Clinical Trial Finder

Inclusion criteria Prospective Cohort. Patients will be eligible for inclusion only if ALL of the following criteria apply:

• - Age: above 18 years, no upper limit.

• - Diagnosis of brain metastases or meningioma, where the treatment is going to be stereotactic radiosurgery.

• - Karnofsky Performance Status (KPS) ≥70.

• - Established diagnosis of cancer with absent or controllable primary disease.

• - Tumour volume of less than 20cc.

• - Life expectancy of more than 6 months.

• - Able to give informed consent.

Exclusion criteria Prospective Cohort.

• - Previous RT to the brain, including SRS.

• - Previous surgery to the brain.

• - Not willing or not able to give informed consent.

Inclusion criteria Retrospective Cohort. Patients will be eligible for inclusion only if ALL of the following criteria apply:

• - Age: above 18 years, no upper limit.

• - Diagnosis of meningioma.

• - Previous SRS treatment at least 1 year prior to inclusion in the study.

• - Most recent MRI scan (within 1 year) shows stable appearances.

• - Able to give informed consent.

Exclusion criteria Retrospective Cohort.

• - Previous RT to the brain, excluding SRS.

• - Previous surgery to the brain.

- Not willing or not able to give informed consent

Brain metastases affect roughly 20-40% of all cancer patients with a primary extracranial disease. Lamba et at estimated that patients' median survival without treatment is approximately one month. This number increases from one month to between three and 12 months if whole brain radiotherapy (WBRT) is used. WBRT is a radiotherapy treatment that is delivered in five to ten sessions and where the whole brain is irradiated. With the advent of new systemic treatments, prognosis for patients is constantly improving . The widespread use of MRI imaging has also increased the number of patients being diagnosed by improving the detection of very small tumours (one or two millimetres in diameter). Consequently, more people are referred for treatment with a curative intent for their brain metastases. Patients with brain metastases can be treated with surgery, WBRT, Stereotactic Radiosurgery (SRS) or a combination of the above. SRS is the treatment of choice for single or multiple metastases, unless there is a large mass (more than 3 cm in diameter) when surgery would be the preferred option. This is due to the invasiveness of the surgery, SRS is non or minimally invasive, and the associated risks of having a surgical resection. SRS is a highly focused treatment that makes use of stereotactic localisation techniques to deliver a high radiation dose to an outlined area of the brain. The treatment is usually delivered in a single radiotherapy treatment. In prospective randomised controlled trials, it was shown that Stereotactic Radiosurgery is as effective as whole brain radiotherapy, in terms of local tumour control, but the burden of cognitive decline for the patients is less. The primary tumours can vary, but the majority of the patients have a lung, breast, melanoma, kidney or colon primary. Radiation damages the brain, with different areas being more or less susceptible to radiation. The main organs used to optimise radiotherapy treatment plans by reducing the dose delivered to these, include the eyes, optic nerves, chiasma, brainstem, cochleas, lenses and lacrimal glands. These are organs that affect physical functions. Currently, during radiotherapy treatment planning, no consideration is given to areas of the brain that affect cognitive function, such as the hippocampus, basal ganglia, insula and corpus callosum to name a few. The effects of radiotherapy in the brain are well documented but this is mostly for WBRT. The effects of focal radiotherapy, such as SRS, on cognition have not been studied in detail. This pilot study will be using voxel-based lesion symptom mapping (VLSM) to correlate the treatment planning dose maps with clinical outcomes on neurocognitive function. Voxel-based lesion symptom mapping is a technique where the relationship between damage to certain locations of the brain can be corelated with symptoms that affect cognitive function. This is done on a voxel-by-voxel basis. A voxel is a volume in a three-dimensional structure. VLSM has been used extensively in the past in stroke patients, but the literature is scarce for patients with brain metastases. Individual MR images of the brain will be used along with the dose maps from each patient's SRS treatment plan. The dose maps will be overlayed and correlated with results from neurocognitive testing. The identified areas of the brain will then be outlined and the dose level of significance (the level of dose at which cognitive change becomes quantifiable) will be assessed. Benefits. The identification of areas in the brain and associated doses with cognitive changes will help advise future guidelines on volumetric dose constraints for those areas in the brain. As lesion location will be correlated with clinical outcomes from neurocognitive testing, a better understanding of the side-effects of the radiotherapy treatment may be gained. This will allow the optimisation of future radiotherapy treatments, to spare these areas thereby minimising the side-effects of the radiotherapy treatment. Finally, with the acquired knowledge, consultants will be better placed to inform patients about the effects that their treatment will have. Patients will therefore be able to make informed decisions about their treatment. This is especially important in this population, as the majority of patients treated with SRS do not have a very long life-expectancy. Methods Magnetic Resonance Imaging or MRI is a medical imaging technique that uses magnetic fields and radio waves to generate detailed images of the inside of the body. MRI is the preferred imaging method used to diagnose tumours in the brain, both benign and malignant, due to its ability to provide high contrast for these tissues. Tumours as small as 2 mm can be easily visualised with the aid of an MRI scanner. The methodology that will be used to analyse the data, VLSM, is well established and has been used extensively in patients with stroke lesions. It uses a regression model that is univariate and can associate the cognitive performance of patients to whether or not a lesion is present in each voxel. In this pilot study instead of using lesions we will be using the dose maps of the radiotherapy treatment plans. The structural MRI scans of the patients will be spatially normalised to a common coordinate system, the Montreal Neurological Institute (MNI) space. The transformations will then be used to fit the dose maps to the same coordinate system. The data will then be smoothed. The voxel-based lesion symptom mapping analysis will involve the use of a Matlab statistical parametric mapping toolbox. For each voxel a group comparison between patients will be undertaken with the use of the dose maps from the radiotherapy treatment plans. The t statistic will be computed based on the results from the neurocognitive testing. A corresponding t-map of the brain will be created showing all the voxels related to the relevant cognitive deficits. A correction for multiple comparisons needs to be carried out to ensure that the rate of false positives will be minimised.

Arms

: Prospective

Patients with brain metastases and meningiomas that are eligible for SRS treatment will be included in the prospective arm of the trial. The patients will have neurocognitive testing in the form of the Montreal Cognitive Assessment (MoCA) and will answer two Quality of Life questionnaires (QLQs) by EORTC QLQ-C30 and BN20). The baseline visit will happen before they start their SRS treatment. The patients will be seen an additional 4 times, at 3, 6, 9 and 12 months after radiotherapy treatment. During each visit they will complete the MoCA and the QLQs. During the first follow up appointment they will also be asked to think back to before they had the treatment and answer the QLQs based on that.

: Retrospective

Patients with meningiomas that have received SRS treatment more than a year ago will be included in the retrospective arm of the trial. The patients will have neurocognitive testing in the form of the Montreal Cognitive Assessment (MoCA) and will answer two Quality of Life questionnaires (QLQs) by EORTC QLQ-C30 and BN20) once. They will also be asked to think back to before they had the treatment and answer the QLQs based on that.

Interventions

Behavioral: - Neurocognitive testing

The MoCA is a brief tool developed to screen mild cognitive impairment and has been validated in patients aged 55-85 years old. It has been tested and validated in patients with brain metastases, and its acceptability has been tested in the general brain tumour population. The paper version of the MoCA is available in nearly 100 languages. The online version is available currently in 5 languages.

Behavioral: - Quality of Life questionnaire

The EORTC-QLQ-C30 is a quality-of-life questionnaire that was developed by the European Organisation for Research and Treatment of Cancer (EORTC) for use in clinical trials. It is a 30-item questionnaire that incorporates the following five scales: physical, role, cognitive, emotional and social. It has also been validated and is available in more than 100 languages. The EORTC-QLQ-BN20 is a questionnaire that was developed for use specifically with patients that have brain cancer. The BN20 is a 20-item questionnaire and addresses four different scales (multi-item): future uncertainty, visual disorder, motor dysfunction and communication deficit. There are seven items that assess physical symptoms: headaches, seizures, drowsiness, hair loss, itchy skin, weakness of legs and bladder control. The questionnaire has been validated in over 15 languages. The two questionnaires are meant to complement each other when used in patients with brain cancer.

Radiation: - Stereotactic radiosurgery

This is a Standard of Care treatment for all the patients that will be recruited in both cohorts. Stereotactic radiosurgery will be delivered to one or more sites and in the prospective cohort can be delivered more than once.