Stereotactic Body Radiotherapy in the Treatment of Adrenal Metastases

*Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL †Department of Radiation Oncology, Mayo Clinic, Rochester, MN ‡Department of Radiation Oncology, Providence Medical Center, Kansas City, Kansas.
American journal of clinical oncology (Impact Factor: 3.06). 07/2012; 36(5). DOI: 10.1097/COC.0b013e3182569189
Source: PubMed


To evaluate the dosimetry, clinical outcomes, and toxicity of patients treated with stereotactic body radiotherapy (SBRT) for adrenal metastases.

Materials and methods:
From February 2009 to February 2011, a total of 13 patients were treated with SBRT for metastases to the adrenal glands. Median age was 71 years (range, 60.8 to 83.2). Primary sites included lung (n=6), kidney (n=2), skin (n=2), bladder (n=1), colon (n=1), and liver (n=1). Nine patients had metastases to the left adrenal gland and 4 to the right. The median prescribed total dose was 45 Gy (range, 33.75 to 60 Gy), all in 5 fractions.

Median follow-up for living patients was 12.3 months (range, 3.1 to 18 mo). Twelve of the 13 patients (92.3%) were evaluable for local control (LC). The crude LC rate was 100%, with no cases of local or marginal failure. Two patients had a complete response to treatment, 9 patients had a partial response, and 1 patient displayed stable disease. One-year overall survival and distant control were 62.9% and 55%, respectively. Median OS was 7.2 months (range, 2 to 18 mo). Grade 2 nausea was noted in 2 patients.

SBRT seems to be a safe and effective measure to achieve LC for adrenal metastases.

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    • "Kupelian et al. [27] treated 770 consecutive patients with ultrasound-guided IMRT using 2.5-Gy daily fractionation to 70 Gy over 5 weeks and obtained favorable outcomes including tumor control and toxicities. Considering the development and success of SBRT for various cancers [28–30] and favorable results for hypofractionated high-dose-rate brachytherapy [31, 32], SBRT might be an alternative treatment to conventional IMRT for prostate cancer [33–37]. Promising middle-term results have been reported recently [33]. "
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    ABSTRACT: Outcomes of three protocols of intensity-modulated radiation therapy (IMRT) for localized prostate cancer were evaluated. A total of 259 patients treated with 5-field IMRT between 2005 and 2011 were analyzed. First, 74 patients were treated with a daily fraction of 2.0 Gy to a total of 74 Gy (low risk) or 78 Gy (intermediate or high risk). Then, 101 patients were treated with a 2.1-Gy daily fraction to 73.5 or 77.7 Gy. More recently, 84 patients were treated with a 2.2-Gy fraction to 72.6 or 74.8 Gy. The median patient age was 70 years (range, 54–82) and the follow-up period for living patients was 47 months (range, 18–97). Androgen deprivation therapy was given according to patient risk. The overall and biochemical failure-free survival rates were, respectively, 96 and 82% at 6 years in the 2.0-Gy group, 99 and 96% at 4 years in the 2.1-Gy group, and 99 and 96% at 2 years in the 2.2-Gy group. The biochemical failure-free rate for high-risk patients in all groups was 89% at 4 years. Incidences of Grade ≥2 acute genitourinary toxicities were 9.5% in the 2.0-Gy group, 18% in the 2.1-Gy group, and 15% in the 2.2-Gy group (P = 0.29). Cumulative incidences of Grade ≥2 late gastrointestinal toxicity were 13% in the 2.0-Gy group at 6 years, 12% in the 2.1-Gy group at 4 years, and 3.7% in the 2.2-Gy group at 2 years (P = 0.23). So far, this stepwise shortening of treatment periods seems to be successful.
    Full-text · Article · Oct 2013 · Journal of Radiation Research
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    ABSTRACT: Purpose The adrenal glands are common sites of metastatic disease in lung cancer and can be highly symptomatic. Current treatment approaches for adrenal oligometastases, including surgical resection and chemoembolization, are invasive and can be associated with considerable morbidity. More recently, stereotactic body radiotherapy (SBRT) has shown promising tumor control rates in primary lung cancer and oligometastases of various sites, but relatively less data exist on the efficacy of SBRT for adrenal metastases. The purpose of this study is to assess tumor regression pattern, local control, overall survival, pain relief, and treatment morbidity in patients treated with SBRT for adrenal metastases from lung cancer. Methods and materials Eleven lesions were treated with SBRT in nine patients with lung cancer and followed with post-therapy clinical exams and computed tomography. Response Evaluation Criteria in Solid Tumors (RECIST)-based tumor response was assessed and volumetric tumor measurements were obtained by serial three-dimensional contouring. Symptomatic control, overall survival, and radiation therapy-associated side effects were assessed at follow-up visits. Mean post-therapy follow-up was 7.3 months. Results The prescribed dose ranged from 20.0 to 37.5 Gy in five fractions (mean, 24.9 ± 7.6 Gy), corresponding to a BED10 of 28.0 to 65.6 (mean, 41.6 ± 11.6) Gy. Overall RECIST-based response rate was 67%; 1-year and 2-year local control was 44%; and 1-year and 2-year overall survival were 52% and 13%, respectively. Volumetric response was much more rapid in small cell than in non-small cell carcinomas (slope, −31.0% vs. −5.9%/month, respectively, p = 0.06). Patients with metachronous lesions had longer survival (1 year, 60%; 2 year, 20%) than patients with synchronous lesions (1 year, 38%; 2 year, 0%). No early or late grade ≤ 3 adverse effects occurred. Conclusion SBRT is a useful non-invasive treatment option for adrenal metastases from lung cancer, providing good local control with minimal morbidity. Small cell carcinoma lesions show rapid response that may require adaptive re-planning.
    Full-text · Article · Jun 2012
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    ABSTRACT: Adrenal metastasis is common in oncology but patients with this diagnosis are usually asymptomatic. The diagnosis can be challenging and delayed. Incidence, presenting symptoms and diagnostic modalities are reviewed. Various treatment options are also discussed, including open and laparoscopic surgery, local ablation (radiofrequency ablation, cryoablation, microwave thermal ablation, and chemical ablation) as well as radiation therapy. These treatment modalities were compared and contrasted in regards to their invasiveness, risks, side effects, outcomes, and patients’ tolerance. Radiotherapy including stereotactic body radiation therapy (SBRT) is the only non-invasive approach, which is important as majority of the patients with adrenal metastases also receive systemic therapy, e.g., chemotherapy. The initial goal of conventional radiotherapy for metastatic adrenal lesion is for palliation which has been shown to be effective. With the advent of technological advances in radiation oncology, e.g., image-guidance during radiation delivery, patient immobilization and patient re-positioning, tumor motion management, sophisticated treatment planning allowing rapid dose fall-off, accurate QA, etc., the clinical implementation of SBRT has been very successful. SBRT is defined as a “treatment method to deliver high dose of radiation to the target, utilizing either a single dose or a small number of fractions with a high degree of precision within the body”. Adrenal metastasis, an example of oligometastases even from radioresistant primary, could be successfully treated with SBRT without significant toxicity as evidenced by various recently reported clinical trials. An additional advantage could be adrenal function preservation when compared to surgical intervention. The optimal total dose and fractionation scheme are yet to be determined. SBRT is an emerging non-invasive, safe, and effective treatment modality, and further research is warranted to define its role in the management of adrenal metastasis.
    Preview · Article · Mar 2012
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