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Postoperative local fractionated radiotherapy for resected single brain metastases

  • Ahmad Walid Ayas
  • Stefan Grau
  • Karolina Jablonska
  • Daniel Ruess
  • Maximilian Ruge
  • Simone Marnitz
  • Roland Goldbrunner
  • Martin Kocher
Original Article
  • 88 Downloads

Abstract

Purpose

Evaluation of postoperative fractionated local 3D-conformal radiotherapy (3DRT) of the resection cavity in brain metastases.

Patients and methods

Between 2011 and 2016, 57 patients underwent resection of a single, previously untreated (37/57, 65%) or recurrent (20/57, 35%) brain metastasis (median maximal diameter 3.5 cm [1.1–6.5 cm]) followed by 3DRT. For definition of the gross tumor volume (GTV), the resection cavity was used and for the clinical target volume (CTV), margins of 1.0–1.5 cm were added. Median dose was 48.0 Gy (30.0–50.4 Gy) in 25 (10–28) fractions; most patients had 36.0–42.0 Gy in 3.0 Gy fractions (n = 16, EQD210Gy 39.0–45.5 Gy) or 40.0–50.4 Gy in 1.8–2.0 Gy fractions (n = 37, EQD210Gy 39.3–50.0 Gy).

Results

Median follow-up was 18 months. Local control rates were 83% at 1 year and 78% at 2 years and were significantly influenced by histology (breast cancer 100%, non-small lung cancer 87%, melanoma 80%, colorectal cancer 26% at 2 years, p = 0.006) and resection status (p < 0.0001), but not by EQD210Gy or size of the planning target volume (median 96.7 ml [16.7–282.8 ml]). At 1 and 2 years, 74% and 52% of the patients were free from distant brain metastases. Salvage procedures were applied in 25/27 (93%) of recurrent patients. Survival was 68% at 1 year and 41% at 2 years and was significantly improved in younger patients (p = 0.006) with higher Karnofsky performance score (p < 0.0001) and without prior radiotherapy (54% vs. 9% at 2 years, p = 0.006). No cases of radiographic or symptomatic radionecrosis were observed.

Conclusion

Adjuvant fractionated local 3DRT is highly effective in radiosensitive, completely resected metastases and should be considered for treating large resection cavities as an alternative to postoperative stereotactic single dose or hypofractionated radiosurgery.

Keywords

Neoplasm metastasis Survival analysis Malignant melanoma Breast cancer Non-small cell lung cancer 

Postoperative lokale, fraktionierte Strahlentherapie nach Resektion einer singulären Hirnmetastase

Zusammenfassung

Ziel

Untersuchung der Wirksamkeit einer postoperativen fraktionierten, lokalen 3‑D-konformalen Strahlentherapie (3DRT) der Resektionshöhle bei Hirnmetastasen.

Patienten und Methoden

Von 2011–2016 wurde bei 57 Patienten eine unbehandelte (37/57, 65 %) oder rezidivierte (20/57, 35 %) Hirnmetastase (medianer maximaler Durchmesser 3,5 cm [1,1–6,5 cm]) reseziert und postoperativ lokal bestrahlt. Für das klinische Zielvolumen (CTV) wurden Säume von 1,0–1,5 cm um die Resektionshöhle verwendet. Die mediane Dosis betrug 48,0 Gy (30,0–50,4 Gy) in 25 (10–28) Fraktionen (meistens 36,0–42,0 Gy/3,0 Gy [n = 16, EQD210Gy 39,0–45,5 Gy] oder 40,0–50,4 Gy/1,8–2,0 Gy [n = 37, EQD210Gy 39,3–50,0 Gy]).

Ergebnisse

Die lokalen Kontrollraten von 83 % nach 1 Jahr und 78 % nach 2 Jahren wurden signifikant durch den Primärtumor (Mammakarzinom 100 %, nichtkleinzelliges Lungenkarzinom 87 %, Melanom 80 %, kolorektale Tumoren 26 % nach 2 Jahren, p = 0,006) und den Resektionsstatus (p < 0,0001), nicht aber durch die EQD210Gy oder die Größe des Planungszielvolumens (Median 96,7 ml [16,7–282,8 ml]) beeinflusst. Nach 1(2) Jahren waren 74 % (52 %) frei von neuen Hirnmetastasen. Salvage-Verfahren wurden bei 25/27 (93 %) angewendet. Das Überleben lag nach 1(2) Jahren bei 68 % (41 %) und war bei jüngeren Patienten (p = 0,006), bei höherem Karnofsky-Score (p < 0,0001) und ohne Vorbestrahlung (54 % vs. 9 % nach 2 Jahren, p = 0,006) signifikant verbessert. Es wurden keine radiologischen oder symptomatischen Radionekrosen beobachtet.

Schlussfolgerung

Die adjuvante fraktionierte, lokale 3DRT ist bei strahlensensiblen, vollständig resezierten Metastasen hoch wirksam und sollte zur Behandlung großer Resektionshöhlen als Alternative zur postoperativen stereotaktischen Einzeldosis- oder hypofraktionierten Radiochirurgie in Betracht gezogen werden.

Schlüsselwörter

Metastasen Überlebensanalyse Malignes Melanom Mammakarzinom Nichtkleinzelliges Lungenkarzinom 

Notes

Compliance with ethical guidelines

Conflict of interest

A. W. Ayas, S. Grau, K. Jablonska, D. Ruess, M. Ruge, S. Marnitz, R. Goldbrunner and M. Kocher declare that they have no competing interests.

Ethical standards

This article does not contain any studies with human participants or animals performed by any of the authors. For images or other information within the manuscript which identify patients, consent was obtained from them and/or their legal guardians.

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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Radiation Oncology, Center for Integrated OncologyUniversity Hospital CologneCologneGermany
  2. 2.Department of Neurosurgery, Center for Integrated OncologyUniversity Hospital CologneCologneGermany
  3. 3.Department of Stereotactic and Functional Neurosurgery, Center for Integrated OncologyUniversity Hospital CologneCologneGermany
  4. 4.Institute of Neuroscience and Medicine (INM-4)Forschungszentrum JuelichJuelichGermany

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