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Neuro-oncology Jun 2019Primary spinal cord tumors represent a hetereogeneous group of central nervous system malignancies whose management is complex given the relatively uncommon nature of... (Review)
Review
Primary spinal cord tumors represent a hetereogeneous group of central nervous system malignancies whose management is complex given the relatively uncommon nature of the disease and variety of tumor subtypes, functional neurologic deficits from the tumor, and potential morbidities associated with definitive treatment. Advances in neuroimaging; integration of diagnostic, prognostic, and predictive molecular testing into tumor classification; and developments in neurosurgical techniques have refined the current role of radiotherapy in the multimodal management of patients with primary spinal cord tumors, and corroborated the need for prospective, multidisciplinary discussion and treatment decision making. Radiotherapeutic technological advances have dramatically improved the entire continuum from treatment planning to treatment delivery, and the development of stereotactic radiosurgery and proton radiotherapy provides new radiotherapy options for patients treated in the definitive, adjuvant, or salvage setting. The objective of this comprehensive review is to provide a contemporary overview of the management of primary intradural spinal cord tumors, with a focus on radiotherapy.
Topics: Disease Management; Humans; Radiation Oncology; Radiosurgery; Radiotherapy; Spinal Cord Neoplasms
PubMed: 30977511
DOI: 10.1093/neuonc/noz014 -
Missouri Medicine 2015Lung stereotactic body radiation therapy (SBRT) is a novel and effective modality for treatment of early stage non-sail cell lung cancer (NSCLC), with expanding... (Review)
Review
Lung stereotactic body radiation therapy (SBRT) is a novel and effective modality for treatment of early stage non-sail cell lung cancer (NSCLC), with expanding indications in locally advanced and metastatic disease. Herein, we will review current treatment recommendations for early stage NSCLC, detail treatment planning of SBRT, and discuss future directions.
Topics: Carcinoma, Non-Small-Cell Lung; Humans; Lung Neoplasms; Radiosurgery
PubMed: 26606817
DOI: No ID Found -
Neurology India 2023There is a plethora of papers on the role of stereotactic radiosurgery (SRS) in various benign and malignant intracranial tumors, and it is possible to overlook the most... (Review)
Review
There is a plethora of papers on the role of stereotactic radiosurgery (SRS) in various benign and malignant intracranial tumors, and it is possible to overlook the most important and landmark studies. Thus, the necessity of citation analysis arises, which reviews the most cited articles and recognizes the impact made by these articles. Utilizing the 100 most cited articles describing the use of SRS for intracranial and spinal pathologies, this article aims to provide meaningful information regarding the historical trends and recent directions in which this field is headed. We performed a search of the Web of Science database using the keywords "stereotactic radiosurgery," "gamma knife," "GKRS," "gamma knife radiosurgery," "LINAC," and "Cyberknife" on May 14, 2022. Our search retrieved a total of 30,652 articles published between the years 1968 and 2017. The top 100 cited articles were arranged in descending order based on citation count (CC) and citation per year (CY). The journal with the largest number of publications as well as citation count was the International Journal of Radiation Oncology Biology Physics (n = 33), followed by Journal of Neurosurgery (n = 25). The most cited article was authored by Andrews, which was published in 2004 in The Lancet (1699 CC, 89.42 CY). Flickinger, with 25 papers and 7635 total citations, was the author with the highest impact. Lunsford, with 25 publications and total citations of 7615, was a close second. The USA was the leading country with the maximum number of total citations (n = 23,054). Ninety-two articles described the use of SRS for intracranial pathologies (metastases, n = 38; AVM, n = 16; vestibular schwannoma, n = 9; meningioma, n = 8; trigeminal neuralgia, n = 6; sellar lesion, n = 2; glioma, n = 2; functional, n = 1; and procedure related, n = 10). Eight studies describing spinal radiosurgery were included, out of which four were on spinal metastases. Citation analyses of the top 100 articles revealed that the focus of research in the field of SRS started with functional neurosurgery and progressed to benign intracranial tumors and AVMs. More recently, central nervous system (CNS) metastases have received the maximum attention with 38 articles, including 14 randomized controlled trials finding a place in the top 100 cited articles. Presently, the use of SRS is concentrated in developed countries. Efforts need to be made for more widespread use in developing nations to bring the maximum possible benefits of this focused noninvasive treatment to a wider population.
Topics: Humans; Radiosurgery; Neurosurgery; Neurosurgical Procedures; Brain Neoplasms; Arteriovenous Malformations; Meningeal Neoplasms
PubMed: 37026333
DOI: 10.4103/0028-3886.373651 -
Journal of Applied Clinical Medical... Nov 2023A 6FFF Monte Carlo (MC) dose calculation algorithm was commissioned for spine stereotactic radiosurgery (SRS). Model generation, validation, and ensuing model tuning are...
PURPOSE
A 6FFF Monte Carlo (MC) dose calculation algorithm was commissioned for spine stereotactic radiosurgery (SRS). Model generation, validation, and ensuing model tuning are presented.
METHODS
The model was generated using in-air and in-water commissioning measurements of field sizes between 10 and 400 mm . Commissioning measurements were compared to simulated water tank MC calculations to validate output factors, percent depth doses (PDDs), profile sizes and penumbras. Previously treated Spine SRS patients were re-optimized with the MC model to achieve clinically acceptable plans. Resulting plans were calculated on the StereoPHAN phantom and subsequently delivered to the microDiamond and SRSMapcheck to verify calculated dose accuracy. Model tuning was performed by adjusting the model's light field offset (LO) distance between physical and radiological positions of the MLCs, to improve field size and StereoPHAN calculation accuracy. Following tuning, plans were generated and delivered to an anthropomorphic 3D-printed spine phantom featuring realistic bone anatomy, to validate heterogeneity corrections. Finally, plans were validated using polymer gel (VIPAR based formulation) measurements.
RESULTS
Compared to open field measurements, MC calculated output factors and PDDs were within 2%, profile penumbra widths were within 1 mm, and field sizes were within 0.5 mm. Calculated point dose measurements in the StereoPHAN were within 0.26% ± 0.93% and -0.10% ± 1.37% for targets and spinal canals, respectively. Average SRSMapcheck per-plan pass rates using a 2%/2 mm/10% threshold relative gamma analysis was 99.1% ± 0.89%. Adjusting LOs improved open field and patient-specific dosimetric agreement. Anthropomorphic phantom measurements were within -1.29% ± 1.00% and 0.27% ± 1.36% of MC calculated for the vertebral body (target) and spinal canal, respectively. VIPAR gel measurements confirmed good dosimetric agreement near the target-spine junction.
CONCLUSION
Validation of a MC algorithm for simple fields and complex SRS spine deliveries in homogeneous and heterogeneous phantoms has been performed. The MC algorithm has been released for clinical use.
Topics: Humans; Radiosurgery; Radiotherapy Planning, Computer-Assisted; Algorithms; Radiometry; Water
PubMed: 37431696
DOI: 10.1002/acm2.14092 -
World Journal of Gastroenterology Aug 2015To present a systematic review of techniques and clinical results. (Review)
Review
AIM
To present a systematic review of techniques and clinical results.
METHODS
A systematic review of published literature was performed. Only studies reporting patient outcome after radiosurgery (single fraction) delivered with robotic devices [i.e., robotic radiosurgery (RRS)] have been analyzed.
RESULTS
A total of 96 patients from 5 studies were included. The studies are characterized by small series and different methods in terms of dose, target definition, combination with chemotherapy and/or standard fractionated radiotherapy and evaluation modalities. Preliminary results are positive in terms of tumor response (ORR = 56%) and local control of the tumor (crude rate of local progressions: 19.5%). Results for median overall survival (11.4 mo) seem comparable with the ones of prolonged chemoradiation (range: 8.6-13.0 mo). However, gastrointestinal toxicity seems to be the main limitation of RRS, especially at the duodenal level.
CONCLUSION
RRS allows for local treatment in a shortened time (1 fraction) compared to traditional treatments (about 1 mo), providing the possibility for an easy integration with systemic therapies. Preliminary results did not show any outcome differences compared to standard chemoradiation. Thus, further efforts to reduce gastrointestinal toxicity are strongly needed.
Topics: Chemoradiotherapy; Dose Fractionation, Radiation; Humans; Pancreatic Neoplasms; Radiosurgery; Robotic Surgical Procedures; Treatment Outcome
PubMed: 26309369
DOI: 10.3748/wjg.v21.i31.9420 -
JAMA Oncology Nov 2022After the publication of the landmark SABR-COMET trial, concerns arose regarding high-grade toxic effects of treatment with stereotactic ablative body radiotherapy...
Treatment With Stereotactic Ablative Radiotherapy for Up to 5 Oligometastases in Patients With Cancer: Primary Toxic Effect Results of the Nonrandomized Phase 2 SABR-5 Clinical Trial.
IMPORTANCE
After the publication of the landmark SABR-COMET trial, concerns arose regarding high-grade toxic effects of treatment with stereotactic ablative body radiotherapy (SABR) for oligometastases.
OBJECTIVE
To document toxic effects of treatment with SABR in a large cohort from a population-based, provincial cancer program.
DESIGN, SETTING, AND PARTICIPANTS
From November 2016 to July 2020, 381 patients across all 6 cancer centers in British Columbia were treated in this single-arm, phase 2 trial of treatment with SABR for patients with oligometastatic or oligoprogressive disease. During this period, patients were only eligible to receive treatment with SABR in these settings in trials within British Columbia; therefore, this analysis is population based, with resultant minimal selection bias compared with previously published SABR series.
INTERVENTIONS
Stereotactic ablative body radiotherapy to up to 5 metastases.
MAIN OUTCOMES AND MEASURES
Rate of grade 2, 3, 4, and 5 toxic effects associated with SABR.
FINDINGS
Among 381 participants (122 women [32%]), the mean (SD; range) age was 68 (11.1; 30-97) years, and the median (range) follow-up was 25 (1-54) months. The most common histological findings were prostate cancer (123 [32%]), colorectal cancer (63 [17%]), breast cancer (42 [11%]), and lung cancer (33 [9%]). The number of SABR-treated sites were 1 (263 [69%]), 2 (82 [22%]), and 3 or more (36 [10%]). The most common sites of SABR were lung (188 [34%]), nonspine bone (136 [25%]), spine (85 [16%]), lymph nodes (78 [14%]), liver (29 [5%]), and adrenal (15 [3%]). Rates of grade 2, 3, 4, and 5 toxic effects associated with SABR (based on the highest-grade toxic effect per patient) were 14.2%; (95% CI, 10.7%-17.7%), 4.2% (95% CI, 2.2%-6.2%), 0%, and 0.3% (95% CI, 0%-0.8%), respectively. The cumulative incidence of grade 2 or higher toxic effects associated with SABR at year 2 by Kaplan-Meier analysis was 8%, and for grade 3 or higher, 4%.
CONCLUSIONS AND RELEVANCE
This single-arm, phase 2 clinical trial found that the incidence of grade 3 or higher SABR toxic effects in this population-based study was less than 5%. Furthermore, the rates of grade 2 or higher toxic effects (18.6%) were lower than previously published for SABR-COMET (29%). These results suggest that SABR treatment for oligometastases has acceptable rates of toxic effects and potentially support further enrollment in randomized phase 3 clinical trials.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT02933242.
Topics: Male; Humans; Radiosurgery; Lung Neoplasms; Dose Fractionation, Radiation; Prostatic Neoplasms; Kaplan-Meier Estimate
PubMed: 36173619
DOI: 10.1001/jamaoncol.2022.4394 -
Journal of Clinical Oncology : Official... Sep 2014Advances in radiotherapy planning and delivery have been used to treat patients with limited metastatic disease. With these techniques, high rates of treated metastasis... (Review)
Review
Advances in radiotherapy planning and delivery have been used to treat patients with limited metastatic disease. With these techniques, high rates of treated metastasis control and low toxicity have been reported. Some patients have long disease-free intervals after radiotherapy similar to those seen after surgical resection. Ongoing studies will determine the benefit of these irradiation techniques to treat limited metastases, identify appropriate candidates, and assist in integrating these treatments into management strategies for specific diseases.
Topics: Humans; Neoplasm Metastasis; Neoplasms; Radiosurgery; Radiotherapy Planning, Computer-Assisted
PubMed: 25113765
DOI: 10.1200/JCO.2014.55.9567 -
JAMA Oncology Jun 2021Stereotactic body radiotherapy (SBRT) for oligometastases is hypothesized to improve survival and is increasingly used. Little evidence supports its safe use to treat...
IMPORTANCE
Stereotactic body radiotherapy (SBRT) for oligometastases is hypothesized to improve survival and is increasingly used. Little evidence supports its safe use to treat patients with multiple metastases.
OBJECTIVE
To establish safety of SBRT dose schedules in patients with 3 to 4 metastases or 2 metastases in close proximity to each other.
DESIGN, SETTING, AND PARTICIPANTS
This phase 1 trial opened on August 4, 2014, and closed to accrual on March 20, 2018. Metastases to 7 anatomic locations were included: bone/osseous (BO), spinal/paraspinal (SP), peripheral lung (PL), central lung (CL), abdominal-pelvic (AP), mediastinal/cervical lymph node (MC), and liver (L). Six patients could be enrolled per anatomic site. The setting was a consortium of North American academic and community practice cancer centers participating in NRG Oncology trials. Patients with breast, prostate, or non-small cell lung cancer with 3 to 4 metastases or 2 metastases in close proximity (≤5 cm) amenable to SBRT were eligible for this phase 1 study. Statistical analyses were performed from December 31, 2017, to September 19, 2019.
INTERVENTIONS
The starting dose was 50 Gy in 5 fractions (CL, MC), 45 Gy in 3 fractions (PL, AP, L), and 30 Gy in 3 fractions (BO, SP).
MAIN OUTCOMES AND MEASURES
The primary end point was dose-limiting toxicity (DLT) defined by the Common Terminology Criteria for Adverse Events, version 4.0, as specific adverse events (AEs) of grades 3 to 5 (definite or probable per the protocol DLT definition) related to SBRT within 180 days of treatment. Dose levels were considered safe if DLTs were observed in no more than 1 of 6 patients per location; otherwise, the dose at that location would be de-escalated.
RESULTS
A total of 42 patients enrolled, 39 were eligible, and 35 (mean [SD] age, 63.1 [14.2] years; 20 men [57.1%]; 30 White patients [85.7%]) were evaluable for DLT. Twelve patients (34.3%) had breast cancer, 10 (28.6%) had non-small cell lung cancer, and 13 (37.1%) had prostate cancer; there was a median of 3 metastases treated per patient. Median survival was not reached. No protocol-defined DLTs were observed. When examining all AEs, 8 instances of grade 3 AEs, most likely related to protocol therapy, occurred approximately 125 to 556 days from SBRT initiation in 7 patients.
CONCLUSIONS AND RELEVANCE
This phase 1 trial demonstrated the safety of SBRT for patients with 3 to 4 metastases or 2 metastases in close proximity. There were no treatment-related deaths. Late grade 3 AEs demonstrate the need for extended follow-up in long-surviving patients with oligometastatic disease. Treatment with SBRT for multiple metastases has been expanded into multiple ongoing randomized phase 2/3 National Cancer Institute-sponsored trials (NRG-BR002, NRG-LU002).
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT02206334.
Topics: Breast Neoplasms; Carcinoma, Non-Small-Cell Lung; Female; Humans; Lung Neoplasms; Male; Prostatic Neoplasms; Radiosurgery
PubMed: 33885704
DOI: 10.1001/jamaoncol.2021.0687 -
Chinese Clinical Oncology Apr 2022The management of metastatic disease has been greatly influenced by molecular-based tumor classification and associated therapeutic targets, leading to a significant... (Review)
Review
BACKGROUND AND OBJECTIVE
The management of metastatic disease has been greatly influenced by molecular-based tumor classification and associated therapeutic targets, leading to a significant improvement in survival in many cases. This improvement, in both progression free survival and overall survival, has led to an increased incidence of brain metastases (BM) in a population with systemically well controlled disease or patients with promising therapeutic options available. Within this review, we discuss the paradigm of treatment for 5 to 15 BM, and how the treatment has evolved away from short-term palliation towards providing long term intracranial control.
METHODS
A review of literature pertaining to treatment of multiple BM was performed. We searched in PubMed to identify literature on treatment of multiple brain metastases. Only English literature published until February 1st, 2022 was reviewed.
KEY CONTENT AND FINDINGS
The management of 5-15 BM include multi-modality treatment pathways that are tailored towards each individual's primary cancer and burden of disease. Surgical resection of a dominant metastasis is still reserved for large symptomatic lesions, and is combined with post-operative local disease control. Overall, there is a shift away from whole brain radiation therapy (WBRT) due to side effect profile towards stereotactic radiosurgery (SRS). However, advances in WBRT continue to be studied, as well as the use of immunotherapy, targetable mutations, and synergistic effects between SRS and targeted therapies.
CONCLUSIONS
The use of SRS to treat 5 to 15 BM is an increasingly acceptable and well-regarded practice, along with a combinatorial approach taking into account systemic options during all treatment timepoints.
Topics: Brain Neoplasms; Combined Modality Therapy; Cranial Irradiation; Humans; Radiosurgery
PubMed: 35534795
DOI: 10.21037/cco-22-15 -
Seminars in Radiation Oncology Apr 2022For patients with oligometastatic cancer, radiotherapy presents a promising avenue for achieving meaningful symptom relief and durable disease control. Data from... (Review)
Review
For patients with oligometastatic cancer, radiotherapy presents a promising avenue for achieving meaningful symptom relief and durable disease control. Data from recently published and ongoing randomized studies are helping to define the appropriate contexts for effective intervention with stereotactic ablative body radiotherapy (SABR) in the oligometastatic setting. Importantly, older adults represent a significant portion of patients with oligometastatic disease, yet often comprise a minority of patients in clinical trials. Moreover, older adults of the same chronologic age may have variable degrees of fitness and frailty. In this review, we highlight the specific challenges and considerations for the use of radiotherapy for older adults with oligometastatic disease-noting the importance of geriatric assessments in clinical decision-making about the appropriateness of SABR and other metastasis-directed therapies in this population. We then review data from existing trials, including a subset analysis of adverse events and survival estimates among older adults enrolled in the landmark SABR-COMET trial. Finally, we discuss future directions for research, including the need for focused clinical trials in older adult cohorts. Ultimately, a multidisciplinary approach is critical when carefully balancing the potential risks and benefits of this emerging treatment paradigm in the older adult population.
Topics: Aged; Humans; Neoplasms; Radiosurgery
PubMed: 35307115
DOI: 10.1016/j.semradonc.2021.11.009