Does WBRT “age” the brain?
Anatomic surface-based deep learning to estimate brain age w/MRI before & after WBRT
WBRT aged brain 9x faster than controls
WBRT hippos aged 9x faster than HA-WBRT
SRS alone NOT diff compared to controls
Examples of target volume delineation errors for GBM, some egregious
A common error: crossing the tent with a supratentorial tumor, refer to coronals to help prevent this
Final Results CC001
Addition HA to WBRT+memantine
· Prevented cognitive failure (HR 0.74,p=0.016)
· Less symptom burden 6 & 12 mos
· Less symptom interference 6 & 12 mos
· Fewer cognitive symptoms overtime
· NO diff OS, PFS, Toxicity
There is no such thing as a famous rad onc
I could not name the most famous living rheumatologist or cardiac surgeon even though they are likely a big deal and I work in the medical field
Does Pseudoprogression occur after spine met SBRT?
Yes, 16% of time after SBRT
· Transient ↑ signal abnl centered @ treated lesion followed by signal improvement on FU MR imaging not attributable to systemic therapy
Progressive brain met after SRS, often resection is indicated
Is risk recurrence high after GTR of progressive brain met?
YES, 40% local failure even after GTR of tumor
Adjuvant RT indicated following salvage resection even after GTR
Congrats
#NRGonc
landmark trial RTOG 0539
•Grade 1
#meningioma
S/P GTR or STR
•Central review 10 yr Prog Rate after GTR 3%, STR 27%
•Increasing tumor size assoc with worse PFS, OS
•Typically no role adjuvant RT in this population
#radonc
#roedu
Putting Indigo Trial PFS benefit in context:
· EORTC 22845 different era
· RTOG9802 control arm ACTIVE treatment (RT as opposed to placebo)
· RTOG9802 Chemo&RT PFS benefit ↑ if exclude IDHwildtype
· After Vorasidenib resistance is Salvage Chemo&RT less effective?
RTOG 0631 Randomized Trial
· Primary Endpoint Pain Response 3 mos favors EBRT61% vs SBRT 41%
· Poor Pain Scale completion rates 63% @ 3 mos
· NO diff QOL, adverse effects
· 2 yr Vert compression fracture EBRT 22% vs 20%
via
@JAMAOnc
part of
@JAMANetwork
Interesting study RT margins 207 patients
#GBM
by Minniti et al
•Replanned with reduced GTV-to-CTV margin 1cm
•Compared to standard 2 cm margin similar pattern of failure and less RT normal brain, hippos
•Link:
#radonc
#roedu
Post element only spine met SBRT, do you need to include the vertebral body?
31 cases SBRT post elements only
NO isolated vertebral body failures
Supports SBRT Consensus Contouring Guidelines
Landmark trial RTOG1205 reirradiation recurrent
#GBM
•Small GTVs 18 cc
•80% 1st relapse
•Significant PFS benefit, important clinically if options limited
•No OS benefit possibly due to salvage RT on Bev alone arm
•Link:
#roedu
Paraganglioma week 1/6
Case based reviews
In my practice:
· rarely/never biopsy (bleed risk)
· SRS (15 Gy) for smaller lesions, large lesions 45-50.4 Gy
· Surgery consider if already CN deficits/low risk
Bone Met week 4/5
Any benefit RT for asymptomatic high-risk bone mets?
Randomized Trial Prophylactic RT less skeletal events/hospitalizations (& improved OS) compared to standard of care (SOC)
Does molecular GBM have better prog compared to histologic GBM?
NO, according to this Dutch study
Compared histologically&imagingGr2/3 but molecular GBM to histologic GBM
In GBM is there a role for “supramaximal” resection of FLAIR/T2 tumor beyond contrast enhancing tumor?
· RANO resect group study would suggest YES
· Thought provoking study difficult to tease out inherent selection bias (favorable location, smaller tumor)
In modern era does PCI improve OS in Small Cell Lung Cancer?
YES in both limited & extensive stage in this meta-analysis
In subset of trials w/MRI screening pre-PCI, Suggestion OS benefit in limited stage
ASTRO (
#264
) Randomized Trial Different RT Techniques High Grade Glioma
· No Diff PFS, OS, Toxicity
· Would be most interested in cognitive testing if prospectively acquired
Incredibly thoughtful editorial balancing tumor control and risks
The Art of Radiation Therapy: The Necessary Risk of Radiation Necrosis for Durable Control of Brain Metastases
#roedu
#brainmet
#radiosurgery
ASTRO Late-Breaking Abstract (LBA13): Randomized Trial fSRS vs WBRT Resected Brain Met
· Excellent Surg Bed Control w/fSRS
· LMD rate w/fSRS similar to post-op single frac SRS
MetaAnalysis
#SBRT
vs CRT
#bone
#metastasis
SBRT better pain relief, less benefit w/ elevation BED
Local Control (primary reason for SBRT) best assessed by CCTG SC.24
What are the cognitive outcomes for glioma w/ modern focal RT?
· Prospective Study F/U up to 11 years!
· Stable w/some improvement
· Despite more aggressive tumors outcomes comparable to Watchful-Waiting cohort
Large cranial targets should fSRS be used?
Duke study 445 patients brain met 5 fraction SRS 25-30Gy
Median diameter dominant lesion 3 cm intact & 4.6 cm resected
1 yr LC 86%
Gr 2+ radionecrosis 8%
Indigo RCT first breakthrough LGG since RTOG9802
· Crossover allowed so prob won’t be survival benefit
· Vorasidenib can delay RT&Chemo
· Would upfront Vorasidenib with RT & Chemo improve outcomes?
Prospective registry meningioma 68Ga-DOTATATE PET
· 60 pts
· Early F/U median 20 mos
· 2 of 3 local failures had PET-avid disease post-op & had elected observation
· 5 pts no PET uptake & observed no recurrences
95% papillary craniopharyngiomas have BRAF V600E mutations
Vemurafenib/cobimetinib BRAF/MEK inhibitor
7 patients had no local consolidation after BRAF/MEK inhibitor therapy, 6 of them have not progressed
New (RANO) surgical classification system based on resection of BOTH contrast enhancing & FLAIR/T2 predicts survival
· Inherent selection bias between classes
· Prognostic value RANO classes retained in multivariate model
Is fractionated SRS as good as single frac SRS for meningiomas?
Possibly Yes. Meta‑analysis No diff in 5 yr LC (93-94%) or Complication rate despite FSRS signif larger volumes 24 cc vs 6 cc
#radonc
Meningioma cognitive outcomes
•
#BTSM
mean dose hippocampus correlates w/hippo volume loss
•Signif atrophy if mean >40Gy but NOT if low dose (<10Gy)
#radonc
Insightful review recurrent
#GBM
Drs. Knisely & Fine
•Provides clinical context landmark trial
#NRGonc
RTOG1205
•Table 1 good guidance reRT/no RT
•In select cases I reRT only prog tumor & exclude tumor that has been stable on several serial MRIs
If asked Med Oncs to name 5 most famous living radoncs they couldn’t do it & likely would not recognize the names. Prob best ticket to being well known is NOT good clinical care/scientific achievement but is large social media presence w/ good content & controversial comments.
Case based review SRSbrain metastases
· 1st case multiple brain mets (7)SRS 20 Gy
· Rec’d total met volume <15cc
· Pertinent ongoing trial mult brain mets CE.7 SRS vs. HA-WBRT+memantine
T2-FLAIR Mismatch Sign for
IDHmutant
#Astrocytoma
Gr2+3 (noncodel)
•T2 homogenous hyperintense signal; FLAIR decreased core signal vs hyperintense rim
•Highly Specific IDHm (nearly 100% in ADULTS)
•Low sensitivity
•
#radonc
5 patients Early Alzheimer’s dementia Low Dose WBRT 10Gy/5
4/5 improved/stable MMSE-2 Tscores @ 1 yr
3 patients w/improved MMSE-2 Tscores ↑ to average range
Other cognitive assessments broadly stable or mildly declined over time
ASCO 2023: Elderly patients GBM 18F-DOPA PET Targeted Proton Dose Escalation w/TMZ
· Primary endpoint met median PFS/OS 7/13mos
· 13% Gr3 radiation necrosis
· PET volume more predictive OS than MRI volume
· QOL outcomes compare fav to other elderly GBM trials
@NataliyaMedPhys
LOL you are too kind, thank you. Prob the only renown CNS rad onc is Minesh.
My family likes & loves me, I have good relationships w/most my colleagues, and I take good care of patients that is all that really matters
Concise review
#Glioma
Vaccines
Tcells DO home to CNS
•Think
#immuno
& brain mets
Antigen clonality & function matter
•EGFRvIII subclonal & vaccines failed to date
•IDH clonal & being tested
•SurVaxM (survivin) promising Phase II
@BrainTumorDoc
Thoughtful review single vs. multi fraction
#SBRT
•SF potential better LC radioresis, less financial toxicity
•MF potential immunogenicity, less geographic miss, OARs
•
#MSKCC
trial not reviewed
#SRS
treatment option Vestibular
#Schwannoma
in
#NF2
Tumor control lower than Sporadic (i.e. >90%)
•Possibly due to lower dose? Each Gy increase 21% ↓ risk prog
•BUT each Gy increase 1.5-fold ↑ risk hearing loss
#radonc
Kudos Dr. McGovern and team
#prospective
trial conventional fractionation re-RT
#brain
tumor
•Essentially keep max dose non-target brain composite plan approx. <EQD2 of 100 Gy
•Table 1 good reference dose constraints
#radonc
#roedu
Research letter
#Leptomeningeal
#Metastases
•Reviewed 244 phase 3 trial mets breast, lung, melanoma
•Only 3% explicitly allowed
#LMD
enrollment
•Need to improve outcomes
•Encourage inclusion LMD in clinical trials
via
@JAMAOnc
part of
@JAMANetwork
Is Myelogram required to delineate cord for spine SBRT?
Maybe not if visualization cord feasible w/MRI
75% had hardware
Mean diff btwn Myelogram & fused T2 axials only 0.06cc
T2 may slightly overestimate cord at cord-CTV interface
#radonc