title: Cesium-131 brachytherapy for recurrent brain metastases: durable salvage treatment for previously irradiated metastatic disease.
abstract: OBJECTIVE Managing patients whose intraparenchymal brain metastases recur after radiotherapy remains a challenge. Intraoperative cesium-131 (Cs-131) brachytherapy performed at the time of neurosurgical resection may represent an excellent salvage treatment option. The authors evaluated the outcomes of this novel treatment with permanent intraoperative Cs-131 brachytherapy. METHODS Thirteen patients with 15 metastases to the brain that recurred after stereotactic radiosurgery and/or whole brain radiotherapy were treated between 2010 and 2015. Stranded Cs-131 seeds were placed as a permanent volume implant. Prescription dose was 80 Gy at 5-mm depth from the resection cavity surface. The primary end point was resection cavity freedom from progression (FFP). Resection cavity freedom from progression (FFP), regional FFP, distant FFP, median survival, overall survival (OS), and toxicity were assessed. RESULTS The median duration of follow-up after salvage treatment was 5 months (range 0.5-18 months). The patients' median age was 64 years (range 51-74 years). The median resected tumor diameter was 2.9 cm (range 1.0-5.6 cm). The median number of seeds implanted was 19 (range 10-40), with a median activity per seed of 2.25 U (range 1.98-3.01 U) and median total activity of 39.6 U (range 20.0-95.2 U). The 1-year actuarial local FFP was 83.3%. The median OS was 7 months, and 1-year OS was 24.7%. Complications included infection (3), pseudomeningocele (1), seizure (1), and asymptomatic radionecrosis (RN) (1). CONCLUSIONS After failure of prior irradiation of brain metastases, re-irradiation with intraoperative Cs-131 brachytherapy implants provides durable local control and limits the risk of RN. The authors' initial experience demonstrates that this treatment approach is well tolerated and safe for patients with previously irradiated tumors after failure of more than 1 radiotherapy regimen and that it results in excellent response rates and minimal toxicity.
authors.affiliation: Stich Radiation Oncology Center.
authors.forename: A Gabriella
authors.initials: AG
authors.lastname: Wernicke
authors.affiliation: University of Rochester School of Medicine and Dentistry, Rochester, New York.
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Smith
authors.affiliation: Stich Radiation Oncology Center.
authors.forename: Shoshana
authors.initials: S
authors.lastname: Taube
authors.affiliation: Stich Radiation Oncology Center.
authors.forename: Menachem Z
authors.initials: MZ
authors.lastname: Yondorf
authors.affiliation: Stich Radiation Oncology Center.
authors.forename: Bhupesh
authors.initials: B
authors.lastname: Parashar
authors.affiliation: Stich Radiation Oncology Center.
authors.forename: Samuel
authors.initials: S
authors.lastname: Trichter
authors.affiliation: Stich Radiation Oncology Center.
authors.forename: Lucy
authors.initials: L
authors.lastname: Nedialkova
authors.affiliation: Stich Radiation Oncology Center.
authors.forename: Albert
authors.initials: A
authors.lastname: Sabbas
authors.affiliation: Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, and.
authors.forename: Paul
authors.initials: P
authors.lastname: Christos
authors.affiliation: Department of Neurosurgery, Weill Medical College of Cornell University, New York; and.
authors.forename: Rohan
authors.initials: R
authors.lastname: Ramakrishna
authors.affiliation: Department of Neurosurgery, Weill Medical College of Cornell University, New York; and.
authors.forename: Susan C
authors.initials: SC
authors.lastname: Pannullo
authors.affiliation: Department of Neurosurgery, Weill Medical College of Cornell University, New York; and.
authors.forename: Philip E
authors.initials: PE
authors.lastname: Stieg
authors.affiliation: Department of Neurosurgery, Weill Medical College of Cornell University, New York; and.
authors.forename: Theodore H
authors.initials: TH
authors.lastname: Schwartz
mesh_terms: D000368:Aged; D001918:Brachytherapy; D001932:Brain Neoplasms / Q000453:epidemiology / Q000532:radiotherapy*; D002588:Cesium Radioisotopes / Q000627:therapeutic use*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology / Q000532:radiotherapy*; D000069475:Re-Irradiation; D016879:Salvage Therapy; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D002588:Cesium Radioisotopes; C000614985:Cesium-131
keywords: ADC = apparent diffusion coefficient; FFP = freedom from progression; OS = overall survival; QOL = quality of life; RN = radionecrosis; RPA = recursive partitioning analysis; SRS = stereotactic radiosurgery; WBRT = whole brain radiotherapy; brachytherapy; cesium-131; metastases; oncology; radiation; re-irradiation; recurrence