactic radiation therapy (SRT) against BM. Materials/Methods: Patients with BM from NSCLC were treated with SRT (22 Gy/1 fx or 35 Gy/3 fx) as a first-line therapy for BM between 2007 and 2011. After the treatment, patients were evaluated at 2- to 3month intervals using contrast-enhanced magnetic resonance imaging. When new BM developed, they were treated again with SRT or whole brain radiation therapy. Regarding systemic therapy, our policy was as