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Outcomes of Patients with Resected Metastatic Brain Lesions Treated with Gamma Knife or Whole Brain Irradiation
I. J. Radiation Oncology d Biology d Physics
S288
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Volume 78, Number 3, Supplement, 2010
Radiosurgery for Meningiomas: Does Fractionation Prevent Brain Edema?
F. S. Cardinale1, V. M. Dest1, P. Dickey1, I. Goodrich1, J. Gorelick1, R. Sinha2 1
Hospital of Saint Raphael, New Haven, CT, 2El Camino Hospital, Mountain View, CA
Purpose/Objective(s): Most studies of radiosurgery for meningioma have shown a high rate of post-treatment symptomatic brain edema (SBE) for parasagittal lesions and lower, but still significant rates at other locations. However, there is some evidence that rates are lower with fractionated stereotactic radiotherapy than with single fraction treatment. We present a series of meningiomas treated since 1999 at a single institution utilizing three regimens: LINAC-based fractionated stereotactic radiotherapy (FSR), single fraction LINAC-based radiosurgery (LRS), and fractionated radiosurgery with Cyberknife (CK)–in order to determine whether rates of SBE were different between the 3 modalities. Materials/Methods: We retrospectively reviewed records of 86 patients with 104 meningiomas treated either with FSR, LRS, or CK. Since 2008, all treatments were accomplished with CK. Mean marginal dose for treatments with FSR (53 tumors), LRS (19 tumors), and CK (32 tumors) respectively was 47.9 Gy, 13.94 Gy, and 25 Gy. Mean number of fractions for FSR and CK were 26 and 5. Rates of SBE were calculated for the entire population and for each of the 3 treatment modalities. Mean follow-up for all patients was 49 months. Results: Rates of the development of SBE for the entire population, the FSR, LRS, and CK groups were, respectively: 1.0%, 2%, 0, and 0%. The differences did not reach statistical significance. Only 1 patient developed SBE, an 89 year old man with a parasagittal lesion. One patient with atypical histology died as a result of SBE and tumor progression, and one patient had visual loss after treatment of an optic canal tumor. Tumor control rate was 96%. Conclusions: Very low rates of SBE can be achieved with effective tumor control in the radiosurgical treatment of meningiomas. With only one case of SBE, we cannot determine whether fractionation is superior to single fraction therapy. However, 80% of tumors in our series were treated with fractionation which suggests that this modality is associated with lower rates of SBE. Author Disclosure: F.S. Cardinale, None; V.M. Dest, EUSA Pharmaceuticals, D. Speakers Bureau/Honoraria; Myriad Laboratories, D. Speakers Bureau/Honoraria; P. Dickey, None; I. Goodrich, None; J. Gorelick, None; R. Sinha, Xoft, F. Consultant/Advisory Board.
2189
Outcomes of Patients with Resected Metastatic Brain Lesions Treated with Gamma Knife or Whole Brain Irradiation
J. T. Dilworth1, N. J. Hurst2, P. Y. Chen1, S. F. Shaitelman1, A. Baschnagel1, H. Ye1, A. Maitz1, D. J. Krauss1, D. Pieper1, I. S. Grills1 1
William Beaumont Hospital, Royal Oak, MI, 2Wayne State University School of Medicine, Detroit, MI
Purpose/Objective(s): To report the efficacy of Gamma Knife radiosurgery (GK) or whole brain irradiation (WB) following resection in patients with solitary or limited brain metastases. Materials/Methods: A total of 69 patients underwent resection of a single lesion followed by either GK (n = 47 patients; 123 tumors) or WB (n = 22 patients; 23 tumors) between 1/2004 and 12/2009. Median age, tumor histology, KPS, and RPA distributions were similar among groups. 57%, 21%, 13%, 2%, and 6% of patients in the GK group had 1, 2, 3, 4, or .4 lesions vs. 77%, 9%, 5%, 0%, and 0% in the WB (p = NS). The median max linear dimension of resection cavities (3.1 cm) was greater than that of unresected lesions treated with GK (0.8 cm). Median marginal dose for GK cases was 16 Gy to the 50% isodose (13-18 Gy); median WB dose was 35 Gy in 14 fractions. Statistical analysis correlated outcomes with demographic, tumor, and treatment characteristics. Results: The 1 and 2 yr local control (LC) rates after GK were 91% and 75% for resection cavities vs. 98% and 93% for unresected lesions (p = 0.015). Only max tumor linear dimension predicted LC (p = 0.015) with tumors #2.3 cm having higher LC (p = 0.007, 91% sensitivity, 62% specificity) after GK. LC was 82% after WB (mean time from WBI to recurrence = 5.6 mos). Elsewhere brain failure (EBF) was higher after GK than after WB with 1-year and 2-year rates of 51% and 76% vs. 16% and 31%, respectively (p = 0.012). Six resection cavities and 2 unresected lesions treated with GK required GK re-treatment; 9 GK patients had salvage WB. Although GK was associated with higher EBF, overall survival (OS) was similar after GK or WB (1y OS 52% GK vs. 59% WB; 2y OS 34% GK vs. 36% GK, p = NS). On univariate analysis, tumor histology, number of extracranial metastatic sites, and controlled primary disease predicted OS. Patients with brain only disease had 1.2-yr mean survival vs. 0.5 yr and 0.6 yr for 1 or multiple other sites (p = 0.05); those with controlled primary disease survived mean 1.27y vs. 0.75y without (p = 0.04). Control of primary disease also conferred higher survival for patients treated with WBI (3.4 yrs vs. 0.9 yrs for those with uncontrolled disease, p \ 0.001). Other than one case of grade 3 nausea/emesis and one grade 1 skin reaction, GK patients had no other acute toxicities. Conclusions: GK following resection in patients with brain metastases provides effective LC of the resection bed and unresected lesions. When compared to the more standard therapy of WB administered postoperatively, GK is associated with higher EBF but does not reduce OS. Because GK offers effective LC, has a favorable toxicity profile, and avoids long-term cognitive effects of WBI, it warrants further study as a WB alternative after brain metastasis resection. Author Disclosure: J.T. Dilworth, None; N.J. Hurst, None; P.Y. Chen, None; S.F. Shaitelman, None; A. Baschnagel, None; H. Ye, None; A. Maitz, None; D.J. Krauss, None; D. Pieper, None; I.S. Grills, GMGK stock ownership, G. Other.
2190
Radiosurgery of Glomus Jugulare Tumors: A Meta-analysis 1
Z. D. Guss , S. Batra1, G. Li2, S. D. Chang2, A. T. Parsa3, D. Rigamonti1, L. Kleinberg4, M. Lim1 1
Johns Hopkins Hospital Department of Neurosurgery, Baltimore, MD, 2Stanford University Medical Center Department of Neurosurgery, Stanford, CA, 3UCSF Department of Neurological Surgery, San Francisco, CA, 4Johns Hopkins Hospital Department of Radiation Oncology, Baltimore, MD
S288
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Volume 78, Number 3, Supplement, 2010
Radiosurgery for Meningiomas: Does Fractionation Prevent Brain Edema?
F. S. Cardinale1, V. M. Dest1, P. Dickey1, I. Goodrich1, J. Gorelick1, R. Sinha2 1
Hospital of Saint Raphael, New Haven, CT, 2El Camino Hospital, Mountain View, CA
Purpose/Objective(s): Most studies of radiosurgery for meningioma have shown a high rate of post-treatment symptomatic brain edema (SBE) for parasagittal lesions and lower, but still significant rates at other locations. However, there is some evidence that rates are lower with fractionated stereotactic radiotherapy than with single fraction treatment. We present a series of meningiomas treated since 1999 at a single institution utilizing three regimens: LINAC-based fractionated stereotactic radiotherapy (FSR), single fraction LINAC-based radiosurgery (LRS), and fractionated radiosurgery with Cyberknife (CK)–in order to determine whether rates of SBE were different between the 3 modalities. Materials/Methods: We retrospectively reviewed records of 86 patients with 104 meningiomas treated either with FSR, LRS, or CK. Since 2008, all treatments were accomplished with CK. Mean marginal dose for treatments with FSR (53 tumors), LRS (19 tumors), and CK (32 tumors) respectively was 47.9 Gy, 13.94 Gy, and 25 Gy. Mean number of fractions for FSR and CK were 26 and 5. Rates of SBE were calculated for the entire population and for each of the 3 treatment modalities. Mean follow-up for all patients was 49 months. Results: Rates of the development of SBE for the entire population, the FSR, LRS, and CK groups were, respectively: 1.0%, 2%, 0, and 0%. The differences did not reach statistical significance. Only 1 patient developed SBE, an 89 year old man with a parasagittal lesion. One patient with atypical histology died as a result of SBE and tumor progression, and one patient had visual loss after treatment of an optic canal tumor. Tumor control rate was 96%. Conclusions: Very low rates of SBE can be achieved with effective tumor control in the radiosurgical treatment of meningiomas. With only one case of SBE, we cannot determine whether fractionation is superior to single fraction therapy. However, 80% of tumors in our series were treated with fractionation which suggests that this modality is associated with lower rates of SBE. Author Disclosure: F.S. Cardinale, None; V.M. Dest, EUSA Pharmaceuticals, D. Speakers Bureau/Honoraria; Myriad Laboratories, D. Speakers Bureau/Honoraria; P. Dickey, None; I. Goodrich, None; J. Gorelick, None; R. Sinha, Xoft, F. Consultant/Advisory Board.
2189
Outcomes of Patients with Resected Metastatic Brain Lesions Treated with Gamma Knife or Whole Brain Irradiation
J. T. Dilworth1, N. J. Hurst2, P. Y. Chen1, S. F. Shaitelman1, A. Baschnagel1, H. Ye1, A. Maitz1, D. J. Krauss1, D. Pieper1, I. S. Grills1 1
William Beaumont Hospital, Royal Oak, MI, 2Wayne State University School of Medicine, Detroit, MI
Purpose/Objective(s): To report the efficacy of Gamma Knife radiosurgery (GK) or whole brain irradiation (WB) following resection in patients with solitary or limited brain metastases. Materials/Methods: A total of 69 patients underwent resection of a single lesion followed by either GK (n = 47 patients; 123 tumors) or WB (n = 22 patients; 23 tumors) between 1/2004 and 12/2009. Median age, tumor histology, KPS, and RPA distributions were similar among groups. 57%, 21%, 13%, 2%, and 6% of patients in the GK group had 1, 2, 3, 4, or .4 lesions vs. 77%, 9%, 5%, 0%, and 0% in the WB (p = NS). The median max linear dimension of resection cavities (3.1 cm) was greater than that of unresected lesions treated with GK (0.8 cm). Median marginal dose for GK cases was 16 Gy to the 50% isodose (13-18 Gy); median WB dose was 35 Gy in 14 fractions. Statistical analysis correlated outcomes with demographic, tumor, and treatment characteristics. Results: The 1 and 2 yr local control (LC) rates after GK were 91% and 75% for resection cavities vs. 98% and 93% for unresected lesions (p = 0.015). Only max tumor linear dimension predicted LC (p = 0.015) with tumors #2.3 cm having higher LC (p = 0.007, 91% sensitivity, 62% specificity) after GK. LC was 82% after WB (mean time from WBI to recurrence = 5.6 mos). Elsewhere brain failure (EBF) was higher after GK than after WB with 1-year and 2-year rates of 51% and 76% vs. 16% and 31%, respectively (p = 0.012). Six resection cavities and 2 unresected lesions treated with GK required GK re-treatment; 9 GK patients had salvage WB. Although GK was associated with higher EBF, overall survival (OS) was similar after GK or WB (1y OS 52% GK vs. 59% WB; 2y OS 34% GK vs. 36% GK, p = NS). On univariate analysis, tumor histology, number of extracranial metastatic sites, and controlled primary disease predicted OS. Patients with brain only disease had 1.2-yr mean survival vs. 0.5 yr and 0.6 yr for 1 or multiple other sites (p = 0.05); those with controlled primary disease survived mean 1.27y vs. 0.75y without (p = 0.04). Control of primary disease also conferred higher survival for patients treated with WBI (3.4 yrs vs. 0.9 yrs for those with uncontrolled disease, p \ 0.001). Other than one case of grade 3 nausea/emesis and one grade 1 skin reaction, GK patients had no other acute toxicities. Conclusions: GK following resection in patients with brain metastases provides effective LC of the resection bed and unresected lesions. When compared to the more standard therapy of WB administered postoperatively, GK is associated with higher EBF but does not reduce OS. Because GK offers effective LC, has a favorable toxicity profile, and avoids long-term cognitive effects of WBI, it warrants further study as a WB alternative after brain metastasis resection. Author Disclosure: J.T. Dilworth, None; N.J. Hurst, None; P.Y. Chen, None; S.F. Shaitelman, None; A. Baschnagel, None; H. Ye, None; A. Maitz, None; D.J. Krauss, None; D. Pieper, None; I.S. Grills, GMGK stock ownership, G. Other.
2190
Radiosurgery of Glomus Jugulare Tumors: A Meta-analysis 1
Z. D. Guss , S. Batra1, G. Li2, S. D. Chang2, A. T. Parsa3, D. Rigamonti1, L. Kleinberg4, M. Lim1 1
Johns Hopkins Hospital Department of Neurosurgery, Baltimore, MD, 2Stanford University Medical Center Department of Neurosurgery, Stanford, CA, 3UCSF Department of Neurological Surgery, San Francisco, CA, 4Johns Hopkins Hospital Department of Radiation Oncology, Baltimore, MD