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Taslimi S, Brar K, Ellenbogen Y, Deng J, Hou W, Moraes FY, Glantz M, Zacharia BE, Tan A, Ahluwalia MS, Khasraw M, Zadeh G, Mansouri A. Comparative Efficacy of Systemic Agents for Brain Metastases From Non-Small-Cell Lung Cancer With an EGFR Mutation/ALK Rearrangement: A Systematic Review and Network Meta-Analysis. Front Oncol 2021; 11:739765. [PMID: 34950579 PMCID: PMC8691653 DOI: 10.3389/fonc.2021.739765] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 11/15/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Brain metastases (BM) from non-small-cell lung cancer (NSCLC) are frequent and carry significant morbidity, and current management options include varying local and systemic therapies. Here, we performed a systematic review and network meta-analysis to determine the ideal treatment regimen for NSCLC BMs with targetable EGFR-mutations/ALK-rearrangements. METHODS We searched MEDLINE, EMBASE, Web of Science, ClinicalTrials.gov, CENTRAL and references of key studies for randomized controlled trials (RCTs) published from inception until June 2020. Comparative RCTs including ≥10 patients were selected. We used a frequentist random-effects model for network meta-analysis (NMA) and assessed the certainty of evidence using the GRADE approach. Our primary outcome of interest was intracranial progression-free survival (iPFS). RESULTS We included 24 studies representing 19 trials with 1623 total patients. Targeted tyrosine kinase inhibitors (TKIs) significantly improved iPFS, with second-and third- generation TKIs showing the greatest benefit (HR=0.25, 95%CI 0.15-0.40). Overall PFS was also improved compared to conventional chemotherapy (HR=0.47, 95%CI 0.36-0.61). In EGFR-mutant patients, osimertinib showed the greatest benefit in iPFS (HR=0.32, 95%CI 0.15-0.69) compared to conventional chemotherapy, while gefitinib + chemotherapy showed the greatest overall PFS benefit (HR=0.26, 95%CI 0.10-0.70). All ALKi improved overall PFS compared to conventional chemotherapy, with alectinib having the greatest benefit (HR=0.13, 95%CI 0.07-0.24). CONCLUSIONS In patients with NSCLC BMs and EGFR/ALK mutations, targeted TKIs improve intracranial and overall PFS compared to conventional modalities such as chemotherapy, with greater efficacy seen using newer generations of TKIs. This data is important for treatment selection and patient counseling, and highlights areas for future RCT research. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=179060.
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Affiliation(s)
- Shervin Taslimi
- Division of Neurosurgery, Department of Surgery, Queen’s University, Kingston, ON, Canada
| | - Karanbir Brar
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Yosef Ellenbogen
- Division of Neurosurgery, Department of Surgery, Queen’s University, Kingston, ON, Canada
| | - Jiawen Deng
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Winston Hou
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Fabio Y. Moraes
- Department of Oncology, Queen’s University, Kingston, ON, Canada
| | - Michael Glantz
- Department of Neurosurgery, Penn State Health, Hershey, PA, United States
- Penn State Cancer Institute, Hershey, PA, United States
| | - Brad E. Zacharia
- Department of Neurosurgery, Penn State Health, Hershey, PA, United States
- Penn State Cancer Institute, Hershey, PA, United States
| | - Aaron Tan
- Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Manmeet S. Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Mustafa Khasraw
- The Preston Robert Tisch Brain Tumor Center, Duke University, Durham, NC, United States
| | - Gelareh Zadeh
- Division of Neurosurgery, Department of Surgery, Queen’s University, Kingston, ON, Canada
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State Health, Hershey, PA, United States
- Penn State Cancer Institute, Hershey, PA, United States
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Kim AE, Wang GM, Waite KA, Elder S, Fine A, Ahluwalia MS, Brat D, Mehta MP, Page R, Dunbar E, Calderone HM, Robins DS, DeVitto R, Willmarth NE, Barnholtz-Sloan JS, Brastianos PK. Cross-sectional survey of patients, caregivers, and physicians on diagnosis and treatment of brain metastases. Neurooncol Pract 2021; 8:662-673. [PMID: 34777835 PMCID: PMC8579087 DOI: 10.1093/nop/npab042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The development of brain metastases (BM) is one of the most feared complications of cancer due to the substantial neurocognitive morbidity and a grim prognosis. In the past decade, targeted therapies and checkpoint inhibitors have demonstrated promising intracranial response rates for tumors of multiple histologies. As overall survival for these patients improves, there is a growing need to identify issues surrounding patient survivorship and to standardize physician practice patterns for these patients. To date, there has not been an adequate study to specifically explore these questions of survivorship and practice standardization for patients with advanced cancer and BM. METHODS Here, we present results from a cross-sectional survey in which we analyze responses from 237 patients, 209 caregivers, and 239 physicians to identify areas of improvement in the clinical care of BM. RESULTS In comparing physician and patient/caregiver responses, we found a disparity in the perceived discussion of topics pertaining to important aspects of BM clinical care. We identified variability in practice patterns for this patient population between private practice and academic physicians. Many physicians continue to have patients with BM excluded from clinical trials. Finally, we obtained patient/physician recommendations on high-yield areas for federal funding to improve patient quality of life. CONCLUSION By identifying potential areas of unmet need, we anticipate this wealth of actionable information will translate into tangible benefits for both patients and caregivers. Future studies are needed to validate our findings.
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Affiliation(s)
- Albert E Kim
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Gi-Ming Wang
- Case Comprehensive Cancer Center and Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Kristin A Waite
- Case Comprehensive Cancer Center and Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Scott Elder
- Penn, Schoen, and Berland (PSB) Research, Washington, DC, USA
| | - Avery Fine
- Penn, Schoen, and Berland (PSB) Research, Washington, DC, USA
| | - Manmeet S Ahluwalia
- Burkhardt Brain Tumor Neuro-Oncology Center, Neurological Institute, Taussig Cancer Center Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniel Brat
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Robin Page
- American Brain Tumor Association, Chicago, Illinois, USA
| | - Erin Dunbar
- Piedmont Brain Tumor Center, Piedmont Cancer Institute, Atlanta, Georgia, USA
| | | | | | - Ralph DeVitto
- American Brain Tumor Association, Chicago, Illinois, USA
| | | | - Jill S Barnholtz-Sloan
- Case Comprehensive Cancer Center and Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Case Comprehensive Cancer Center, University Hospitals of Cleveland, Cleveland, Ohio, USA
| | - Priscilla K Brastianos
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
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53
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Kutuk T, Tolakanahalli R, Williams A, Tom MC, Vadhan JD, Appel H, Hall MD, Wieczorek DJJ, Davis S, McDermott MW, Ahluwalia MS, Mehta MP, Gutierrez AN, Kotecha R. Impact of MRI timing on tumor volume and anatomic displacement for brain metastases undergoing stereotactic radiosurgery. Neurooncol Pract 2021; 8:674-683. [PMID: 34777836 DOI: 10.1093/nop/npab047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background The objective of this study was to evaluate the impact of the time interval between planning imaging and stereotactic radiosurgery (SRS) delivery on tumor volumes and spatial anatomic displacements of brain metastases (BM). Methods Consecutive patients diagnosed with BM treated with SRS over a 3-year period were evaluated. Only patients who underwent an institutionally standardized diagnostic MRI (MRI-1) and a treatment planning MRI (MRI-2) were included. The impact of histology, inter-scan time interval, lesion location, tumor volume, and diameter were evaluated on final lesion diameter, volume, anatomic displacement, and ultimate need for change in management (ie, expanding margins, rescanning). Results 101 patients (531 lesions) with a median inter-scan time interval of 8 days (range: 1-42 days) met the inclusion criteria. The median percentage increase in BM diameter and volume were 9.5% (IQR: 2.25%-24.0%) and 20% (IQR: 0.7%-66.7%). Overall, 147 lesions (27.7%) in 57 patients (56.4%) required a change in management. There was a statistically significant relationship between initial tumor diameter (cm) and change in management (OR: 2.69, 95% CI: 1.93-3.75; P < .001). Each day between MRI-1 and MRI-2 was associated with a change in management with an OR of 1.05 (95% CI: 1.03-1.07; P < .001). Conclusions Changes in tumor diameter, volume, and spatial position occur as a function of time. Planning imaging for SRS is recommended to occur in close temporal proximity to treatment; for those with delays, a larger setup margin may need to be used to ensure tumor coverage and account for positional changes.
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Affiliation(s)
- Tugce Kutuk
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Ranjini Tolakanahalli
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Andre Williams
- Department of Clinical Informatics, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Martin C Tom
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Jason D Vadhan
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Haley Appel
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - D Jay J Wieczorek
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Stephen Davis
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Michael W McDermott
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA.,Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Manmeet S Ahluwalia
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA.,Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Alonso N Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
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54
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Tonse R, Rubens M, Appel H, Tom MC, Hall MD, Odia Y, McDermott MW, Ahluwalia MS, Mehta MP, Kotecha R. Systematic review and meta-analysis of lung cancer brain metastasis and primary tumor receptor expression discordance. Discov Oncol 2021; 12:48. [PMID: 35201504 PMCID: PMC8777541 DOI: 10.1007/s12672-021-00445-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/27/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Treatment paradigms for metastatic non-small cell lung cancer are increasingly based on biomarker-driven therapies, with the most common alteration being mutation in the epidermal growth factor receptor (EGFR). Change in expression of such biomarkers could have a profound impact on the choice and efficacy of a selected targeted therapeutic, and hence the objective of this study was to analyze discordance in EGFR status in patients with lung cancer brain metastasis (LCBM). METHODS Using PRISMA guidelines, a systematic review was performed of series in the Medline database of biopsied or resected LCBM published before May, 2020. Key words included "lung cancer" and "brain metastasis" combined with "epidermal growth factor receptor/EGFR," and "receptor conversion/discordance or concordance." Weighted random effects models were used to calculate pooled estimates. RESULTS We identified 501 patients from 19 full-text articles for inclusion in this study. All patients underwent biopsy or resection of at least one intracranial lesion to compare to the primary tumor. On primary/LCBM comparison, the weighted pooled estimate for overall EGFR receptor discordance was 10% (95% CI 5-17%). The weighted effects model estimated a gain of an EGFR mutation in a brain metastases in patients with negative primary tumors was 7% (95% CI 4-12%). Alternatively, the weighted effects model estimate of loss of an EGFR mutation in patients with detected mutations in the primary tumor was also 7% (95% CI 4-10%). KRAS testing was also performed on both primary tumors and LCBM in a subset of 148 patients. The weighted effects estimate of KRAS-mutation discordance among LCBM compared to primary tumors was 13% (95% CI 5-27%). The weighted effects estimated of KRAS gain and loss in LCBM was 10% (95% CI 6-18%) and 8% (95% CI 4-15%), respectively. Meta-regression analysis did not find any association with any factors that could be associated with discordances. CONCLUSIONS EGFR and KRAS mutation status discordance between primary tumor and LCBM occurs in approximately 10% and 13% of patients, respectively. Evaluation of LCBM receptor status is key to biomarker-driven targeted therapy for intracranial disease and awareness of subtype switching is critical for those patients treated with systemic therapy alone for intracranial disease.
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Affiliation(s)
- Raees Tonse
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Office 1R203, Miami, FL, 33176, USA
| | - Muni Rubens
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Haley Appel
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Office 1R203, Miami, FL, 33176, USA
| | - Martin C Tom
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Office 1R203, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Office 1R203, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Yazmin Odia
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
- Division of Neuro-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Michael W McDermott
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
- Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Manmeet S Ahluwalia
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Office 1R203, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Office 1R203, Miami, FL, 33176, USA.
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
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55
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Wieczorek DJ, Kotecha R, Hall MD, Tom MC, Davis S, Ahluwalia MS, McDermott MW, Mehta MP, Gutierrez AN, Tolakanahalli R. Systematic evaluation and plan quality assessment of the Leksell® gamma knife® lightning dose optimizer. Med Dosim 2021; 47:70-78. [PMID: 34696931 DOI: 10.1016/j.meddos.2021.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 08/02/2021] [Accepted: 08/27/2021] [Indexed: 11/28/2022]
Abstract
To compare stereotactic radiosurgery (SRS) plan quality metrics of manual forward planning (MFP) and Elekta Fast Inverse Planning™ (FIP)-based inversely optimized plans for patients treated with Gamma Knife®. Clinically treated, MFP SRS plans for 100 consecutive patients (115 lesions; 67 metastatic and 48 benign) were replanned with the FIP dose optimizer based on a convex linear programming formulation. Comparative plans were generated to match or exceed the following metrics in order of importance: Target Coverage (TC), Paddick Conformity Index (PCI), beam-on time (BOT), and Gradient Index (GI). Plan quality metrics and delivery parameters between MFP and FIP were compared for all lesions and stratified into subgroups for further analysis. Additionally, performance of FIP for multiple punctate (<4 mm) metastatic lesions on a subset of cases was investigated. A Wilcoxon signed-rank test for non-normal distributions was used to assess the statistical differences between the MFP and FIP treatment plans. Overall, 76% (87/115) of FIP plans showed a statistically significant improvement in plan quality compared to MFP plans. As compared to MFP, FIP plans demonstrated an increase in the median PCI by 1.1% (p<0.01), a decrease in GI by 3.7% (p< 0.01), and an increase in median number of shots by 74% (p< 0.01). TC and BOT were not statistically significantly different between MFP and FIP plans (p>0.05). FIP plans showed a statistically significant increase in use of 16 mm (p< 0.01) and blocked shots (p< 0.01), with a corresponding decrease in 4 mm shots (p< 0.01). Use of multiple shots per coordinate was significantly higher in FIP plans (p<0.01). The FIP optimizer failed to generate a clinically acceptable plan in 4/115 (3.5%) lesions despite optimization parameter changes. The mean optimization time for FIP plans was 5.0 min (Range: 1.0 - 10.0 min). In the setting of multiple punctate lesions, PCI for FIP was significantly improved (p<0.01) by changing the default low-dose/BOT penalty optimization setting from a default of 50/50 to 75-85/40. FIP offers a significant reduction in manual effort for SRS treatment planning while achieving comparable plan quality to an expert planner-substantially improving overall planning efficiency. FIP plans employ a non-intuitive increased use of blocked sectors and shot-in-shot technique to achieve high quality plans. Several FIP plans failed to achieve clinically acceptable treatments and warrant further investigation.
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Affiliation(s)
- D Jay Wieczorek
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176 USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176 USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176 USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA
| | - Martin C Tom
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176 USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA
| | - Stephen Davis
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176 USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA
| | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176 USA
| | - Michael W McDermott
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA; Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL 33176 USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176 USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA
| | - Alonso N Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176 USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA
| | - Ranjini Tolakanahalli
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176 USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA.
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56
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Brar K, Taslimi S, Ellenbogen Y, Deng J, Hou W, Moraes FY, Glantz M, Zacharia BE, Tan A, Ahluwalia MS, Khasraw M, Zadeh G, Mansouri A. Comparative Efficacy of Treatments for Brain Metastases from Non-Small Cell Lung Cancer without an EGFR-Mutation/ALK-Rearrangement: A Systematic Review and Network Meta-Analysis. World Neurosurg 2021; 158:e87-e102. [PMID: 34688937 DOI: 10.1016/j.wneu.2021.10.113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 10/13/2021] [Accepted: 10/13/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION As many as 30% of patients with non-small cell lung cancer (NSCLC) will develop brain metastases (BMs) over the course of their illness. Here, we quantitatively compare the efficacy of the various emerging regimens for NSCLC BMs without a definitive targetable epidermal growth factor receptor mutation/ALK rearrangement. METHODS We searched MEDLINE, EMBASE, Web of Science, ClinicalTrials.gov, CENTRAL, and references of key studies for randomized controlled trials (RCTs) published from inception until June 2020. Comparative RCTs that included ≥10 patients were included. We used a frequentist fixed or random-effects model for network meta-analysis. The outcomes of interest included intracranial progression-free survival (iPFS), overall survival (OS), and overall progression-free survival. RESULTS In total, 18 studies representing 17 trials (n = 2726 patients) were identified. Immune checkpoint inhibitor regimens showed significant improvement in OS compared with chemotherapy alone, including pembrolizumab and chemotherapy (6 studies, hazard ratio [HR] 0.36, 95% confidence interval [CI] 0.21-0.62), atezolizumab alone (HR 0.54, 95% CI 0.33-0.89), and nivolumab and ipilimumab (HR 0.64, 95% CI 0.42-0.97). An improvement in overall PFS was seen with use of pembrolizumab and chemotherapy compared with chemotherapy alone (3 studies, HR 0.42, 95% CI 0.26-0.68). Studies evaluating checkpoint inhibitors did not report iPFS data, and we did not find improvement in iPFS or OS with the addition of any chemotherapy regimen to whole-brain radiation therapy. CONCLUSIONS In this network meta-analysis, we demonstrate the promising survival benefit with use of checkpoint inhibitor-based regimens in NSCLC BMs without a targetable epidermal growth factor receptor mutation/ALK rearrangement. Moving forward, large-scale BM-focused RCTs are necessary to establish the iPFS benefit of immune checkpoint inhibitor-based immunotherapy in this patient population.
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Affiliation(s)
- Karanbir Brar
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shervin Taslimi
- Division of Neurosurgery, Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Yosef Ellenbogen
- Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Jiawen Deng
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Winston Hou
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Fabio Y Moraes
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Michael Glantz
- Department of Neurosurgery, Penn State Health, Hershey, Pennsylvania, USA; Penn State Cancer Institute, Hershey, Pennsylvania, USA
| | - Brad E Zacharia
- Department of Neurosurgery, Penn State Health, Hershey, Pennsylvania, USA; Penn State Cancer Institute, Hershey, Pennsylvania, USA
| | - Aaron Tan
- Division of Medical Oncology, National Cancer Center Singapore, Singapore
| | - Manmeet S Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mustafa Khasraw
- The Preston Robert Tisch Brain Tumor Center, Duke University, Durham, North Carolina, USA
| | - Gelareh Zadeh
- Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State Health, Hershey, Pennsylvania, USA; Penn State Cancer Institute, Hershey, Pennsylvania, USA.
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Lauko A, Kotecha R, Barnett A, Li H, Tatineni V, Ali A, Patil P, Mohammadi AM, Chao ST, Murphy ES, Angelov L, Suh JH, Barnett GH, Pennell NA, Ahluwalia MS. Impact of KRAS mutation status on the efficacy of immunotherapy in lung cancer brain metastases. Sci Rep 2021; 11:18174. [PMID: 34518623 PMCID: PMC8438061 DOI: 10.1038/s41598-021-97566-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/06/2021] [Indexed: 12/02/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have resulted in improved outcomes in non-small cell lung cancer (NSCLC) patients. However, data demonstrating the efficacy of ICIs in NSCLC brain metastases (NSCLCBM) is limited. We analyzed overall survival (OS) in patients with NSCLCBM treated with ICIs within 90 days of NSCLCBM diagnosis (ICI-90) and compared them to patients who never received ICIs (no-ICI). We reviewed 800 patients with LCBM who were diagnosed between 2010 and 2019 at a major tertiary care institution, 97% of whom received stereotactic radiosurgery (SRS) for local treatment of BM. OS from BM was compared between the ICI-90 and no-ICI groups using the Log-Rank test and Cox proportional-hazards model. Additionally, the impact of KRAS mutational status on the efficacy of ICI was investigated. After accounting for known prognostic factors, ICI-90 in addition to SRS led to significantly improved OS compared to no-ICI (12.5 months vs 9.1, p < 0.001). In the 109 patients who had both a known PD-L1 expression and KRAS status, 80.4% of patients with KRAS mutation had PD-L1 expression vs 61.9% in wild-type KRAS patients (p = 0.04). In patients without a KRAS mutation, there was no difference in OS between the ICI-90 vs no-ICI cohort with a one-year survival of 60.2% vs 54.8% (p = 0.84). However, in patients with a KRAS mutation, ICI-90 led to a one-year survival of 60.4% vs 34.1% (p = 0.004). Patients with NSCLCBM who received ICI-90 had improved OS compared to no-ICI patients. Additionally, this benefit appears to be observed primarily in patients with KRAS mutations that may drive the overall benefit, which should be taken into account in the development of future trials.
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Affiliation(s)
- Adam Lauko
- Case Western Reserve University School of Medicine MSTP, Cleveland, OH, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Addison Barnett
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, OH, USA
| | - Hong Li
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Vineeth Tatineni
- Department of Internal Medicine, Summa Health, Akron City Hospital, Akron, OH, USA
| | - Assad Ali
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, OH, USA
| | - Pradnya Patil
- Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alireza M Mohammadi
- Case Western Reserve University School of Medicine MSTP, Cleveland, OH, USA.,Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, OH, USA.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samuel T Chao
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, OH, USA.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Erin S Murphy
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, OH, USA.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lilyana Angelov
- Case Western Reserve University School of Medicine MSTP, Cleveland, OH, USA.,Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, OH, USA.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John H Suh
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, OH, USA.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gene H Barnett
- Case Western Reserve University School of Medicine MSTP, Cleveland, OH, USA.,Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, OH, USA.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nathan A Pennell
- Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Manmeet S Ahluwalia
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA. .,Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, 8900 North Kendall Drive, Miami, FL, 33176, USA.
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Lauko A, Thapa B, Sharma M, Muhsen BA, Barnett A, Rauf Y, Borghei-Razavi H, Tatineni V, Patil P, Mohammadi A, Chao S, Murphy ES, Angelov L, Suh J, Barnett GH, Nowacki AS, Pennell N, Ahluwalia MS. Author Correction: Neutrophil to lymphocyte ratio influences impact of steroids on efficacy of immune checkpoint inhibitors in lung cancer brain metastases. Sci Rep 2021; 11:18212. [PMID: 34497288 PMCID: PMC8426399 DOI: 10.1038/s41598-021-96915-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Adam Lauko
- Cleveland Clinic Lerner College of Medicine At Case Western Reserve University, 9500 Euclid Ave, CA‑51, Cleveland, OH, 44195, USA
| | - Bicky Thapa
- Foedtert and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mayur Sharma
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
| | - Baha'eddin A Muhsen
- Rosa Ella Burkhart Brain Tumor and Neuro‑Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Addison Barnett
- Rosa Ella Burkhart Brain Tumor and Neuro‑Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Yasmeen Rauf
- Rosa Ella Burkhart Brain Tumor and Neuro‑Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Pradnya Patil
- Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alireza Mohammadi
- Cleveland Clinic Lerner College of Medicine At Case Western Reserve University, 9500 Euclid Ave, CA‑51, Cleveland, OH, 44195, USA.,Rosa Ella Burkhart Brain Tumor and Neuro‑Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samuel Chao
- Rosa Ella Burkhart Brain Tumor and Neuro‑Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Erin S Murphy
- Rosa Ella Burkhart Brain Tumor and Neuro‑Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lilyana Angelov
- Cleveland Clinic Lerner College of Medicine At Case Western Reserve University, 9500 Euclid Ave, CA‑51, Cleveland, OH, 44195, USA.,Rosa Ella Burkhart Brain Tumor and Neuro‑Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John Suh
- Rosa Ella Burkhart Brain Tumor and Neuro‑Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gene H Barnett
- Cleveland Clinic Lerner College of Medicine At Case Western Reserve University, 9500 Euclid Ave, CA‑51, Cleveland, OH, 44195, USA.,Rosa Ella Burkhart Brain Tumor and Neuro‑Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy S Nowacki
- Cleveland Clinic Lerner College of Medicine At Case Western Reserve University, 9500 Euclid Ave, CA‑51, Cleveland, OH, 44195, USA.,Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nathan Pennell
- Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA.
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Kotecha R, Tonse R, Menendez MAR, Williams A, Diaz Z, Tom MC, Hall MD, Mehta MP, Siomin V, Ahluwalia MS, McDermott MW. RADI-11. Evaluating the Tissue Effects of Dose-escalated Pre-operative Stereotactic Radiotherapy for Resectable Brain Metastasis. Neurooncol Adv 2021. [PMCID: PMC8351174 DOI: 10.1093/noajnl/vdab071.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Although the classic radiobiologic principles of radiotherapy are well understood, the unique effects of the large fractional does that characterize stereotactic radiotherapy (SRT), specifically in terms of antitumor immune cellular processes, vascular damage, tumor necrosis, and apoptosis on brain metastasis have yet to be adequately demonstrated. The objective of this study is to provide the first in-human evaluation of the biological effects of SRT in resected brain metastasis.
Methods
All paired primary tumors and metastases for patients who underwent dose-escalated preoperative SRT followed by resection were evaluated for tumor necrosis using hematoxylin-eosin staining. T cells (CD3+, CD4+, CD8+), natural killer cells (CD56+), vessel density (CD31+), and apoptotic factors (caspase-3) were determined by immunohistochemical analysis.
Results
Fifteen patients with brain metastases from solid tumors received a median preoperative SRT dose of 18 Gy (range: 15–18 Gy) in 1 fraction, with 2 patients receiving 27–30 Gy in 3–5 fractions, followed by resection within a median interval of 90 hours (Range: 17.1–260 hours). The rate of necrosis was found to be significantly higher in irradiated brain metastases than in non-irradiated primary tumor samples (mean paired difference: 30.47, SD: 29.28, p=0.001). A decrease in all immunomodulatory cell populations was found in irradiated metastasis: CD3 (mean paired difference -19.4, SD: 31.7, p=0.03), CD4 (-10.0, SD: 20, p=0.01), and CD8 (-17.4, SD: 22.1, p=0.008). While irradiated samples had numerically lower CD 31+, CD 56+, and caspase-3 scores, the difference was not statistically significant. Time interval from SRT to surgery had no effect on these parameters.
Conclusions
There is complex interplay between tumor-associated cells and the unique radiobiological effects of SRT on tumor tissue. Although time interval from SRT to surgery was associated with increased tumor necrosis, differences in immunomodulatory factors may be multifactorial, including concurrent corticosteroids or the immunosuppressive effect of SRT.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Raees Tonse
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | | | - Andre Williams
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Zuanel Diaz
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Martin C Tom
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Vitaly Siomin
- Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Michael W McDermott
- Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
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60
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Tonse R, Rubens M, Appel H, Tom MC, Hall MD, Odia Y, Mehta MP, McDermott MW, Ahluwalia MS, Kotecha R. OTHR-07. Systematic Review and Meta-analysis of Lung Cancer Brain Metastasis and Primary Tumor PD-L1 Expression Discordance. Neurooncol Adv 2021. [PMCID: PMC8351290 DOI: 10.1093/noajnl/vdab071.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Novel immunotherapeutic strategies, such as those targeting the PD-1/PD-L1 axis, are promising in patients with metastatic lung cancer and are often administered when tumors show PD-L1 positivity. The objective of this study was to analyze PD-L1 receptor discordance in tumor cell between the primary tumor and lung cancer brain metastasis (LCBM).
Methods
A systematic review of series published prior to April 2021 obtained from the Medline database of biopsied or resected LCBM evaluating PD-L1 discordance was performed using PRISMA guidelines. Weighted random effects models were used to calculate pooled estimates.
Results
Six full-text articles (n=247 patients) with a median of 32 patients in each study (range: 24–73 patients) reported PD-L1 receptor expression analyses of both primary lung tumors and brain metastases. The majority of patients (81%) were smokers, with 67% non-small cell lung cancer and 33% small cell lung cancer. The pooled estimate for overall PD-LI receptor concordance between primary and LCBM was 76% (95% CI: 52%-90). The positivity rate varied when analyzed by various cutoff levels of PD-L1 expression; for <1% expression, it was 41% (95% CI: 22%-62%) for primary vs. 58% (95% CI: 35%-78%) for LCBM; for PD-L1 expression of 1–50%, it was 24% (95% CI: 13%-40%) vs. 19% (95% CI: 10%-33%); and for PD-L1 >50% it was 12% (95% CI: 4%-33%) vs. 21% (95% CI: 14%-29%) (p=0.425). The pooled estimate for overall PD-LI receptor discordance between primary and LCBM was 17% (95% CI: 10%-27%). Meta-regression analysis showed that age, sex, smoking status, and histology were not associated with PD-LI receptor discordance.
Conclusions
PD-L1 status discordance in tumor cell occurs in approximately 20% of LCBM, with the greatest discordance in the <1% expression category. Awareness of this discordance is important for the selection of immune checkpoint inhibitor therapy as well as in the analysis of patterns of failures.
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Affiliation(s)
- Raees Tonse
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Muni Rubens
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Haley Appel
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Martin C Tom
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Yazmin Odia
- Division of Neuro-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Michael W McDermott
- Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
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Tonse R, Tom MC, Mehta MP, Ahluwalia MS, Kotecha R. Integration of Systemic Therapy and Stereotactic Radiosurgery for Brain Metastases. Cancers (Basel) 2021; 13:cancers13153682. [PMID: 34359583 PMCID: PMC8345095 DOI: 10.3390/cancers13153682] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/16/2021] [Accepted: 07/20/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary In the multi-modal treatment of brain metastasis (BM), the role of systemic therapy has undergone a recent revolution. Due to the development of multiple agents with modest central nervous system penetration of the blood-brain barrier, targeted therapies and immune checkpoint inhibitors are increasingly being utilized alone or in combination with radiation therapy. However, the adoption of sequential or concurrent strategies varies considerably, and treatment strategies employed in clinical practice have rapidly outpaced evidence development. Therefore, this review critically analyzes the data regarding combinatorial approaches for a variety of systemic therapeutics with stereotactic radiosurgery and provides an overview of ongoing clinical trials. Abstract Brain metastasis (BM) represents a common complication of cancer, and in the modern era requires multi-modal management approaches and multi-disciplinary care. Traditionally, due to the limited efficacy of cytotoxic chemotherapy, treatment strategies are focused on local treatments alone, such as whole-brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), and resection. However, the increased availability of molecular-based therapies with central nervous system (CNS) penetration now permits the individualized selection of tailored systemic therapies to be used alongside local treatments. Moreover, the introduction of immune checkpoint inhibitors (ICIs), with demonstrated CNS activity has further revolutionized the management of BM patients. The rapid introduction of these cancer therapeutics into clinical practice, however, has led to a significant dearth in the published literature about the optimal timing, sequencing, and combination of these systemic therapies along with SRS. This manuscript reviews the impact of tumor biology and molecular profiles on the management paradigm for BM patients and critically analyzes the current landscape of SRS, with a specific focus on integration with systemic therapy. We also discuss emerging treatment strategies combining SRS and ICIs, the impact of timing and the sequencing of these therapies around SRS, the effect of corticosteroids, and review post-treatment imaging findings, including pseudo-progression and radiation necrosis.
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Affiliation(s)
- Raees Tonse
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (R.T.); (M.C.T.); (M.P.M.)
| | - Martin C. Tom
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (R.T.); (M.C.T.); (M.P.M.)
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA;
| | - Minesh P. Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (R.T.); (M.C.T.); (M.P.M.)
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA;
| | - Manmeet S. Ahluwalia
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA;
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (R.T.); (M.C.T.); (M.P.M.)
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA;
- Correspondence: ; Tel.: +1-(786)-596-2000
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Kotecha R, Kim JM, Miller JA, Juloori A, Chao ST, Murphy ES, Peereboom DM, Mohammadi AM, Barnett GH, Vogelbaum MA, Angelov L, Suh JH, Ahluwalia MS. The impact of sequencing PD-1/PD-L1 inhibitors and stereotactic radiosurgery for patients with brain metastasis. Neuro Oncol 2021; 21:1060-1068. [PMID: 30796838 DOI: 10.1093/neuonc/noz046] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The response of brain metastases (BM) treated with stereotactic radiosurgery (SRS) and immune checkpoint inhibitors (ICIs; programmed cell death 1 and its ligand) is of significant interest. METHODS Patients were divided into cohorts based on ICI sequencing around SRS. The primary outcome was best objective response (BOR) that was lesion specific. Secondary outcomes included overall objective response (OOR), response durability, radiation necrosis (RN), and overall survival (OS). RESULTS One hundred fifty patients underwent SRS to 1003 BM and received ICI. Five hundred sixty-four lesions (56%) treated with concurrent ICI (±5 half-lives) demonstrated superior BOR, OOR, and response durability compared with lesions treated with SRS and delayed ICI. Responses were best in those treated with immediate (±1 half-life) ICI (BOR: -100 vs -57%, P < 0.001; complete response: 50 vs 32%; 12-month durable response: 94 vs 71%, P < 0.001). Lesions pre-exposed to ICI and treated with SRS had poorer BOR (-45%) compared with ICI naive lesions (-63%, P < 0.001); best response was observed in ICI naive lesions receiving SRS and immediate ICI (-100%, P < 0.001). The 12-month cumulative incidence of RN with immediate ICI was 3.2% (95% CI: 1.3-5.0%). First radiographic follow-up and best intracranial response were significantly associated with longer OS; steroids were associated with inferior response rates and poorer OS (median 10 vs 25 mo, P = 0.002). CONCLUSIONS Sequencing of ICI around SRS is associated with overall response, best response, and response durability, with the most substantial effect in ICI naive BM undergoing immediate combined modality therapy. First intracranial response for patients treated with immediate ICI and SRS may be prognostic for OS, whereas steroids are detrimental.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Joseph M Kim
- School of Medicine, Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Jacob A Miller
- Department of Radiation Oncology, Stanford University, Palo Alto, California
| | - Aditya Juloori
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samuel T Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Erin S Murphy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - David M Peereboom
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alireza M Mohammadi
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Vogelbaum
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Manmeet S Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
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63
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Lee J, Kay K, Troike K, Ahluwalia MS, Lathia JD. Sex Differences in Glioblastoma Immunotherapy Response. Neuromolecular Med 2021; 24:50-55. [PMID: 33864598 DOI: 10.1007/s12017-021-08659-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 04/09/2021] [Indexed: 12/12/2022]
Abstract
Glioblastoma (GBM), the most common primary malignant brain tumor, remains difficult to treat and shares phenotypes, including an aberrant immune response, with other neurological disorders. Understanding the cellular and molecular mechanisms underlying this pathological immune response remains a priority, particularly as standard of care for advanced cancers evolves to include immunotherapies, which have yet to show strong clinical efficacy in GBM. Epidemiological evidence supports a sex difference in GBM, with increased prevalence in males, and recent studies identified differences between males and females ranging from genetic aberrations to cellular programs. Sex differences have also been identified in immune response, and in this mini-review, we present these differences to highlight potential sex-specific cellular and molecular mechanisms that underly GBM growth and response to immunotherapies. These sex differences offer an opportunity to understand GBM pathogenesis and extend beyond GBM to other tumors and neurological disorders to inform the development of next-generation therapies.
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Affiliation(s)
- Juyeun Lee
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, USA
| | - Kristen Kay
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, USA.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | - Katie Troike
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, USA.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | - Manmeet S Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, USA.,Case Comprehensive Cancer Center, Cleveland, USA
| | - Justin D Lathia
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, USA. .,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA. .,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, USA. .,Case Comprehensive Cancer Center, Cleveland, USA.
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64
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Lauko A, Thapa B, Sharma M, Muhsen B, Barnett A, Rauf Y, Borghei-Razavi H, Tatineni V, Patil P, Mohammadi A, Chao S, Murphy ES, Angelov L, Suh J, Barnett GH, Nowacki AS, Pennell N, Ahluwalia MS. Neutrophil to lymphocyte ratio influences impact of steroids on efficacy of immune checkpoint inhibitors in lung cancer brain metastases. Sci Rep 2021; 11:7490. [PMID: 33820922 PMCID: PMC8021556 DOI: 10.1038/s41598-021-85328-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/06/2021] [Indexed: 11/12/2022] Open
Abstract
Steroids are often utilized to manage patients with non-small cell lung cancer brain metastases (NSCLCBM). Steroids and elevated neutrophil-to-lymphocyte ratio (NLR) have been associated with decreased overall survival (OS) in patients treated with immune checkpoint inhibitors (ICI). We retrospectively investigated patients treated with ICI after the diagnosis of NSCLCBM at a single tertiary care institution examing the impact of steroids and NLR. Overall survival (OS) and intracranial progression-free survival (PFS) were analyzed. 171 patients treated with ICI for NSCLCBM were included. Thirty-six received steroids within 30 days of the start of ICI, and 53 patients had an NLR ≥ 5 before the start of ICI. Upfront steroids was associated with decreased OS on multivariable analysis (median OS 10.5 vs. 17.9 months, p = .03) and intracranial PFS (5.0 vs. 8.7 months, p = .045). NLR ≥ 5 was indicative of worse OS (10.5 vs. 18.4 months, p = .04) but not intracranial PFS (7.2 vs. 7.7 months, p = .61). When NLR and upfront steroids are modeled together, there is a strong interaction (p = .0008) indicating that the impact of steroids depended on the patient’s NLR. In a subgroup analysis, only in patients with NLR < 4 was there a significant difference in OS with upfront steroids (26.1 vs. 15.6 months, p = .032). The impact of steroids on the efficacy of ICI in patients with NSCLCBM is dependent on the patient's NLR underscoring its importance in these patients. Patients with a low NLR, steroid use decreases the efficacy of ICI. These results can inform clinicians about the impact of steroids in patients treated with ICI.
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Affiliation(s)
- Adam Lauko
- Cleveland Clinic Lerner College of Medicine At Case Western Reserve University, 9500 Euclid Ave, CA-51, Cleveland, OH, 44195, USA
| | - Bicky Thapa
- Foedtert and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mayur Sharma
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
| | - Baha'eddin Muhsen
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Addison Barnett
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Yasmeen Rauf
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Pradnya Patil
- Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alireza Mohammadi
- Cleveland Clinic Lerner College of Medicine At Case Western Reserve University, 9500 Euclid Ave, CA-51, Cleveland, OH, 44195, USA.,Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samuel Chao
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Erin S Murphy
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lilyana Angelov
- Cleveland Clinic Lerner College of Medicine At Case Western Reserve University, 9500 Euclid Ave, CA-51, Cleveland, OH, 44195, USA.,Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John Suh
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gene H Barnett
- Cleveland Clinic Lerner College of Medicine At Case Western Reserve University, 9500 Euclid Ave, CA-51, Cleveland, OH, 44195, USA.,Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy S Nowacki
- Cleveland Clinic Lerner College of Medicine At Case Western Reserve University, 9500 Euclid Ave, CA-51, Cleveland, OH, 44195, USA.,Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nathan Pennell
- Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA.
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65
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Beig N, Singh S, Bera K, Prasanna P, Singh G, Chen J, Saeed Bamashmos A, Barnett A, Hunter K, Statsevych V, Hill VB, Varadan V, Madabhushi A, Ahluwalia MS, Tiwari P. Sexually dimorphic radiogenomic models identify distinct imaging and biological pathways that are prognostic of overall survival in glioblastoma. Neuro Oncol 2021; 23:251-263. [PMID: 33068415 PMCID: PMC7906064 DOI: 10.1093/neuonc/noaa231] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Recent epidemiological studies have suggested that sexual dimorphism influences treatment response and prognostic outcome in glioblastoma (GBM). To this end, we sought to (i) identify distinct sex-specific radiomic phenotypes-from tumor subcompartments (peritumoral edema, enhancing tumor, and necrotic core) using pretreatment MRI scans-that are prognostic of overall survival (OS) in GBMs, and (ii) investigate radiogenomic associations of the MRI-based phenotypes with corresponding transcriptomic data, to identify the signaling pathways that drive sex-specific tumor biology and treatment response in GBM. METHODS In a retrospective setting, 313 GBM patients (male = 196, female = 117) were curated from multiple institutions for radiomic analysis, where 130 were used for training and independently validated on a cohort of 183 patients. For the radiogenomic analysis, 147 GBM patients (male = 94, female = 53) were used, with 125 patients in training and 22 cases for independent validation. RESULTS Cox regression models of radiomic features from gadolinium T1-weighted MRI allowed for developing more precise prognostic models, when trained separately on male and female cohorts. Our radiogenomic analysis revealed higher expression of Laws energy features that capture spots and ripple-like patterns (representative of increased heterogeneity) from the enhancing tumor region, as well as aggressive biological processes of cell adhesion and angiogenesis to be more enriched in the "high-risk" group of poor OS in the male population. In contrast, higher expressions of Laws energy features (which detect levels and edges) from the necrotic core with significant involvement of immune related signaling pathways was observed in the "low-risk" group of the female population. CONCLUSIONS Sexually dimorphic radiogenomic models could help risk-stratify GBM patients for personalized treatment decisions.
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Affiliation(s)
- Niha Beig
- Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Kaustav Bera
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Prateek Prasanna
- Department of Biomedical Informatics, Stony Brook University,
Stony Brook, New York, USA
| | - Gagandeep Singh
- Department of Radiology, Newark Beth Israel Medical Center,
Newark, New Jersey, USA
| | - Jonathan Chen
- Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Addison Barnett
- Brain Tumor and Neuro-Oncology Center, Cleveland Clinic,
Cleveland, Ohio, USA
| | - Kyle Hunter
- Brain Tumor and Neuro-Oncology Center, Cleveland Clinic,
Cleveland, Ohio, USA
| | | | - Virginia B Hill
- Section of Neuroradiology, Department of Radiology, Northwestern University
Feinberg School of Medicine, Chicago, Illinois, USA
| | - Vinay Varadan
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Anant Madabhushi
- Case Western Reserve University, Cleveland, Ohio, USA
- Louis Stokes Cleveland Veterans Administration Medical Center,
Cleveland, Ohio, USA
| | - Manmeet S Ahluwalia
- Brain Tumor and Neuro-Oncology Center, Cleveland Clinic,
Cleveland, Ohio, USA
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66
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Balasubramanian SK, Sharma M, Venur VA, Schmitt P, Kotecha R, Chao ST, Suh JH, Angelov L, Mohammadi AM, Vogelbaum MA, Barnett GH, Jia X, Pennell NA, Ahluwalia MS. Impact of EGFR mutation and ALK rearrangement on the outcomes of non-small cell lung cancer patients with brain metastasis. Neuro Oncol 2021; 22:267-277. [PMID: 31648302 DOI: 10.1093/neuonc/noz155] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The impact of activating alterations in non-small cell lung cancer (NSCLC) (epidermal growth factor receptor [EGFR] mutation/anaplastic lymphoma kinase [ALK] translocation) in prognosticating patients with brain metastasis (BM) is not well defined. This study was sought to identify this impact in NSCLC patients with BM accounting for the known validated variables. METHODS Among 1078 NSCLC-BM patients diagnosed/treated between January 1, 2000 and December 31, 2015, three hundred and forty-eight with known EGFR/ALK status were analyzed. Overall survival (OS) and intracranial progression-free survival (PFS) were measured from the time of BM. RESULTS Ninety-one patients had either ALK (n = 23) alterations or EGFR (n = 68) mutation and 257 were wild type (WT; negative actionable mutations/alterations). Median age of EGFR/ALK+ NSCLC BM patients was 60 years (range 29.8-82.6 y) and ~50% (n = 44) had Karnofsky performance status (KPS) score >80. Median number of BM was 2 (1 to ≥99). The median OS for the ALK/EGFR+ NSCLC BM was 19.9 versus 10.1 months for the WT (P = 0.028). The number of BM in the EGFR/ALK+ group did not impact OS (BM = 1 with 21.1 months vs 2-3 with 19.1 months and >3 with 23.7 months, P = 0.74), whereas fewer BM in the WT cohort had significantly better OS (BM = 1 with 13.8 mo, 2-3 with 11.0 mo and >3 with 8.1 mo; P = 0.006) with the adjustment of age, KPS, symptoms from BM and synchronicity. CONCLUSIONS Number of BM does not impact outcomes in the EGFR/ALK+ NSCLC patients, implying that targeted therapy along with surgery and/or radiation may improve OS irrespective of the number of BM. Number of BM, extracranial metastasis (ECM), and KPS independently affected OS/PFS in WT NSCLC BM, which was consistent with the known literature.
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Affiliation(s)
| | - Mayur Sharma
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | | | - Philipp Schmitt
- Research Volunteer, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Rupesh Kotecha
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samuel T Chao
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - John H Suh
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alireza M Mohammadi
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Vogelbaum
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Xuefei Jia
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Nathan A Pennell
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manmeet S Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
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67
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Otvos B, Alban TJ, Grabowski MM, Bayik D, Mulkearns-Hubert EE, Radivoyevitch T, Rabljenovic A, Johnson S, Androjna C, Mohammadi AM, Barnett GH, Ahluwalia MS, Vogelbaum MA, Fecci PE, Lathia JD. Preclinical Modeling of Surgery and Steroid Therapy for Glioblastoma Reveals Changes in Immunophenotype that are Associated with Tumor Growth and Outcome. Clin Cancer Res 2021; 27:2038-2049. [PMID: 33542075 DOI: 10.1158/1078-0432.ccr-20-3262] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/08/2020] [Accepted: 02/02/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Glioblastoma (GBM) immunotherapy clinical trials are generally initiated after standard-of-care treatment-including surgical resection, perioperative high-dose steroid therapy, chemotherapy, and radiation treatment-has either begun or failed. However, the impact of these interventions on the antitumoral immune response is not well studied. While discoveries regarding the impact of chemotherapy and radiation on immune response have been made and translated into clinical trial design, the impact of surgical resection and steroids on the antitumor immune response has yet to be determined. EXPERIMENTAL DESIGN We developed a murine model integrating tumor resection and steroid treatment and used flow cytometry to analyze systemic and local immune changes. These mouse model findings were validated in a cohort of 95 patients with primary GBM. RESULTS Using our murine resection model, we observed a systemic reduction in lymphocytes corresponding to increased tumor volume and decreased circulating lymphocytes that was masked by dexamethasone treatment. The reduction in circulating T cells was due to reduced CCR7 expression, resulting in T-cell sequestration in lymphoid organs and the bone marrow. We confirmed these findings in a cohort of patients with primary GBM and found that prior to steroid treatment, circulating lymphocytes inversely correlated with tumor volume. Finally, we demonstrated that peripheral lymphocyte content varies with progression-free survival and overall survival, independent of tumor volume, steroid use, or molecular profiles. CONCLUSIONS These data reveal that prior to intervention, increased tumor volume corresponds with reduced systemic immune function and that peripheral lymphocyte counts are prognostic when steroid treatment is taken into account.
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Affiliation(s)
- Balint Otvos
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Tyler J Alban
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Matthew M Grabowski
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Defne Bayik
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Erin E Mulkearns-Hubert
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Tomas Radivoyevitch
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Anja Rabljenovic
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sarah Johnson
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Charlie Androjna
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alireza M Mohammadi
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Gene H Barnett
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Manmeet S Ahluwalia
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | | | - Peter E Fecci
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina
| | - Justin D Lathia
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio. .,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
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68
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Reardon DA, Brandes AA, Omuro A, Mulholland P, Lim M, Wick A, Baehring J, Ahluwalia MS, Roth P, Bähr O, Phuphanich S, Sepulveda JM, De Souza P, Sahebjam S, Carleton M, Tatsuoka K, Taitt C, Zwirtes R, Sampson J, Weller M. Effect of Nivolumab vs Bevacizumab in Patients With Recurrent Glioblastoma: The CheckMate 143 Phase 3 Randomized Clinical Trial. JAMA Oncol 2021; 6:1003-1010. [PMID: 32437507 PMCID: PMC7243167 DOI: 10.1001/jamaoncol.2020.1024] [Citation(s) in RCA: 727] [Impact Index Per Article: 242.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Question Does programmed cell death 1 immune checkpoint inhibition with nivolumab improve overall survival compared with bevacizumab treatment for patients with recurrent glioblastoma? Findings In this randomized phase 3 clinical trial of 369 patients diagnosed with recurrent glioblastoma treated with nivolumab, an improved survival benefit was not observed in patients who received nivolumab compared with bevacizumab-treated control patients. Meaning Additional research is needed; nivolumab monotherapy did not improve overall survival compared with bevacizumab in the treatment of recurrent glioblastoma. A study of nivolumab in combination with radiotherapy and temozolomide in patients with newly diagnosed glioblastoma with methylated MGMT promoter is ongoing. Importance Clinical outcomes for glioblastoma remain poor. Treatment with immune checkpoint blockade has shown benefits in many cancer types. To our knowledge, data from a randomized phase 3 clinical trial evaluating a programmed death-1 (PD-1) inhibitor therapy for glioblastoma have not been reported. Objective To determine whether single-agent PD-1 blockade with nivolumab improves survival in patients with recurrent glioblastoma compared with bevacizumab. Design, Setting, and Participants In this open-label, randomized, phase 3 clinical trial, 439 patients with glioblastoma at first recurrence following standard radiation and temozolomide therapy were enrolled, and 369 were randomized. Patients were enrolled between September 2014 and May 2015. The median follow-up was 9.5 months at data cutoff of January 20, 2017. The study included 57 multicenter, multinational clinical sites. Interventions Patients were randomized 1:1 to nivolumab 3 mg/kg or bevacizumab 10 mg/kg every 2 weeks until confirmed disease progression, unacceptable toxic effects, or death. Main Outcomes and Measures The primary end point was overall survival (OS). Results A total of 369 patients were randomized to nivolumab (n = 184) or bevacizumab (n = 185). The MGMT promoter was methylated in 23.4% (43/184; nivolumab) and 22.7% (42/185; bevacizumab), unmethylated in 32.1% (59/184; nivolumab) and 36.2% (67/185; bevacizumab), and not reported in remaining patients. At median follow-up of 9.5 months, median OS (mOS) was comparable between groups: nivolumab, 9.8 months (95% CI, 8.2-11.8); bevacizumab, 10.0 months (95% CI, 9.0-11.8); HR, 1.04 (95% CI, 0.83-1.30); P = .76. The 12-month OS was 42% in both groups. The objective response rate was higher with bevacizumab (23.1%; 95% CI, 16.7%-30.5%) vs nivolumab (7.8%; 95% CI, 4.1%-13.3%). Grade 3/4 treatment-related adverse events (TRAEs) were similar between groups (nivolumab, 33/182 [18.1%]; bevacizumab, 25/165 [15.2%]), with no unexpected neurological TRAEs or deaths due to TRAEs. Conclusions and Relevance Although the primary end point was not met in this randomized clinical trial, mOS was comparable between nivolumab and bevacizumab in the overall patient population with recurrent glioblastoma. The safety profile of nivolumab in patients with glioblastoma was consistent with that in other tumor types. Trial Registration ClinicalTrials.gov Identifier: NCT02017717
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Affiliation(s)
| | - Alba A Brandes
- AUSL-IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Antonio Omuro
- Department of Neurology and Yale Cancer Center, Yale University, New Haven, Connecticut
| | | | - Michael Lim
- The Johns Hopkins Hospital, Baltimore, Maryland
| | - Antje Wick
- Neurology Clinic, University of Heidelberg, National Center for Tumor Diseases, Heidelberg, Germany
| | | | | | - Patrick Roth
- Department of Neurology and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Oliver Bähr
- Dr Senckenberg Institute of Neurooncology, Goethe University Hospital, Frankfurt, Germany
| | - Surasak Phuphanich
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Paul De Souza
- University of Wollongong School of Medicine, Wollongong, NSW, Australia
| | - Solmaz Sahebjam
- Moffitt Cancer Center, University of South Florida, Tampa, Florida
| | | | | | | | | | - John Sampson
- Duke University Hospital, Durham, North Carolina
| | - Michael Weller
- Department of Neurology and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
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69
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Peereboom DM, Ye X, Mikkelsen T, Lesser GJ, Lieberman FS, Robins HI, Ahluwalia MS, Sloan AE, Grossman SA. A Phase II and Pharmacodynamic Trial of RO4929097 for Patients With Recurrent/Progressive Glioblastoma. Neurosurgery 2021; 88:246-251. [PMID: 33027815 PMCID: PMC7919338 DOI: 10.1093/neuros/nyaa412] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 07/05/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Cancer stem-like cells are a major cause of resistance to therapy in patients with glioblastoma (GBM) as well as other cancers. Tumor cells are maintained in a stem-like proliferative state in large part through the Notch signaling pathway. The function of this pathway in turn depends on gamma secretase activity. Inhibition of this enzyme therefore inhibits the Notch pathway and tumor growth as measured by a reduction in the formation of brain tumor neurospheres in murine models. RO4929097 is an oral gamma secretase inhibitor. OBJECTIVE To estimate the 6-mo progression-free survival rate (PFS6) in patients with progressive GBM and to inhibit by 50% the generation of neurospheres in fresh tissue resected from patients treated with RO4929097. METHODS In this phase II and pharmacodynamic study, patients with recurrent GBM received RO4929097 in a study of 2 groups. Group A patients had unresectable disease and received drug in a standard phase II design. Group B patients had resectable disease and received drug before and after surgical resection. Endpoints included PFS6 and the inhibition of neurosphere formation in the resected tumor samples. RESULTS A total of 47 patients received treatment, 7 of whom had tumor resection. The PFS6 was 4%, and the inhibition of neurosphere formation occurred in 1 of 7 patient samples. CONCLUSION RO4929097 was inactive in recurrent GBM patients and demonstrated minimal inhibition of neurosphere formation in fresh tissue samples.
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Affiliation(s)
| | - Xiaobu Ye
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - Tom Mikkelsen
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan
| | - Glenn J Lesser
- Hematology and Oncology, Comprehensive Cancer Center of Wake Forest University, Winston-Salem, North Carolina
| | - Frank S Lieberman
- Department of Neurology, Hillman Cancer Center of University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - H Ian Robins
- Department of Human Oncology, University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
| | | | - Andrew E Sloan
- Department of Neurological Surgery, Seidman Cancer Center, University Hospitals & Case Comprehensive Cancer Center, Cleveland, Ohio
| | - Stuart A Grossman
- The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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70
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Tonse R, Rubens M, Appel H, Tom MC, Hall MD, Odia Y, McDermott MW, Ahluwalia MS, Mehta MP, Kotecha R. Systematic review and meta-analysis of PD-L1 expression discordance between primary tumor and lung cancer brain metastasis. Neurooncol Adv 2021; 3:vdab166. [PMID: 34988451 PMCID: PMC8704382 DOI: 10.1093/noajnl/vdab166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Novel immunotherapeutic strategies targeting the programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) axis are often administered when metastatic tumors show PD-L1 positivity, even in the setting of lung cancer brain metastasis (LCBM). However, biological differences exist between primary tumors and metastatic sites. The objective of this study was to analyze rates of PD-L1 receptor discordance between primary tumors and LCBM. Methods A systematic review of studies of biopsied or resected LCBM evaluating PD-L1 discordance published in the Medline database was performed using PRISMA guidelines. Weighted random effects models were used to calculate pooled estimates. Results Six full-text articles (n = 230 patients) with a median of 32 patients in each study (range: 24–73) reported PD-L1 receptor expression analyses of both primary lung tumors and brain metastases and met inclusion criteria. The pooled estimate for tumor cell (TC) PD-L1 receptor discordance between primary tumors and LCBM was 19% (95% confidence interval [CI]: 10–27%). For PD-L1 receptor expression in tumor-infiltrating lymphocytes (TIL), the weighted pooled estimate for discordance was 21% (95% CI: 8–44%). For primary versus LCBM, the positive rates by expression levels of <1%, 1–50%, and >50% were 52% (95% CI: 30–73%) versus 56% (95% CI: 34–76%), 30% (95% CI: 22–40%) versus 20% (95% CI: 10–35%), and 15% (95% CI: 6–36%) versus 22% (95% CI: 15–31%) (P = .425), respectively. Conclusions PD-L1 discordance occurs in ~20% of LCBM, with the greatest discordance in the 1–50% expression category. Although controversial, confirming discordance might be important for selection of immune checkpoint inhibitor therapy and in the analysis of patterns of failure after treatment.
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Affiliation(s)
- Raees Tonse
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Muni Rubens
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Haley Appel
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Martin C Tom
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Yazmin Odia
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
- Division of Neuro-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Michael W McDermott
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
- Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Manmeet S Ahluwalia
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
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71
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Tao W, Zhang A, Zhai K, Huang Z, Huang H, Zhou W, Huang Q, Fang X, Prager BC, Wang X, Wu Q, Sloan AE, Ahluwalia MS, Lathia JD, Yu JS, Rich JN, Bao S. SATB2 drives glioblastoma growth by recruiting CBP to promote FOXM1 expression in glioma stem cells. EMBO Mol Med 2020; 12:e12291. [PMID: 33124191 PMCID: PMC7721366 DOI: 10.15252/emmm.202012291] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 09/19/2020] [Accepted: 09/22/2020] [Indexed: 12/16/2022] Open
Abstract
Nuclear matrix-associated proteins (NMPs) play critical roles in regulating chromatin organization and gene transcription by binding to the matrix attachment regions (MARs) of DNA. However, the functional significance of NMPs in glioblastoma (GBM) progression remains unclear. Here, we show that the Special AT-rich Binding Protein-2 (SATB2), one of crucial NMPs, recruits histone acetyltransferase CBP to promote the FOXM1-mediated cell proliferation and tumor growth of GBM. SATB2 is preferentially expressed by glioma stem cells (GSCs) in GBM. Disrupting SATB2 markedly inhibited GSC proliferation and GBM malignant growth by down-regulating expression of key genes involved in cell proliferation program. SATB2 activates FOXM1 expression to promote GSC proliferation through binding to the MAR sequence of FOXM1 gene locus and recruiting CBP to the MAR. Importantly, pharmacological inhibition of SATB2/CBP transcriptional activity by the CBP inhibitor C646 suppressed GSC proliferation in vitro and GBM growth in vivo. Our study uncovers a crucial role of the SATB2/CBP-mediated transcriptional regulation in GBM growth, indicating that targeting SATB2/CBP may effectively improve GBM treatment.
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Affiliation(s)
- Weiwei Tao
- Department of Cancer BiologyLerner Research InstituteCleveland ClinicClevelandOHUSA
| | - Aili Zhang
- Department of Cancer BiologyLerner Research InstituteCleveland ClinicClevelandOHUSA
| | - Kui Zhai
- Department of Cancer BiologyLerner Research InstituteCleveland ClinicClevelandOHUSA
| | - Zhi Huang
- Department of Cancer BiologyLerner Research InstituteCleveland ClinicClevelandOHUSA
| | - Haidong Huang
- Department of Cancer BiologyLerner Research InstituteCleveland ClinicClevelandOHUSA
| | - Wenchao Zhou
- Department of Cancer BiologyLerner Research InstituteCleveland ClinicClevelandOHUSA
| | - Qian Huang
- Department of Cancer BiologyLerner Research InstituteCleveland ClinicClevelandOHUSA
| | - Xiaoguang Fang
- Department of Cancer BiologyLerner Research InstituteCleveland ClinicClevelandOHUSA
| | - Briana C Prager
- Division of Regenerative MedicineDepartment of MedicineUniversity of California, San DiegoSan DiegoCAUSA
- Department of PathologyCase Western Reserve University School of MedicineClevelandOHUSA
| | - Xiuxing Wang
- Division of Regenerative MedicineDepartment of MedicineUniversity of California, San DiegoSan DiegoCAUSA
| | - Qiulian Wu
- Division of Regenerative MedicineDepartment of MedicineUniversity of California, San DiegoSan DiegoCAUSA
| | - Andrew E Sloan
- Brain Tumor and Neuro‐Oncology Center & Center of Excellence for Translational Neuro‐OncologyUniversity Hospitals Seidman Cancer CenterCase Western Reserve UniversityClevelandOHUSA
- Case Comprehensive Cancer CenterCase Western Reserve University School of MedicineClevelandOHUSA
| | - Manmeet S Ahluwalia
- Brain Tumor and Neuro‐Oncology CenterTaussig Cancer InstituteCleveland ClinicClevelandOHUSA
| | - Justin D Lathia
- Case Comprehensive Cancer CenterCase Western Reserve University School of MedicineClevelandOHUSA
- Brain Tumor and Neuro‐Oncology CenterTaussig Cancer InstituteCleveland ClinicClevelandOHUSA
- Department of Cardiovascular and Metabolic SciencesCleveland ClinicClevelandOHUSA
| | - Jennifer S Yu
- Department of Cancer BiologyLerner Research InstituteCleveland ClinicClevelandOHUSA
- Case Comprehensive Cancer CenterCase Western Reserve University School of MedicineClevelandOHUSA
- Center for Cancer Stem Cell ResearchLerner Research InstituteCleveland ClinicClevelandOHUSA
- Department of Radiation OncologyTaussig Cancer InstituteCleveland ClinicClevelandOHUSA
| | - Jeremy N Rich
- Division of Regenerative MedicineDepartment of MedicineUniversity of California, San DiegoSan DiegoCAUSA
| | - Shideng Bao
- Department of Cancer BiologyLerner Research InstituteCleveland ClinicClevelandOHUSA
- Case Comprehensive Cancer CenterCase Western Reserve University School of MedicineClevelandOHUSA
- Center for Cancer Stem Cell ResearchLerner Research InstituteCleveland ClinicClevelandOHUSA
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72
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Kim JM, Miller JA, Kotecha R, Chao ST, Ahluwalia MS, Peereboom DM, Mohammadi AM, Barnett GH, Murphy ES, Vogelbaum MA, Angelov L, Abraham J, Moore H, Budd GT, Suh JH. Stereotactic radiosurgery with concurrent HER2-directed therapy is associated with improved objective response for breast cancer brain metastasis. Neuro Oncol 2020; 21:659-668. [PMID: 30726965 DOI: 10.1093/neuonc/noz006] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Patients with breast cancer positive for human epidermal growth factor receptor 2 (HER2) remain at high risk of intracranial relapse following treatment and experience increased rates of intracranial failure after stereotactic radiosurgery (SRS). We hypothesized that the addition of concurrent lapatinib to SRS would improve intracranial complete response rates. METHODS Patients with newly diagnosed HER2-amplified breast cancer brain metastases from 2005-2014 who underwent SRS were included and divided into 2 cohorts based on timing of treatment with lapatinib. Outcome variables included the proportion of patients who achieved an intracranial complete response or progressive disease according to the RECIST 1.1 criteria, as well as individual lesion response rates, distant intracranial failure, and radiation necrosis. RESULTS Eighty-four patients with 487 brain metastases met inclusion criteria during the study period. Over 138 treatment sessions, 132 lesions (27%) were treated with SRS and concurrent lapatinib, while 355 (73%) were treated with SRS without lapatinib. Compared with patients treated with SRS alone, patients treated with concurrent lapatinib had higher rates of complete response (35% vs 11%, P = 0.008). On a per-lesion basis, best objective response was superior in the concurrent lapatinib group (median 100% vs 70% reduction, P < 0.001). Concurrent lapatinib was not associated with an increased risk of grade 2+ radiation necrosis (1.0% with concurrent lapatinib vs 3.5% without, P = 0.27). Lapatinib had no protective effect on distant intracranial failure rates (48% vs 49%, P = 0.91). CONCLUSION The addition of concurrent lapatinib to SRS was associated with improved complete response rates among patients with HER2-positive brain metastases.
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Affiliation(s)
- Joseph M Kim
- School of Medicine, Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Jacob A Miller
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford University Medical Center, Palo Alto, California
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida
| | - Samuel T Chao
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio
| | - Manmeet S Ahluwalia
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Department of Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio
| | - David M Peereboom
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Department of Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio
| | - Alireza M Mohammadi
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Erin S Murphy
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio
| | - Michael A Vogelbaum
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jame Abraham
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio
| | - Halle Moore
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio
| | - G Thomas Budd
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio
| | - John H Suh
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio
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73
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Zuccato JA, Aizer AA, Lee EQ, Ahluwalia MS, O'Halloran PJ, Mansouri A, Wen PY, Zadeh G. Highlights of the 2019 Society for Neuro-Oncology Inaugural Brain Metastases Conference: establishing a dedicated meeting to address an unmet need in the field. Neurooncol Adv 2020; 2:vdaa036. [PMID: 32793883 PMCID: PMC7415252 DOI: 10.1093/noajnl/vdaa036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Brain metastases comprise the majority of central nervous tumors in adults and confer poorer survival for patients with primary cancer. Systemic disease control is improving with advances in treatment for primary tumors and the complexity of brain metastases management is increasing with multimodality approaches incorporating combinations of surgery, radiotherapy, chemotherapy, targeted therapies, and immunotherapy. Accordingly, the Society for Neuro-Oncology established an annual brain metastases conference to unite colleagues from multiple disciplines with content spanning a range of timely topics relevant to improving our understanding of brain metastases and how they are optimally treated. The inaugural meeting on August 16–17, 2019 was very successful with 163 impactful presentations being delivered to a large multidisciplinary audience on current research advances in the field of neuro-oncology. This review summarizes the major themes of the meeting and highlights the main findings presented.
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Affiliation(s)
- Jeffrey A Zuccato
- Division of Neurosurgery, University Health Network, University of Toronto, Toronto, Ontario, Canada.,MacFeeters-Hamilton Center for Neuro-Oncology, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Ayal A Aizer
- Center for Neuro-Oncology, Dana Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Eudocia Quant Lee
- Center for Neuro-Oncology, Dana Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Manmeet S Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Philip J O'Halloran
- Division of Neurosurgery, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Alireza Mansouri
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Gelareh Zadeh
- Division of Neurosurgery, University Health Network, University of Toronto, Toronto, Ontario, Canada.,MacFeeters-Hamilton Center for Neuro-Oncology, Princess Margaret Cancer Center, Toronto, Ontario, Canada
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Abstract
The development of brain metastases occurs in 10–20% of all patients with cancer. Brain metastases portend poor survival and contribute to increased cancer mortality and morbidity. Despite multimodal treatment options, which include surgery, radiotherapy, and chemotherapy, 5-year survival remains low. Besides, our current treatment modalities can have significant neurological comorbidities, which result in neurocognitive decline and a decrease in a patient’s quality of life. However, innovations in technology, improved understanding of tumor biology, and new therapeutic options have led to improved patient care. Novel approaches in radiotherapy are minimizing the neurocognitive decline while providing the same therapeutic benefit. In addition, advances in targeted therapies and immune checkpoint inhibitors are redefining the management of lung and melanoma brain metastases. Similar approaches to brain metastases from other primary tumors promise to lead to new and effective therapies. We are beginning to understand the appropriate combination of these novel approaches with our traditional treatment options. As advances in basic and translational science and innovative technologies enter clinical practice, the prognosis of patients with brain metastases will continue to improve.
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Affiliation(s)
- Adam Lauko
- Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yasmeen Rauf
- Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Manmeet S Ahluwalia
- Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
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75
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Alban TJ, Bayik D, Otvos B, Rabljenovic A, Leng L, Jia-Shiun L, Roversi G, Lauko A, Momin AA, Mohammadi AM, Peereboom DM, Ahluwalia MS, Matsuda K, Yun K, Bucala R, Vogelbaum MA, Lathia JD. Glioblastoma Myeloid-Derived Suppressor Cell Subsets Express Differential Macrophage Migration Inhibitory Factor Receptor Profiles That Can Be Targeted to Reduce Immune Suppression. Front Immunol 2020; 11:1191. [PMID: 32625208 PMCID: PMC7315581 DOI: 10.3389/fimmu.2020.01191] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 05/13/2020] [Indexed: 12/20/2022] Open
Abstract
The application of tumor immunotherapy to glioblastoma (GBM) is limited by an unprecedented degree of immune suppression due to factors that include high numbers of immune suppressive myeloid cells, the blood brain barrier, and T cell sequestration to the bone marrow. We previously identified an increase in immune suppressive myeloid-derived suppressor cells (MDSCs) in GBM patients, which correlated with poor prognosis and was dependent on macrophage migration inhibitory factor (MIF). Here we examine the MIF signaling axis in detail in murine MDSC models, GBM-educated MDSCs and human GBM. We found that the monocytic subset of MDSCs (M-MDSCs) expressed high levels of the MIF cognate receptor CD74 and was localized in the tumor microenvironment. In contrast, granulocytic MDSCs (G-MDSCs) expressed high levels of the MIF non-cognate receptor CXCR2 and showed minimal accumulation in the tumor microenvironment. Furthermore, targeting M-MDSCs with Ibudilast, a brain penetrant MIF-CD74 interaction inhibitor, reduced MDSC function and enhanced CD8 T cell activity in the tumor microenvironment. These findings demonstrate the MDSC subsets differentially express MIF receptors and may be leveraged for specific MDSC targeting.
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Affiliation(s)
- Tyler J. Alban
- Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, OH, United States
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States
| | - Defne Bayik
- Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, OH, United States
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States
| | - Balint Otvos
- Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, OH, United States
- Cleveland Clinic, Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, United States
| | - Anja Rabljenovic
- Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, OH, United States
| | - Lin Leng
- Departments of Medicine, Pathology, and Epidemiology & Public Health, Yale Cancer Center, Yale School of Medicine, New Haven, CT, United States
| | - Leu Jia-Shiun
- Department of Neurology, Houston Methodist Research Institute, Houston, TX, United States
| | - Gustavo Roversi
- Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, OH, United States
| | - Adam Lauko
- Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, OH, United States
| | - Arbaz A. Momin
- Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, OH, United States
| | - Alireza M. Mohammadi
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, United States
| | - David M. Peereboom
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, United States
| | - Manmeet S. Ahluwalia
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, United States
| | | | - Kyuson Yun
- Department of Neurology, Houston Methodist Research Institute, Houston, TX, United States
- Department of Neurosurgery, Weill Cornell Medical College, New York, NY, United States
| | - Richard Bucala
- Departments of Medicine, Pathology, and Epidemiology & Public Health, Yale Cancer Center, Yale School of Medicine, New Haven, CT, United States
| | | | - Justin D. Lathia
- Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, OH, United States
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, United States
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Bayik D, Zhou Y, Park C, Hong C, Vail D, Silver DJ, Lauko AJ, Roversi GA, Watson DC, Lo A, Alban TJ, McGraw M, Sorensen MD, Grabowski MM, Otvos B, Vogelbaum MA, Horbinski CM, Khalil AM, Hwang TH, Ahluwalia MS, Cheng F, Lathia JD. Myeloid-derived suppressor cell subset heterogeneity drives glioblastoma progression in a sex-dependent manner. The Journal of Immunology 2020. [DOI: 10.4049/jimmunol.204.supp.164.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
Immunosuppression is a major factor facilitating glioblastoma (GBM) progression and therapeutic resistance. We previously demonstrated that myeloid-derived suppressor cells (MDSCs) expand in GBM patients, but the mechanisms by which MDSC subsets promote tumorigenesis remain unknown. Using multiple syngeneic mouse GBM models, we show that monocytic MDSCs (mMDSCs) accumulate in tumors of males and associate with poor prognosis. Consistent with preclinical observations, males, who constitute 60% of GBM patients and have a worse prognosis than females, had significantly more tumor-infiltrating mMDSCs. In contrast, female tumor-bearing mice had a two-fold increase in circulating granulocytic MDSC (gMDSC) frequency, and a high gMDSC gene signature correlated with poor prognosis of female patients. Male-to-female bone marrow transplantation indicated that immune cell-intrinsic discrepancies drive the sex differences in GBM survival. In line with the differential MDSC localization, targeting gMDSCs with anti-Ly6G neutralizing antibodies extended the lifespan of female mice without affecting males. However, mMDSCs were protected from the anti-Ly6C depletion strategy due to their systemic and local proliferation, as indicated by ex vivo Ki-67 staining and subsequently confirmed by gene expression analysis. Drug-prediction using the differential expression profiles and subsequent pre-clinical testing established that mMDSCs can be targeted by chemotherapies, while IL-1 inhibitors are effective against gMDSCs. These findings indicate that MDSC subset variation represents an opportunity for improved immunotherapy efficacy while accounting for sex as a biological variable.
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Affiliation(s)
- Defne Bayik
- 1Lerner Research Institute, Cleveland Clinic Foundation
| | - Yadi Zhou
- 1Lerner Research Institute, Cleveland Clinic Foundation
| | - Chihyun Park
- 1Lerner Research Institute, Cleveland Clinic Foundation
| | - Changjin Hong
- 1Lerner Research Institute, Cleveland Clinic Foundation
| | | | | | - Adam J Lauko
- 1Lerner Research Institute, Cleveland Clinic Foundation
| | | | | | | | - Tyler J Alban
- 1Lerner Research Institute, Cleveland Clinic Foundation
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77
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Parsai S, Miller JA, Juloori A, Chao ST, Kotecha R, Mohammadi AM, Ahluwalia MS, Murphy ES, Barnett GH, Vogelbaum MA, Angelov L, Peereboom DM, Suh JH. Stereotactic radiosurgery with concurrent lapatinib is associated with improved local control for HER2-positive breast cancer brain metastases. J Neurosurg 2020; 132:503-511. [PMID: 30738402 DOI: 10.3171/2018.10.jns182340] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/04/2018] [Indexed: 01/07/2023]
Abstract
OBJECTIVE With increasing survival for patients with human epidermal growth factor receptor 2-positive (HER2+) breast cancer in the trastuzumab era, there is an increased risk of brain metastasis. Therefore, there is interest in optimizing intracranial disease control. Lapatinib is a small-molecule dual HER2/epidermal growth factor receptor inhibitor that has demonstrated intracranial activity against HER2+ breast cancer brain metastases. The objective of this study was to investigate the impact of lapatinib combined with stereotactic radiosurgery (SRS) on local control of brain metastases. METHODS Patients with HER2+ breast cancer brain metastases who underwent SRS from 1997-2015 were included. The primary outcome was the cumulative incidence of local failure following SRS. Secondary outcomes included the cumulative incidence of radiation necrosis and overall survival. RESULTS One hundred twenty-six patients with HER2+ breast cancer who underwent SRS to 479 brain metastases (median 5 lesions per patient) were included. Among these, 75 patients had luminal B subtype (hormone receptor-positive, HER2+) and 51 patients had HER2-enriched histology (hormone receptor-negative, HER2+). Forty-seven patients received lapatinib during the course of their disease, of whom 24 received concurrent lapatinib with SRS. The median radiographic follow-up among all patients was 17.1 months. Concurrent lapatinib was associated with reduction in local failure at 12 months (5.7% vs 15.1%, p < 0.01). For lesions in the ≤ 75th percentile by volume, concurrent lapatinib significantly decreased local failure. However, for lesions in the > 75th percentile (> 1.10 cm3), concurrent lapatinib did not significantly improve local failure. Any use of lapatinib after development of brain metastasis improved median survival compared to SRS without lapatinib (27.3 vs 19.5 months, p = 0.03). The 12-month risk of radiation necrosis was consistently lower in the lapatinib cohort compared to the SRS-alone cohort (1.3% vs 6.3%, p < 0.01), despite extended survival. CONCLUSIONS For patients with HER2+ breast cancer brain metastases, the use of lapatinib concurrently with SRS improved local control of brain metastases, without an increased rate of radiation necrosis. Concurrent lapatinib best augments the efficacy of SRS for lesions ≤ 1.10 cm3 in volume. In patients who underwent SRS for HER2+ breast cancer brain metastases, the use of lapatinib at any time point in the therapy course was associated with a survival benefit. The use of lapatinib combined with radiosurgery warrants further prospective evaluation.
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Affiliation(s)
| | - Jacob A Miller
- 2Department of Radiation Oncology, Stanford Hospital, Palo Alto, California
| | | | - Samuel T Chao
- Departments of1Radiation Oncology and.,3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,4Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Rupesh Kotecha
- 5Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida.,6Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; and
| | - Alireza M Mohammadi
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,4Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,7Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manmeet S Ahluwalia
- Departments of1Radiation Oncology and.,3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,8Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Erin S Murphy
- Departments of1Radiation Oncology and.,3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,4Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,4Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,7Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Vogelbaum
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,4Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,7Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,4Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,7Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - David M Peereboom
- Departments of1Radiation Oncology and.,3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,8Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - John H Suh
- Departments of1Radiation Oncology and.,3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,4Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
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78
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Bayik D, Zhou Y, Park C, Hong C, Vail D, Silver DJ, Lauko A, Roversi G, Watson DC, Lo A, Alban TJ, McGraw M, Sorensen M, Grabowski MM, Otvos B, Vogelbaum MA, Horbinski C, Kristensen BW, Khalil AM, Hwang TH, Ahluwalia MS, Cheng F, Lathia JD. Myeloid-Derived Suppressor Cell Subsets Drive Glioblastoma Growth in a Sex-Specific Manner. Cancer Discov 2020; 10:1210-1225. [PMID: 32300059 DOI: 10.1158/2159-8290.cd-19-1355] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/29/2020] [Accepted: 04/13/2020] [Indexed: 11/16/2022]
Abstract
Myeloid-derived suppressor cells (MDSC) that block antitumor immunity are elevated in glioblastoma (GBM) patient blood and tumors. However, the distinct contributions of monocytic (mMDSC) versus granulocytic (gMDSC) subsets have yet to be determined. In mouse models of GBM, we observed that mMDSCs were enriched in the male tumors, whereas gMDSCs were elevated in the blood of females. Depletion of gMDSCs extended survival only in female mice. Using gene-expression signatures coupled with network medicine analysis, we demonstrated in preclinical models that mMDSCs could be targeted with antiproliferative agents in males, whereas gMDSC function could be inhibited by IL1β blockade in females. Analysis of patient data confirmed that proliferating mMDSCs were predominant in male tumors and that a high gMDSC/IL1β gene signature correlated with poor prognosis in female patients. These findings demonstrate that MDSC subsets differentially drive immune suppression in a sex-specific manner and can be leveraged for therapeutic intervention in GBM. SIGNIFICANCE: Sexual dimorphism at the level of MDSC subset prevalence, localization, and gene-expression profile constitutes a therapeutic opportunity. Our results indicate that chemotherapy can be used to target mMDSCs in males, whereas IL1 pathway inhibitors can provide benefit to females via inhibition of gMDSCs.See related commentary by Gabrilovich et al., p. 1100.This article is highlighted in the In This Issue feature, p. 1079.
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Affiliation(s)
- Defne Bayik
- Cancer Impact Area and Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Case Comprehensive Cancer Center, Cleveland, Ohio
| | - Yadi Zhou
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Chihyun Park
- Quantitative Health Science, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Changjin Hong
- Quantitative Health Science, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel Vail
- Department of Genetics and Genome Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Daniel J Silver
- Cancer Impact Area and Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Case Comprehensive Cancer Center, Cleveland, Ohio
| | - Adam Lauko
- Cancer Impact Area and Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio.,Department of Pathology, Case Western Reserve University, Cleveland, Ohio
| | - Gustavo Roversi
- Cancer Impact Area and Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | - Dionysios C Watson
- Cancer Impact Area and Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Case Comprehensive Cancer Center, Cleveland, Ohio.,University Hospitals Cleveland Medical Center, Cleveland, Ohio.,School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Alice Lo
- Cancer Impact Area and Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Case Western Reserve University, Cleveland, Ohio
| | - Tyler J Alban
- Cancer Impact Area and Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Case Comprehensive Cancer Center, Cleveland, Ohio.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | - Mary McGraw
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Mia Sorensen
- Department of Pathology, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Matthew M Grabowski
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Balint Otvos
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | | | - Craig Horbinski
- Department of Pathology and Neurosurgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Bjarne Winther Kristensen
- Department of Pathology, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ahmad M Khalil
- Case Comprehensive Cancer Center, Cleveland, Ohio.,Department of Genetics and Genome Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Tae Hyun Hwang
- Case Comprehensive Cancer Center, Cleveland, Ohio.,Quantitative Health Science, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manmeet S Ahluwalia
- Case Comprehensive Cancer Center, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Feixiong Cheng
- Case Comprehensive Cancer Center, Cleveland, Ohio.,Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | - Justin D Lathia
- Cancer Impact Area and Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio. .,Case Comprehensive Cancer Center, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
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Beig N, Bera K, Prasanna P, Antunes J, Correa R, Singh S, Saeed Bamashmos A, Ismail M, Braman N, Verma R, Hill VB, Statsevych V, Ahluwalia MS, Varadan V, Madabhushi A, Tiwari P. Radiogenomic-Based Survival Risk Stratification of Tumor Habitat on Gd-T1w MRI Is Associated with Biological Processes in Glioblastoma. Clin Cancer Res 2020; 26:1866-1876. [PMID: 32079590 PMCID: PMC7165059 DOI: 10.1158/1078-0432.ccr-19-2556] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 10/11/2019] [Accepted: 01/14/2020] [Indexed: 01/31/2023]
Abstract
PURPOSE To (i) create a survival risk score using radiomic features from the tumor habitat on routine MRI to predict progression-free survival (PFS) in glioblastoma and (ii) obtain a biological basis for these prognostic radiomic features, by studying their radiogenomic associations with molecular signaling pathways. EXPERIMENTAL DESIGN Two hundred three patients with pretreatment Gd-T1w, T2w, T2w-FLAIR MRI were obtained from 3 cohorts: The Cancer Imaging Archive (TCIA; n = 130), Ivy GAP (n = 32), and Cleveland Clinic (n = 41). Gene-expression profiles of corresponding patients were obtained for TCIA cohort. For every study, following expert segmentation of tumor subcompartments (necrotic core, enhancing tumor, peritumoral edema), 936 3D radiomic features were extracted from each subcompartment across all MRI protocols. Using Cox regression model, radiomic risk score (RRS) was developed for every protocol to predict PFS on the training cohort (n = 130) and evaluated on the holdout cohort (n = 73). Further, Gene Ontology and single-sample gene set enrichment analysis were used to identify specific molecular signaling pathway networks associated with RRS features. RESULTS Twenty-five radiomic features from the tumor habitat yielded the RRS. A combination of RRS with clinical (age and gender) and molecular features (MGMT and IDH status) resulted in a concordance index of 0.81 (P < 0.0001) on training and 0.84 (P = 0.03) on the test set. Radiogenomic analysis revealed associations of RRS features with signaling pathways for cell differentiation, cell adhesion, and angiogenesis, which contribute to chemoresistance in GBM. CONCLUSIONS Our findings suggest that prognostic radiomic features from routine Gd-T1w MRI may also be significantly associated with key biological processes that affect response to chemotherapy in GBM.
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Affiliation(s)
- Niha Beig
- Case Western Reserve University, Cleveland, Ohio
| | - Kaustav Bera
- Case Western Reserve University, Cleveland, Ohio
| | | | | | - Ramon Correa
- Case Western Reserve University, Cleveland, Ohio
| | | | | | - Marwa Ismail
- Case Western Reserve University, Cleveland, Ohio
| | | | | | - Virginia B Hill
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Anant Madabhushi
- Case Western Reserve University, Cleveland, Ohio
- Louis Stokes Cleveland Veterans Administration Medical Center, Cleveland, Ohio
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80
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Mohammadi AM, Sharma M, Beaumont TL, Juarez KO, Kemeny H, Dechant C, Seas A, Sarmey N, Lee BS, Jia X, Fecci PE, Baehring J, Moliterno J, Chiang VL, Ahluwalia MS, Kim AH, Barnett GH, Leuthardt EC. Upfront Magnetic Resonance Imaging-Guided Stereotactic Laser-Ablation in Newly Diagnosed Glioblastoma: A Multicenter Review of Survival Outcomes Compared to a Matched Cohort of Biopsy-Only Patients. Neurosurgery 2020; 85:762-772. [PMID: 30476325 DOI: 10.1093/neuros/nyy449] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 08/21/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Laser ablation (LA) is used as an upfront treatment in patients with deep seated newly diagnosed Glioblastoma (nGBM). OBJECTIVE To evaluate the outcomes of LA in patients with nGBM and compare them with a matched biopsy-only cohort. METHODS Twenty-four nGBM patients underwent upfront LA at Cleveland clinic, Washington University in St. Louis, and Yale University (6/2011-12/2014) followed by chemo/radiotherapy. Also, 24 out of 171 nGBM patients with biopsy followed by chemo/radiotherapy were matched based on age (< 70 vs ≥ 70), gender, tumor location (deep vs lobar), and volume (<11 cc vs ≥11 cc). Progression-free survival (PFS), overall survival (OS), and disease-specific PFS and OS were outcome measures. Three prognostic groups were identified based on extent of tumor ablation by thermal-damage-threshold (TDT)-lines. RESULTS The median tumor volume in LA (n = 24) and biopsy only (n = 24) groups was 9.3 cm3 and 8.2 cm3 respectively. Overall, median estimate of OS and PFS in LA cohort was 14.4 and 4.3 mo compared to 15.8 mo and 5.9 mo for biopsy only cohort. On multivariate analysis, favorable TDT-line prognostic groups were associated with lower incidence of disease specific death (P = .03) and progression (P = .05) compared to other groups including biopsy only cohort. Only age (<70 yr, P = .02) and tumor volume (<11 cc, P = .03) were favorable prognostic factors for OS. CONCLUSION The maximum tumor coverage by LA followed by radiation/chemotherapy is an effective treatment modality in patients with nGBM, compared to biopsy only cohort. The TDT-line prognostic groups were independent predictor of disease specific death and progression after LA.
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Affiliation(s)
- Alireza M Mohammadi
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery, Neurological Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Mayur Sharma
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery, Neurological Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Thomas L Beaumont
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Kevin O Juarez
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Hanna Kemeny
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Cosette Dechant
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Andreas Seas
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Nehaw Sarmey
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery, Neurological Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Bryan S Lee
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery, Neurological Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Xuefei Jia
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Joachim Baehring
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Jennifer Moliterno
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Veronica L Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Manmeet S Ahluwalia
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery, Neurological Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gene H Barnett
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery, Neurological Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Eric C Leuthardt
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
- Department of Biomedical Engineering, Center for Innovation in Neuroscience and Technology, Washington University School of Medicine, St. Louis, Missouri
- Department of Mechanical Engineering and Material Science, Center for Innovation in Neuroscience and Technology, Washington University, School of Medicine, St. Louis, Missouri
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81
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Fallah J, Ahluwalia MS. The role of immunotherapy in the management of patients with renal cell carcinoma and brain metastases. Ann Transl Med 2020; 7:S313. [PMID: 32016032 DOI: 10.21037/atm.2019.10.31] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Jaleh Fallah
- Taussig Cancer Institute, Cleveland Clinic, Cleveland Ohio, OH, USA
| | - Manmeet S Ahluwalia
- Taussig Cancer Institute, Cleveland Clinic, Cleveland Ohio, OH, USA.,Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland Ohio, OH, USA
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82
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Kumthekar P, Tang SC, Brenner AJ, Kesari S, Piccioni DE, Anders C, Carrillo J, Chalasani P, Kabos P, Puhalla S, Tkaczuk K, Garcia AA, Ahluwalia MS, Wefel JS, Lakhani N, Ibrahim N. ANG1005, a Brain-Penetrating Peptide–Drug Conjugate, Shows Activity in Patients with Breast Cancer with Leptomeningeal Carcinomatosis and Recurrent Brain Metastases. Clin Cancer Res 2020; 26:2789-2799. [DOI: 10.1158/1078-0432.ccr-19-3258] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/12/2019] [Accepted: 01/17/2020] [Indexed: 11/16/2022]
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83
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Erickson AW, Ghodrati F, Habbous S, Jerzak KJ, Sahgal A, Ahluwalia MS, Das S. HER2-targeted therapy prolongs survival in patients with HER2-positive breast cancer and intracranial metastatic disease: a systematic review and meta-analysis. Neurooncol Adv 2020; 2:vdaa136. [PMID: 33305268 PMCID: PMC7720818 DOI: 10.1093/noajnl/vdaa136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Intracranial metastatic disease (IMD) is a serious and known complication of human epidermal growth factor receptor 2 (HER2)-positive breast cancer. The role of targeted therapy for patients with HER2-positive breast cancer and IMD remains unclear. In this study, we sought to evaluate the effect of HER2-targeted therapy on IMD from HER2-positive breast cancer. METHODS We searched MEDLINE, EMBASE, CENTRAL, and gray literature sources for interventional and observational studies reporting survival, response, and safety outcomes for patients with IMD receiving HER2-targeted therapy. We pooled outcomes through meta-analysis and examined confounder effects through forest plot stratification and meta-regression. Evidence quality was evaluated using GRADE (PROSPERO CRD42020161209). RESULTS A total of 97 studies (37 interventional and 60 observational) were included. HER2-targeted therapy was associated with prolonged overall survival (hazard ratio [HR] 0.47; 95% confidence interval [CI], 0.39-0.56) without significantly prolonged progression-free survival (HR 0.52; 95% CI, 0.27-1.02) versus non-targeted therapy; the intracranial objective response rate was 19% (95% CI, 12-27%), intracranial disease control rate 62% (95% CI, 55-69%), intracranial complete response rate 0% (95% CI, 0-0.01%), and grade 3+ adverse event rate 26% (95% CI, 11-45%). Risk of bias was high in 40% (39/97) of studies. CONCLUSION These findings support a potential role for systemic HER2-targeted therapy in the treatment of patients with IMD from HER2-positive metastatic breast cancer.
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Affiliation(s)
- Anders W Erickson
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Farinaz Ghodrati
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Steven Habbous
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Katarzyna J Jerzak
- Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Hospital, Toronto, Ontario, Canada
| | - Manmeet S Ahluwalia
- Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sunit Das
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
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84
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Peereboom DM, Alban TJ, Grabowski MM, Alvarado AG, Otvos B, Bayik D, Roversi G, McGraw M, Huang P, Mohammadi AM, Kornblum HI, Radivoyevitch T, Ahluwalia MS, Vogelbaum MA, Lathia JD. Metronomic capecitabine as an immune modulator in glioblastoma patients reduces myeloid-derived suppressor cells. JCI Insight 2019; 4:130748. [PMID: 31600167 DOI: 10.1172/jci.insight.130748] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 10/03/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUNDMyeloid-derived suppressor cells (MDSCs) are elevated in the circulation of patients with glioblastoma (GBM), present in tumor tissue, and associated with poor prognosis. While low-dose chemotherapy reduces MDSCs in preclinical models, the use of this strategy to reduce MDSCs in GBM patients has yet to be evaluated.METHODSA phase 0/I dose-escalation clinical trial was conducted in patients with recurrent GBM treated 5-7 days before surgery with low-dose chemotherapy via capecitabine, followed by concomitant low-dose capecitabine and bevacizumab. Clinical outcomes, including progression-free and overall survival, were measured, along with safety and toxicity profiles. Over the treatment time course, circulating MDSC levels were measured by multiparameter flow cytometry, and tumor tissue immune profiles were assessed via time-of-flight mass cytometry.RESULTSEleven patients total were enrolled across escalating dose cohorts of 150, 300, and 450 mg bid. No serious adverse events related to the drug combination were observed. Compared with pretreatment baseline, circulating MDSCs were found to be higher after surgery in the 150-mg treatment arm and lower in the 300-mg and 450-mg treatment arms. Increased cytotoxic immune infiltration was observed after low-dose capecitabine compared with untreated GBM patients in the 300-mg and 450-mg treatment arms.CONCLUSIONSLow-dose, metronomic capecitabine in combination with bevacizumab was well tolerated in GBM patients and was associated with a reduction in circulating MDSC levels and an increase in cytotoxic immune infiltration into the tumor microenvironment.TRIAL REGISTRATIONClinicalTrials.gov NCT02669173.FUNDINGThis research was funded by the Cleveland Clinic, Case Comprehensive Cancer Center, the Musella Foundation, B*CURED, the NIH, the National Cancer Institute, the Sontag Foundation, Blast GBM, the James B. Pendleton Charitable Trust, and the Dr. Miriam and Sheldon G. Adelson Medical Research Foundation. Capecitabine was provided in kind by Mylan Pharmaceuticals.
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Affiliation(s)
- David M Peereboom
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA.,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Tyler J Alban
- Cancer Impact Area and Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Matthew M Grabowski
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alvaro G Alvarado
- Department of Psychiatry and Biobehavioral Sciences and Semel Institute for Neuroscience, University of California, Los Angeles, Los Angeles, California, USA
| | - Balint Otvos
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Defne Bayik
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA.,Cancer Impact Area and Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gustavo Roversi
- Cancer Impact Area and Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mary McGraw
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pengjing Huang
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alireza M Mohammadi
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Harley I Kornblum
- Department of Psychiatry and Biobehavioral Sciences and Semel Institute for Neuroscience, University of California, Los Angeles, Los Angeles, California, USA
| | - Tomas Radivoyevitch
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Manmeet S Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA.,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Justin D Lathia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA.,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA.,Cancer Impact Area and Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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85
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Chatterjee S, Angelov L, Ahluwalia MS, Yeaney GA. Epstein-Barr virus-associated primary central nervous system lymphoma in a patient with diffuse cutaneous systemic sclerosis on long-term mycophenolate mofetil. Joint Bone Spine 2019; 87:163-166. [PMID: 31669807 DOI: 10.1016/j.jbspin.2019.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 10/09/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Epstein Barr virus (EBV)-associated primary central nervous system lymphoma (ePCNSL) is increasingly recognized in immunocompromised subjects, including patients receiving systemic immunosuppressive therapy. Here, we report the first case of primary CNS lymphoma associated with EBV in a patient with diffuse cutaneous systemic sclerosis (dcSSc) receiving long-term mycophenolate mofetil (MMF). CASE REPORT A 51-year-old female with dcSSc had been on MMF 2 grams daily, which was initiated for a rapidly rising modified Rodnan skin score (mRSS), severe pruritus, and progressive joint contractures. She had an impressive response to this therapy with a significant decrease in her mRSS. Her condition remained stable for the next five years, after which she developed worsening headaches for 2-3 weeks, associated with dizziness, gait instability, and left homonymous hemianopia. MRI scan of the brain revealed a solitary 2.4cm peripherally enhancing right parietal lobe mass. Excised tissue from the right parietal lobe mass showed EBV-associated diffuse large B cell lymphoma. She received four cycles of chemotherapy (high dose methotrexate and rituximab). Currently, her condition is being monitored. Her left homonymous hemianopia persists. CONCLUSION Because of a favorable toxicity profile, MMF is increasingly being used as long-term immunomodulatory therapy for a wide variety of autoimmune disorders. Nevertheless, patients on long-term MMF should still undergo regular CNS surveillance, not only for opportunistic infections but also for opportunistic malignancies such as PCNSL. Progressive focal or non-focal neurological deficits should always raise the alarm. Prompt evaluation and management can prevent irreversible neurological sequelae.
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Affiliation(s)
- Soumya Chatterjee
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Staff, Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio 44195, United States.
| | - Lilyana Angelov
- Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Section of Spinal Radiosurgery and Director of BBTC's Primary CNS Lymphoma Program, Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio 44195, United States
| | - Manmeet S Ahluwalia
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Brain Metastasis Research Program, and the Associate Director, Clinical Trials, Operations in the BBTC, Neurological Institute, Cleveland Clinic, Section Head of NeuroOncology Outcomes, Staff, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio 44195, United States
| | - Gabrielle A Yeaney
- Pathology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Section Head, Ocular Pathology, Division of Neuropathology, Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio 44195, United States
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86
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Sharma M, Schilero C, Peereboom DM, Hobbs BP, Elson P, Stevens GHJ, McCrae K, Nixon AB, Ahluwalia MS. Phase II study of Dovitinib in recurrent glioblastoma. J Neurooncol 2019; 144:359-368. [PMID: 31292802 DOI: 10.1007/s11060-019-03236-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 06/27/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Dovitinib is an oral, potent inhibitor of FGFR and VEGFR, and can be a promising strategy in patients with recurrent or progressive glioblastoma (GBM). METHODS This was an open label phase II study of two arms: Arm 1 included anti-angiogenic naïve patients with recurrent GBM and Arm 2 included patients with recurrent GBM that had progressed on prior anti-angiogenic therapy. Nineteen subjects were enrolled in Arm 1 and 14 subjects in Arm 2. The primary endpoint was 6-month progression-free survival (PFS-6) in Arm 1 and time to progression (TTP) in Arm 2. The secondary endpoints were toxicity, objective response rate (ORR) and overall survival. RESULTS Patients in Arm 2 (compared to Arm 1) tended to have longer intervals from diagnosis to study entry (median 26.9 vs. 8.9 months, p = 0.002), experienced more recurrences (64%, had 3-4 prior recurrences compared to 0, p < 0.0001) and tended to be heavily pretreated (71% vs. 26-32% p = 0.04 or 0.02). 6-month PFS was 12% ± 6% for the Arm 1 and 0% for Arm 2. TTP was similar in both treatment arms (median 1.8 months Arm 1 and 0.7-1.8 months Arm 2, p = 0.36). Five patients (15%) had grade 4 toxicities and 22 patients (67%) had grade 3 toxicities. There were no significant differences between the two arms with respect to the amount of change in the levels of biomarkers from baseline. CONCLUSION Dovitinib was not efficacious in prolonging the PFS in patients with recurrent GBM irrespective of prior treatment with anti-angiogenic therapy (including bevacizumab).
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Affiliation(s)
- Mayur Sharma
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, S73, Cleveland, OH, 44195, USA
| | - Cathy Schilero
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, S73, Cleveland, OH, 44195, USA
| | - David M Peereboom
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, S73, Cleveland, OH, 44195, USA.,Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Brian P Hobbs
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Paul Elson
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Glen H J Stevens
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, S73, Cleveland, OH, 44195, USA.,Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Keith McCrae
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andrew B Nixon
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Manmeet S Ahluwalia
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, S73, Cleveland, OH, 44195, USA. .,Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
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87
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Lim-Fat MJ, Bi WL, Lo J, Lee EQ, Ahluwalia MS, Batchelor TT, Chang SM, Chiocca EA, Chukwueke U, Cloughesy TF, Colman H, Deangelis LM, Galanis E, Gilbert MR, De Groot JF, Lassman AB, Liau LM, Mason W, McFaline-Figueroa JR, Mehta MP, Mellinghoff IK, Nabors LB, Nayak L, Reardon DA, Wen PY. Letter: When Less is More: Dexamethasone Dosing for Brain Tumors. Neurosurgery 2019; 85:E607-E608. [PMID: 31215634 DOI: 10.1093/neuros/nyz186] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mary Jane Lim-Fat
- Center for Neuro-Oncology Dana Farber Cancer Institute Boston, Massachusetts
| | - Wenya Linda Bi
- Department of Neurosurgery Brigham and Women's Hospital Boston, Massachusetts
| | - Janet Lo
- Neuroendocrine Unit Massachusetts General Hospital Boston, Massachusetts
| | - Eudocia Quant Lee
- Center for Neuro-Oncology Dana Farber Cancer Institute Boston, Massachusetts.,Department of Neurology Brigham and Women's Hospital Boston, Massachusetts
| | - Manmeet S Ahluwalia
- Burkhardt Brain Tumor and Neuro-Oncology Center Cleveland Clinic Cleveland, Ohio
| | - Tracy T Batchelor
- Center for Neuro-Oncology Dana Farber Cancer Institute Boston, Massachusetts.,Department of Neurology Brigham and Women's Hospital Boston, Massachusetts
| | - Susan M Chang
- Department of Neurological Surgery University of California, San Francisco San Francisco, California
| | - E Antonio Chiocca
- Department of Neurosurgery Brigham and Women's Hospital Boston, Massachusetts
| | - Ugonma Chukwueke
- Center for Neuro-Oncology Dana Farber Cancer Institute Boston, Massachusetts.,Department of Neurology Brigham and Women's Hospital Boston, Massachusetts
| | - Timothy F Cloughesy
- UCLA Neuro-Oncology Program University of California, Los Angeles Los Angeles, California
| | - Howard Colman
- Huntsman Cancer Institute and Department of Neurosurgery University of Utah Salt Lake City, Utah
| | - Lisa M Deangelis
- Department of Neurology Memorial Sloan Kettering Cancer Center New York, New York
| | | | - Mark R Gilbert
- Neuro-Oncology Branch Center for Cancer Research National Cancer Institute Bethesda, Maryland
| | - John F De Groot
- Department of Neuro-Oncology The University of Texas M.D. Anderson Cancer Center Houston, Texas
| | - Andrew B Lassman
- Division of Neuro-Oncology Department of Neurology, and Herbert Irving Comprehensive Cancer Center Columbia University Irving Medical Center New York-Presbyterian Hospital New York, New York
| | - Linda M Liau
- Department of Neurosurgery University of California, Los Angeles Los Angeles, California
| | - Warren Mason
- Division of Neurology Princess Margaret Hospital, Toronto Ontario, Canada
| | - J Ricardo McFaline-Figueroa
- Center for Neuro-Oncology Dana Farber Cancer Institute Boston, Massachusetts.,Department of Neurology Brigham and Women's Hospital Boston, Massachusetts
| | - Minesh P Mehta
- Department of Radiation Oncology Miami Cancer Institute Coral Gables, Florida
| | - Ingo K Mellinghoff
- Department of Neurology Memorial Sloan Kettering Cancer Center New York, New York
| | - L Burt Nabors
- UAB Comprehensive Cancer Center The University of Alabama at Birmingham Birmingham, Alabama
| | - Lakshmi Nayak
- Center for Neuro-Oncology Dana Farber Cancer Institute Boston, Massachusetts.,Department of Neurology Brigham and Women's Hospital Boston, Massachusetts
| | - David A Reardon
- Center for Neuro-Oncology Dana Farber Cancer Institute Boston, Massachusetts.,Department of Neurology Brigham and Women's Hospital Boston, Massachusetts
| | - Patrick Y Wen
- Center for Neuro-Oncology Dana Farber Cancer Institute Boston, Massachusetts.,Department of Neurology Brigham and Women's Hospital Boston, Massachusetts
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Abstract
The most common primary cancers that metastasize to the brain are lung cancer, breast cancer, and melanoma. The established management approaches for brain metastasis include stereotactic radiosurgery, fractionated radiation therapy, and surgical resection. In the past the role of medical therapies in brain metastases was limited. In the last decade, our understanding of molecular drivers of brain metastases and CNS penetration of drugs across the blood-brain barrier has improved. The molecular targeted tyrosine kinase inhibitors have shown effectiveness in brain metastases with activating mutations from non-small cell lung cancer, breast cancer, and melanoma. More recently, immunotherapies have also shown efficacy in the management of these patients. These agents can be effective for both intracranial as well as extracranial disease and are being actively employed in this patient population.
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Affiliation(s)
- Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA,
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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89
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Tom MC, Varra V, Leyrer CM, Park DY, Chao ST, Yu JS, Suh JH, Reddy CA, Balagamwala EH, Broughman JR, Kotagal KA, Vogelbaum MA, Barnett GH, Ahluwalia MS, Peereboom DM, Prayson RA, Stevens GHJ, Murphy ES. Risk Factors for Progression Among Low-Grade Gliomas After Gross Total Resection and Initial Observation in the Molecular Era. Int J Radiat Oncol Biol Phys 2019; 104:1099-1105. [PMID: 31022510 DOI: 10.1016/j.ijrobp.2019.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/16/2019] [Accepted: 04/14/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE To identify risk factors for progression-free survival (PFS) in the molecular era among patients with low-grade glioma (LGG) who undergo gross total resection (GTR) followed by initial observation. METHODS AND MATERIALS We reviewed patients with World Health Organization grade 2 LGG treated at a single institution. We included only those who underwent magnetic resonance imaging (MRI)-confirmed GTR followed by initial observation. Molecular classification was obtained at either the time of diagnosis or pathology review. Cox proportional hazards regression, the Kaplan-Meier method, and the log-rank test were used. P values <.05 were considered statistically significant. RESULTS We included 144 patients who underwent MRI-confirmed GTR between 1994 and 2014 followed by initial observation. Median age was 29 years (interquartile range [IQR], 18-41), median tumor size was 2.7 cm (IQR, 1.8-4.0), and median follow-up was 81 months (IQR, 36-132). Molecular classification was 13% IDH-mutant 1p19q-codeleted; 21% IDH-mutant 1p19q-intact; 39% IDH1-R132H-wildtype; and 28% undetermined. For the entire cohort, 5- and 10-year PFS and overall survival were 71% and 53%, and 98% and 90%, respectively. On multivariate analysis, factors associated with worse PFS included increasing age at diagnosis (hazard ratio [HR], 1.05; 95% CI, 1.00-1.09; P = .03), increasing preoperative tumor size (HR, 1.07; 95% CI, 1.04-1.10; P < .0001), and IDH-mutant 1p19q-intact classification (HR, 3.18; 95% CI, 1.15-8.74, P = .025). Median PFS for patients with IDH-mutant 1p19q-codeleted, IDH-mutant 1p19q-intact, and IDH1-R132H-wildtype tumors were 113 months, 56 months, and not reached, respectively. Molecular classification was significantly associated with PFS (P < .0001) but not overall survival (P = .20). CONCLUSIONS Among patients with LGG who undergo MRI-confirmed GTR and initial observation in the molecular era, increasing age, increasing tumor size, and IDH-mutant 1p19q-intact classification are associated with worse PFS. Because tumor progression is associated with adverse health-related quality of life, these factors may aid clinicians and patients in the shared decision-making process regarding goals of surgery and timing of postoperative therapy. Further study is required to elucidate why IDH-mutant 1p19q-intact LGGs are at higher risk for early progression.
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Affiliation(s)
- Martin C Tom
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vamsi Varra
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - C Marc Leyrer
- Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Deborah Y Park
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Samuel T Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Jennifer S Yu
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ehsan H Balagamwala
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - James R Broughman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Gene H Barnett
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio; Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manmeet S Ahluwalia
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio; Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - David M Peereboom
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio; Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richard A Prayson
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio; Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Glen H J Stevens
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio; Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Erin S Murphy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.
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90
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Alexander BM, Trippa L, Gaffey S, Arrillaga-Romany IC, Lee EQ, Rinne ML, Ahluwalia MS, Colman H, Fell G, Galanis E, de Groot J, Drappatz J, Lassman AB, Meredith DM, Nabors LB, Santagata S, Schiff D, Welch MR, Ligon KL, Wen PY. Individualized Screening Trial of Innovative Glioblastoma Therapy (INSIGhT): A Bayesian Adaptive Platform Trial to Develop Precision Medicines for Patients With Glioblastoma. JCO Precis Oncol 2019; 3:1800071. [PMID: 32914038 PMCID: PMC7448806 DOI: 10.1200/po.18.00071] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2018] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Adequately prioritizing the numerous therapies and biomarkers available in late-stage testing for patients with glioblastoma (GBM) requires an efficient clinical testing platform. We developed and implemented INSIGhT (Individualized Screening Trial of Innovative Glioblastoma Therapy) as a novel adaptive platform trial (APT) to develop precision medicine approaches in GBM. METHODS INSIGhT compares experimental arms with a common control of standard concurrent temozolomide and radiation therapy followed by adjuvant temozolomide. The primary end point is overall survival. Patients with newly diagnosed unmethylated GBM who are IDH R132H mutation negative and with genomic data available for biomarker grouping are eligible. At the initiation of INSIGhT, three experimental arms (neratinib, abemaciclib, and CC-115), each with a proposed genomic biomarker, are tested simultaneously. Initial randomization is equal across arms. As the trial progresses, randomization probabilities adapt on the basis of accumulating results using Bayesian estimation of the biomarker-specific probability of treatment impact on progression-free survival. Treatment arms may drop because of low probability of treatment impact on overall survival, and new arms may be added. Detailed information on the statistical model and randomization algorithm is provided to stimulate discussion on trial design choices more generally and provide an example for other investigators developing APTs. CONCLUSION INSIGhT (NCT02977780) is an ongoing novel biomarker-based, Bayesian APT for patients with newly diagnosed unmethylated GBM. Our goal is to dramatically shorten trial execution timelines while increasing scientific power of results and biomarker discovery using adaptive randomization. We anticipate that trial execution efficiency will also be improved by using the APT format, which allows for the collaborative addition of new experimental arms while retaining the overall trial structure.
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Affiliation(s)
- Brian M Alexander
- Dana-Farber Cancer Institute, Boston, MA.,Brigham and Women's Hospital, Boston, MA
| | | | | | | | | | - Mikael L Rinne
- Brigham and Women's Hospital, Boston, MA.,Novartis Institutes for Biomedical Research, Boston, MA
| | | | | | | | | | | | - Jan Drappatz
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - David M Meredith
- Dana-Farber Cancer Institute, Boston, MA.,Brigham and Women's Hospital, Boston, MA
| | | | - Sandro Santagata
- Dana-Farber Cancer Institute, Boston, MA.,Brigham and Women's Hospital, Boston, MA
| | - David Schiff
- University of Virginia Health System, Charlottesville, VA
| | - Mary R Welch
- Columbia University Medical Center, New York, NY
| | - Keith L Ligon
- Dana-Farber Cancer Institute, Boston, MA.,Brigham and Women's Hospital, Boston, MA
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91
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Juloori A, Miller JA, Parsai S, Kotecha R, Ahluwalia MS, Mohammadi AM, Murphy ES, Suh JH, Barnett GH, Yu JS, Vogelbaum MA, Rini B, Garcia J, Stevens GH, Angelov L, Chao ST. Overall survival and response to radiation and targeted therapies among patients with renal cell carcinoma brain metastases. J Neurosurg 2019; 132:1-9. [PMID: 30660120 DOI: 10.3171/2018.8.jns182100] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 08/14/2018] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The object of this retrospective study was to investigate the impact of targeted therapies on overall survival (OS), distant intracranial failure, local failure, and radiation necrosis among patients treated with radiation therapy for renal cell carcinoma (RCC) metastases to the brain. METHODS All patients diagnosed with RCC brain metastasis (BM) between 1998 and 2015 at a single institution were included in this study. The primary outcome was OS, and secondary outcomes included local failure, distant intracranial failure, and radiation necrosis. The timing of targeted therapies was recorded. Multivariate Cox proportional-hazards regression was used to model OS, while multivariate competing-risks regression was used to model local failure, distant intracranial failure, and radiation necrosis, with death as a competing risk. RESULTS Three hundred seventy-six patients presented with 912 RCC BMs. Median OS was 9.7 months. Consistent with the previously validated diagnosis-specific graded prognostic assessment (DS-GPA) for RCC BM, Karnofsky Performance Status (KPS) and number of BMs were the only factors prognostic for OS. One hundred forty-seven patients (39%) received vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitors (TKIs). Median OS was significantly greater among patients receiving TKIs (16.8 vs 7.3 months, p < 0.001). Following multivariate analysis, KPS, number of metastases, and TKI use remained significantly associated with OS.The crude incidence of local failure was 14.9%, with a 12-month cumulative incidence of 13.4%. TKIs did not significantly decrease the 12-month cumulative incidence of local failure (11.4% vs 14.5%, p = 0.11). Following multivariate analysis, age, number of BMs, and lesion size remained associated with local failure. The 12-month cumulative incidence of radiation necrosis was 8.0%. Use of TKIs within 30 days of SRS was associated with a significantly increased 12-month cumulative incidence of radiation necrosis (10.9% vs 6.4%, p = 0.04). CONCLUSIONS Use of targeted therapies in patients with RCC BM treated with intracranial SRS was associated with improved OS. However, the use of TKIs within 30 days of SRS increases the rate of radiation necrosis without improving local control or reducing distant intracranial failure. Prospective studies are warranted to determine the optimal timing to reduce the rate of necrosis without detracting from survival.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Glen H Stevens
- 4Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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92
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Achrol AS, Rennert RC, Anders C, Soffietti R, Ahluwalia MS, Nayak L, Peters S, Arvold ND, Harsh GR, Steeg PS, Chang SD. Brain metastases. Nat Rev Dis Primers 2019; 5:5. [PMID: 30655533 DOI: 10.1038/s41572-018-0055-y] [Citation(s) in RCA: 499] [Impact Index Per Article: 99.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
An estimated 20% of all patients with cancer will develop brain metastases, with the majority of brain metastases occurring in those with lung, breast and colorectal cancers, melanoma or renal cell carcinoma. Brain metastases are thought to occur via seeding of circulating tumour cells into the brain microvasculature; within this unique microenvironment, tumour growth is promoted and the penetration of systemic medical therapies is limited. Development of brain metastases remains a substantial contributor to overall cancer mortality in patients with advanced-stage cancer because prognosis remains poor despite multimodal treatments and advances in systemic therapies, which include a combination of surgery, radiotherapy, chemotherapy, immunotherapy and targeted therapies. Thus, interest abounds in understanding the mechanisms that drive brain metastases so that they can be targeted with preventive therapeutic strategies and in understanding the molecular characteristics of brain metastases relative to the primary tumour so that they can inform targeted therapy selection. Increased molecular understanding of the disease will also drive continued development of novel immunotherapies and targeted therapies that have higher bioavailability beyond the blood-tumour barrier and drive advances in radiotherapies and minimally invasive surgical techniques. As these discoveries and innovations move from the realm of basic science to preclinical and clinical applications, future outcomes for patients with brain metastases are almost certain to improve.
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Affiliation(s)
- Achal Singh Achrol
- Department of Neurosurgery and Neurosciences, John Wayne Cancer Institute and Pacific Neuroscience Institute, Santa Monica, CA, USA.
| | - Robert C Rennert
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA.
| | - Carey Anders
- Division of Hematology/Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | | | - Manmeet S Ahluwalia
- Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Lakshmi Nayak
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Solange Peters
- Medical Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Nils D Arvold
- Department of Radiation Oncology, St. Luke's Cancer Center, Duluth, MN, USA
| | - Griffith R Harsh
- Department of Neurosurgery, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Patricia S Steeg
- Women's Malignancies Branch, Center for Cancer Research, National Cancer Center, Bethesda, MD, USA
| | - Steven D Chang
- Department of Neurosurgery, University of California-Davis, School of Medicine, Sacramento, CA, USA.
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93
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Chinnaiyan P, Won M, Wen PY, Rojiani AM, Werner-Wasik M, Shih HA, Ashby LS, Michael Yu HH, Stieber VW, Malone SC, Fiveash JB, Mohile NA, Ahluwalia MS, Wendland MM, Stella PJ, Kee AY, Mehta MP. A randomized phase II study of everolimus in combination with chemoradiation in newly diagnosed glioblastoma: results of NRG Oncology RTOG 0913. Neuro Oncol 2019; 20:666-673. [PMID: 29126203 DOI: 10.1093/neuonc/nox209] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background This phase II study was designed to determine the efficacy of the mammalian target of rapamycin (mTOR) inhibitor everolimus administered daily with conventional radiation therapy and chemotherapy in patients with newly diagnosed glioblastoma. Methods Patients were randomized to radiation therapy with concurrent and adjuvant temozolomide with or without daily everolimus (10 mg). The primary endpoint was progression-free survival (PFS) and the secondary endpoints were overall survival (OS) and treatment-related toxicities. Results A total of 171 patients were randomized and deemed eligible for this study. Patients randomized to receive everolimus experienced a significant increase in both grade 4 toxicities, including lymphopenia and thrombocytopenia, and treatment-related deaths. There was no significant difference in PFS between patients randomized to everolimus compared with control (median PFS time: 8.2 vs 10.2 mo, respectively; P = 0.79). OS for patients randomized to receive everolimus was inferior to that for control patients (median survival time: 16.5 vs 21.2 mo, respectively; P = 0.008). A similar trend was observed in both O6-methylguanine-DNA-methyltransferase promoter hypermethylated and unmethylated tumors. Conclusion Combining everolimus with conventional chemoradiation leads to increased treatment-related toxicities and does not improve PFS in patients with newly diagnosed glioblastoma. Although the median survival time in patients receiving everolimus was comparable to contemporary studies, it was inferior to the control in this randomized study.
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Affiliation(s)
| | - Minhee Won
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania, USA
| | - Patrick Y Wen
- Dana-Farber/Harvard Cancer Center, Boston, Massachusetts, USA
| | - Amyn M Rojiani
- Augusta University-Medical College of Georgia, Augusta, Georgia, USA
| | | | - Helen A Shih
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lynn S Ashby
- Barrow Neurological Institute accruals under Arizona Oncology Services Foundation, Phoenix, Arizona, USA
| | | | - Volker W Stieber
- Novant Health Forsyth Regional Cancer Center accruals under Southeast Cancer Control Consortium, Inc, CCOP, Goldsboro, North Carolina, USA
| | - Shawn C Malone
- The Ottawa Hospital Regional Cancer Centre, Ottawa, Ontario, Canada
| | - John B Fiveash
- University of Alabama at Birmingham Medical Center, Birmingham, Alabama, USA
| | | | | | | | - Philip J Stella
- Saint Joseph Mercy Hospital accruals under Michigan Cancer Research Consortium CCOP, Ypsilanti, Michigan, USA
| | - Andrew Y Kee
- Legacy Health Systems accruals under Mayo Clinic, Portland, Oregon, USA
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94
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Camidge DR, Lee EQ, Lin NU, Margolin K, Ahluwalia MS, Bendszus M, Chang SM, Dancey J, de Vries EGE, Harris GJ, Hodi FS, Lassman AB, Macdonald DR, Peereboom DM, Schiff D, Soffietti R, van den Bent MJ, Wefel JS, Wen PY. Clinical trial design for systemic agents in patients with brain metastases from solid tumours: a guideline by the Response Assessment in Neuro-Oncology Brain Metastases working group. Lancet Oncol 2018; 19:e20-e32. [PMID: 29304358 DOI: 10.1016/s1470-2045(17)30693-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/24/2017] [Accepted: 08/22/2017] [Indexed: 12/30/2022]
Abstract
Patients with active CNS disease are often excluded from clinical trials, and data regarding the CNS efficacy of systemic agents are usually obtained late in the drug development process or not at all. In this guideline from the Response Assessment in Neuro-Oncology Brain Metastases (RANO-BM) working group, we provide detailed recommendations on when patients with brain metastases from solid tumours should be included or excluded in clinical trials of systemic agents. We also discuss the limitations of retrospective studies in determining the CNS efficacy of systemic drugs. Inclusion of patients with brain metastases early on in the clinical development of a drug or a regimen is needed to generate appropriate CNS efficacy or non-efficacy signals. We consider how to optimally incorporate or exclude such patients in systemic therapy trials depending on the likelihood of CNS activity of the agent by considering three scenarios: drugs that are considered very unlikely to have CNS antitumour activity or efficacy; drugs that are considered very likely to have CNS activity or efficacy; and drugs with minimal baseline information on CNS activity or efficacy. We also address trial design issues unique to patients with brain metastases, including the selection of appropriate CNS endpoints in systemic therapy trials.
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Affiliation(s)
- D Ross Camidge
- Anschutz Medical Campus, University of Colorado, Aurora, CO, USA.
| | - Eudocia Q Lee
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Kim Margolin
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Manmeet S Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Solid Tumor Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Susan M Chang
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Janet Dancey
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | - Elisabeth G E de Vries
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Netherlands
| | - Gordon J Harris
- Department of Radiology, 3D Imaging Lab, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - F Stephen Hodi
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA; Department of Medicine, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Andrew B Lassman
- Department of Neurology and Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, Columbia University, NY, USA
| | - David R Macdonald
- Department of Oncology and Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - David M Peereboom
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Solid Tumor Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - David Schiff
- Division of Neuro-Oncology, University of Virginia, Charlottesville, VA, USA
| | - Ricardo Soffietti
- Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy
| | | | - Jeffrey S Wefel
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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95
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Abstract
Brain metastases are the most common malignancy encountered in the central nervous system (CNS), with up to 30-40% of cancer patients developing brain metastases at some point during the course of their disease. The management of brain metastasis is rapidly evolving and the roles of local therapies such as whole-brain radiation therapy, stereotactic radiosurgery, and resection along with systemic therapies are in flux. An emphasis on the neurocognitive side effects associated with treatment has gained prominence. Novel molecular studies have demonstrated important evolutionary patterns underpinning the development of brain metastasis and leptomeningeal disease, which may be key to unlocking new therapeutic strategies. This article provides a framework for incorporating the results of recent randomized radiotherapy clinical trials into practice, expounds upon the emphasis on cognition being an important driver in therapeutic selection, describes the importance of CNS-penetrating systemic therapies, and provides an overview of the novel molecular insights that will likely set the stage for future developments in this field.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville, Warrenville, IL, USA
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Manmeet S Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Priscilla K Brastianos
- Divisions of Hematology/Oncology and Neuro-Oncology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
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96
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Alban TJ, Alvarado AG, Sorensen MD, Bayik D, Volovetz J, Serbinowski E, Mulkearns-Hubert EE, Sinyuk M, Hale JS, Onzi GR, McGraw M, Huang P, Grabowski MM, Wathen CA, Ahluwalia MS, Radivoyevitch T, Kornblum HI, Kristensen BW, Vogelbaum MA, Lathia JD. Global immune fingerprinting in glioblastoma patient peripheral blood reveals immune-suppression signatures associated with prognosis. JCI Insight 2018; 3:122264. [PMID: 30385717 DOI: 10.1172/jci.insight.122264] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 10/02/2018] [Indexed: 12/17/2022] Open
Abstract
Glioblastoma (GBM) remains uniformly lethal, and despite a large accumulation of immune cells in the microenvironment, there is limited antitumor immune response. To overcome these challenges, a comprehensive understanding of GBM systemic immune response during disease progression is required. Here, we integrated multiparameter flow cytometry and mass cytometry TOF (CyTOF) analysis of patient blood to determine changes in the immune system among tumor types and over disease progression. Utilizing flow cytometry analysis in a cohort of 259 patients ranging from benign to malignant primary and metastatic brain tumors, we found that GBM patients had a significant elevation in myeloid-derived suppressor cells (MDSCs) in peripheral blood but not immunosuppressive Tregs. In GBM patient tissue, we found that increased MDSC levels in recurrent GBM portended poor prognosis. CyTOF analysis of peripheral blood from newly diagnosed GBM patients revealed that reduced MDSCs over time were accompanied by a concomitant increase in DCs. GBM patients with extended survival also had reduced MDSCs, similar to the levels of low-grade glioma (LGG) patients. Our findings provide a rationale for developing strategies to target MDSCs, which are elevated in GBM patients and predict poor prognosis.
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Affiliation(s)
- Tyler J Alban
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case, Western Reserve University, Cleveland, Ohio, USA
| | - Alvaro G Alvarado
- Department of Psychiatry and Biobehavioral Sciences and Semel Institute for Neuroscience, UCLA, USA
| | - Mia D Sorensen
- Department of Pathology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Defne Bayik
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Josephine Volovetz
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case, Western Reserve University, Cleveland, Ohio, USA
| | - Emily Serbinowski
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erin E Mulkearns-Hubert
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Maksim Sinyuk
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - James S Hale
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Giovana R Onzi
- Department of Psychiatry and Biobehavioral Sciences and Semel Institute for Neuroscience, UCLA, USA.,Department of Biophysics and Center of Biotechnology, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS-Brazil
| | - Mary McGraw
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and
| | - Pengjing Huang
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and
| | - Matthew M Grabowski
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and.,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Connor A Wathen
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case, Western Reserve University, Cleveland, Ohio, USA.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and
| | - Manmeet S Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and.,Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Tomas Radivoyevitch
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Harley I Kornblum
- Department of Psychiatry and Biobehavioral Sciences and Semel Institute for Neuroscience, UCLA, USA
| | - Bjarne W Kristensen
- Department of Pathology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Michael A Vogelbaum
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case, Western Reserve University, Cleveland, Ohio, USA.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and.,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA.,Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Justin D Lathia
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case, Western Reserve University, Cleveland, Ohio, USA.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and.,Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
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97
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Blakeley JO, Grossman SA, Chi AS, Mikkelsen T, Rosenfeld MR, Ahluwalia MS, Nabors LB, Eichler A, Ribas IG, Desideri S, Ye X. Phase II Study of Iniparib with Concurrent Chemoradiation in Patients with Newly Diagnosed Glioblastoma. Clin Cancer Res 2018; 25:73-79. [PMID: 30131387 DOI: 10.1158/1078-0432.ccr-18-0110] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/04/2018] [Accepted: 08/16/2018] [Indexed: 12/24/2022]
Abstract
PURPOSE Iniparib is a purported prodrug causing cell death through intracellular conversion to nitro radical ions. We assessed the efficacy and safety of iniparib with standard radiotherapy and temozolomide in patients with newly diagnosed glioblastoma (GBM). PATIENTS AND METHODS Adults meeting eligibility criteria were enrolled in this prospective, single-arm, open-label multi- institution phase II trial with median overall survival (mOS) compared with a historical control as the primary objective. A safety run-in component of radiotherapy + temozolomide + iniparib (n = 5) was followed by an efficacy study (n = 76) with the recommended phase II doses of iniparib (8.0 mg/kg i.v. twice/week with radiotherapy + daily temozolomide followed by 8.6 mg/kg i.v. twice/week with 5/28-day temozolomide). RESULTS The median age of the 81 evaluable participants was 58 years (63% male). Baseline KPS was ≥ 80% in 87% of participants. The mOS was 22 months [95% confidence interval (CI), 17-24] and the HR was 0.44 (95% CI, 0.35-0.55) per-person-year of follow-up. The 2- and 3-year survival rates were 38% and 25%, respectively. Treatment-related grade 3 adverse events (AEs) occurred in 27% of patients; 9 patients had AEs requiring drug discontinuation including infusion-related reaction, rash, gastritis, increased liver enzymes, and thrombocytopenia. CONCLUSIONS Iniparib is well tolerated with radiotherapy and temozolomide in patients with newly diagnosed GBM at up to 17.2 mg/kg weekly. The primary objective of improved mOS compared with a historical control was met, indicating potential antitumor activity of iniparib in this setting. Dosing optimization (frequency and sequence) is needed prior to additional efficacy studies.
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Affiliation(s)
- Jaishri O Blakeley
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland. .,Department of Oncology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stuart A Grossman
- Department of Oncology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew S Chi
- Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, New York, New York
| | | | - Myrna R Rosenfeld
- Institute for Biomedical Research (IDIBAPS)/Hospital Clinic, Barcelona, Spain
| | | | - L Burt Nabors
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
| | - April Eichler
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Serena Desideri
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xiaobu Ye
- Department of Oncology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Abstract
PURPOSE OF THE REVIEW Brain metastasis is a common complication of advanced malignancies, especially, lung cancer, breast cancer, renal cell carcinoma, and melanoma. Traditionally surgery, when indicated, and radiation therapy, either as whole-brain radiation therapy or stereotactic radiosurgery, constituted the major treatment options for brain metastases. Until recently, most of the systemic chemotherapy agents had limited activity for brain metastases. However, with the advent of small molecule tyrosine kinase inhibitors and immunotherapy agents, there has been renewed interest in using these agents in the management of brain metastases. RECENT FINDINGS Immune checkpoint inhibitors have revolutionized the treatment of metastatic melanoma, lung cancer, kidney cancer, and bladder cancer among others. They modulate the immune system to recognize tumor antigens as "non-self" antigens and mount an immune response against them. Initial studies of using immune checkpoint inhibitors in brain metastases have shown promising activity, and several clinical trials are currently underway. Studies are also assessing the combination of radiation therapy and immunotherapy in brain metastases. The results of these ongoing clinical trials have the potential to change the therapeutic paradigm in patients with brain metastases.
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Affiliation(s)
- Adam Lauko
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, S73, Cleveland, OH, 44195, USA
| | - Bicky Thapa
- Fairview Hospital-Cleveland Clinic, Cleveland, OH, USA
| | | | - Manmeet S Ahluwalia
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, S73, Cleveland, OH, 44195, USA.
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Sharma M, Bellamkonda S, Mohapatra S, Meola A, Jia X, Mohammadi A, Angelov L, Barnett GH, Vogelbaum M, Ahluwalia MS. Correlation Between the Residual Tumor Volume, Extent of Tumor Resection, and O6-Methylguanine DNA Methyltransferase Status in Patients with Glioblastoma. World Neurosurg 2018; 116:e147-e161. [DOI: 10.1016/j.wneu.2018.04.134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 04/16/2018] [Accepted: 04/17/2018] [Indexed: 10/17/2022]
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100
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Kim JM, Kim JM, Miller JA, Kotecha R, Chao ST, Ahluwalia MS, Peereboom DM, Mohammadi AM, Barnett GH, Murphy ES, Vogelbaum MA, Angelov L, Abraham J, Moore HC, Budd GT, Suh JH. (OA13) Stereotactic Radiosurgery and Concurrent Targeted Therapy: Improving the Response Rate for Breast Cancer Brain Metastasis. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.02.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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