1 Sun Is Setting' on Whole-Brain Radiation for Mets
2 Survival among patients with 10 or more brain metastases treated with stereotactic radiosurgery.
3Local control after radiosurgery for brain metastases: predictive factors and implications for clinical decision
4Integral Whole Brain Dose from Stereotactic Radiosurgery of 47 Metastatic Lesions: A Dosimetric Case Study.
5Long-term survivors after gamma knife radiosurgery for brain metastases.
My conclusion(just my personal opinion (I am not a doctor I never graduated from medical school.): Currently it is not uncommon to treat up to 20 brain mets with srs. But up to 47 have been treated with success and high quality life. So I believe as long as lesions are small treating them all with srs is often safest and most effective treatment. Bigger mets should indeed be treated with surgery. Based on studies I believe hospital can refuse to do srs for multiple brain mets because they dont have enough experience doing so, but they cant say that there is no scientific evidence supporting srs even with multiple mets. Again asps patient should never have whole brain radiation. Srs simply gives much less radiation to healthy brain tissue and is more effective. Neurological side effects from whole brain radiation would be devastating. Repeated srs approach needs brain mri as often as possible. Every 2 - 3 moths. the idea that treatment of all mets improves survival is not new. Exactly same concept is true for lung mets surgery and traditional neurosurgery for brain mets, so I hope same is true for stereotactic radiosurgery.
Supporting articles for srs for multiple brain mets.
Re: Supporting articles for srs for multiple brain mets.
Oh and gamma knife is inmy opinion superior machine for brain mets treatment and I believe I am not the only one thinking this way. Based on my knowledge cyber knife and linear arc are not as accurate. Linear arc results in way higher normal brain tissue radiation dose and ablations with linear arc fail little more often than treatments with gamma knife. Difference wasn't statistically significant, but why have more radiation if there is no better local control? I would use radiation dose of 18- 24 grays for asps. High doses of radiation might increase the likelihood of radiation necrosis. For bigger tumors radiation dose have to be reduced, so for big tumors srs is often not curative. Of course the experience of specialist doing stereotactic radiation is more important factor than machine used.
Last edited by arojussi on Fri Sep 01, 2017 9:13 am, edited 1 time in total.
Re: Supporting articles for srs for multiple brain mets.
Journal of Neurosurgery
Posted online on February 17, 2017.
Toward the complete control of brain metastases using surveillance screening and stereotactic radiosurgery
Posted online on February 17, 2017.
Toward the complete control of brain metastases using surveillance screening and stereotactic radiosurgery
Re: Supporting articles for srs for multiple brain mets.
The incidence of brain metastases is increasing with improved systemic therapies, many of which have a limited impact on intracranial disease. Stereotactic radiosurgery (SRS) is a first-line management option for brain metastases. The purpose of this study was to determine if there is a threshold tumor size below which local control (LC) rates approach 100%, and to relate these findings to the use of routine surveillance brain imaging.
METHODS
From a prospective registry, 200 patients with 1237 brain metastases were identified who underwent SRS between December 2012 and May 2015. The median imaging follow-up duration was 7.9 months, and the median margin dose was 18 Gy. The maximal diameter and volume of tumors were measured. Histological analysis included 96 patients with non–small cell lung cancers (NSCLCs), 40 with melanoma, 35 with breast cancer, and 29 with other histologies.
RESULTS
Almost 50% of brain metastases were NSCLCs and commonly measured less than 6 mm in maximal diameter or 70 mm3 in volume. Thirty-three of 1237 tumors had local progression at a median of 8.8 months. The 1- and 2-year actuarial LC rates were 97% and 93%, respectively. LC of 100% was achieved for all intracranial metastases less than 100 mm3 in volume or 6 mm in diameter. Patients whose tumors at first SRS were less than 10 mm maximal diameter or a volume of 250 mm3 had improved overall survival.
CONCLUSIONS
SRS can achieve LC rates approaching 100% for subcentimeter metastases. The earlier initial detection and prompt treatment of small intracranial metastases may prevent the development of neurological symptoms and the need for resection, and improve overall survival. To identify tumors when they are small, routine surveillance brain imaging should be considered as part of the standard of care for lung, breast, and melanoma metastases.
■ CLASSIFICATION OF EVIDENCE Type of question: prognostic; study design: retrospective cohort; evidence: Class II.
...Show all
ABBREVIATIONS CI = confidence interval; DS-GPA = diagnosis-specific graded prognostic assessment; FDG = fluorodeoxyglucose; HR = hazard ratio; KPS = Karnofsky Performance Scale; LC = local control; LMD = leptomeningeal disease; NCCN = National Comprehensive Cancer Network; NSCLC = non–small cell lung cancer; SRS = stereotactic radiosurgery; WBRT = whole-brain radiation therapy.
INCLUDE WHEN CITING Published online February 17, 2017; DOI: 10.3171/2016.10.JNS161036.
Correspondence Douglas Kondziolka, Departments of Neurosurgery, NYU Langone Medical Center, New York University, Ste. 8R, 530 First Ave., New York, NY 10016. email: douglas.kondziolka@nyumc.org.
METHODS
From a prospective registry, 200 patients with 1237 brain metastases were identified who underwent SRS between December 2012 and May 2015. The median imaging follow-up duration was 7.9 months, and the median margin dose was 18 Gy. The maximal diameter and volume of tumors were measured. Histological analysis included 96 patients with non–small cell lung cancers (NSCLCs), 40 with melanoma, 35 with breast cancer, and 29 with other histologies.
RESULTS
Almost 50% of brain metastases were NSCLCs and commonly measured less than 6 mm in maximal diameter or 70 mm3 in volume. Thirty-three of 1237 tumors had local progression at a median of 8.8 months. The 1- and 2-year actuarial LC rates were 97% and 93%, respectively. LC of 100% was achieved for all intracranial metastases less than 100 mm3 in volume or 6 mm in diameter. Patients whose tumors at first SRS were less than 10 mm maximal diameter or a volume of 250 mm3 had improved overall survival.
CONCLUSIONS
SRS can achieve LC rates approaching 100% for subcentimeter metastases. The earlier initial detection and prompt treatment of small intracranial metastases may prevent the development of neurological symptoms and the need for resection, and improve overall survival. To identify tumors when they are small, routine surveillance brain imaging should be considered as part of the standard of care for lung, breast, and melanoma metastases.
■ CLASSIFICATION OF EVIDENCE Type of question: prognostic; study design: retrospective cohort; evidence: Class II.
...Show all
ABBREVIATIONS CI = confidence interval; DS-GPA = diagnosis-specific graded prognostic assessment; FDG = fluorodeoxyglucose; HR = hazard ratio; KPS = Karnofsky Performance Scale; LC = local control; LMD = leptomeningeal disease; NCCN = National Comprehensive Cancer Network; NSCLC = non–small cell lung cancer; SRS = stereotactic radiosurgery; WBRT = whole-brain radiation therapy.
INCLUDE WHEN CITING Published online February 17, 2017; DOI: 10.3171/2016.10.JNS161036.
Correspondence Douglas Kondziolka, Departments of Neurosurgery, NYU Langone Medical Center, New York University, Ste. 8R, 530 First Ave., New York, NY 10016. email: douglas.kondziolka@nyumc.org.
Re: Supporting articles for srs for multiple brain mets.
I simply copy pasted this abstract, because to me looks like it support my idea of repeated scanning and srs treatment. Of course asps is not included in this study, but there is melanoma, which behaves like asps. My oncologist used breast cancer as an example why my brain scans were ignored. He said that there was not evidence supporting bain mri in breast cancer. Well this article mentions breast cancer. Doctors often use breast cancer as an example, when they try to trick me. Reason is simple I believe I know more about asps than some doctors, but breast cancer is common, obviously average doctor knows more about it than I do. Also asps and breast cancer are 2 completely different diseases, so approaches that make sense for breast cancer most likely don't work in asps.
One last idea: Yes regular brain mri is expensive, but brain surgery is so much more expensive than gamma knife, that in long term this approach might actually save money. Brain mri costs around 1000 euros. I think gamma knife is around 10 000 euros and brain surgery around 100 000(but I am not certain about these prices.) and when here is symptomatic brain tumor not doing brain surgery is not an option especially if cortisol treatment is not an option.
My thinking is really chaotic, so this text can be chaotic as well. Sorry about that. If this is completely impossible to understand I try to fix it if/when my brains heal.
One last idea: Yes regular brain mri is expensive, but brain surgery is so much more expensive than gamma knife, that in long term this approach might actually save money. Brain mri costs around 1000 euros. I think gamma knife is around 10 000 euros and brain surgery around 100 000(but I am not certain about these prices.) and when here is symptomatic brain tumor not doing brain surgery is not an option especially if cortisol treatment is not an option.
My thinking is really chaotic, so this text can be chaotic as well. Sorry about that. If this is completely impossible to understand I try to fix it if/when my brains heal.
Re: Supporting articles for srs for multiple brain mets.
Pretty good Jussi. You could also include the links for the first list of the supportive articles. The overall idea that WBRT does not make sense anymore since it causes more brain damage than even the radiosurgery for the very multiple brain mets providing it is done on a less than 6-7 mm size, preferably on the few mm size, with the frequent MRI brain scans needed to catch and radiosurgically treat the mets early. With GammaKnife being the best type of the radiosurgery at the moment by the accuracy and less radiation damage to the surrounding tissue.
Re. breast cancer - that a very dumb thing to compare ASPS to the breast cancer, their clinical behavior is very different in all aspects - chemo and radiosensitivity, speed of growth. In the metastatic breast cancer chasing the mets - frequent scanning and locally destroying them with the surgery and ablative techniques - does not make sense, as they grow fast and besides they are often sensitive to the hormonal treatments so it make a perfect sense to start the systemic treatment as soon as possible. In ASPS the slow growing nature of the metastatic state gives us an opportunity to scan, catch and destroy and have a pretty good quality of life in between, it lasts years, not months as with the breast cancer.
Re. breast cancer - that a very dumb thing to compare ASPS to the breast cancer, their clinical behavior is very different in all aspects - chemo and radiosensitivity, speed of growth. In the metastatic breast cancer chasing the mets - frequent scanning and locally destroying them with the surgery and ablative techniques - does not make sense, as they grow fast and besides they are often sensitive to the hormonal treatments so it make a perfect sense to start the systemic treatment as soon as possible. In ASPS the slow growing nature of the metastatic state gives us an opportunity to scan, catch and destroy and have a pretty good quality of life in between, it lasts years, not months as with the breast cancer.
Olga
Re: Supporting articles for srs for multiple brain mets.
https://www.ncbi.nlm.nih.gov/pubmed/23662828
http://www.medscape.com/viewarticle/840857
https://www.ncbi.nlm.nih.gov/pubmed/26858917
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4353457/
https://www.ncbi.nlm.nih.gov/pubmed/16288488
As I said before I am really bad with computers, so some or all these links might not work, but write article name to google and it can usually be found quite easily. Scientific evidence supporting gamma knife is indeed overwhelming, so if I look I can most likely find more articles, but these convinced me to go ahead with srs for all my brain mets, so I stopped looking. In future radiation combined with immunotherapy might be better treatment, but at the moment srs for all brain mets should be first goal if systemic disease is under control. _Radiation for one or two mets can achieve abscopal effect and achieve systemic response, but nowadays it is still rare phenomenon. Maybe in the future immunotherapy can increase the likelihood of abscopal effect.
http://www.medscape.com/viewarticle/840857
https://www.ncbi.nlm.nih.gov/pubmed/26858917
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4353457/
https://www.ncbi.nlm.nih.gov/pubmed/16288488
As I said before I am really bad with computers, so some or all these links might not work, but write article name to google and it can usually be found quite easily. Scientific evidence supporting gamma knife is indeed overwhelming, so if I look I can most likely find more articles, but these convinced me to go ahead with srs for all my brain mets, so I stopped looking. In future radiation combined with immunotherapy might be better treatment, but at the moment srs for all brain mets should be first goal if systemic disease is under control. _Radiation for one or two mets can achieve abscopal effect and achieve systemic response, but nowadays it is still rare phenomenon. Maybe in the future immunotherapy can increase the likelihood of abscopal effect.
Re: Supporting articles for srs for multiple brain mets.
Jussi
All the links worked for me
These are excellent references !
Appreciate all your input as well.
All the links worked for me
These are excellent references !
Appreciate all your input as well.
Debbie
Re: Supporting articles for srs for multiple brain mets.
One last thing again. I found one article comparing gamma knife and volumetric modulated arc radiosurgery.
J Neurosurg. 2014 Dec;121 Suppl:51-9. doi: 10.3171/2014.7.GKS141358.
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.
http://www.ncbi.nlm.nih.gov/pubmed/25434937
Of course gamma knife treatment takes longer time, but it is so far only downside I found. Linear arc can treat mets from everywhere, so most hospitals use their money to linear arc or cyber knife rather than gamma knife. For example I haven't found single hospital in Finland with Gamma knife. Basically all universal hospitals have cyperknife, so they don't have to send patients to other hospitals. Difference between gamma knife and cyber knife is indeed small:Less than 1 mm I think.
J Neurosurg. 2014 Dec;121 Suppl:51-9. doi: 10.3171/2014.7.GKS141358.
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.
http://www.ncbi.nlm.nih.gov/pubmed/25434937
Of course gamma knife treatment takes longer time, but it is so far only downside I found. Linear arc can treat mets from everywhere, so most hospitals use their money to linear arc or cyber knife rather than gamma knife. For example I haven't found single hospital in Finland with Gamma knife. Basically all universal hospitals have cyperknife, so they don't have to send patients to other hospitals. Difference between gamma knife and cyber knife is indeed small:Less than 1 mm I think.