Volumetric changes of intracranial metastases during the course of fractionated stereotactic radiosurgery and significance of adaptive planning

Restricted access

OBJECTIVE

Fractionated Gamma Knife surgery (FGKS) has recently been used to treat large brain metastases. However, little is known about specific volume changes of lesions during the course of treatment. The authors investigated short-term volume changes of metastatic lesions during FGKS.

METHODS

The authors analyzed 33 patients with 40 lesions who underwent FGKS for intracranial metastases of non–small-cell lung cancer (NSCLC; 25 patients with 32 lesions) and breast cancer (8 patients with 8 lesions). FGKS was performed in 3–5 fractions. Baseline MRI was performed before the first fraction. MRI was repeated after 1 or 2 fractions. Adaptive planning was executed based on new images. The median prescription dose was 8 Gy (range 6–10 Gy) with a 50% isodose line.

RESULTS

On follow-up MRI, 18 of 40 lesions (45.0%) showed decreased tumor volumes (TVs). A significant difference was observed between baseline (median 15.8 cm3) and follow-up (median 14.2 cm3) volumes (p < 0.001). A conformity index was significantly decreased when it was assumed that adaptive planning was not implemented, from baseline (mean 0.96) to follow-up (mean 0.90, p < 0.001). The average reduction rate was 1.5% per day. The median follow-up duration was 29.5 weeks (range 9–94 weeks). During the follow-up period, local recurrence occurred in 5 lesions.

CONCLUSIONS

The TV showed changes with a high dose of radiation during the course of FGKS. Volumetric change caused a significant difference in the clinical parameters. It is expected that adaptive planning would be helpful in the case of radiosensitive tumors such as NSCLCs or breast cancer to ensure an adequate dose to the target area and reduce unnecessary exposure of normal tissue to radiation.

ABBREVIATIONS BSM = Basic Score for Brain Metastases; CI = conformity index; dsGPA = diagnosis-specific graded prognostic assessment; FGKS = fractionated GKS; GKS = Gamma Knife surgery; KPS = Karnofsky Performance Scale; NSCLC = non–small-cell lung cancer; OR = odds ratio; PIV = prescription isodose volume; RPA = recursive partitioning analysis; SIR = Score Index for Radiosurgery; TV = tumor volume.

Article Information

Correspondence Jung-Il Lee: Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. jilee@skku.edu.

INCLUDE WHEN CITING Published online May 31, 2019; DOI: 10.3171/2019.3.JNS183130.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    TV change rate and lesion characteristics. Among 40 lesions, 22 showed no change at follow-up MRI, whereas 18 showed reduced size compared with baseline MRI. Yellow circles represent NSCLC cases; blue circles represent breast cancer (BCA) cases. Figure is available in color online only.

  • View in gallery

    Case 1. A: A 61-year-old man received FGKS for intracranial metastasis from an NSCLC. GKS was performed in 3 fractions with 8 Gy (50% isodose line) per fraction. After the second fraction, a repeat MRI was performed before the third fraction. B: The TV decreased from 33.7 cm3 to 23.9 cm3, with a 29.0% volume reduction. The blue outline represents the baseline tumor; the yellow outline represents the follow-up tumor. Figure is available in color online only.

  • View in gallery

    Case 2. A: A 37-year-old woman received FGKS for intracranial metastasis from breast cancer. GKS was performed in 3 fractions with 10 Gy (50% isodose line) per fraction. After the second fraction, repeat MRI was performed before the third fraction. B: The TV decreased from 8.4 cm3 to 7.2 cm3, with a 13.6% volume reduction. The blue outline represents the baseline tumor; the yellow outline represents the follow-up tumor. Figure is available in color online only.

References

  • 1

    Barker JL JrGarden ASAng KKO’Daniel JCWang HCourt LE: Quantification of volumetric and geometric changes occurring during fractionated radiotherapy for head-and-neck cancer using an integrated CT/linear accelerator system. Int J Radiat Oncol Biol Phys 59:9609702004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Cho KRLee MHKong DSSeol HJNam DHSun JM: Outcome of gamma knife radiosurgery for metastatic brain tumors derived from non-small cell lung cancer. J Neurooncol 125:3313382015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Eaton BRGebhardt BPrabhu RShu HKCurran WJ JrCrocker I: Hypofractionated radiosurgery for intact or resected brain metastases: defining the optimal dose and fractionation. Radiat Oncol 8:1352013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Ernst-Stecken AGanslandt OLambrecht USauer RGrabenbauer G: Phase II trial of hypofractionated stereotactic radiotherapy for brain metastases: results and toxicity. Radiother Oncol 81:18242006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Hansen EKBucci MKQuivey JMWeinberg VXia P: Repeat CT imaging and replanning during the course of IMRT for head-and-neck cancer. Int J Radiat Oncol Biol Phys 64:3553622006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Hasegawa TKato TYamamoto TIizuka HNishikawa TIto H: Multisession gamma knife surgery for large brain metastases. J Neurooncol 131:5175242017

  • 7

    Hunt AHansen VNOelfke UNill SHafeez S: Adaptive radiotherapy enabled by MRI guidance. Clin Oncol (R Coll Radiol) 30:7117192018

  • 8

    Jeon SHShin KHPark SYKim JIPark JMKim JH: Seroma change during magnetic resonance imaging-guided partial breast irradiation and its clinical implications. Radiat Oncol 12:1032017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Kim KHLee MHCho KRChoi JWKong DSSeol HJ: The influence of histology on the response of brain metastases to gamma knife radiosurgery: a propensity score-matched study. Acta Neurochir (Wien) 160:237923862018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Kirkpatrick JPSoltys SGLo SSBeal KShrieve DCBrown PD: The radiosurgery fractionation quandary: single fraction or hypofractionation? Neuro Oncol 19 (Suppl 2):ii38ii492017

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Lim TKKim WKYoo CJKim EYKim MJYee GT: Fractionated stereotactic radiosurgery for brain metastases using the Novalis Tx® system. J Korean Neurosurg Soc 61:5255292018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    McTyre EHelis CAFarris MWilkins LSloan DHinson WH: Emerging indications for fractionated Gamma Knife radiosurgery. Neurosurgery 80:2102162017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Minniti GD’Angelillo RMScaringi CTrodella LEClarke EMatteucci P: Fractionated stereotactic radiosurgery for patients with brain metastases. J Neurooncol 117:2953012014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Minniti GScaringi CPaolini SLanzetta GRomano ACicone F: 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 95:114211482016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Murai TOgino HManabe YIwabuchi MOkumura TMatsushita Y: Fractionated stereotactic radiotherapy using CyberKnife for the treatment of large brain metastases: a dose escalation study. Clin Oncol (R Coll Radiol) 26:1511582014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Paddick I: A simple scoring ratio to index the conformity of radiosurgical treatment plans. Technical note. J Neurosurg 93 (Suppl 3):2192222000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Patil CGPricola KSarmiento JMGarg SKBryant ABlack KL: Whole brain radiation therapy (WBRT) alone versus WBRT and radiosurgery for the treatment of brain metastases. Cochrane Database Syst Rev 9:CD0061212017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Pereira SPinto AOliveira JMendrik AMCorreia JHSilva CA: Automatic brain tissue segmentation in MR images using random forests and conditional random fields. J Neurosci Methods 270:1111232016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Salvetti DJNagaraja TGMcNeill ITXu ZSheehan J: Gamma Knife surgery for the treatment of 5 to 15 metastases to the brain: clinical article. J Neurosurg 118:125012572013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Serag AWilkinson AGTelford EJPataky RSparrow SAAnblagan D: SEGMA: An automatic SEGMentation approach for human brain MRI using sliding window and random forests. Front Neuroinform 11:22017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Surucu MShah KKRoeske JCChoi MSmall W JrEmami B: Adaptive radiotherapy for head and neck cancer. Technol Cancer Res Treat 16:2182232017

  • 22

    Van den Begin RKleijnen JPEngels BPhilippens Mvan Asselen BRaaymakers B: Tumor volume regression during preoperative chemoradiotherapy for rectal cancer: a prospective observational study with weekly MRI. Acta Oncol 57:7237272018

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23

    Wegner RELeeman JEKabolizadeh PRwigema JCMintz AHBurton SA: Fractionated stereotactic radiosurgery for large brain metastases. Am J Clin Oncol 38:1351392015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 301 301 52
Full Text Views 80 80 39
PDF Downloads 18 18 12
EPUB Downloads 0 0 0

PubMed

Google Scholar