Radiosurgery Dose Reduction for Brain Metastases on Immunotherapy (RADREMI): A Prospective Pilot Study (RADREMI)

• ClinicalTrials.gov Identifier: NCT04047602
• Recruitment Status: Completed
• First Posted: August 7, 2019
• Last Update Posted: April 12, 2024
• Sponsor: Indiana University
• Information provided by (Responsible Party): Kevin Shiue, MD, Indiana University

Study Description

Brief Summary:

This study will evaluate the rate of radiation necrosis following treatment with immune checkpoint inhibitor (ICI) treatment and radiation therapy in subjects with metastatic brain cancer. Subjects will be treated with the standard of care immunotherapy followed by radiation therapy via stereotactic radiosurgery at a reduced dose.

Condition or disease	Intervention/treatment	Phase
Brain Tumor; Brain Metastases; Brain Cancer	Radiation: Reduced Dose SRS	Not Applicable

Detailed Description:

This is a prospective, single arm, pilot study to determine the symptomatic radiation necrosis rate at 6 months utilizing dose-reduced stereotactic radiosurgery with immunotherapy for subjects with a diagnosis of 1-10 brain metastases from MRI and tissue diagnosis of primary malignancy.

Primary end-point is 6 month symptomatic radiation necrosis, defined as a 6-month rate of clinical symptomatology requiring steroid administration (i.e. Decadron) and/or operative intervention concomitant with advanced and routine brain imaging findings consistent with radiation necrosis. Follow-up MRIs will be fused with the planning scan for this assessment.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 21 participants
• Allocation: N/A
• Intervention Model: Single Group Assignment
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: Radiosurgery Dose Reduction for Brain Metastases on Immunotherapy (RADREMI): A Prospective Pilot Study
• Actual Study Start Date: December 12, 2019
• Actual Primary Completion Date: July 25, 2023
• Actual Study Completion Date: February 20, 2024

Arms and Interventions

Arm	Intervention/treatment
Experimental: Reduced Dose Stereotactic Radiosurgery; Subjects will receive one stereotactic radiosurgery (SRS) treatment at a reduced dose based on the brain tumor size concurrently with their standard of care immunotherapy. Subjects will undergo follow up with clinical exams and brain MRI scans at 1, 3, 6, 9, and 12 months post SRS treatment	Radiation: Reduced Dose SRS; Subjects will receive SRS treatment at a reduced dose based on the brain tumor size

Outcome Measures

Primary Outcome Measures :

1. Symptomatic radiation necrosis rate [ Time Frame: 6 months post SRS ]
   Defined as the rate of clinical symptomatology requiring steroid administration (i.e. Decadron) and/or operative intervention concomitant with advanced and routine brain imaging findings consistent with radiation necrosis

Secondary Outcome Measures :

1. Local control rate [ Time Frame: 6 months, 12 months post SRS ]
   Defined as the rate of any new, recurrent, or progressing tumor as defined by Response Assessment in Neuro-oncology (RANO) criteria within the planning target volume
2. Radiographic radiation necrosis rate [ Time Frame: 6 months, 12 months post SRS ]
   Defined as brain imaging findings on magnetic resonance imaging (MRI), magnetic resonance (MR) perfusion, MR Spectroscopy, and/or positron emission tomography (PET) imaging consistent with radiation necrosis.
3. Symptomatic radiation necrosis rate [ Time Frame: 12 months post SRS ]
   Defined as the rate of clinical symptomatology requiring steroid administration (i.e. Decadron) and/or operative intervention concomitant with advanced and routine brain imaging findings consistent with radiation necrosis
4. Gamma Knife local control rate [ Time Frame: 12 months post SRS ]
   Defined as the rate of any new, recurrent, or progressing tumor as defined by RANO criteria within the planning target volume in subjects who receive SRS via gamma knife techniques
5. Linear accelerator local control rate [ Time Frame: 12 months post SRS ]
   Defined as the rate of any new, recurrent, or progressing tumor as defined by RANO criteria within the planning target volume in subjects who receive SRS via linear accelerator techniques
6. Multi agent immune checkpoint inhibitor local control rate [ Time Frame: 12 months post SRS ]
   Defined as the rate of any new, recurrent, or progressing tumor as defined by RANO criteria within the planning target volume in subjects who are treated with multi-agent immune checkpoint inhibitor therapy.
7. Single agent immune checkpoint inhibitor local control rate [ Time Frame: 12 months post SRS ]
   Defined as the rate of any new, recurrent, or progressing tumor as defined by RANO criteria within the planning target volume in subjects who are treated with single agent immune checkpoint inhibitor therapy.
8. Melanoma brain metastases local control rate [ Time Frame: 12 months post SRS ]
   Defined as the rate of any new, recurrent, or progressing tumor as defined by RANO criteria within the planning target volume in subjects with metastatic melanoma
9. Non-melanoma brain metastases local control rate [ Time Frame: 12 months post SRS ]
   Defined as the rate of any new, recurrent, or progressing tumor as defined by RANO criteria within the planning target volume in subjects with non melanoma metastatic disease
10. Gamma knife symptomatic radiation necrosis rate [ Time Frame: 12 months post SRS ]
    Defined as the rate of clinical symptomatology requiring steroid administration (i.e. Decadron) and/or operative intervention concomitant with advanced and routine brain imaging findings consistent with radiation necrosis in subjects who receive SRS using gamma knife techniques
11. Linear accelerator symptomatic radiation necrosis rate [ Time Frame: 12 months post SRS ]
    Defined as the rate of clinical symptomatology requiring steroid administration (i.e. Decadron) and/or operative intervention concomitant with advanced and routine brain imaging findings consistent with radiation necrosis in subjects who receive SRS using linear accelerator techniques
12. Single agent immune checkpoint inhibitor symptomatic radiation necrosis rate [ Time Frame: 12 months post SRS ]
    Defined as the rate of clinical symptomatology requiring steroid administration (i.e. Decadron) and/or operative intervention concomitant with advanced and routine brain imaging findings consistent with radiation necrosis in subjects who are treated with single agent immune checkpoint inhibitor therapy
13. Multi agent immune checkpoint inhibitor symptomatic radiation necrosis rate [ Time Frame: 12 months post SRS ]
    Defined as the rate of clinical symptomatology requiring steroid administration (i.e. Decadron) and/or operative intervention concomitant with advanced and routine brain imaging findings consistent with radiation necrosis in subjects who are treated with multi agent immune checkpoint inhibitor therapy
14. Non melanoma brain metastases symptomatic radiation necrosis rate [ Time Frame: 12 months post SRS ]
    Defined as the rate of clinical symptomatology requiring steroid administration (i.e. Decadron) and/or operative intervention concomitant with advanced and routine brain imaging findings consistent with radiation necrosis in subjects with metastatic melanoma
15. Melanoma brain metastases symptomatic radiation necrosis rate [ Time Frame: 12 months post SRS ]
    Defined as the rate of clinical symptomatology requiring steroid administration (i.e. Decadron) and/or operative intervention concomitant with advanced and routine brain imaging findings consistent with radiation necrosis in subjects with non melanoma metastatic disease

Eligibility Criteria

• Ages Eligible for Study: 18 Years and older (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

1. Brain MRI-confirmed 1-10 solid tumor brain metastases
2. Biopsy-confirmed primary malignancy
3. ds-GPA estimated median survival of at least 6 months, for histologies not included in the ds-GPA, publications or noted online at brainmetgpa.com, the PI will use either published or validated data or their best clinical judgment to determine the patient's expected survival
4. Stereotactic radiosurgery candidate per treating Radiation Oncologist
5. ≥ 18 years old at the time of informed consent
6. Ability to provide written informed consent and HIPAA (Health Insurance Portability and Accountability Act) authorization.
7. ALC > 800/ul (Ku et al., 2010)
8. Patients currently on cytotoxic chemotherapy are eligible
9. Patients receiving ICI up to 30 days prior to delivery of SRS are eligible
10. Patients having undergone operative resection for metastatic brain disease within 30 days of immune checkpoint inhibitor (ICI) administration are eligible.

Exclusion Criteria:

1. Major medical illnesses or psychiatric impairments, which in the investigator's opinion will prevent administration or completion of the protocol therapy and/or interfere with follow-up
2. Patients unable to receive MRI Brain
3. Patients with more than 10 brain metastases on MRI Brain imaging
4. Any lesion > 4 centimeter maximum diameter
5. Total volume of metastatic disease more than 30 cubic centimeters
6. Previous whole brain radiation therapy
7. For Cohort 1: Previous stereotactic radiosurgery where the 50% isodose line overlaps with current treatment field
8. For Cohort 2: Patients whose treatment will have a dose overlap within the target from prior treatments of 20% or greater
9. Already receiving chronic dexamethasone (chronic = > 2 weeks) prior to SRS
10. Not a radiosurgical candidate per Radiation Oncology discretion
11. Existing autoimmune disease
12. Patients who have an unknown primary cancer
13. Histology not amenable for SRS (i.e. lymphoma). (Small Cell Lung Cancer IS amenable.)

Contacts and Locations

Locations

United States, Indiana

Indiana University Health Hospital

Indianapolis, Indiana, United States, 46202

Indiana University Methodist Hospital

Indianapolis, Indiana, United States, 46202

United States, Oregon

Oregon Health and Sciences

Portland, Oregon, United States, 97239

Sponsors and Collaborators

Indiana University

Investigators

• Principal Investigator: Kevin Shiue, MD; Indiana University

More Information

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

McClelland S 3rd, Lautenschlaeger T, Zang Y, Hanna NH, Shiue K, Kamer AP, Agrawal N, Ellsworth SG, Rhome RM, Watson GA. Radiosurgery dose reduction for brain metastases on immunotherapy (RADREMI): A prospective phase I study protocol. Rep Pract Oncol Radiother. 2020 Jul-Aug;25(4):500-506. doi: 10.1016/j.rpor.2020.04.007. Epub 2020 Apr 23.

• Responsible Party: Kevin Shiue, MD, Associate Professor of Clinical Radiation Oncology, Indiana University
• ClinicalTrials.gov Identifier: NCT04047602
• Other Study ID Numbers: RAON-IIR-IUSCC-0710
• First Posted: August 7, 2019
• Last Update Posted: April 12, 2024
• Last Verified: April 2024

• Studies a U.S. FDA-regulated Drug Product: No
• Studies a U.S. FDA-regulated Device Product: Yes
• Product Manufactured in and Exported from the U.S.: No

Keywords provided by Kevin Shiue, MD, Indiana University:

Radiation; Immune therapy; Stereotactic Radiosurgery

Additional relevant MeSH terms:

Neoplasm Metastasis; Brain Neoplasms; Neoplastic Processes; Neoplasms; Pathologic Processes; Central Nervous System Neoplasms; Nervous System Neoplasms; Neoplasms by Site; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases