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Cavity volume changes after surgery of a brain metastasis—consequences for stereotactic radiation therapy

Volumenveränderungen der Resektionshöhlen nach Operation von Hirnmetastasen – Konsequenzen für die stereotaktische Strahlentherapie

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Abstract

Purpose

For a large or symptomatic brain metastasis, resection and adjuvant radiotherapy are recommended. Hypofractionated stereotactic radiotherapy (HFSRT) is increasingly applied in patients with a limited number of lesions. Exact target volume definition is critical given the small safety margins. Whilst technical advances have minimized inaccuracy due to patient positioning and radiation targeting, little is known about changes in target volume. This study sought to evaluate potential changes in the resection cavity of a brain metastasis.

Methods

In all, 57 patients treated with HFSRT after surgical resection of one brain metastasis between 2008 and 2015 in our institution were included in this study. Gross tumor volume (GTV) of the initial metastasis and the volume of the resection cavity in the post-operative, planning, and follow-up MRIs were measured and compared.

Results

The mean cavity size decreased after surgery with the greatest change of −23.4% (±41.5%) occurring between post-operative MRI and planning MRI (p < 0.01). During this time period, the cavity volume decreased, remained stable, and increased in 79.1, 3.5, and 17.4%, respectively. A further decrease of −20.7% (±58.1%) was perceived between planning MRI and first follow-up (p < 0.01). No significant difference in pattern of change could be observed depending on the volume of initial GTV, size of the post-operative resection cavity, initial or post-resection FLAIR (fluid-attenuated inversion recovery) hyper-intensity, postsurgical ischemia, or primary tumor. The resection cavities of patients with post-operative ischemia were significantly larger than resection cavities of patients without ischemia.

Conclusion

The resection cavity seems to be very dynamic after surgery. Hence, it remains necessary to use very recent scans for treatment planning.

Zusammenfassung

Hintergrund

Die empfohlene Therapie für große und symptomatische Hirnmetastasen ist die chirurgische Resektion mit nachfolgender Bestrahlung der Resektionshöhle. Bei Patienten mit einer begrenzten Metastasenanzahl werden zunehmend stereotaktisch fraktionierte Konzepte (HFSRT) angewandt. Aufgrund der geringen Sicherheitssäume, die bei der HFSRT verwendet werden, ist die genaue Definition des Zielvolumens entscheidend. Während lagerungsbedingte Ungenauigkeiten durch technische Fortschritte weitgehend minimiert werden konnten, sind bisher wenige Informationen über Veränderungen der Zielvolumina bekannt. Ziel dieser Studie war es, Veränderungen der Resektionshöhlen von Hirnmetastasen zu untersuchen.

Methoden

In die Studie wurden 57 Patienten eingeschlossen, die zwischen 2008 und 2015 an unserer Klinik eine HFSRT der Resektionshöhle einer Hirnmetastase erhalten hatten. Das Tumorvolumen (GTV) der Metastase und die Volumina der Resektionshöhlen in der postoperativen Magnetresonanztomographie (MRT), im Planungs- und Nachsorge-MRT wurden gemessen und verglichen.

Ergebnisse

Die durchschnittliche Größe der Resektionshöhle nahm im Verlauf ab, wobei die größten Veränderungen von −23,4 % (±41,5 %) zwischen dem postoperativen MRT und dem Planungs-MRT auftraten (p < 0,01). In diesem Zeitraum wurde die Resektionshöhle in 79,1 % der Fälle kleiner, blieb in 3,5 % gleich und nahm in 17,4 % zu. Eine weitere signifikante Reduktion des Resektionshöhlenvolumens um −20,7 (±58,1 %) trat zwischen dem Planungs-MRT und der ersten Nachsorge auf. Signifikante Zusammenhänge zwischen der Veränderung der Resektionshöhlenvolumina und dem initialen Volumen der Metastase (GTV), der Größe der postoperativen Resektionskavität, der FLAIR(„fluid-attenuated inversion recovery‟)-Hyperintensität, der postoperativen Ischämie oder des Primärtumors konnten nicht nachgewiesen werden. Patienten mit postoperativer Ischämie hatten eine signifikant größere Resektionshöhle als Patienten ohne postoperative Ischämie.

Schlussfolgerung

Nach Operation von Hirnmetastasen treten Änderungen der Resektionshöhlenvolumina auf. Daher ist es notwendig, aktuelle Bildgebungen zur Bestrahlungsplanung zu verwenden.

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Acknowledgements

The authors thank our team of technicians for excellent patient care.

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Authors and Affiliations

  1. Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany

    Sophia Scharl, Anna Kirstein, Kerstin A. Kessel, Marciana-Nona Duma, Markus Oechsner, Christoph Straube &  Stephanie E. Combs

  2. Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany

    Anna Kirstein, Kerstin A. Kessel, Marciana-Nona Duma &  Stephanie E. Combs

  3. Partner Site Munich, Deutsches Konsortium für Translationale Krebsforschung (DKTK), Munich, Germany

    Kerstin A. Kessel &  Stephanie E. Combs

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  1. Sophia Scharl
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Corresponding author

Correspondence to Stephanie E. Combs.

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Conflict of interest

S. Scharl, A. Kirstein, K.A. Kessel, M.-N. Duma, M. Oechsner, C. Straube, and S.E. Combs declare that they have no competing interests.

Ethical standards

All patients were treated in accordance with the Declaration of Helsinki. A written informed consent for the use of scientific data was obtained from all patients. This study was approved by the Ethics Committee of the Technical University Munich, Faculty of Medicine.

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Scharl, S., Kirstein, A., Kessel, K.A. et al. Cavity volume changes after surgery of a brain metastasis—consequences for stereotactic radiation therapy. Strahlenther Onkol 195, 207–217 (2019). https://doi.org/10.1007/s00066-018-1387-y

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