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Use of Helical TomoTherapy for the Focal Hypofractionated Treatment of Limited Brain Metastases in the Initial and Recurrent Setting.

Elson A, Walker A, Bovi JA, Schultz C - Front Oncol (2015)

Bottom Line: We reviewed our institutional experience to assess patient selection factors, fractionation scheme, and outcomes associated with this technique.Freedom from local failure for treated lesions was 71% and 59% at 6 and 12 months.TomoTherapy-based hypofractionated radiotherapy to a limited number of metastatic lesions is associated with acceptable intracranial disease control and survival outcomes and represents a viable treatment option in the primary and recurrent setting for select patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiation Oncology, Medical College of Wisconsin , Milwaukee, WI , USA.

ABSTRACT

Background: Whole-brain radiation therapy (WBRT), stereotactic radiosurgery (SRS), or both are commonly employed in the treatment of limited brain metastases in the initial or recurrent setting. Hypofractionated partial volume irradiation is also employed, however, published experience using helical TomoTherapy (HT) for this purposes is limited. We reviewed our institutional experience to assess patient selection factors, fractionation scheme, and outcomes associated with this technique.

Methods: A retrospective chart review was performed to evaluate patients treated with partial volume hypofractionated HT-based IMRT for brain metastases at our institution.

Results: Thirteen patients (7M/6F, median age 62, median KPS 90) with a limited (1-9) number of brain metastases in the primary or recurrent setting were identified. Primary malignancies included colorectal (3), NSCLC (5), RCC (1), breast (1), melanoma (1), uterine (1), and ovarian (1). The median time from initial diagnosis to brain metastases was 20.7 months (range 0-61.3). Treatment was delivered to intact metastases in six patients, to a single resection cavity in six patients, and to both in one patient. A total of 27 lesions were treated. The median number of intact metastases treated was two (range 1-9). Previous treatments included WBRT (5), WBRT + SRS (3), SRS alone (1), and none (4). The most common fractionation schemes were 25 Gy in five fractions and 27.5 Gy in five fractions to each lesion. At a median of 6 months follow up (range 1.26-20.13) after TomoTherapy, 10 patients were deceased, 2 were alive, and 1 was lost to follow up. Systemic progression occurred in seven patients and intracranial progression occurred in five. The median intracranial progression free survival and overall survival after TomoTherapy was 6.3 months. Freedom from local failure for treated lesions was 71% and 59% at 6 and 12 months.

Conclusion: TomoTherapy-based hypofractionated radiotherapy to a limited number of metastatic lesions is associated with acceptable intracranial disease control and survival outcomes and represents a viable treatment option in the primary and recurrent setting for select patients.

No MeSH data available.


Related in: MedlinePlus

Representative screenshots depicting isodose distributions of a plan delivered to a single intact brain metastasis with conformal avoidance of the brainstem. The prescription does was 27.5 Gy in five fractions.
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Figure 1: Representative screenshots depicting isodose distributions of a plan delivered to a single intact brain metastasis with conformal avoidance of the brainstem. The prescription does was 27.5 Gy in five fractions.

Mentions: Thirteen patients were identified (7M/6F) with a median age of 62 and median KPS of 90. The majority of patients (9/13) had a single focal lesion (intact metastasis or resection cavity), and 4/13 had multiple lesions treated simultaneously. A total of 27 metastases were treated. Six patients were treated for intact lesions, six patients were treated for post-operative resection cavities, and one patient has one intact lesion and one resection cavity treated. The median and mean PTV volume was 20 and 33 cc, respectively (range 2–96 cc). The most common fractionation schemes were 25 Gy in five fractions of 500 cGy per fraction, and 27.5 Gy in five fractions of 550 cGy per fraction. One patient’s plan per patient request was modified after the first fraction from 500 cGy per fraction to 250 cGy per fraction. Histologic subtypes included colorectal (3), non-small cell lung cancer (5), renal cell carcinoma (1), breast (1), melanoma (1), uterine (1), and ovarian (1). Metastases were located in both cerebral and cerebellar locations. The majority of patients (9/13) had previously undergone intracranial radiotherapy including WBRT alone (5), WBRT + SRS (3), and SRS alone (1). Four patients had previously undergone no prior intracranial radiotherapy. Four patients were diagnosed with brain metastases concurrently with the primary tumor diagnosis, and nine patients were diagnosed with brain metastases after the initial primary tumor diagnosis. The median time from initial diagnosis to the occurrence of brain metastases was 21 months. The primary disease was stable in 7/13 patients and progressive in 6/13 patients prior to the start of XRT. The majority of patients (12/13) had at least one neurologic symptom prior to radiation including diplopia (1), headache (2), gait ataxia (2), aphasia (1), confusion and memory decline (1), weakness (3), and seizures (2). One patient was neurologically asymptomatic prior to treatment. The median follow up period after XRT was 6.2 months (range 1.26–20.13 months). Patient characteristics are summarized in Table 1. Representative plans are depicted in Figures 1 and 2.


Use of Helical TomoTherapy for the Focal Hypofractionated Treatment of Limited Brain Metastases in the Initial and Recurrent Setting.

Elson A, Walker A, Bovi JA, Schultz C - Front Oncol (2015)

Representative screenshots depicting isodose distributions of a plan delivered to a single intact brain metastasis with conformal avoidance of the brainstem. The prescription does was 27.5 Gy in five fractions.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4321406&req=5

Figure 1: Representative screenshots depicting isodose distributions of a plan delivered to a single intact brain metastasis with conformal avoidance of the brainstem. The prescription does was 27.5 Gy in five fractions.
Mentions: Thirteen patients were identified (7M/6F) with a median age of 62 and median KPS of 90. The majority of patients (9/13) had a single focal lesion (intact metastasis or resection cavity), and 4/13 had multiple lesions treated simultaneously. A total of 27 metastases were treated. Six patients were treated for intact lesions, six patients were treated for post-operative resection cavities, and one patient has one intact lesion and one resection cavity treated. The median and mean PTV volume was 20 and 33 cc, respectively (range 2–96 cc). The most common fractionation schemes were 25 Gy in five fractions of 500 cGy per fraction, and 27.5 Gy in five fractions of 550 cGy per fraction. One patient’s plan per patient request was modified after the first fraction from 500 cGy per fraction to 250 cGy per fraction. Histologic subtypes included colorectal (3), non-small cell lung cancer (5), renal cell carcinoma (1), breast (1), melanoma (1), uterine (1), and ovarian (1). Metastases were located in both cerebral and cerebellar locations. The majority of patients (9/13) had previously undergone intracranial radiotherapy including WBRT alone (5), WBRT + SRS (3), and SRS alone (1). Four patients had previously undergone no prior intracranial radiotherapy. Four patients were diagnosed with brain metastases concurrently with the primary tumor diagnosis, and nine patients were diagnosed with brain metastases after the initial primary tumor diagnosis. The median time from initial diagnosis to the occurrence of brain metastases was 21 months. The primary disease was stable in 7/13 patients and progressive in 6/13 patients prior to the start of XRT. The majority of patients (12/13) had at least one neurologic symptom prior to radiation including diplopia (1), headache (2), gait ataxia (2), aphasia (1), confusion and memory decline (1), weakness (3), and seizures (2). One patient was neurologically asymptomatic prior to treatment. The median follow up period after XRT was 6.2 months (range 1.26–20.13 months). Patient characteristics are summarized in Table 1. Representative plans are depicted in Figures 1 and 2.

Bottom Line: We reviewed our institutional experience to assess patient selection factors, fractionation scheme, and outcomes associated with this technique.Freedom from local failure for treated lesions was 71% and 59% at 6 and 12 months.TomoTherapy-based hypofractionated radiotherapy to a limited number of metastatic lesions is associated with acceptable intracranial disease control and survival outcomes and represents a viable treatment option in the primary and recurrent setting for select patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiation Oncology, Medical College of Wisconsin , Milwaukee, WI , USA.

ABSTRACT

Background: Whole-brain radiation therapy (WBRT), stereotactic radiosurgery (SRS), or both are commonly employed in the treatment of limited brain metastases in the initial or recurrent setting. Hypofractionated partial volume irradiation is also employed, however, published experience using helical TomoTherapy (HT) for this purposes is limited. We reviewed our institutional experience to assess patient selection factors, fractionation scheme, and outcomes associated with this technique.

Methods: A retrospective chart review was performed to evaluate patients treated with partial volume hypofractionated HT-based IMRT for brain metastases at our institution.

Results: Thirteen patients (7M/6F, median age 62, median KPS 90) with a limited (1-9) number of brain metastases in the primary or recurrent setting were identified. Primary malignancies included colorectal (3), NSCLC (5), RCC (1), breast (1), melanoma (1), uterine (1), and ovarian (1). The median time from initial diagnosis to brain metastases was 20.7 months (range 0-61.3). Treatment was delivered to intact metastases in six patients, to a single resection cavity in six patients, and to both in one patient. A total of 27 lesions were treated. The median number of intact metastases treated was two (range 1-9). Previous treatments included WBRT (5), WBRT + SRS (3), SRS alone (1), and none (4). The most common fractionation schemes were 25 Gy in five fractions and 27.5 Gy in five fractions to each lesion. At a median of 6 months follow up (range 1.26-20.13) after TomoTherapy, 10 patients were deceased, 2 were alive, and 1 was lost to follow up. Systemic progression occurred in seven patients and intracranial progression occurred in five. The median intracranial progression free survival and overall survival after TomoTherapy was 6.3 months. Freedom from local failure for treated lesions was 71% and 59% at 6 and 12 months.

Conclusion: TomoTherapy-based hypofractionated radiotherapy to a limited number of metastatic lesions is associated with acceptable intracranial disease control and survival outcomes and represents a viable treatment option in the primary and recurrent setting for select patients.

No MeSH data available.


Related in: MedlinePlus