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Guo S.,Cleveland Clinic | Reddy C.A.,Cleveland Clinic | Chao S.T.,Cleveland Clinic | Chao S.T.,Rose Ella Burkhardt Brain Tumor and Neuro oncology Center | And 7 more authors.
Lung Cancer

Introduction: The Graded Prognostic Assessment (GPA) provides prognostic classification for patients with brain metastases (BM), based on Radiation Therapy Oncology Group (RTOG) data. Recent evidence suggests differential response and outcomes to chemotherapy for different non-small cell lung cancer (NSCLC) histologies. Using a large BM patient database, we assessed the impact of histologic subtypes on survival stratified by the GPA. Methods: From an IRB-approved database, we analyzed 780 patients with NSCLC BM treated from 1982 to 2004. GPA classification variables included age, KPS, number of BM, and presence of extracranial disease. Histology was identified for each patient. Median survival time (MST) based on GPA class and histology were calculated using Kaplan-Meier analysis. The log rank test was used to determine statistical differences. Results: MST, in months, by histology were: adenocarcinoma (AC) 6.2 (n= 464), large cell (LC) 4.1 (n= 98), squamous (SQ) 4.2 (n= 108) (p=0.0549). For GPA 3.5-4.0, MSTs did not differ significantly by histology. Differences in MST by histology were noted for GPA 3.0 (p=0.04), GPA 1.5-2.5 (p=0.01), and GPA 0-1.0 (p=0.02). For all patients with brain metastases BM from NSCLC, MSTs by GPA score were: GPA 3.5-4.0, 12.6; GPA 3.0, 10.2; GPA 1.5-2.5, 5.8; and GPA 0-1.0, 2.7. Conclusions: Adenocarcinoma showed a statistically significant higher MST than other histologies of NSCLC for patients with GPA 0-3.0. Using histology as a prognostic factor for BM from NSCLC warrants further investigation. Our cohort of NSCLC BM patients validates the GPA, with MST comparable to that of published data. © 2012 Elsevier Ireland Ltd. Source

Hunter G.K.,Rose Ella Burkhardt Brain Tumor and Neuro oncology Center | Suh J.H.,Rose Ella Burkhardt Brain Tumor and Neuro oncology Center | Reuther A.M.,Rose Ella Burkhardt Brain Tumor and Neuro oncology Center | Vogelbaum M.A.,Cleveland Clinic | And 5 more authors.
International Journal of Radiation Oncology Biology Physics

Purpose: To examine the outcomes of patients with five or more brain metastases treated in a single session with stereotactic radiosurgery (SRS). Methods and Materials: Sixty-four patients with brain metastases treated with SRS to five or more lesions in a single session were reviewed. Primary disease type, number of lesions, Karnofsky performance score (KPS) at SRS, and status of primary and systemic disease at SRS were included. Patients were treated using dosing as defined by Radiation Therapy Oncology Group Protocol 90-05, with adjustments for critical structures. We defined prior whole-brain radiotherapy (WBRT) as WBRT completed >1 month before SRS and concurrent WBRT as WBRT completed within 1 month before or after SRS. Kaplan-Meier estimates and Cox proportional hazard regression were used to determine which patient and treatment factors predicted overall survival (OS). Results: The median OS after SRS was 7.5 months. The median KPS was 80 (range, 60-100). A KPS of ≥80 significantly influenced OS (median OS, 4.8 months for KPS ≤70 vs. 8.8 months for KPS ≥80, p = 0.0097). The number of lesions treated did not significantly influence OS (median OS, 6.6 months for eight or fewer lesions vs. 9.9 months for more than eight, p = nonsignificant). Primary site histology did not significantly influence median OS. On multivariate Cox modeling, KPS and prior WBRT significantly predicted for OS. Whole-brain radiotherapy before SRS compared with concurrent WBRT significantly influenced survival, with a risk ratio of 0.423 (95% confidence interval 0.191-0.936, p = 0.0338). No significant differences were observed when no WBRT was compared with concurrent WBRT or when the no WBRT group was compared with prior WBRT. A KPS of ≤70 predicted for poorer outcomes, with a risk ratio of 2.164 (95% confidence interval 1.157-4.049, p = 0.0157). Conclusions: Stereotactic radiosurgery to five or more brain lesions is an effective treatment option for patients with metastatic cancer, especially for patients previously treated with WBRT. A KPS of ≥80 predicts for an improved outcome. © 2012 Elsevier Inc. All rights reserved. Source

Sharma M.,Rose Ella Burkhardt Brain Tumor and Neuro oncology Center | Balasubramanian S.,Rose Ella Burkhardt Brain Tumor and Neuro oncology Center | Silva D.,Rose Ella Burkhardt Brain Tumor and Neuro oncology Center | Barnett G.H.,Rose Ella Burkhardt Brain Tumor and Neuro oncology Center | Mohammadi A.M.,Rose Ella Burkhardt Brain Tumor and Neuro oncology Center
Expert Review of Neurotherapeutics

With advances in stereotactic and neuroimaging techniques, various minimally invasive image-guided techniques have gained widespread acceptance in the field of neuro-oncology. Laser interstitial thermal therapy (LITT) is an image-guided technique that involves generation of high temperatures using a laser fiber, to ablate pathological tissue. Radiation necrosis (RN) and radiosurgery resistant brain metastasis often pose significant challenges to the treating physicians. In the last two decades, various studies have documented the efficacy of LITT in managing radiosurgery resistant metastases, radiation necrosis, surgically inaccessible malignant gliomas and ablation of epileptogenic foci. The aim of this paper is to summarize the current literature on the efficacy of LITT in patients with radiation necrosis and brain metastasis. We have also touched upon the physical properties of currently available LITT systems and the mechanism of action of laser therapy including histopathological changes. © 2016 Taylor & Francis. Source

Shiue K.,Case Western Reserve University | Barnett G.H.,Rose Ella Burkhardt Brain Tumor and Neuro oncology Center | Barnett G.H.,Neurological Institute | Suh J.H.,Rose Ella Burkhardt Brain Tumor and Neuro oncology Center | And 11 more authors.

Background: Higher isodose lines (IDLs) in Gamma Knife (GK) Perfexion treatment of brain metastases (BMet) could result in lower local control (LC) or higher radiation necrosis (RN) rates, but reduce treatment time. Objective: To assess the impact of the heterogeneity index (HI) and conformality index (CFI) ion local failure (LF) for patients treated with GK for 1 to 3 BMet. Methods: From an institutional review board-approved database, 320 patients with 496 BMet were identified, treated for 1 to 3 BMet from July 2007 to April 2011 on GK Perfexion. Cox proportional hazards regression was used to analyze significance of HI, CFI, IDL, dose, tumor diameter, recursive partitioning analysis class, tumor radioresistance, primary, smoking history, metastasis location, and whole-brain radiation therapy (WBRT) history with LF and RN. Results: Median follow-up by lesion was 6.8 months (range, 0-49.6). The series median survival was 14.2 months. Per RECIST, 9.5% of lesions failed, 33.9% were stable, 38.3% partially responded, 17.1% responded completely, and 1.2% could not be assessed. The 12-month LC rate was 87.3%. On univariate analysis, a dose less than 20 Gy (hazard ratio [HR]: 2.940, P <.001); tumor size (HR: 1.674, P <.001); and cerebellum/brainstem location vs other (HR: 1.891, P =.043) were significant for LF. Non-small cell lung cancer (HR: 0.333, P =.0097) was associated with better LC. On multivariate analysis, tumor size (HR: 1.696, P <.001) and cerebellum/brainstem location vs other (HR: 1.959, P =.033) remained significant for LF. Variables not significant for LF included CI, IDL, and HI. Conclusion: Our study of patients with 1 to 3 BMet treated with GK demonstrated no difference in LC or RN with varying HI, indicating that physicians can treat to IDL at 70% or higher IDL to reduce treatment time without increased LF or RN. Source

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