Hostname: page-component-8448b6f56d-gtxcr Total loading time: 0 Render date: 2024-04-25T02:14:50.768Z Has data issue: false hasContentIssue false
  • English
  • Français

LINAC-based stereotactic radiosurgery/radiotherapy for brain metastases in patients with breast cancer

Published online by Cambridge University Press:  15 February 2021

Ankita Gupta ,
Budhi Singh Yadav Open the ORCID record for Budhi Singh Yadav [Opens in a new window] ,
Nagarjun Ballari ,
Namrata Das  and
Ngangom Robert
Ankita Gupta
Affiliation:
Radiation Oncology, Post Graduate Institute of Medical Education, Sector-12, Chandigarh, India, 91160012
Budhi Singh Yadav*
Affiliation:
Radiation Oncology, Post Graduate Institute of Medical Education, Sector-12, Chandigarh, India, 91160012
Nagarjun Ballari
Affiliation:
Radiation Oncology, Post Graduate Institute of Medical Education, Sector-12, Chandigarh, India, 91160012
Namrata Das
Affiliation:
Radiation Oncology, Post Graduate Institute of Medical Education, Sector-12, Chandigarh, India, 91160012
Ngangom Robert
Affiliation:
Radiation Oncology, Post Graduate Institute of Medical Education, Sector-12, Chandigarh, India, 91160012
*
Author for correspondence: Budhi Singh Yadav, Radiation Oncology, Post Graduate Institute of Medical Education, Sector-12, Chandigarh, India, 91160012. E-mail: drbudhi@gmail.com
Get access Rights & Permissions [Opens in a new window]

Abstract

Background:

Brain metastases (BM) are common in patients with HER2-positive and triple-negative breast cancer. In this study we aim to report clinical outcomes with LINAC-based stereotactic radiosurgery/radiotherapy (SRS/SRT) for BM in patients of breast cancer.

Methods:

Clinical and dosimetric records of breast cancer patients treated for BM at our institute between May, 2015 and December, 2019 were retrospectively reviewed. Patients of previously treated or newly diagnosed breast cancer with at least a radiological diagnosis of BM; 1–4 in number, ≤3·5 cm in maximum dimension, with a Karnofsky Performance Score of ≥60 were taken up for treatment with SRS. SRT was generally considered if a tumour was >3·5 cm in diameter, near a critical or eloquent structure, or if the proximity of moderately sized tumours would lead to dose bridging in a single-fraction SRS plan. The median prescribed SRS dose was 15 Gy (range 7–24 Gy) and SRT dose was 27 Gy in 3 fractions.

Clinical assessment and MR imaging was done at 6 weeks post-SRS and then every 3 months thereafter. Intracranial progression-free survival (PFS) and overall survival (OS) were calculated using Kaplan–Meier method and subgroups were compared using log rank test.

Results:

Total, 40 tumours were treated in 31 patients. The median tumour diameter was 2·3 cm (range 1·0–4·6 cm). SRS and SRT were delivered in 27 and 4 patients, respectively. SRS/SRT was given as a boost to whole brain radiotherapy (WBRT) in four patients and as salvage for progression after WBRT in six patients. In general, nine patients underwent prior surgery. The median follow-up was 7·9 months (0·2–34 months). Twenty (64·5%) patients developed local recurrence, 10 (32·3%) patients developed distant intracranial relapse and 7 patients had both local and distant intracranial relapse. The estimated local control at 6 months and 1 year was 48 and 35%, respectively. Median intracranial progression free survival (PFS) was 3·73 months (range 0·2–25 months). Median intracranial PFS was 3·02 months in patients who received SRS alone or as boost after WBRT, while it was 4·27 months in those who received SRS as salvage after WBRT (p = 0·793). No difference in intracranial PFS was observed with or without prior surgery (p = 0·410). Median overall survival (OS) was 21·7 months (range 0·2–34 months) for the entire cohort. Patients who received prior WBRT had a poor OS (13·31 months) as compared to SRS alone (21·4 months; p = 0·699).

Conclusion:

In patients with BM after breast cancer SRS alone, WBRT + SRS and surgery + SRS had comparable PFS and OS.

Keywords

brain metastasesbreast cancerstereotactic radiotherapystereotactic radiosurgery
Type
Original Article
Information
Journal of Radiotherapy in Practice , Volume 21 , Issue 3 , September 2022 , pp. 351 - 359
Check for updates
Copyright
© The Author(s), 2021. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Hicks, D G, Short, S M, Prescott, N L et al. Breast cancers with brain metastases are more likely to be estrogen receptor negative, express the basal cytokeratin CK5/6, and overexpress HER2 or EGFR. Am J Surg Pathol 2006; 30 (9): 1097–1104.CrossRefGoogle ScholarPubMed
Heitz, F, Harter, P, Lueck, H J et al. Triple-negative and HER2-overexpressing breast cancers exhibit an elevated risk and an earlier occurrence of cerebral metastases. Eur J cancer 2009; 45 (16): 2792–2798.CrossRefGoogle Scholar
Smid, M, Wang, Y, Zhang, Y et al. Subtypes of breast cancer show preferential site of relapse. Cancer Res 2008; 68 (9): 3108–3114.CrossRefGoogle Scholar
Nam, B H, Kim, S Y, Han, H S et al. Breast cancer subtypes and survival in patients with brain metastases. Breast Cancer Res 2008; 10 (1): R20.CrossRefGoogle ScholarPubMed
Niwinska, A, Murawska, M, Pogoda, K. Breast cancer brain metastases: differences in survival depending on biological subtype, RPA RTOG prognostic class and systemic treatment after whole-brain radiotherapy (WBRT). Ann Oncol 2010; 21 (5): 942–948.CrossRefGoogle Scholar
Melisko, M E, Moore, D H, Sneed, P K, De Franco, J, Rugo, H S. Brain metastases in breast cancer: clinical and pathologic characteristics associated with improvements in survival. J Neurooncol 2008; 88 (3): 359–365.CrossRefGoogle ScholarPubMed
Niwińska, A, Murawska, M, Pogoda, K. Breast cancer brain metastases: differences in survival depending on biological subtype, RPA RTOG prognostic class and systemic treatment after whole-brain radiotherapy (WBRT). Ann Oncol 2009; 21: 942–948.CrossRefGoogle Scholar
Schulder, M, Patil, V. The History of Stereotactic Radiosurgery. In: Chin, L S, Regine, W F (eds). Principles and Practice of Stereotactic Radiosurgery. New York, NY: Springer New York, 2008: 3–7.CrossRefGoogle Scholar
Leksell, L. The stereotaxic method and radiosurgery of the brain. Acta Chir Scand 1951; 102 (4): 316–319.Google ScholarPubMed
Marcrom, S R, McDonald, A M, Thompson, J W et al. Fractionated stereotactic radiation therapy for intact brain metastases. Adv Radiat Oncol 2017; 2 (4): 564–571.CrossRefGoogle ScholarPubMed
Mazzola, R, Corradini, S, Gregucci, F, Figlia, V, Fiorentino, A, Alongi, F. Role of Radiosurgery/Stereotactic Radiotherapy in Oligometastatic Disease: Brain Oligometastases. Front Oncol 2019; 9 (206).CrossRefGoogle ScholarPubMed
Aoyama, H, Shirato, H, Tago, M et al. Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA 2006; 295 (21): 2483–2491.CrossRefGoogle ScholarPubMed
Kocher, M, Soffietti, R, Abacioglu, U et al. 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): 134–141.CrossRefGoogle ScholarPubMed
Andrews, D W, Scott, C B, Sperduto, P W et al. Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG 9508 randomised trial. Lancet 2004; 363 (9422): 1665–1672.CrossRefGoogle ScholarPubMed
Kelly, P J, Lin, N U, Claus, E B, Quant, E C, Weiss, S E, Alexander, B M. Salvage stereotactic radiosurgery for breast cancer brain metastases: outcomes and prognostic factors. Cancer 2012; 118 (8): 2014–2020.CrossRefGoogle ScholarPubMed
Hartgerink, D, Swinnen, A, Roberge, D et al. LINAC based stereotactic radiosurgery for multiple brain metastases: guidance for clinical implementation. Acta Oncol 2019; 58 (9): 1275–1282.CrossRefGoogle ScholarPubMed
Opp, D, Feygelman, V, Sarangkasiri, S et al. Pretreatment Simulation of Target Motion for Frameless Intracranial Stereotactic Radiosurgery Treatments using the Novalis Exactrac System. Fuel Energy Abstracts 2009; 75.Google Scholar
Combs, S E, Schulz-Ertner, D, Thilmann, C, Edler, L, Debus, J. Treatment of cerebral metastases from breast cancer with stereotactic radiosurgery. Strahlentherapie und Onkologie : Organ der Deutschen Rontgengesellschaft [et al]. 2004; 180 (9): 590–596.CrossRefGoogle ScholarPubMed
Bilger, A, Frenzel, F, Oehlke, O et al. Local control and overall survival after frameless radiosurgery: a single center experience. Clin Transl Radiat Oncol 2017; 7: 55–61.CrossRefGoogle ScholarPubMed
Armstrong, K, Ward, J, Dunne, M et al. Linac-Based Radiosurgery for Patients With Brain Oligometastases From a Breast Primary, in the Trastuzumab Era-Impact of Tumor Phenotype and Prescribed SRS Dose. Front Oncol 2019; 9 (377).CrossRefGoogle ScholarPubMed
Shaw, E, Scott, C, Souhami, L et al. 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): 291–298.CrossRefGoogle ScholarPubMed
Minniti, G, Scaringi, C, Paolini, S et al. 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 2016; 95 (4): 1142–1148.CrossRefGoogle ScholarPubMed
Milano, M T, Usuki, K Y, Walter, K A, Clark, D, Schell, M C. Stereotactic radiosurgery and hypofractionated stereotactic radiotherapy: normal tissue dose constraints of the central nervous system. Cancer Treat Rev 2011; 37 (7): 567–578.CrossRefGoogle ScholarPubMed
Paddick, I. A simple scoring ratio to index the conformity of radiosurgical treatment plans. Technical note. J Neurosurg 2000; 93 (Suppl 3): 219–222.CrossRefGoogle ScholarPubMed
Paddick, I, Lippitz, B. A simple dose gradient measurement tool to complement the conformity index. J Neurosurg 2006; 105 (Suppl): 194–201.CrossRefGoogle ScholarPubMed
Eisele, S C, Wen, P Y, Lee, E Q. Assessment of Brain Tumor Response: RANO and Its Offspring. Curr Treat Options Oncol 2016; 17 (7): 35.CrossRefGoogle ScholarPubMed
Sperduto, P W, Kased, N, Roberge, D et al. The effect of tumor subtype on the time from primary diagnosis to development of brain metastases and survival in patients with breast cancer. J Neurooncol 2013; 112 (3): 467–472.CrossRefGoogle ScholarPubMed
Mahajan, A, Ahmed, S, McAleer, M F et al. Post-operative stereotactic radiosurgery versus observation for completely resected brain metastases: a single-centre, randomised, controlled, phase 3 trial. Lancet Oncol 2017; 18 (8): 1040–1048.CrossRefGoogle ScholarPubMed
Stumpf, P K, Cittelly, D M, Robin, T P et al. Combination of Trastuzumab Emtansine and Stereotactic Radiosurgery Results in High Rates of Clinically Significant Radionecrosis and Dysregulation of Aquaporin-4. Clin Cancer Res 2019; 25 (13): 3946–3953.CrossRefGoogle ScholarPubMed
Tanguturi, S, Warren, L E G. The Current and Evolving Role of Radiation Therapy for Central Nervous System Metastases from Breast Cancer. Curr Oncol Rep 2019; 21 (6): 50.CrossRefGoogle ScholarPubMed