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Browsing by Subject "Stereotactic radiosurgery"
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Item Development of a standardized method for radiation therapy contouring of the piriform cortex(Old City Publishing, 2019) McClelland, Shearwood; Watson, Gordon A.; Radiation Oncology, School of MedicineItem Efficacy of pre-operative stereotactic radiosurgery followed by surgical resection and correlative radiobiological analysis for patients with 1-4 brain metastases: study protocol for a phase II trial(Biomed Central, 2018-12-20) Huff, Wei X.; Agrawal, Namita; Shapiro, Scott; Miller, James; Kulwin, Charles; Shah, Mitesh; Savage, Jesse J.; Payner, Troy; Vortmeyer, Alexander; Watson, Gordon; Dey, Mahua; Neurological Surgery, School of MedicineBACKGROUND: Stereotactic radiosurgery (SRS) has emerged as a common adjuvant modality used with surgery for resectable brain metastases (BMs). However, the optimal sequence of the multi-modality therapy has not been established. The goal of the study is to evaluate 6-month local control utilizing pre-operative SRS followed by surgical resection for patients with 1-4 brain metastases. METHODS: This prospective, single arm, phase II trial will recruit patients with up to 4 brain metastases and at least one resectable lesion. All lesions will be treated with SRS and symptomatic lesions will be resected within 1-4 days after SRS. Patients will be monitored for 6-month local control, in-brain progression free survival, distant in-brain failure, rate of leptomeningeal spread, radiation necrosis and overall survival. Additionally, we will also perform correlative radiobiological molecular studies to assess the effect of radiation dosing on the tumor tissue and clinical outcomes. We expect that pre-operative SRS to the gross tumor prior to surgical resection will improve local control and decrease leptomeningeal failure. DISCUSSION: Our study is the second prospective trial to investigate the efficacy of pre-operative SRS in the treatment of multiple BMs. In addition, the correlative molecular studies will be the first to investigate early response of BMs at a cellular and genetic level in response to radiation doses and potentially provide molecular prognostic markers for local control and overall survival.Item Evidence-based methodology for obtaining commercial insurance coverage of stereotactic radiosurgery for intractable epilepsy(Elsevier, 2020) McClelland, Shearwood, III.; Verma, Vivek; Radiation Oncology, School of MedicineObjectives: The coverage policies of many commercial insurers in the United States do not include coverage of stereotactic radiosurgery (SRS) for intractable epilepsy despite recent Level I evidence supporting its efficacy. We sought to assess the efficacy of an evidence-based methodology in obtaining coverage approval of SRS for intractable epilepsy. Patients and methods: The clinical policy guidelines from five of the largest United States commercial insurers were reviewed for their language regarding coverage of SRS for epilepsy. An evidence-based questionnaire was created for temporal lobe epilepsy and extratemporal lobe epilepsy based on recent evidence. Telephone interviewers of Insurers assessed the likelihood of SRS coverage for an epilepsy patient meeting the clinical inclusion criteria in the questionnaire. This likelihood was assessed numerically based on interviewee response (2 = yes, 1 = dependent on peer-to-peer, 0 = no). Results: Of the five policy guidelines, none included literature more recent than 2017. For TLE, 3/5 insurance companies indicated likely SRS coverage; 2/5 indicated peer-to-peer discussion dependence for patients meeting questionnaire criteria for a score of 8/10. For extratemporal TLE, 2/5 companies indicated likely SRS coverage and 3/5 indicated peer-to-peer discussion dependence for a total score of 7/10. Conclusion: Creation of an evidence-based methodology in approaching commercial insurers greatly increased the likelihood of SRS coverage for an indication (intractable epilepsy) widely perceived as investigational. These results should pave the way for epilepsy patients to receive coverage should they be appropriate SRS candidates.Item Neoadjuvant Stereotactic Radiotherapy for Brain Metastases: Systematic Review and Meta-Analysis of the Literature and Ongoing Clinical Trials(MDPI, 2022-09-04) Palmisciano, Paolo; Ferini, Gianluca; Khan, Ramlah; Bin-Alamer, Othman; Umana, Giuseppe E.; Yu, Kenny; Cohen-Gadol, Aaron A.; El Ahmadieh, Tarek Y.; Haider, Ali S.; Neurological Surgery, School of MedicineBackground: Brain metastases (BMs) carry a high morbidity and mortality burden. Neoadjuvant stereotactic radiotherapy (NaSRT) has shown promising results. We systematically reviewed the literature on NaSRT for BMs. Methods: PubMed, EMBASE, Scopus, Web-of-Science, Cochrane, and ClinicalTrial.gov were searched following the PRISMA guidelines to include studies and ongoing trials reporting NaSRT for BMs. Indications, protocols, and outcomes were analyzed using indirect random-effect meta-analyses. Results: We included 7 studies comprising 460 patients with 483 BMs, and 13 ongoing trials. Most BMs originated from non-small lung cell carcinoma (41.4%), breast cancer (18.7%) and melanoma (43.6%). Most patients had single-BM (69.8%) located supratentorial (77.8%). Patients were eligible if they had histologically-proven primary tumors and ≤4 synchronous BMs candidate for non-urgent surgery and radiation. Patients with primary tumors clinically responsive to radiotherapy, prior brain radiation, and leptomeningeal metastases were deemed non-eligible. Median planning target volume was 9.9 cm3 (range, 2.9-57.1), and NaSRT was delivered in 1-fraction (90.9%), 5-fraction (4.8%), or 3-fraction (4.3%), with a median biological effective dose of 39.6 Gy10 (range, 35.7-60). Most patients received piecemeal (76.3%) and gross-total (94%) resection after a median of 1-day (range, 1-10) post-NaSRT. Median follow-up was 19.2-months (range, 1-41.3). Actuarial post-treatment rates were 4% (95%CI: 2-6%) for symptomatic radiation necrosis, 15% (95%CI: 12-18%) and 47% (95%CI: 42-52%) for local and distant recurrences, 6% (95%CI: 3-8%) for leptomeningeal metastases, 81% (95%CI: 75-87%) and 59% (95%CI: 54-63%) for 1-year local tumor control and overall survival. Conclusion: NaSRT is effective and safe for BMs. Ongoing trials will provide high-level evidence on long-term post-treatment outcomes, further compared to adjuvant stereotactic radiotherapy.Item Predictors of linear accelerator versus Gamma Knife stereotactic radiosurgery use for brain metastases in the United States(Oxford Academic, 2019-11) McClelland, Shearwood, III.; Degnin, Catherine; Chen, Yiyi; Watson, Gordon A.; Jaboin, Jerry J.; Radiation Oncology, School of MedicineINTRODUCTION Stereotactic radiosurgery (SRS) for brain metastases is predominantly delivered via single-fraction Gamma Knife SRS (GKRS) or linear accelerator (LINAC) in 1–5 fractions. Predictors of SRS modality have been sparsely examined on a nationwide level. METHODS The 2010–2016 National Cancer Database identified brain metastases patients from non-small cell lung cancer throughout the United States (US) having undergone SRS. A multivariable logistic regression model characterized SRS receipt, adjusting for patient age, dose, geographic location of treatment, facility type, and distance from treatment facility. RESULTS A total of 1,760 patients received GKRS, while 1,064 patients received LINAC SRS. Treatment at non-academic facilities was associated with increased LINAC SRS receipt, most prominently in the Midwestern (OR= 6.23; p< 0.001), Northeastern (OR= 4.42; p< 0.001), and Southern US (OR= 1.96;p< 0.001). Administered doses of 18–19 Gy (OR= 1.42;p= 0.025), 20–21 Gy (OR= 1.82;p< 0.001), and 22–24 Gy (OR= 3.11;p< 0.001) were associated with increased LINAC SRS receipt, as was patient location within 20 miles of a radiation treatment facility (OR= 1.27;p= 0.007). CONCLUSIONS Despite Gamma Knife being more prominently used over LINAC for SRS, patients treated at non-academic facilities outside of the Western US were substantially more likely to receive LINAC over Gamma Knife. Patients located in the Midwest were 523% more likely, Northeast 342% more likely, and South 96% more likely to receive LINAC when treated at a non-academic facility. Increasing dose independently predicted LINAC over GKRS, indicating that smaller tumors – particularly those less than two centimeters (consistent with RTOG 90-05 recommendations) – are being treated with LINAC. Finally, patients residing in close proximity to a treatment center were 27% more likely to receive LINAC, likely indicative of the increased geographic accessibility of LINAC compared with GKRS. These findings should result in hypothesis-generating questions to further explore predictors of LINAC versus GKRS.Item Radiosurgery dose reduction for brain metastases on immunotherapy (RADREMI): A prospective phase I study protocol(Elsevier, 2020) McClelland, Shearwood, III.; Lautenschlaeger, Tim; Zang, Yong; Hanna, Nasser H.; Shiue, Kevin; Kamer, Aaron P.; Agrawal, Namita; Ellsworth, Susannah G.; Rhome, Ryan M.; Watson, Gordon A.; Radiation Oncology, School of MedicineIntroduction: Up to 20% of patients with brain metastases treated with immune checkpoint inhibitor (ICI) therapy and concomitant stereotactic radiosurgery (SRS) suffer from symptomatic radiation necrosis. The goal of this study is to evaluate Radiosurgery Dose Reduction for Brain Metastases on Immunotherapy (RADREMI) on six-month symptomatic radiation necrosis rates. Methods: This study is a prospective single arm Phase I pilot study which will recruit patients with brain metastases receiving ICI delivered within 30 days before SRS. All patients will be treated with RADREMI dosing, which involves SRS doses of 18 Gy for 0-2 cm lesions, 14 Gy for 2.1-3 cm lesions, and 12 Gy for 3.1-4 cm lesions. All patients will be monitored for six-month symptomatic radiation necrosis (defined as a six-month rate of clinical symptomatology requiring steroid administration and/or operative intervention concomitant with imaging findings consistent with radiation necrosis) and six-month local control. We expect that RADREMI dosing will significantly reduce the symptomatic radiation necrosis rate of concomitant SRS + ICI without significantly sacrificing the local control obtained by the present RTOG 90-05 SRS dosing schema. Local control will be defined according to the Response Assessment in Neuro-Oncology (RANO) criteria. Discussion: This study is the first prospective trial to investigate the safety of dose-reduced SRS in treatment of brain metastases with concomitant ICI. The findings should provide fertile soil for future multi-institutional collaborative efficacy trials of RADREMI dosing for this patient population.Item Radt-43. Treatment of Retroperitoneal Leiomyosarcoma Brain Metastases With Stereotactic Radiosurgery(Oxford University Press, 2020-11) McClelland, Shearwood, III.; Gardner, Ulysses; Langer, Mark; Shiue, Kevin; Radiation Oncology, School of MedicineIntroduction: Retroperitoneal leiomyosarcoma is a relatively rare disease, with infrequent metastatic spread to the CNS. We present the first report of radiosurgical treatment of this disease. Methods: A 49-year-old woman developed leiomyosarcoma of the inferior vena cava and retroperitoneum with lung metastases on diagnosis. Following multiple courses of systemic and operative treatment, she developed a tender ulcerating mass in the left upper maxillary incisor associated with numbness along the upper gum, lip, and premaxillary area. CT revealed a 3.0 cm left posterior alveolar ridge gum lesion with bone invasion, for which she elected to undergo palliative radiation therapy (30 Gy in 10 fractions). Due to potential maxillary nerve involvement altering the intended radiation therapy treatment fields, an orbit/face MRI was performed to better delineate the lesion. On this MRI, two frontal lobe lesions were visualized; subsequent dedicated brain MRI revealed a total of five metastases (0.9 cm right superior frontal gyrus, 0.9 cm left middle frontal gyrus, 0.9 cm right postcentral gyrus, 0.7 cm right occipital, and 1.6 cm left occipital). Consequently, the decision was made to treat the brain metastases with linear accelerator (LINAC) stereotactic radiosurgery (SRS) to allow simultaneous treatment of the maxillary lesion and brain metastases. Results: A single CT simulation was performed for her intracranial and extracranial disease, using the Encompass face mask to allow for simultaneous head immobilization and optimal SRS targeting accuracy. LINAC SRS was delivered simultaneously during maxillary lesion radiation therapy to all five lesions (22 Gy to the 80% isodose line) in a single fraction with a 0.2 cm planning target volume (PTV) margin for each lesion. Conclusions: The first reported case of metastatic retroperitoneal leiomyosarcoma brain metastases treated with SRS demonstrates the flexibility of LINAC (rather than Gamma Knife) SRS in allowing for simultaneous treatment of intracranial and extracranial metastatic disease.Item Resolution of Radiation-Induced Necrosis in Arteriovenous Malformation with Bevacizumab: A Case Report and Review of Current Literature(Karger, 2021-05-27) Kwong, Forrest; Scarpelli, Daphne B.; Barajas, Ramon F.; Monaco, Debra; Tanyi, James A.; McClelland, Shearwood; Jaboin, Jerry J.; Radiation Oncology, School of MedicineStereotactic radiosurgery (SRS) is a proven treatment modality for inoperable arteriovenous malformations (AVMs). However, the rate of radiation-induced necrosis (RIN) is as high as 10%. A 6-year-old female patient presented with severe headache, emesis, and syncope, and workup revealed a Spetzler-Martin grade 4 AVM with intraventricular hemorrhage and hydrocephalus. The patient underwent a right frontal ventriculostomy followed by a linear accelerator-based SRS of 16.9 Gy. At 19 years, she developed progressive neurological symptoms. Diagnostic magnetic resonance imaging (MRI) revealed a recurrent parietal AVM nidus. We delivered the linear accelerator-based SRS of 18.5 Gy to the AVM nidus. Within 9 months, she experienced episodic headaches and left-sided weakness and spasticity; symptoms were initially managed with dexamethasone. Follow-up MRI was notable for edema and nondetectable blood flow, consistent with RIN and AVM obliteration. The second course of steroids did not provide the symptom control. Persistent RIN was noted on MRI, and she had stigmata of steroid toxicity (centripetal obesity, depression, and sleep disorder). Two infusions of bevacizumab (5 mg/kg) were administered concurrently with a tapering dose of dexamethasone. The patient noted a near immediate improvement in her headaches, and 2 months following the second bevacizumab infusion, she reported a near-complete resolution of her symptoms and displayed improved ambulation. The development of RIN remains a noteworthy concern post-SRS of AVMs. While steroids aid with initial management of RIN, for persistent and recurrent symptoms, bevacizumab infusions serve as a viable treatment course, with the added benefit of reducing the likelihood of adverse effects resulting from prolonged steroid therapy.Item Upfront immunotherapy leads to lower brain metastasis velocity in patients undergoing stereotactic radiosurgery for brain metastases(Old City Publishing, 2022) Abdulhaleem, Mohammed; Scott, Emmanuel; Johnston, Hannah; Isom, Scott; Lanier, Claire; LeCompte, Michael; Cramer, Christina K.; Ruiz, Jimmy; Lo, Hui-Wen; Watabe, Kuonosuke; O’Neill, Stacey; Whitlow, Christopher; Tatter, Stephen B.; Laxton, Adrian W.; Su, Jing; Chan, Michael D.; Biostatistics, School of Public HealthBackground: While immunotherapy has been shown to improve survival and decrease neurologic death in patients with brain metastases, it remains unclear whether this improvement is due to prevention of new metastasis to the brain. Method: We performed a retrospective review of patients presenting with brain metastases simultaneously with the first diagnosis of metastatic disease and were treated with upfront immunotherapy as part of their treatment regimen and stereotactic radiosurgery (SRS) to the brain metastases. We compared this cohort with a historical control population (prior to the immunotherapy era) who were treated with pre-immunotherapy standard of care systemic therapy and with SRS to the brain metastases. Results: Median overall survival time was improved in the patients receiving upfront immunotherapy compared to the historical cohort (48 months vs 8.4 months, p=0.001). Median time to distant brain failure was statistically equivalent (p=0.3) between the upfront immunotherapy cohort and historical control cohort (10.3 vs 12.6 months). Brain metastasis velocity was lower in the upfront immunotherapy cohort (median 3.72 metastases per year) than in the historical controls (median 9.48 metastases per year, p=0.001). Cumulative incidence of neurologic death at one year was 12% in the upfront immunotherapy cohort and 28% in the historical control cohort (p=0.1). Conclusions: Upfront immunotherapy appears to improve overall survival and decrease BMV compared to historical controls. While these data remain to be validated, they suggest that brain metastasis patients may benefit from concurrent immunotherapy with SRS.