RESUMO
Objectives Brain metastases (BM) are the most common intracranial tumors in adults. Surgery and frame-based stereotactic radiosurgery (SRS) are well-described treatment options. Frameless SRS is an emerging BM treatment option offering fewer side effects. The aim of this study was to describe the therapeutic outcomes and toxicity of frameless SRS with linear accelerator (LINAC)-based technology for BM treatment in our institution. Materials and methods We performed a retrospective study including all adult patients treated with frameless SRS with LINAC-based technology for BM between October 2010 and July 2016. Patients were followed routinely with MRI scans at three-month intervals. Primary endpoints were progression-free survival, local control, overall survival, and toxicity related to the treatment. All survival times were computed with the Kaplan-Meier method. All cumulative incidences were computed using competing risk analyses. Results A total of 194 metastatic lesions in 141 patients were treated in a 69-month interval. At the time of analysis, 33 patients were still alive, with a median follow-up time of 25.1 months. The overall median survival was 8.7 months. The median progression-free survival was 5.3 months. Local recurrence as a first event was 25% and 38% at one and two years, respectively, while distant brain recurrence as a first event was 18% and 21%. Death before any brain event occurred in 31% of patients. The cumulative incidence of radiation necrosis as a first brain event was 2% at one and two years. Conclusions The treatment of BM with LINAC-based frameless SRS in our institution had an overall and progression-free survival comparable with the literature for frameless SRS and for conventional frame-based SRS while being less invasive and more comfortable for the patient. In our study, frameless SRS with LINAC technology seems to be safe for BM treatment with minimal rates of radiation necrosis.
RESUMO
The management of prostate cancer (PC) recurrence after definitive radiation therapy (RT) is shifting and there is no consensus regarding the optimal strategy. The major challenge is determining the anatomical site of relapse. In case of biochemical relapse (BR), androgen deprivation therapy (ADT) is a non-curative option commonly used, while patients with a local PC recurrence could be managed through a curative intent. Based on a Pubmed data search, this manuscript focused on the management of post-RT local PC recurrences. In case of BR (nadir+2 ng/ml), classical imaging work-up is not contributive for PSA levels <10 ng/ml while new imaging investigations (diffusion MRI, 11C-choline PET) are more sensitive to detect local and distant recurrences at lower PSA levels. Positive prostate biopsies are the only method for confirming local recurrence, although this technique presents limitations. Primary PC presentation as well as PSA-related features (interval to failure, PSA kinetic) and patient features (life expectancy, urinary, sexual status) are important to consider. Results of curative salvage options (radical prostatectomy, cryotherapy, brachytherapy and high-intensity focused ultrasound-HIFU) are analyzed and discussed. Each of these therapies appears feasible and has its own set of experience and toxicity profile. Other therapeutic options (photodynamic therapy, ADT, observation) are discussed. Longer follow-up and mature series are needed to evaluate the optimal strategy and prospective trials are warranted. Each clinical situation should be discussed in a multidisciplinary setting. Different options should be explained to the patient and decision should be taken after balancing treatment outcomes with life expectancy.
