A matched-pair analysis of clinical outcomes after intracavitary cesium-131 brachytherapy versus stereotactic radiosurgery for resected brain metastases

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  • 1 Stich Radiation Oncology, Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York, New York;
  • 2 Department of Surgery, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts; and
  • 3 Department of Neurosurgery, Brain and Spine Center, Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York, New York
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OBJECTIVE

Adjuvant radiation therapy (RT), such as cesium-131 (Cs-131) brachytherapy or stereotactic radiosurgery (SRS), reduces local recurrence (LR) of brain metastases (BM). However, SRS is less efficacious for large cavities, and the delay between surgery and SRS may permit tumor repopulation. Cs-131 has demonstrated improved local control, with reduced radiation necrosis (RN) compared to SRS. This study represents the first comparison of outcomes between Cs-131 brachytherapy and SRS for resected BM.

METHODS

Patients with BM treated with Cs-131 and SRS following gross-total resection were retrospectively identified. Thirty patients who underwent Cs-131 brachytherapy were compared to 60 controls who received SRS. Controls were selected from a larger cohort to match the patients treated with Cs-131 in a 2:1 ratio according to tumor size, histology, performance status, and recursive partitioning analysis class. Overall survival (OS), LR, regional recurrence, distant recurrence (DR), and RN were compared.

RESULTS

With a median follow-up of 17.5 months for Cs-131–treated and 13.0 months for SRS-treated patients, the LR rate was significantly lower with brachytherapy; 10% for the Cs-131 cohort compared to 28.3% for SRS patients (OR 0.281, 95% CI 0.082–0.949; p = 0.049). Rates of regional recurrence, DR, and OS did not differ significantly between the two cohorts. Kaplan-Meier analysis with log-rank testing showed a significantly higher likelihood of freedom from LR (p = 0.027) as well as DR (p = 0.018) after Cs-131 compared to SRS treatment (p = 0.027), but no difference in likelihood of OS (p = 0.093). Six (10.0%) patients who underwent SRS experienced RN compared to 1 (3.3%) patient who received Cs-131 (p = 0.417).

CONCLUSIONS

Postresection patients with BM treated with Cs-131 brachytherapy were more likely to achieve local control compared to SRS-treated patients. This study provides preliminary evidence of the potential of Cs-131 to reduce LR following gross-total resection of single BM, with minimal toxicity, and suggests the need for a prospective study to address this question.

ABBREVIATIONS BM = brain metastases; DR = distant recurrence; DRFS = DR-free survival; ECOG = Eastern Cooperative Oncology Group; GTR = gross-total resection; KPS = Karnofsky Performance Scale; LC = local control; LR = local recurrence; LRFS = LR-free survival; OS = overall survival; RN = radiation necrosis; RPA = recursive partitioning analysis; RR = regional recurrence; RRFS = RR-free survival; RT = radiation therapy; SRS = stereotactic radiosurgery; WBRT = whole-brain radiation therapy.

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Contributor Notes

Correspondence A. Gabriella Wernicke: Weill Cornell Medical College, New York, NY. gabriella.wernicke5@gmail.com.

INCLUDE WHEN CITING Published online May 15, 2020; DOI: 10.3171/2020.3.JNS193419.

D.A.J. and S.P.L. share first authorship of this work.

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

  • 1

    Patchell RA, Tibbs PA, Walsh JW, A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med. 1990;322(8):494500.

    • Search Google Scholar
    • Export Citation
  • 2

    Gaspar L, Scott C, Rotman M, Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy Oncology Group (RTOG) brain metastases trials. Int J Radiat Oncol Biol Phys. 1997;37(4):745751.

    • Search Google Scholar
    • Export Citation
  • 3

    Gaspar LE, Scott C, Murray K, Curran W. Validation of the RTOG recursive partitioning analysis (RPA) classification for brain metastases. Int J Radiat Oncol Biol Phys. 2000;47(4):10011006.

    • Search Google Scholar
    • Export Citation
  • 4

    Kalkanis SN, Kondziolka D, Gaspar LE, The role of surgical resection in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. J Neurooncol. 2010;96(1):3343.

    • Search Google Scholar
    • Export Citation
  • 5

    Chang EL, Wefel JS, Hess KR, Neurocognition in patients with brain metastases treated with radiosurgery or radiosurgery plus whole-brain irradiation: a randomised controlled trial. Lancet Oncol. 2009;10(11):10371044.

    • Search Google Scholar
    • Export Citation
  • 6

    Brown PD, Ballman KV, Cerhan JH, 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):10491060.

    • Search Google Scholar
    • Export Citation
  • 7

    Mahajan A, Ahmed S, McAleer MF, Post-operative stereotactic radiosurgery versus observation for completely resected brain metastases: a single-centre, randomised, controlled, phase 3 trial. Lancet Oncol. 2017;18(8):10401048.

    • Search Google Scholar
    • Export Citation
  • 8

    Gans JH, Raper DMS, Shah AH, The role of radiosurgery to the tumor bed after resection of brain metastases. Neurosurgery. 2013;72(3):317326.

    • Search Google Scholar
    • Export Citation
  • 9

    Hartford AC, Paravati AJ, Spire WJ, Postoperative stereotactic radiosurgery without whole-brain radiation therapy for brain metastases: potential role of preoperative tumor size. Int J Radiat Oncol Biol Phys. 2013;85(3):650655.

    • Search Google Scholar
    • Export Citation
  • 10

    Jagannathan J, Yen CP, Ray DK, Gamma Knife radiosurgery to the surgical cavity following resection of brain metastases. J Neurosurg. 2009;111(3):431438.

    • Search Google Scholar
    • Export Citation
  • 11

    Ling DC, Vargo JA, Wegner RE, 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):150157.

    • Search Google Scholar
    • Export Citation
  • 12

    Mahase SS, Navrazhina K, Schwartz TH, Intraoperative brachytherapy for resected brain metastases. Brachytherapy. 2019;18(3):258270.

  • 13

    Han DY, Ma L, Braunstein S, Resection cavity contraction effects in the use of radioactive sources (1-25 versus Cs-131) for intra-operative brain implants. Cureus. 2018;10(1):e2079.

    • Search Google Scholar
    • Export Citation
  • 14

    Wernicke AG, Lazow SP, Taube S, Surgical technique and clinically relevant resection cavity dynamics following implantation of Cesium-131 (Cs-131) brachytherapy in patients with brain metastases. Oper Neurosurg (Hagerstown). 2016;12(1):4960.

    • Search Google Scholar
    • Export Citation
  • 15

    Wernicke AG, Yondorf MZ, Peng L, Phase I/II study of resection and intraoperative cesium-131 radioisotope brachytherapy in patients with newly diagnosed brain metastases. J Neurosurg. 2014;121(2):338348.

    • Search Google Scholar
    • Export Citation
  • 16

    Benedict SH, Yenice KM, Followill D, Stereotactic body radiation therapy: the report of AAPM Task Group 101 [erratum in: Med Phys. 2012;39(1):563]. Med Phys. 2010;37(8):40784101.

    • Search Google Scholar
    • Export Citation
  • 17

    Shaw E, Scott C, Souhami L, 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):291298.

    • Search Google Scholar
    • Export Citation
  • 18

    Cox JD, Stetz J, Pajak TF. Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC). Int J Radiat Oncol Biol Phys. 1995;31(5):13411346.

    • Search Google Scholar
    • Export Citation
  • 19

    Kocher M, Soffietti R, Abacioglu U, 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):134141.

    • Search Google Scholar
    • Export Citation
  • 20

    Suwinski R, Sowa A, Rutkowski T, Time factor in postoperative radiotherapy: a multivariate locoregional control analysis in 868 patients. Int J Radiat Oncol Biol Phys. 2003;56(2):399412.

    • Search Google Scholar
    • Export Citation
  • 21

    Marchan EM, Peterson J, Sio TT, Postoperative cavity stereotactic radiosurgery for brain metastases. Front Oncol. 2018;8:342.

  • 22

    Ruge MI, Kocher M, Maarouf M, Comparison of stereotactic brachytherapy (125iodine seeds) with stereotactic radiosurgery (LINAC) for the treatment of singular cerebral metastases. Strahlenther Onkol. 2011;187(1):714.

    • Search Google Scholar
    • Export Citation
  • 23

    Hall EJ, Giaccia AJ, eds. Radiobiology for the Radiologist. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.

  • 24

    Baschnagel AM, Meyer KD, Chen PY, Tumor volume as a predictor of survival and local control in patients with brain metastases treated with Gamma Knife surgery. J Neurosurg. 2013;119(5):11391144.

    • Search Google Scholar
    • Export Citation
  • 25

    Linskey ME, Andrews DW, Asher AL, The role of stereotactic radiosurgery in the management of patients with newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. J Neurooncol. 2010;96(1):4568.

    • Search Google Scholar
    • Export Citation
  • 26

    Choi CY, Chang SD, Gibbs IC, Stereotactic radiosurgery of the postoperative resection cavity for brain metastases: prospective evaluation of target margin on tumor control. Int J Radiat Oncol Biol Phys. 2012;84(2):336342.

    • Search Google Scholar
    • Export Citation
  • 27

    Ebner D, Rava P, Gorovets D, Stereotactic radiosurgery for large brain metastases. J Clin Neurosci. 2015;22(10):16501654.

  • 28

    Atalar B, Choi CY, Harsh GR IV, Cavity volume dynamics after resection of brain metastases and timing of postresection cavity stereotactic radiosurgery. Neurosurgery. 2013;72(2):180185.

    • Search Google Scholar
    • Export Citation
  • 29

    Jarvis LA, Simmons NE, Bellerive M, Tumor bed dynamics after surgical resection of brain metastases: implications for postoperative radiosurgery. Int J Radiat Oncol Biol Phys. 2012;84(4):943948.

    • Search Google Scholar
    • Export Citation
  • 30

    Wernicke AG, Yondorf MZ, Parashar B, The cost-effectiveness of surgical resection and cesium-131 intraoperative brachytherapy versus surgical resection and stereotactic radiosurgery in the treatment of metastatic brain tumors. J Neurooncol. 2016;127(1):145153.

    • Search Google Scholar
    • Export Citation
  • 31

    Xia Y, Mashouf LA, Baker BR, Outcomes of metastatic brain lesions treated with radioactive Cs-131 seeds after surgery: experience from one institution. Cureus. 2018;10(7):e3075.

    • Search Google Scholar
    • Export Citation
  • 32

    Wernicke AG, Hirschfeld CB, Smith AW, Clinical outcomes of large brain metastases treated with neurosurgical resection and intraoperative cesium-131 brachytherapy: results of a prospective trial. Int J Radiat Oncol Biol Phys. 2017;98(5):10591068.

    • Search Google Scholar
    • Export Citation
  • 33

    Yondorf MZ, Schwartz TH, Boockvar JA, Radiation exposure and safety precautions following 131Cs brachytherapy in patients with brain tumors. Health Phys. 2017;112(4):403408.

    • Search Google Scholar
    • Export Citation

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