Top

Published in:

01-07-2021 | NSCLC | Original Article

Effective method to reduce the normal brain dose in single-isocenter hypofractionated stereotactic radiotherapy for multiple brain metastases

Authors: Jialu Lai, M.Sc., Jia Liu, M.D., Jianling Zhao, Ph.D., An Li, B.Sc., Shoupeng Liu, M.Sc., Zhonghua Deng, B.Sc., Qiaoyue Tan, M.D., Haitao Wang, B.Sc., Yuming Jia, M.D., Kaijian Lei, M.D., Lin Zhou, M.D. Ph.D.

Published in: Strahlentherapie und Onkologie | Issue 7/2021

Abstract

Background and purpose

Island blocking and dose leakage problems will lead to unnecessary irradiation to normal brain tissue (NBT) in hypofractionated stereotactic radiotherapy (HSRT) for multiple brain metastases (BM) with single-isocenter volumetric modulated arc therapy (VMAT). The present study aimed at investigating whether reducing the number of metastases irradiated by each arc beam could minimize these two problems.

Materials and methods

A total of 32 non-small-cell lung cancer (NSCLC) patients with multiple BM received HSRT (24–36 Gy/3 fractions) with single-isocenter VMAT, where each arc beam only irradiated partial metastases (pm-VMAT), were enrolled in this retrospective study. Conventional single-isocenter VMAT plans, where each arc beam irradiated whole metastases (wm-VMAT), was regenerated and compared with pm-VMAT plans. Furthermore, the clinical efficacy and toxicities were evaluated.

Results

Pm-VMAT achieved similar target coverage as that with wm-VMAT, with better dose fall-off (P < 0.001) and NBT sparing (P < 0.001). However, pm-VMAT resulted in more monitor units (MU) and longer beam-on time (P < 0.001). The intracranial objective response rate and disease control rate for all patients were 75% and 100%, respectively. The local control rates at 1 year and 2 year were 96.2% and 60.2%, respectively. The median progression-free survival and overall survival were 10.3 months (95% confidence interval [CI] 6.8–13.2) and 18.5 months (95% CI 15.9–20.1), respectively. All treatment-related adverse events were grade 1 or 2, and 3 lesions (2.31%) from 2 patients (6.25%) demonstrated radiation necrosis after HSRT.

Conclusion

HSRT with pm-VMAT is effective and has limited toxicities for NSCLC patients with multiple BM. Pm-VMAT could provide better NBT sparing while maintaining target dose coverage.

Available only for authorised users

Barnholtz-Sloan JS, Sloan AE, Davis FG, Vigneau FD, Lai P, Sawaya RE (2004) Incidence proportions of brain metastases in patients diagnosed (1973 to 2001) in the metropolitan Detroit cancer surveillance system. J Clin Oncol 22:2865–2872. https://doi.org/10.1200/JCO.2004.12.149CrossRefPubMed

Mujoomdar A, Austin JH, Malhotra R, Powell CA, Pearson GD, Shiau MC, Raftopoulos HJR (2007) Clinical predictors of metastatic disease to the brain from non–small cell lung carcinoma: primary tumor size, cell type, and lymph node metastases. Radiology 242:882–888. https://doi.org/10.1148/radiol.2423051707CrossRefPubMed

Khuntia D, Brown P, Li J, Mehta MP (2006) Whole-brain radiotherapy in the management of brain metastasis. J Clin Oncol 24:1295–1304. https://doi.org/10.1200/JCO.2005.04.6185CrossRefPubMed

Welzel G, Fleckenstein K, Schaefer J, Hermann B, Kraus-Tiefenbacher U, Mai SK, Wenz F (2008) Memory function before and after whole brain radiotherapy in patients with and without brain metastases. Int J Radiat Oncol Biol Phys 72:1311–1318. https://doi.org/10.1016/j.ijrobp.2008.03.009CrossRefPubMed

Ogura K, Mizowaki T, Ogura M, Sakanaka K, Arakawa Y, Miyamoto S, Hiraoka M (2012) Outcomes of hypofractionated stereotactic radiotherapy for metastatic brain tumors with high risk factors. J Neurooncol 109:425–432. https://doi.org/10.1007/s11060-012-0912-6CrossRefPubMed

Yamamoto M, Serizawa T, Shuto T, Akabane A, Higuchi Y, Kawagishi J, Yamanaka K, Sato Y, Jokura H, Yomo S, Nagano O, Kenai H, Moriki A, Suzuki S, Kida Y, Iwai Y, Hayashi M, Onishi H, Gondo M, Sato M, Akimitsu T, Kubo K, Kikuchi Y, Shibasaki T, Goto T, Takanashi M, Mori Y, Takakura K, Saeki N, Kunieda E, Aoyama H, Momoshima S, Tsuchiya K (2014) Stereotactic radiosurgery for patients with multiple brain metastases (JLGK0901): a multi-institutional prospective observational study. Lancet Oncol 15:387–395. https://doi.org/10.1016/S1470-2045(14)70061-0CrossRefPubMed

Yamamoto M, Serizawa T, Higuchi Y, Sato Y, Kawagishi J, Yamanaka K, Shuto T, Akabane A, Jokura H, Yomo S, Nagano O, Aoyama H (2017) A multi-institutional prospective observational study of stereotactic radiosurgery for patients with multiple brain metastases (JLGK0901 study update): irradiation-related complications and long-term maintenance of mini-mental state examination scores. Int J Radiat Oncol Biol Phys 99:31–40. https://doi.org/10.1016/j.ijrobp.2017.04.037CrossRefPubMed

Clark GM, Popple RA, Young PE, Fiveash JB (2010) Feasibility of single-isocenter volumetric modulated arc radiosurgery for treatment of multiple brain metastases. Int J Radiat Oncol Biol Phys 76:296–302. https://doi.org/10.1016/j.ijrobp.2009.05.029CrossRefPubMed

Ruggieri R, Naccarato S, Mazzola R, Ricchetti F, Corradini S, Fiorentino A, Alongi F (2018) Linac-based VMAT radiosurgery for multiple brain lesions: comparison between a conventional multi-isocenter approach and a new dedicated mono-isocenter technique. Radiat Oncol 13:38. https://doi.org/10.1186/s13014-018-0985-2CrossRefPubMedPubMedCentral

10.

Wu Q, Snyder KC, Liu C, Huang Y, Zhao B, Chetty IJ, Wen N (2016) Optimization of treatment geometry to reduce normal brain dose in radiosurgery of multiple brain metastases with single-Isocenter volumetric modulated arc therapy. Sci Rep 6:34511. https://doi.org/10.1038/srep34511CrossRefPubMedPubMedCentral

11.

Kang J, Ford EC, Smith K, Wong J, McNutt TR (2010) A method for optimizing LINAC treatment geometry for volumetric modulated arc therapy of multiple brain metastases. Med Phys 37:4146–4154. https://doi.org/10.1118/1.3455286CrossRefPubMed

12.

Ohira S, Sagawa T, Ueda Y, Inui S, Masaoka A, Akino Y, Mizuno H, Miyazaki M, Koizumi M, Teshima T (2020) Effect of collimator angle on HyperArc stereotactic radiosurgery planning for single and multiple brain metastases. Med Dosim 45:85–91. https://doi.org/10.1016/j.meddos.2019.07.004CrossRefPubMed

13.

Shaw E, Kline R, Gillin M, Souhami L, Hirschfeld A, Dinapoli R, Martin L (1993) Radiation therapy oncology group: radiosurgery quality assurance guidelines. Int J Radiat Oncol Biol Phys 27:1231–1239. https://doi.org/10.1016/0360-3016(93)90548-aCrossRefPubMed

14.

Paddick I, Lippitz B (2006) A simple dose gradient measurement tool to complement the conformity index. J Neurosurg 105:194–201. https://doi.org/10.3171/sup.2006.105.7.194CrossRefPubMed

15.

Wu Q, Mohan R, Morris M, Lauve A, Schmidt-Ullrich R (2003) Simultaneous integrated boost intensity-modulated radiotherapy for locally advanced head-and-neck squamous cell carcinomas. I: dosimetric results. Int J Radiat Oncol Biol Phys 56:573–585. https://doi.org/10.1016/s0360-3016(02)04617-5CrossRefPubMed

16.

Vergalasova I, Liu H, Alonso-Basanta M, Dong L, Li J, Nie K, Shi W, Teo BK, Yu Y, Yue NJ, Zou W, Li T (2019) Multi-institutional dosimetric evaluation of modern day stereotactic radiosurgery (SRS) treatment options for multiple brain metastases. Front Oncol 9:483. https://doi.org/10.3389/fonc.2019.00483CrossRefPubMedPubMedCentral

17.

Parikh NR, Kundu P, Levin-Epstein R, Chang EM, Agazaryan N, Hegde JV, Steinberg ML, Tenn SE, Kaprealian TB (2020) Time-driven activity-based costing comparison of stereotactic radiosurgery to multiple brain lesions using single-isocenter versus multiple-Isocenter technique. Int J Radiat Oncol Biol Phys 108:999–1007. https://doi.org/10.1016/j.ijrobp.2020.06.035CrossRefPubMed

18.

Kim JI, Park JM, Park SY, Choi CH, Wu HG, Ye SJ (2014) Assessment of potential jaw-tracking advantage using control point sequences of VMAT planning. J Appl Clin Med Phys 15:4625. https://doi.org/10.1120/jacmp.v15i2.4625CrossRefPubMed

19.

Thongsawad S, Khamfongkhruea C, Tannanonta C (2018) Dosimetric effect of jaw tracking in volumetric-modulated arc therapy. J Med Phys 43:52–57. https://doi.org/10.4103/jmp.JMP_75_17CrossRefPubMedPubMedCentral

20.

Huang Y, Chin K, Robbins JR, Kim J, Li H, Amro H, Chetty IJ, Gordon J, Ryu S (2014) Radiosurgery of multiple brain metastases with single-isocenter dynamic conformal arcs (SIDCA). Radiother Oncol 112:128–132. https://doi.org/10.1016/j.radonc.2014.05.009CrossRefPubMed

21.

Korytko T, Radivoyevitch T, Colussi V, Wessels BW, Pillai K, Maciunas RJ, Einstein DB (2006) 12 Gy gamma knife radiosurgical volume is a predictor for radiation necrosis in non-AVM intracranial tumors. Int J Radiat Oncol Biol Phys 64:419–424. https://doi.org/10.1016/j.ijrobp.2005.07.980CrossRefPubMed

22.

Blonigen BJ, Steinmetz RD, Levin L, Lamba MA, Warnick RE, Breneman JC (2010) Irradiated volume as a predictor of brain radionecrosis after linear accelerator stereotactic radiosurgery. Int J Radiat Oncol Biol Phys 77:996–1001. https://doi.org/10.1016/j.ijrobp.2009.06.006CrossRefPubMed

23.

Minniti G, Clarke E, Lanzetta G, Osti MF, Trasimeni G, Bozzao A, Romano A, Enrici RM (2011) Stereotactic radiosurgery for brain metastases: analysis of outcome and risk of brain radionecrosis. Radiat Oncol 6:48. https://doi.org/10.1186/1748-717X-6-48CrossRefPubMedPubMedCentral

24.

Ohira S, Ueda Y, Akino Y, Hashimoto M, Masaoka A, Hirata T, Miyazaki M, Koizumi M, Teshima T (2018) HyperArc VMAT planning for single and multiple brain metastases stereotactic radiosurgery: a new treatment planning approach. Radiat Oncol 13:13. https://doi.org/10.1186/s13014-017-0948-zCrossRefPubMedPubMedCentral

25.

Cadman P, McNutt T, Bzdusek K (2005) Validation of physics improvements for IMRT with a commercial treatment-planning system. J Appl Clin Med Phys 6:74–86. https://doi.org/10.1120/jacmp.v6i2.2083CrossRefPubMedPubMedCentral

26.

Mohan R, Jayesh K, Joshi RC, Al-Idrisi M, Narayanamurthy P, Majumdar SK (2008) Dosimetric evaluation of 120-leaf multileaf collimator in a Varian linear accelerator with 6‑MV and 18-MV photon beams. J Med Phys 33:114–118. https://doi.org/10.4103/0971-6203.42757CrossRefPubMedPubMedCentral

27.

McDonald D, Schuler J, Takacs I, Peng J, Jenrette J, Vanek K (2014) Comparison of radiation dose spillage from the gamma knife perfexion with that from volumetric modulated arc radiosurgery during treatment of multiple brain metastases in a single fraction. J Neurosurg 121:51–59. https://doi.org/10.3171/2014.7.GKS141358CrossRefPubMed

28.

Liu H, Andrews DW, Evans JJ, Werner-Wasik M, Yu Y, Dicker AP, Shi W (2016) Plan quality and treatment efficiency for radiosurgery to multiple brain metastases: non-coplanar rapidarc vs. gamma knife. Front Oncol 6:26. https://doi.org/10.3389/fonc.2016.00026CrossRefPubMedPubMedCentral

29.

Potrebko PS, Keller A, All S, Sejpal S, Pepe J, Saigal K, Kandula S, Sensakovic WF, Shridhar R, Poleszczuk J, Biagioli M (2018) GammaKnife versus VMAT radiosurgery plan quality for many brain metastases. J Appl Clin Med Phys 19:159–165. https://doi.org/10.1002/acm2.12471CrossRefPubMedPubMedCentral

30.

Sebastian NT, Glenn C, Hughes R, Raval R, Chu J, DiCostanzo D, Bell EH, Grecula J, Arnett A, Gondal H, McGregor J, Elder JB, Lonser R, Chakravarti A, Trifiletti D, Brown PD, Chan M, Palmer JD (2020) Linear accelerator-based radiosurgery is associated with lower incidence of radionecrosis compared with gamma knife for treatment of multiple brain metastases. Radiother Oncol 147:136–143. https://doi.org/10.1016/j.radonc.2020.03.024CrossRefPubMed

31.

Ishihara T, Yamada K, Harada A, Isogai K, Tonosaki Y, Demizu Y, Miyawaki D, Yoshida K, Ejima Y, Sasaki R (2016) Hypofractionated stereotactic radiotherapy for brain metastases from lung cancer : evaluation of indications and predictors of local control. Strahlenther Onkol 192:386–393. https://doi.org/10.1007/s00066-016-0963-2CrossRefPubMed

32.

Kirkpatrick JP, Soltys SG, Lo SS, Beal K, Shrieve DC, Brown PD (2017) The radiosurgery fractionation quandary: single fraction or hypofractionation? Neuro Oncol 19:ii38–ii49. https://doi.org/10.1093/neuonc/now301CrossRefPubMedPubMedCentral

33.

Shaw E, Scott C, Souhami L, Dinapoli R, Kline R, Loeffler J, Farnan N (2000) 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 47:291–298. https://doi.org/10.1016/s0360-3016(99)00507-6CrossRefPubMed

34.

Tamari K, Suzuki O, Hashimoto N, Kagawa N, Fujiwara M, Sumida I, Seo Y, Isohashi F, Yoshioka Y, Yoshimine T (2015) Treatment outcomes using CyberKnife for brain metastases from lung cancer. J Radiat Res 56:151–158. https://doi.org/10.1093/jrr/rru092CrossRefPubMed

35.

Minniti G, Scaringi C, Paolini S, Lanzetta G, Romano A, Cicone F, Osti M, Enrici RM, Esposito V (2016) Single-fraction versus multifraction (3 x 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 95:1142–1148. https://doi.org/10.1016/j.ijrobp.2016.03.013CrossRefPubMed

Title: Effective method to reduce the normal brain dose in single-isocenter hypofractionated stereotactic radiotherapy for multiple brain metastases
Authors: Jialu Lai, M.Sc.
Jia Liu, M.D.
Jianling Zhao, Ph.D.
An Li, B.Sc.
Shoupeng Liu, M.Sc.
Zhonghua Deng, B.Sc.
Qiaoyue Tan, M.D.
Haitao Wang, B.Sc.
Yuming Jia, M.D.
Kaijian Lei, M.D.
Lin Zhou, M.D. Ph.D.
Publication date: 01-07-2021
Publisher: Springer Berlin Heidelberg
Keywords: NSCLC
Metastasis
NSCLC
Radiotherapy
Published in: Strahlentherapie und Onkologie / Issue 7/2021
Print ISSN: 0179-7158
Electronic ISSN: 1439-099X
DOI: https://doi.org/10.1007/s00066-021-01757-6

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Effective method to reduce the normal brain dose in single-isocenter hypofractionated stereotactic radiotherapy for multiple brain metastases

Abstract

Background and purpose

Materials and methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background and purpose

Materials and methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 7/2021

10-Jahres-Letalität, Krankheitsprogress und behandlungsassoziierte Nebenwirkungen bei Männern mit lokalisiertem Prostatakarzinom aus der randomisierten, kontrollierten ProtecT-Studie, analysiert nach erhaltener Therapie

Lorlatinib als vielversprechendes Medikament in der zukünftigen Therapie des fortgeschrittenen ALK-positiven nichtkleinzelligen Bronchialkarzinoms

Severe skin toxicity during whole-brain radiotherapy, targeted therapy, and additional drug intake including St. John’s wort skin oil

Comparison of treatment position with mask immobilization and standard diagnostic setup in intracranial MRI radiotherapy simulation

Simultaneous stereotactic radiosurgery of multiple brain metastases using single-isocenter dynamic conformal arc therapy: a prospective monocentric registry trial

Einfluss der Fraktionierung (1 × 24 Gy vs. 3 × 9 Gy) auf onkologische Endpunkte bei der SBRT von Oligometastasen

Einfluss der Fraktionierung (1 × 24 Gy vs. 3 × 9 Gy) auf onkologische Endpunkte bei der SBRT von Oligometastasen