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Vol 27, No 1 (2022)
Review paper
Published online: 2021-12-10

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Stereotactic radiotherapy for brain oligometastases

Marco Lupattelli1, Paolo Tini2, Valerio Nardone3, Cynthia Aristei1, Simona Borghesi4, Ernesto Maranzano5, Paola Anselmo5, Gianluca Ingrosso1, Letizia Deantonio6, Michela Buglione di Monale e Bastia7
DOI: 10.5603/RPOR.a2021.0133
Rep Pract Oncol Radiother 2022;27(1):15-22.

Abstract

Brain metastases, the most common metastases in adults, will develop in up to 40% of cancer patients, accounting for more than one-half of all intracranial tumors. They are most associated with breast and lung cancer, melanoma and, less frequently, colorectal and kidney carcinoma. 

MRI is the gold standard for diagnosis. For the treatment plan, CT images are co-registered and fused with a gadolinium-enhanced T1-weighted MRI where tumor volume and organs at risk are contoured. Alternatively, plain and contrast-enhanced CT scans are co-registered. Single-fraction stereotactic radiotherapy (SRT) is used to treat patients with good performance status and up to 4 lesions with a diameter of 30 mm or less that are distant from crucial brain function areas. Fractionated SRT (2–5 fractions) is used for larger lesions, in eloquent areas or in proximity to crucial or surgically inaccessible areas and to reduce treatment-related neurotoxicity. The single-fraction SRT dose, which depends on tumor diameter, impacts local control. Fractionated SRT may encompass different schedules. No randomized trial data compared the safety and efficacy of single and multiple fractions. Both single-fraction and fractionated SRT provide satisfactory local control rates, tolerance, a low risk of transient acute adverse events and of radiation necrosis the incidence of which correlated with the irradiated brain volume. 

Keywords: stereotactic radiotherapyradiosurgeryoligometastasisbrain metastaseshypofractionationlocal controltoxicityradionecrosis

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References

  1. Soffietti R, Cornu P, Delattre JY, et al. EFNS Guidelines on diagnosis and treatment of brain metastases: report of an EFNS Task Force. Eur J Neurol. 2006; 13(7): 674–681.
    CrossRefPubMed
  2. Witzel I, Oliveira-Ferrer L, Pantel K, et al. Breast cancer brain metastases: biology and new clinical perspectives. Breast Cancer Res. 2016; 18(1): 8.
    CrossRefPubMed
  3. Brufsky AM, Mayer M, Rugo HS, et al. Central nervous system metastases in patients with HER2-positive metastatic breast cancer: incidence, treatment, and survival in patients from registHER. Clin Cancer Res. 2011; 17(14): 4834–4843.
    CrossRefPubMed
  4. Lekanidi K, Evans AL, Shah J, et al. Pattern of brain metastatic disease according to HER-2 and ER receptor status in breast cancer patients. Clin Radiol. 2013; 68(10): 1070–1073.
    CrossRefPubMed
  5. Quan AL, Videtic GMM, Suh JH. Brain metastases in small cell lung cancer. Oncology (Williston Park). 2004; 18(8): 961–72; discussion 974, 979.
    PubMed
  6. Hsiao SH, Lin HC, Chou YT, et al. Impact of epidermal growth factor receptor mutations on intracranial treatment response and survival after brain metastases in lung adenocarcinoma patients. Lung Cancer. 2013; 81(3): 455–461.
    CrossRefPubMed
  7. Chukwueke U, Batchelor T, Brastianos P. Management of Brain Metastases in Patients With Melanoma. J Oncol Pract. 2016; 12(6): 536–542.
    CrossRefPubMed
  8. Maranzano E, Casale M, Rispoli R, et al. LINAC-based radiosurgery for melanoma, sarcoma and renal cell carcinoma brain metastases. J Neurosurg Sci. 2020; 64(1): 37–43.
    CrossRefPubMed
  9. Chahine G, Ibrahim T, Felefly T, et al. Colorectal cancer and brain metastases: An aggressive disease with a different response to treatment. Tumori. 2019; 105(5): 427–433.
    CrossRefPubMed
  10. Khan M, Arooj S, Li R, et al. Tumor Primary Site and Histology Subtypes Role in Radiotherapeutic Management of Brain Metastases. Front Oncol. 2020; 10: 781.
    CrossRefPubMed
  11. Patchell RA, Tibbs PA, Regine WF, et al. Postoperative radiotherapy in the treatment of single metastases to the brain: a randomized trial. JAMA. 1998; 280(17): 1485–1489.
    CrossRefPubMed
  12. McPherson CM, Suki D, Feiz-Erfan I, et al. Adjuvant whole-brain radiation therapy after surgical resection of single brain metastases. Neuro Oncol. 2010; 12(7): 711–719.
    CrossRefPubMed
  13. Kocher M, Soffietti R, Abacioglu U, et al. Adjuvant whole-brain radiotherapy versus observation after radiosurgery or surgical resection of one to three cerebral metastases: results of the EORTC 22952-26001 study. J Clin Oncol. 2011; 29(2): 134–141.
    CrossRefPubMed
  14. Gutzmer R, Vordermark D, Hassel JC, et al. Melanoma brain metastases — Interdisciplinary management recommendations 2020. Cancer Treat Rev. 2020; 89: 102083.
    CrossRefPubMed
  15. Perlow HK, Dibs K, Liu K, et al. Whole-Brain Radiation Therapy Versus Stereotactic Radiosurgery for Cerebral Metastases. Neurosurg Clin N Am. 2020; 31(4): 565–573.
    CrossRefPubMed
  16. Minniti G, Clarke E, Lanzetta G, et al. Stereotactic radiosurgery for brain metastases: analysis of outcome and risk of brain radionecrosis. Radiat Oncol. 2011; 6: 48.
    CrossRefPubMed
  17. Fokas E, Henzel M, Surber G, et al. Stereotactic radiosurgery and fractionated stereotactic radiotherapy: comparison of efficacy and toxicity in 260 patients with brain metastases. J Neurooncol. 2012; 109(1): 91–98.
    CrossRefPubMed
  18. Mahajan A, Ahmed S, Li J, et al. Postoperative Stereotactic Radiosurgery Versus Observation for Completely Resected Brain Metastases: Results of a Prospective Randomized Study. Int J Radiat Oncol Biol Phys. 2016; 96(2): S2.
    CrossRef
  19. Lehrer EJ, Peterson JL, Zaorsky NG, et al. Single versus Multifraction Stereotactic Radiosurgery for Large Brain Metastases: An International Meta-analysis of 24 Trials. Int J Radiat Oncol Biol Phys. 2019; 103(3): 618–630.
    CrossRefPubMed
  20. Gutschenritter T, Venur VA, Combs SE, et al. The Judicious Use of Stereotactic Radiosurgery and Hypofractionated Stereotactic Radiotherapy in the Management of Large Brain Metastases. Cancers (Basel). 2020; 13(1).
    CrossRefPubMed
  21. Akeson P, Larsson EM, Kristoffersen DT, et al. Brain metastases--comparison of gadodiamide injection-enhanced MR imaging at standard and high dose, contrast-enhanced CT and non-contrast-enhanced MR imaging. Acta Radiol. 1995; 36(3): 300–306.
    PubMed
  22. Schellinger PD, Meinck HM, Thron A. Diagnostic accuracy of MRI compared to CCT in patients with brain metastases. J Neurooncol. 1999; 44(3): 275–281.
    CrossRefPubMed
  23. Suzuki K, Yamamoto M, Hasegawa Y, et al. Magnetic resonance imaging and computed tomography in the diagnoses of brain metastases of lung cancer. Lung Cancer. 2004; 46(3): 357–360.
    CrossRefPubMed
  24. Shaw E, Scott C, Souhami L, et al. Single dose radiosurgical treatment of recurrent previously irradiated primary brain tumors and brain metastases: final report of RTOG protocol 90-05. Int J Radiat Oncol Biol Phys. 2000; 47(2): 291–298.
    CrossRefPubMed
  25. Wiggenraad R, Verbeek-de Kanter A, Kal HB, et al. Dose-effect relation in stereotactic radiotherapy for brain metastases. A systematic review. Radiother Oncol. 2011; 98(3): 292–297.
    CrossRefPubMed
  26. Kim YJ, Cho KHo, Kim JY, et al. Single-dose versus fractionated stereotactic radiotherapy for brain metastases. Int J Radiat Oncol Biol Phys. 2011; 81(2): 483–489.
    CrossRefPubMed
  27. Fahrig A, Ganslandt O, Lambrecht U, et al. Hypofractionated stereotactic radiotherapy for brain metastases--results from three different dose concepts. Strahlenther Onkol. 2007; 183(11): 625–630.
    CrossRefPubMed
  28. Narayana A, Chang J, Yenice K, et al. Hypofractionated stereotactic radiotherapy using intensity-modulated radiotherapy in patients with one or two brain metastases. Stereotact Funct Neurosurg. 2007; 85(2-3): 82–87.
    CrossRefPubMed
  29. Saitoh Ji, Saito Y, Kazumoto T, et al. Therapeutic effect of linac-based stereotactic radiotherapy with a micro-multileaf collimator for the treatment of patients with brain metastases from lung cancer. Jpn J Clin Oncol. 2010; 40(2): 119–124.
    CrossRefPubMed
  30. Märtens B, Janssen S, Werner M, et al. Hypofractionated stereotactic radiotherapy of limited brain metastases: a single-centre individualized treatment approach. BMC Cancer. 2012; 12: 497.
    CrossRefPubMed
  31. Eaton BR, Gebhardt B, Prabhu R, et al. Hypofractionated radiosurgery for intact or resected brain metastases: defining the optimal dose and fractionation. Radiat Oncol. 2013; 8: 135.
    CrossRefPubMed
  32. Brown PD, Ballman KV, Cerhan JH, et al. Postoperative stereotactic radiosurgery compared with whole brain radiotherapy for resected metastatic brain disease (NCCTG N107C/CEC·3): a multicentre, randomised, controlled, phase 3 trial. Lancet Oncol. 2017; 18(8): 1049–1060.
    CrossRefPubMed
  33. Abuodeh Y, Ahmed KA, Naghavi AO, et al. Postoperative Stereotactic Radiosurgery Using 5-Gy × 5 Sessions in the Management of Brain Metastases. World Neurosurg. 2016; 90: 58–65.
    CrossRefPubMed
  34. Ling DC, Vargo JA, Wegner RE, et al. Postoperative stereotactic radiosurgery to the resection cavity for large brain metastases: clinical outcomes, predictors of intracranial failure, and implications for optimal patient selection. Neurosurgery. 2015; 76(2): 150–6; discussion 156.
    CrossRefPubMed
  35. Minniti G, Esposito V, Clarke E, et al. Multidose stereotactic radiosurgery (9 Gy × 3) of the postoperative resection cavity for treatment of large brain metastases. Int J Radiat Oncol Biol Phys. 2013; 86(4): 623–629.
    CrossRefPubMed
  36. Brennan C, Yang TJ, Hilden P, et al. A phase 2 trial of stereotactic radiosurgery boost after surgical resection for brain metastases. Int J Radiat Oncol Biol Phys. 2014; 88(1): 130–136.
    CrossRefPubMed
  37. Ahmed KA, Freilich JM, Abuodeh Y, et al. Fractionated stereotactic radiotherapy to the post-operative cavity for radioresistant and radiosensitive brain metastases. J Neurooncol. 2014; 118(1): 179–186.
    CrossRefPubMed
  38. Keller A, Doré M, Antoni D, et al. [Risk of radionecrosis after hypofractionated stereotactic radiotherapy targeting the postoperative resection cavity of brain metastases]. Cancer Radiother. 2017; 21(5): 377–388.
    CrossRefPubMed
  39. Pessina F, Navarria P, Cozzi L, et al. Outcome Evaluation of Oligometastatic Patients Treated with Surgical Resection Followed by Hypofractionated Stereotactic Radiosurgery (HSRS) on the Tumor Bed, for Single, Large Brain Metastases. PLoS One. 2016; 11(6): e0157869.
    CrossRefPubMed
  40. Chin LS, Ma L, DiBiase S. Radiation necrosis following gamma knife surgery: a case-controlled comparison of treatment parameters and long-term clinical follow up. J Neurosurg. 2001; 94(6): 899–904.
    CrossRefPubMed
  41. Flickinger JC, Kondziolka D, Maitz AH, et al. Analysis of neurological sequelae from radiosurgery of arteriovenous malformations: how location affects outcome. Int J Radiat Oncol Biol Phys. 1998; 40(2): 273–278.
    CrossRefPubMed
  42. Flickinger JC, Kondziolka D, Pollock BE, et al. Complications from arteriovenous malformation radiosurgery: multivariate analysis and risk modeling. Int J Radiat Oncol Biol Phys. 1997; 38(3): 485–490.
    CrossRefPubMed
  43. Inoue HK, Sato H, Seto Ki, et al. Five-fraction CyberKnife radiotherapy for large brain metastases in critical areas: impact on the surrounding brain volumes circumscribed with a single dose equivalent of 14 Gy (V14) to avoid radiation necrosis. J Radiat Res. 2014; 55(2): 334–342.
    CrossRefPubMed
  44. Blanchard N, Bernier V, Anxionnat R, et al. [Radiosurgery of cerebral arteriovenous malformations: a prescription algorithm]. Cancer Radiother. 2009; 13(1): 1–10.
    CrossRefPubMed
  45. Flickinger J, Kondziolka D, Lunsford L, et al. Development of a model to predict permanent symptomatic postradiosurgery injury for arteriovenous malformation patients. Int J Radiat Oncol Biol Phys. 2000; 46(5): 1143–1148.
    CrossRefPubMed
  46. Lawrence YR, Li XA, el Naqa I, et al. Radiation dose-volume effects in the brain. Int J Radiat Oncol Biol Phys. 2010; 76(3 Suppl): S20–S27.
    CrossRefPubMed
  47. Korytko T, Radivoyevitch T, Colussi V, et al. 12 Gy gamma knife radiosurgical volume is a predictor for radiation necrosis in non-AVM intracranial tumors. Int J Radiat Oncol Biol Phys. 2006; 64(2): 419–424.
    CrossRefPubMed
  48. Kased N, Huang K, Nakamura JL, et al. Gamma knife radiosurgery for brainstem metastases: the UCSF experience. J Neurooncol. 2008; 86(2): 195–205.
    CrossRefPubMed
  49. Tishler RB, Loeffler JS, Lunsford LD, et al. Tolerance of cranial nerves of the cavernous sinus to radiosurgery. Int J Radiat Oncol Biol Phys. 1993; 27(2): 215–221.
    CrossRefPubMed
  50. Leber KA, Berglöff J, Pendl G. Dose-response tolerance of the visual pathways and cranial nerves of the cavernous sinus to stereotactic radiosurgery. J Neurosurg. 1998; 88(1): 43–50.
    CrossRefPubMed
  51. Kondziolka D, Lunsford LD, McLaughlin MR, et al. Long-term outcomes after radiosurgery for acoustic neuromas. N Engl J Med. 1998; 339(20): 1426–1433.
    CrossRefPubMed
  52. Stafford S, Pollock B, Leavitt J, et al. A study on the radiation tolerance of the optic nerves and chiasm after stereotactic radiosurgery. Int J Radiat Oncol Biol Phys. 2003; 55(5): 1177–1181.
    CrossRefPubMed
  53. Hayden Gephart MG, Hansasuta A, Balise RR, et al. Cochlea radiation dose correlates with hearing loss after stereotactic radiosurgery of vestibular schwannoma. World Neurosurg. 2013; 80(3-4): 359–363.
    CrossRefPubMed
  54. Krengli M, Zanoletti E, Deantonio L. Radiation therapy in acoustic neuroma. In: Wenz F, Zanoletti E, Deantonio L. ed. Radiation Oncology. Springer International Publishing, New York 2018: 1–16.
  55. Gondi V, Hermann BP, Mehta MP, et al. Hippocampal dosimetry predicts neurocognitive function impairment after fractionated stereotactic radiotherapy for benign or low-grade adult brain tumors. Int J Radiat Oncol Biol Phys. 2012; 83(4): e487–e493.
    CrossRefPubMed
  56. Huang CF, Chiou SY, Wu MF, et al. Apparent diffusion coefficients for evaluation of the response of brain tumors treated by Gamma Knife surgery. J Neurosurg. 2010; 113 Suppl: 97–104.
    PubMed
  57. Farjam R, Tsien CI, Feng FY, et al. Physiological imaging-defined, response-driven subvolumes of a tumor. Int J Radiat Oncol Biol Phys. 2013; 85(5): 1383–1390.
    CrossRefPubMed
  58. Kimura T, Sako K, Tanaka K, et al. Evaluation of the response of metastatic brain tumors to stereotactic radiosurgery by proton magnetic resonance spectroscopy, 201TlCl single-photon emission computerized tomography, and gadolinium-enhanced magnetic resonance imaging. J Neurosurg. 2004; 100(5): 835–841.
    CrossRefPubMed
  59. Cicone F, Minniti G, Romano A, et al. Accuracy of F-DOPA PET and perfusion-MRI for differentiating radionecrotic from progressive brain metastases after radiosurgery. Eur J Nucl Med Mol Imaging. 2015; 42(1): 103–111.
    CrossRefPubMed
  60. Andrews DW, Scott CB, Sperduto PW, et al. Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG 9508 randomised trial. Lancet. 2004; 363(9422): 1665–1672.
    CrossRefPubMed
  61. Nakamura JL, Verhey LJ, Smith V, et al. Dose conformity of gamma knife radiosurgery and risk factors for complications. Int J Radiat Oncol Biol Phys. 2001; 51(5): 1313–1319.
    CrossRefPubMed
  62. Lupattelli M, Alì E, Ingrosso G, et al. Stereotactic Radiotherapy for Brain Metastases: Imaging Tools and Dosimetric Predictive Factors for Radionecrosis. J Pers Med. 2020; 10(3).
    CrossRefPubMed
  63. Rusthoven CG, Yamamoto M, Bernhardt D, et al. Evaluation of First-line Radiosurgery vs Whole-Brain Radiotherapy for Small Cell Lung Cancer Brain Metastases: The FIRE-SCLC Cohort Study. JAMA Oncol. 2020; 6(7): 1028–1037.
    CrossRefPubMed
  64. Aoyama H, Shirato H, Tago M, et al. Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA. 2006; 295(21): 2483–2491.
    CrossRefPubMed
  65. Petrovich Z, Yu C, Giannotta SL, et al. Survival and pattern of failure in brain metastasis treated with stereotactic gamma knife radiosurgery. J Neurosurg. 2002; 97(5 Suppl): 499–506.
    CrossRefPubMed
  66. Sneed PK, Mendez J, Vemer-van den Hoek JGM, et al. Adverse radiation effect after stereotactic radiosurgery for brain metastases: incidence, time course, and risk factors. J Neurosurg. 2015; 123(2): 373–386.
    CrossRefPubMed
  67. Kohutek ZA, Yamada Y, Chan TA, et al. Long-term risk of radionecrosis and imaging changes after stereotactic radiosurgery for brain metastases. J Neurooncol. 2015; 125(1): 149–156.
    CrossRefPubMed
  68. Trifiletti DM, Lee CC, Kano H, et al. Stereotactic Radiosurgery for Brainstem Metastases: An International Cooperative Study to Define Response and Toxicity. Int J Radiat Oncol Biol Phys. 2016; 96(2): 280–288.
    CrossRefPubMed
  69. Ernst-Stecken A, Ganslandt O, Lambrecht U, et al. Phase II trial of hypofractionated stereotactic radiotherapy for brain metastases: results and toxicity. Radiother Oncol. 2006; 81(1): 18–24.
    CrossRefPubMed
  70. Minniti G, D'Angelillo RM, Scaringi C, et al. Fractionated stereotactic radiosurgery for patients with brain metastases. J Neurooncol. 2014; 117(2): 295–301.
    CrossRefPubMed
  71. Navarria P, Pessina F, Cozzi L, et al. Hypo-fractionated stereotactic radiotherapy alone using volumetric modulated arc therapy for patients with single, large brain metastases unsuitable for surgical resection. Radiat Oncol. 2016; 11: 76.
    CrossRefPubMed
  72. Minniti G, Scaringi C, Paolini S, et al. Single-Fraction Versus Multifraction (3 × 9 Gy) Stereotactic Radiosurgery for Large (>2 cm) Brain Metastases: A Comparative Analysis of Local Control and Risk of Radiation-Induced Brain Necrosis. Int J Radiat Oncol Biol Phys. 2016; 95(4): 1142–1148.
    CrossRefPubMed
  73. Giglio P, Gilbert M. Cerebral Radiation Necrosis. Neurologist. 2003; 9(4): 180–188.
    CrossRefPubMed
  74. Glantz MJ, Burger PC, Friedman AH, et al. Treatment of radiation-induced nervous system injury with heparin and warfarin. Neurology. 1994; 44(11): 2020–2027.
    CrossRefPubMed
  75. Levin AV, Bidaut L, Hou P, et al. Randomized double-blind placebo-controlled trial of bevacizumab therapy for radiation necrosis of the CNS. Int J Radiat Oncol Biol Phys. 2011; 795: 1487–1495.
    CrossRefPubMed
  76. Navarria P, Minniti G, Clerici E, et al. Brain metastases from primary colorectal cancer: is radiosurgery an effective treatment approach? Results of a multicenter study of the radiation and clinical oncology Italian association (AIRO). Br J Radiol. 2020; 93(1116): 20200951.
    CrossRefPubMed

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