901
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Ahluwalia MS, Vogelbaum MV, Chao ST, Mehta MM. Brain metastasis and treatment. F1000PRIME REPORTS 2014; 6:114. [PMID: 25580268 PMCID: PMC4251415 DOI: 10.12703/p6-114] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Despite major therapeutic advances in the management of patients with systemic malignancies, management of brain metastases remains a significant challenge. These patients often require multidisciplinary care that includes surgical resection, radiation therapy, chemotherapy, and targeted therapies. Complex decisions about the sequencing of therapies to control extracranial and intracranial disease require input from neurosurgeons, radiation oncologists, and medical/neuro-oncologists. With advances in understanding of the biology of brain metastases, molecularly defined disease subsets and the advent of targeted therapy as well as immunotherapeutic agents offer promise. Future care of these patients will entail tailoring treatment based on host (performance status and age) and tumor (molecular cytogenetic characteristics, number of metastases, and extracranial disease status) factors. Considerable work involving preclinical models and better clinical trial designs that focus not only on effective control of tumor but also on quality of life and neurocognition needs to be done to improve the outcome of these patients.
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Affiliation(s)
- Manmeet S. Ahluwalia
- Burkhardt Brain Tumor Neuro-Oncology Center, Neurological InstituteCleveland Clinic, 9500 Euclid Avenue, Cleveland, OHUSA
| | - Michael V. Vogelbaum
- Burkhardt Brain Tumor Neuro-Oncology Center, Neurological InstituteCleveland Clinic, 9500 Euclid Avenue, Cleveland, OHUSA
| | - Samuel T. Chao
- Burkhardt Brain Tumor Neuro-Oncology Center, Neurological InstituteCleveland Clinic, 9500 Euclid Avenue, Cleveland, OHUSA
| | - Minesh M. Mehta
- Department of Radiation Oncology, University of Maryland School of MedicineBaltimore, MD 21201USA
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902
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Yamamoto M, Kawabe T, Higuchi Y, Sato Y, Nariai T, Watanabe S, Barfod BE, Kasuya H. Validity of Prognostic Grading Indices for Brain Metastasis Patients Undergoing Repeat Radiosurgery. World Neurosurg 2014; 82:1242-9. [DOI: 10.1016/j.wneu.2014.08.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Revised: 03/09/2014] [Accepted: 08/06/2014] [Indexed: 11/29/2022]
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903
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Neal MT, Chan MD, Lucas JT, Loganathan A, Dillingham C, Pan E, Stewart JH, Bourland JD, Shaw EG, Tatter SB, Ellis TL. Predictors of survival, neurologic death, local failure, and distant failure after gamma knife radiosurgery for melanoma brain metastases. World Neurosurg 2014; 82:1250-5. [PMID: 23402867 PMCID: PMC11177229 DOI: 10.1016/j.wneu.2013.02.025] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 12/16/2012] [Accepted: 02/05/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE This study sought to assess clinical outcomes in patients receiving gamma knife radiosurgery (GK) for treatment of brain metastases from melanoma and evaluate for potential predictive factors. METHODS We reviewed 188 GK procedures in 129 consecutive patients that were treated for brain metastases from melanoma. The population consisted of 84 males and 45 females with a median age of 57 years. Fifty-five patients (43%) had a single metastasis. Seventy-one patients (55%) received chemotherapy, 58 patients (45%) received biologic agents, and 36 patients (28%) received prior whole brain radiation therapy (WBRT). The median marginal dose was 18.8 Gy (range 12 to 24 Gy). RESULTS Actuarial survival was 52%, 26%, and 13% at 6, 12, and 24 months, respectively. The median survival time was 6.7 months. Local tumor control was 95%, 81% 53% at 6, 12, and 24 months, respectively. The median time to LBF was 25.2 months. Freedom from distant brain failure was 40%, 29%, and 10% at 6, 12, and 24 months, and the median time to DBF was 4.6 months. At the time of data analysis, 108 patients (84%) had died. Fifty-eight patients (52%) died from neurologic death. The median time to neurologic death from GK treatment was 7.9 months. Multivariate analysis revealed that hemorrhage of metastases prior to GK (P = .02) and LBF (P = .03) were the dominant predictors of neurologic death. CONCLUSIONS GK achieves excellent local control and may improve outcomes as a component of a multidisciplinary treatment strategy. Distant brain failure and neurologic demise remain problematic and prospective trials are necessary.
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Affiliation(s)
- Matthew T Neal
- Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA.
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - John T Lucas
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Amritraj Loganathan
- Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Christine Dillingham
- Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Edward Pan
- Department of Neurology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - John H Stewart
- Tumor Immunotherapy Program, Wake Forest University, Winston-Salem, North Carolina, USA
| | - J Daniel Bourland
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Edward G Shaw
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Thomas L Ellis
- Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
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904
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Jiang T, Zhou C. [Research progress of targeted therapy in non-small cell lung cancer brain metastases]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2014; 17:824-8. [PMID: 25404274 PMCID: PMC6000351 DOI: 10.3779/j.issn.1009-3419.2014.11.09] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Lung cancer is characterized by the highest incidence of solid tumor-related brain metastases, which are reported the incidence ranged 20% to 65%. This is also one of the reasons why it can cause significant mortality. Molecular targeted therapy plays a major role in the management of brain metastases in lung cancer. Targeted agents have become the novel methods for the treatment of lung cancer with brain metastases beyond the whole brain radiation therapy, stereotactic radiosurgery and chemotherapy. Recently, more and more studies and trials laid emphasis on the targeted agents for non-small cell lung cancer (NSCLC) brain metastases treatment. The key point is the efficacy and safety. In this paper, the targeted treatments of NSCLC brain metastases were summarized.
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Affiliation(s)
- Tao Jiang
- Deportment of Oncology, Shanghai Pulmonary Hospital, Shanghai 200065, China
| | - Caicun Zhou
- Deportment of Oncology, Shanghai Pulmonary Hospital, Shanghai 200065, China
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905
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Berghoff AS, Ricken G, Widhalm G, Rajky O, Dieckmann K, Birner P, Bartsch R, Höller C, Preusser M. Tumour-infiltrating lymphocytes and expression of programmed death ligand 1 (PD-L1) in melanoma brain metastases. Histopathology 2014; 66:289-99. [DOI: 10.1111/his.12537] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 08/22/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Anna Sophie Berghoff
- Department of Medicine I; Medical University of Vienna; Vienna Austria
- Comprehensive Cancer Center; Medical University of Vienna; Vienna Austria
| | - Gerda Ricken
- Comprehensive Cancer Center; Medical University of Vienna; Vienna Austria
- Institute of Neurology; Medical University of Vienna; Vienna Austria
| | - Georg Widhalm
- Comprehensive Cancer Center; Medical University of Vienna; Vienna Austria
- Department of Neurosurgery; Medical University of Vienna; Vienna Austria
| | - Orsolya Rajky
- Department of Medicine I; Medical University of Vienna; Vienna Austria
- Comprehensive Cancer Center; Medical University of Vienna; Vienna Austria
| | - Karin Dieckmann
- Comprehensive Cancer Center; Medical University of Vienna; Vienna Austria
- Department of Radiotherapy; Medical University of Vienna; Vienna Austria
| | - Peter Birner
- Comprehensive Cancer Center; Medical University of Vienna; Vienna Austria
- Institute of Clinical Pathology; Medical University of Vienna; Vienna Austria
| | - Rupert Bartsch
- Department of Medicine I; Medical University of Vienna; Vienna Austria
- Comprehensive Cancer Center; Medical University of Vienna; Vienna Austria
| | - Christoph Höller
- Department of Dermatology; Medical University of Vienna; Vienna Austria
| | - Matthias Preusser
- Department of Medicine I; Medical University of Vienna; Vienna Austria
- Comprehensive Cancer Center; Medical University of Vienna; Vienna Austria
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906
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907
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Sperduto PW, Shanley R, Luo X, Andrews D, Werner-Wasik M, Valicenti R, Bahary JP, Souhami L, Won M, Mehta M. Secondary analysis of RTOG 9508, a phase 3 randomized trial of whole-brain radiation therapy versus WBRT plus stereotactic radiosurgery in patients with 1-3 brain metastases; poststratified by the graded prognostic assessment (GPA). Int J Radiat Oncol Biol Phys 2014; 90:526-31. [PMID: 25304947 PMCID: PMC4700538 DOI: 10.1016/j.ijrobp.2014.07.002] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 06/27/2014] [Accepted: 07/03/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE Radiation Therapy Oncology Group (RTOG) 9508 showed a survival advantage for patients with 1 but not 2 or 3 brain metastasis (BM) treated with whole-brain radiation therapy (WBRT) and stereotactic radiosurgery (SRS) versus WBRT alone. An improved prognostic index, the graded prognostic assessment (GPA) has been developed. Our hypothesis was that if the data from RTOG 9508 were poststratified by the GPA, the conclusions may vary. METHODS AND MATERIALS In this analysis, 252 of the 331 patients were evaluable by GPA. Of those, 211 had lung cancer. Breast cancer patients were excluded because the components of the breast GPA are not in the RTOG database. Multiple Cox regression was used to compare survival between treatment groups, adjusting for GPA. Treatment comparisons within subgroups were performed with the log-rank test. A free online tool (brainmetgpa.com) simplified GPA use. RESULTS The fundamental conclusions of the primary analysis were confirmed in that there was no survival benefit overall for patients with 1 to 3 metastases; however, there was a benefit for the subset of patients with GPA 3.5 to 4.0 (median survival time [MST] for WBRT + SRS vs WBRT alone was 21.0 versus 10.3 months, P=.05) regardless of the number of metastases. Among patients with GPA 3.5 to 4.0 treated with WBRT and SRS, the MST for patients with 1 versus 2 to 3 metastases was 21 and 14.1 months, respectively. CONCLUSIONS This secondary analysis of predominantly lung cancer patients, consistent with the original analysis, shows no survival advantage for the group overall when treated with WBRT and SRS; however, in patients with high GPA (3.5-4), there is a survival advantage regardless of whether they have 1, 2, or 3 BM. This benefit did not extend to patients with lower GPA. Prospective validation of this survival benefit for patients with multiple BM and high GPA when treated with WBRT and SRS is warranted.
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Affiliation(s)
- Paul W Sperduto
- Metro-Minnesota CCOP and Minneapolis Radiation Oncology, Minneapolis, Minnesota.
| | - Ryan Shanley
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Xianghua Luo
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota; Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - David Andrews
- Thomas Jefferson University, Department of NeuroOncology, Philadelphia, Pennsylvania
| | - Maria Werner-Wasik
- Thomas Jefferson University, Department of Radiation Oncology, Philadelphia, Pennsylvania
| | - Richard Valicenti
- UC Davis Medical Center, Department of Radiation Oncology, Sacramento, California
| | | | | | - Minhee Won
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Minesh Mehta
- University of Maryland Medical System, Baltimore, Maryland
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908
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Whole brain radiotherapy plus concurrent chemotherapy in non-small cell lung cancer patients with brain metastases: a meta-analysis. PLoS One 2014; 9:e111475. [PMID: 25347291 PMCID: PMC4210217 DOI: 10.1371/journal.pone.0111475] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 10/01/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of the present meta-analysis is to evaluate the response rate, median survival time (MST) and toxicity in patients with brain metastases (BM) originating from non-small cell lung cancer (NSCLC) and who were treated using either whole brain radiotherapy (WBRT) plus concurrent chemotherapy or WBRT alone. METHODS PubMed, EMBASE, Web of Science, The Cochrane Library, clinical trials and current controlled trials were searched to identify any relevant publications. After screening the literature and undertaking quality assessment and data extraction, the meta-analysis was performed using Stata11.0 software. RESULTS In total, six randomized controlled trials (RCT) involving 910 participants were included in the meta-analysis. The results of the analysis indicate that WBRT plus concurrent chemotherapy was more effective at improving response rate (RR = 2.06, 95% CI [1.13, 3.77]; P = 0.019) than WBRT alone. However, WBRT plus concurrent chemotherapy did not improve median survival time (MST) (HR = 1.09, 95%CI [0.94, 1.26]; P = 0.233) or time of neurological progression (CNS-TTP) (HR = 0.93, 95%CI [0.75, 1.16]; P = 0.543), and increased adverse events (Grade≥3) (RR = 2.59, 95% CI [1.88, 3.58]; P = 0.000). There were no significant differences in Grade 3-5 neurological or hematological toxicity between two patient groups (RR = 1.08, 95%CI [0.23, 5.1]; P = 0.92). CONCLUSION The combination of chemotherapy plus WBRT in patients with BM originating from NSCLC may increase treatment response rates of brain metastases with limited toxicity. Although the therapy schedule did not prolong MST or CNS-TTP, further assessment is warranted.
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909
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Kirkpatrick JP, Wang Z, Sampson JH, McSherry F, Herndon JE, Allen KJ, Duffy E, Hoang JK, Chang Z, Yoo DS, Kelsey CR, Yin FF. Defining the optimal planning target volume in image-guided stereotactic radiosurgery of brain metastases: results of a randomized trial. Int J Radiat Oncol Biol Phys 2014; 91:100-8. [PMID: 25442342 DOI: 10.1016/j.ijrobp.2014.09.004] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 08/27/2014] [Accepted: 09/02/2014] [Indexed: 11/15/2022]
Abstract
PURPOSE To identify an optimal margin about the gross target volume (GTV) for stereotactic radiosurgery (SRS) of brain metastases, minimizing toxicity and local recurrence. METHODS AND MATERIALS Adult patients with 1 to 3 brain metastases less than 4 cm in greatest dimension, no previous brain radiation therapy, and Karnofsky performance status (KPS) above 70 were eligible for this institutional review board-approved trial. Individual lesions were randomized to 1- or 3- mm uniform expansion of the GTV defined on contrast-enhanced magnetic resonance imaging (MRI). The resulting planning target volume (PTV) was treated to 24, 18, or 15 Gy marginal dose for maximum PTV diameters less than 2, 2 to 2.9, and 3 to 3.9 cm, respectively, using a linear accelerator-based image-guided system. The primary endpoint was local recurrence (LR). Secondary endpoints included neurocognition Mini-Mental State Examination, Trail Making Test Parts A and B, quality of life (Functional Assessment of Cancer Therapy-Brain), radionecrosis (RN), need for salvage radiation therapy, distant failure (DF) in the brain, and overall survival (OS). RESULTS Between February 2010 and November 2012, 49 patients with 80 brain metastases were treated. The median age was 61 years, the median KPS was 90, and the predominant histologies were non-small cell lung cancer (25 patients) and melanoma (8). Fifty-five, 19, and 6 lesions were treated to 24, 18, and 15 Gy, respectively. The PTV/GTV ratio, volume receiving 12 Gy or more, and minimum dose to PTV were significantly higher in the 3-mm group (all P<.01), and GTV was similar (P=.76). At a median follow-up time of 32.2 months, 11 patients were alive, with median OS 10.6 months. LR was observed in only 3 lesions (2 in the 1 mm group, P=.51), with 6.7% LR 12 months after SRS. Biopsy-proven RN alone was observed in 6 lesions (5 in the 3-mm group, P=.10). The 12-month DF rate was 45.7%. Three months after SRS, no significant change in neurocognition or quality of life was observed. CONCLUSIONS SRS was well tolerated, with low rates of LR and RN in both cohorts. However, given the higher potential risk of RN with a 3-mm margin, a 1-mm GTV expansion is more appropriate.
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Affiliation(s)
- John P Kirkpatrick
- Department of Radiation Oncology, Duke University, Durham, North Carolina; Department of Surgery, Duke University, Durham, North Carolina.
| | - Zhiheng Wang
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - John H Sampson
- Department of Radiation Oncology, Duke University, Durham, North Carolina; Department of Surgery, Duke University, Durham, North Carolina
| | - Frances McSherry
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina
| | - James E Herndon
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina
| | - Karen J Allen
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Eileen Duffy
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Jenny K Hoang
- Department of Radiology, Duke University, Durham, North Carolina
| | - Zheng Chang
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - David S Yoo
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Fang-Fang Yin
- Department of Radiation Oncology, Duke University, Durham, North Carolina
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910
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Abstract
Brain metastases are less common than bone or visceral metastases in patients with breast cancer. The overall prognosis of breast cancer patients with brain metastases remains poor, and these metastases are less responsive to systemic therapies. Brain metastasis is associated with a reduced quality of life due to progressive neurologic impairments. Recently, a trend of increased incidence of brain metastases in breast cancer has been noted. Reasons for this increased incidence include the more frequent use of sensitive detection methods such as contrast-enhanced magnetic resonance imaging and increased awareness of brain metastasis among patients and clinicians. Adjuvant and systemic therapy with drugs that have a low blood-brain barrier penetrance can lead to an increased risk of brain metastases in breast cancer patients. Molecular subtype is a predictive factor for overall survival after developing brain metastases. Patients who do not have a poor prognosis based on previously identified prognostic factors should be treated with radiation therapy to control symptoms. Whole-brain radiation therapy, stereotactic irradiation and surgery are tools for the local treatment of brain metastases. Novel molecular target therapy, including HER2-targeted therapy, has demonstrated an antitumor effect on brain metastases. In this review, we provide a practical algorithm for the treatment of breast cancer brain metastases. This review provides an overview of the incidence, risk factors, diagnosis, prognostic factors and current and potential future management strategies of breast cancer brain metastases.
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Affiliation(s)
- Naoki Niikura
- Department of Target Therapy Oncology, Kyoto University Graduate School of Medicine, Kyoto Departments of Breast and Endocrine Surgery, Tokai University School of Medicine, Kanagawa
| | - Shigehira Saji
- Department of Target Therapy Oncology, Kyoto University Graduate School of Medicine, Kyoto Department of Medical Oncology, Fukushima Medical University, Fukushima
| | - Yutaka Tokuda
- Departments of Breast and Endocrine Surgery, Tokai University School of Medicine, Kanagawa
| | - Hiroji Iwata
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Japan
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911
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Lee DW, Shin DY, Kim JW, Keam B, Kim TM, Kim HJ, Kim DW, Wu HG, Paek SH, Kim YW, Heo DS, Kim DG, Lee SH. Additional prognostic role of EGFR activating mutations in lung adenocarcinoma patients with brain metastasis: integrating with lung specific GPA score. Lung Cancer 2014; 86:363-8. [PMID: 25453849 DOI: 10.1016/j.lungcan.2014.10.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 09/23/2014] [Accepted: 10/05/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE While several prognostic models have been presented in NSCLC patients with brain metastasis, none of these models have included molecular markers as an index. The aim of our study was to evaluate the prognostic value of EGFR mutations and to integrate these EGFR mutations into the prognostic index in NSCLC patients with brain metastasis. MATERIALS AND METHODS We analyzed retrospectively 292 lung adenocarcinoma patients with brain metastasis. Clinico-pathological features and overall survival (OS) were compared between patients with EGFR mutations and patients with EGFR wild type. EGFR mutation status was integrated with lung specific graded prognostic assessment (GPA) score. RESULTS Among 292 patients, EGFR mutation status was tested in 183 patients. One hundred and five patients (57.4%) had EGFR activating mutations, 14 (7.7%) had EGFR non-activating mutations and 64 (35.0%) had EGFR wild type. OS was significantly longer in patients with EGFR activating mutations than in those with EGFR wild type patients (20.4 vs. 10.1 months, p = 0.002). However, patients with EGFR non-activating mutations did not show superior OS compared with EGFR wild type patients (14.6 vs. 10.1 months, p = 0.83). Multivariate analysis revealed that the presence of EGFR activating mutation is an independent positive prognostic factor for OS (adjusted hazard ratio 0.56, p = 0.002). CONCLUSIONS EGFR activating mutations have a prognostic role in lung adenocarcinoma patients with brain metastasis that is independent of other known prognostic factors. The frequency of EGFR mutation was higher than expected. The presence of EGFR activating mutations should be included as an index in the prognostic models for lung adenocarcinoma patients with brain metastasis.
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Affiliation(s)
- Dae-Won Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Jin Wook Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Bhumsuk Keam
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Tae Min Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hak Jae Kim
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea
| | - Dong-Wan Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hong-Gyun Wu
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea
| | - Sun Ha Paek
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Young Whan Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dae Seog Heo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Gyu Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Se-Hoon Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea.
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912
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Abstract
For nearly 100 years, palliative radiotherapy has been a time-efficient, effective treatment for patients with metastatic or advanced cancer in any area where local tumors are causing symptoms. Short courses including a single fraction of radiotherapy may be effective for symptom relief with minimal side effects and maximization of convenience for patient and family. With recent advances in imaging, surgery, and other local therapies as well as systemic cancer therapies, palliative radiotherapy has been used frequently in patients who may not yet have symptoms of advanced or metastatic cancer. In this setting, more prolonged radiotherapy courses and advanced radiotherapy techniques including intensity-modulated radiotherapy (IMRT) or stereotactic radiotherapy (SRT) may be useful in obtaining local control and durable palliative responses. This review will explore the use of radiotherapy across the spectrum of patients with advanced and metastatic cancer and delineate an updated, rational approach for the use of palliative radiotherapy that incorporates symptoms, prognosis, and other factors into the delivery of palliative radiotherapy.
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Affiliation(s)
- Sonam Sharma
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Lauren Hertan
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Joshua Jones
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA.
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913
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Sia J, Paul E, Dally M, Ruben J. Stereotactic radiosurgery for 318 brain metastases in a single Australian centre: the impact of histology and other factors. J Clin Neurosci 2014; 22:303-7. [PMID: 25304434 DOI: 10.1016/j.jocn.2014.07.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 07/10/2014] [Accepted: 07/15/2014] [Indexed: 10/24/2022]
Abstract
While melanoma brain metastases (BM) are consistently associated with worse survival compared to other histologies, whether they correlate with worse local control (LC) following stereotactic radiosurgery (SRS) is not yet well-defined. In this study of prospectively and retrospectively collected data we investigated the impact of histology and other host, tumour and treatment factors on overall survival (OS) and LC. We analysed 162 patients and 318 BM lesions from various histologies treated with SRS between 2005 and 2011. We included patients who received SRS as first-line treatment, as well as patients who received SRS for residual or recurrent BM following prior surgery, whole brain radiotherapy (WBRT) or both. Median OS for the entire cohort was 8.4 months. Median OS for tumour histologies of melanoma, lung and breast cancer were 5.1, 12.2, and 14.7 months, respectively. On multivariate analysis, melanoma predicted for worse OS (hazard ratio [HR] 1.515, p = 0.003) together with performance status (HR 1.662, p < 0.001) and uncontrolled systemic disease (HR 1.755, p = 0.003). Melanoma histology was also negatively predictive for LC (HR 1.828, p = 0.021) together with increasing tumour size (HR 1.038, p = 0.017). Other factors, including the use of WBRT with SRS, the use of planning treatment volume margins, and prescription dose were not significantly predictive for OS and LC. We conclude melanoma histology also portends poorer LC in the SRS setting. While survival depends significantly on the systemic behaviour of the disease, treatment refinements to reduce local failure still merit exploration, especially in the era of targeted therapies.
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Affiliation(s)
- Joseph Sia
- William Buckland Radiotherapy Centre Melbourne, South Block, The Alfred, 55 Commercial Road, Melbourne, VIC 3004, Australia.
| | - Eldho Paul
- Department of Epidemiology and Preventative Medicine, Monash University, The Alfred Centre (Alfred Hospital), Melbourne, VIC, Australia
| | - Michael Dally
- William Buckland Radiotherapy Centre Melbourne, South Block, The Alfred, 55 Commercial Road, Melbourne, VIC 3004, Australia; Department of Surgery, Monash University, The Alfred Centre (Alfred Hospital), Melbourne, VIC, Australia
| | - Jeremy Ruben
- William Buckland Radiotherapy Centre Melbourne, South Block, The Alfred, 55 Commercial Road, Melbourne, VIC 3004, Australia; Department of Surgery, Monash University, The Alfred Centre (Alfred Hospital), Melbourne, VIC, Australia
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914
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Lukas RV, Gabikian P, Garza M, Chmura SJ. Treatment of brain metastases. Oncology 2014; 87:321-9. [PMID: 25227433 DOI: 10.1159/000362389] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 03/18/2014] [Indexed: 11/19/2022]
Abstract
Brain metastases are associated with substantial morbidity and mortality. Key prognostic classification systems for brain metastases are reviewed. The role of surgery, particularly for single brain metastases, is discussed. This is followed by an overview of radiation, both whole brain and focal, in the treatment of brain metastases. Finally, we review examples of important concepts regarding the role of systemic therapy in the treatment of brain metastases.
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Affiliation(s)
- Rimas V Lukas
- Department of Neurology,University of Chicago, Chicago, Ill., USA
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915
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Jones JA, Lutz ST, Chow E, Johnstone PA. Palliative radiotherapy at the end of life: a critical review. CA Cancer J Clin 2014; 64:296-310. [PMID: 25043971 DOI: 10.3322/caac.21242] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 06/10/2014] [Accepted: 06/10/2014] [Indexed: 12/25/2022] Open
Abstract
When delivered with palliative intent, radiotherapy can help to alleviate a multitude of symptoms related to advanced cancer. In general, time to symptom relief is measured in weeks to months after the completion of radiotherapy. Over the past several years, an increasing number of studies have explored rates of radiotherapy use in the final months of life and have found variable rates of radiotherapy use. The optimal rate is unclear, but would incorporate anticipated efficacy in patients whose survival allows it and minimize overuse among patients with expected short survival. Clinician prediction has been shown to overestimate the length of survival in repeated studies. Prognostic indices can provide assistance with estimations of survival length and may help to guide treatment decisions regarding palliative radiotherapy in patients with potentially short survival times. This review explores the recent studies of radiotherapy near the end of life, examines general prognostic models for patients with advanced cancer, describes specific clinical circumstances when radiotherapy may and may not be beneficial, and addresses open questions for future research to help clarify when palliative radiotherapy may be effective near the end of life.
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Affiliation(s)
- Joshua A Jones
- Assistant Professor, Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
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916
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Kuba S, Ishida M, Nakamura Y, Yamanouchi K, Minami S, Taguchi K, Eguchi S, Ohno S. Treatment and prognosis of breast cancer patients with brain metastases according to intrinsic subtype. Jpn J Clin Oncol 2014; 44:1025-31. [PMID: 25156682 DOI: 10.1093/jjco/hyu126] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE How breast cancer subtypes should affect treatment decisions for breast cancer patients with brain metastases is unclear. We analyzed local brain metastases treatments and their outcomes according to subtype in patients with breast cancer and brain metastases. METHODS We reviewed records and database information for women treated at the National Kyushu Cancer Center between 2001 and 2010. Patients were divided into three breast cancer subtype groups: Luminal (estrogen receptor positive and/or progesterone receptor positive, but human epidermal growth factor receptor 2 negative); human epidermal growth factor receptor 2 positive and triple negative (estrogen receptor negative, progesterone receptor negative and human epidermal growth factor receptor 2 negative). RESULTS Of 524 advanced breast cancer patients, we reviewed 65 (12%) with brain metastases and records showing estrogen receptor, progesterone receptor and human epidermal growth factor receptor 2 status, as well as outcome data; there were 26 (40%) Luminal, 26 (40%) had human epidermal growth factor receptor 2 and 13 (20%) had triple negative subtypes. There was no statistical difference in the number of brain metastases among subtypes; however, rates of stereotactic radiosurgery or surgery for brain metastases differed significantly by subtype (human epidermal growth factor receptor 2: 81%, Luminal: 42% and triple negative: 47%; P = 0.03). Patients having the human epidermal growth factor receptor 2 subtype, a performance status of ≤1 and ≤4 brain metastases, who underwent systemic therapy after brain metastases and underwent stereotactic radiosurgery or surgery, were predicted to have longer overall survival after brain metastases. Multivariate analysis demonstrated that not having systemic therapy and not having the human epidermal growth factor receptor 2 subtype were independent factors associated with an increased risk of death (hazard ratio 2.4, 95% confidence interval 1.01-5.6; P = 0.05 and hazard ratio 2.9, 95% confidence interval 1.5-5.8; P = 0.003, respectively). CONCLUSION Our study showed that local brain treatments and prognosis differed by subtype in breast cancer patients with brain metastases.
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Affiliation(s)
- Sayaka Kuba
- Department of Breast Oncology, National Hospital Organization, Kyushu Cancer Center, Fukuoka Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki
| | - Mayumi Ishida
- Department of Breast Oncology, National Hospital Organization, Kyushu Cancer Center, Fukuoka
| | - Yoshiaki Nakamura
- Department of Breast Oncology, National Hospital Organization, Kyushu Cancer Center, Fukuoka
| | - Kosho Yamanouchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki
| | - Shigeki Minami
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki
| | - Kenichi Taguchi
- Department of Pathology, National Hospital Organization, Kyushu Cancer Center, Fukuoka, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki
| | - Shinji Ohno
- Department of Breast Oncology, National Hospital Organization, Kyushu Cancer Center, Fukuoka
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917
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Berghoff AS, Kovanda AK, Melchardt T, Bartsch R, Hainfellner JA, Sipos B, Schittenhelm J, Zielinski CC, Widhalm G, Dieckmann K, Weller M, Goodman SL, Birner P, Preusser M. αvβ3, αvβ5 and αvβ6 integrins in brain metastases of lung cancer. Clin Exp Metastasis 2014; 31:841-51. [PMID: 25150423 DOI: 10.1007/s10585-014-9675-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 08/13/2014] [Indexed: 11/26/2022]
Abstract
Integrins are transmembranous adhesion molecules postulated to be involved in the brain metastatic cascade. We investigated the correlation of alpha v beta 3 (αvβ3), alpha v beta 5 (αvβ5) and alpha v beta 6 (αvβ6) integrin isoform expression with clinical characteristics including survival times in lung cancer patients with brain metastases (BM). All BM from lung cancer operated at our institution between 1990 and 2011, were identified; where available, primary tumors were retrieved as well. Immunohistochemical analysis for αvβ3, αvβ5 and αvβ6 integrin subunits was performed and correlated with Ki67 and hypoxia-inducible factor (HIF)-1α indexes. Clinical data including survival data were obtained by chart review. 191 BM specimens of 191 patients with histologically confirmed lung cancer (172 non-small cell lung cancer and 19 small cell lung cancer) were included. In 18 patients matched primary tumor samples were available. αvβ6 expression was commonly found on BM tumor cells (103/191; 53.9 %) and showed a significant association with low Ki67 proliferation indices (46 vs. 36 %, p = 0.001, Mann-Whitney U test) and favorable survival times (p = 0.020; log rank test) in patients with non-squamous NSCLC BM. αvβ5 expression was highly expressed on vascular structures (167/191; 87.4 %) and tumor stroma in BM (151/191; 79.1 %) and associated with high HIF-1α indices (60 vs. 90, p = 0.007, Mann-Whitney U test). αvβ3 expression was more frequently found on vascular structures in BM than in primary tumors (68.1 vs. 5.6 %; p = 0.645; Chi square test) and its expression in BM tumor cells correlated with low Ki67 indices (41 vs. 28 %; p = 0.046, Mann-Whitney U test). Expression of αv integrin subunits seem to be of pathobiological and clinical relevance in patients with NSCLC BM. Further investigations of their involvement in the brain metastatic cascade and their role as biomarkers are warranted.
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918
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Lutz ST, Jones J, Chow E. Role of radiation therapy in palliative care of the patient with cancer. J Clin Oncol 2014; 32:2913-9. [PMID: 25113773 DOI: 10.1200/jco.2014.55.1143] [Citation(s) in RCA: 136] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Radiotherapy is a successful, time-efficient, well-tolerated, and cost-effective intervention that is crucial for the appropriate delivery of palliative oncology care. The distinction between curative and palliative goals is blurred in many patients with cancer, requiring that treatments be chosen on the basis of factors related to the patient (ie, poor performance status, advanced age, significant weight loss, severe comorbid disease), the cancer (ie, metastatic disease, aggressive histology), or the treatment (ie, poor response to systemic therapy, previous radiotherapy). Goals may include symptom relief at the site of primary tumor or from metastatic lesions. Attention to a patient's discomfort and transportation limitations requires hypofractionated courses, when feasible. Innovative approaches include rapid response palliative care clinics as well as the formation of palliative radiotherapy specialty services in academic centers. Guidelines are providing better definitions of appropriate palliative radiotherapy interventions, and bone metastases fractionation has become the first radiotherapy quality measure accepted by the National Quality Forum. Further advances in the palliative radiation oncology subspecialty will require integration of education and training between the radiotherapy and palliative care specialties.
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Affiliation(s)
- Stephen T Lutz
- Stephen T. Lutz, Blanchard Valley Regional Cancer Center, Findlay, OH; Joshua Jones, University of Pennsylvania, Philadelphia, PA; Edward Chow, University of Toronto, Toronto, Ontario, Canada.
| | - Joshua Jones
- Stephen T. Lutz, Blanchard Valley Regional Cancer Center, Findlay, OH; Joshua Jones, University of Pennsylvania, Philadelphia, PA; Edward Chow, University of Toronto, Toronto, Ontario, Canada
| | - Edward Chow
- Stephen T. Lutz, Blanchard Valley Regional Cancer Center, Findlay, OH; Joshua Jones, University of Pennsylvania, Philadelphia, PA; Edward Chow, University of Toronto, Toronto, Ontario, Canada
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919
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Reck M, Popat S, Reinmuth N, De Ruysscher D, Kerr KM, Peters S. Metastatic non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2014; 25 Suppl 3:iii27-39. [PMID: 25115305 DOI: 10.1093/annonc/mdu199] [Citation(s) in RCA: 541] [Impact Index Per Article: 54.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- M Reck
- Department of Thoracic Oncology, LungenClinic, Grosshansdorf Member of the German Center for Lung Research (DZL), Germany
| | - S Popat
- Royal Marsden Hospital NHS Foundation Trust, London Royal Marsden Hospital NHS Foundation Trust, Surrey, UK
| | - N Reinmuth
- Department of Thoracic Oncology, LungenClinic, Grosshansdorf Member of the German Center for Lung Research (DZL), Germany
| | - D De Ruysscher
- Department of Radiation Oncology, University Hospitals Leuven/ KU Leuven, Leuven, Belgium
| | - K M Kerr
- Department of Pathology, Aberdeen Royal Infirmary and Aberdeen University Medical School, Aberdeen, UK
| | - S Peters
- Department of Oncology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
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920
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Niikura N, Hayashi N, Masuda N, Takashima S, Nakamura R, Watanabe KI, Kanbayashi C, Ishida M, Hozumi Y, Tsuneizumi M, Kondo N, Naito Y, Honda Y, Matsui A, Fujisawa T, Oshitanai R, Yasojima H, Tokuda Y, Saji S, Iwata H. Treatment outcomes and prognostic factors for patients with brain metastases from breast cancer of each subtype: a multicenter retrospective analysis. Breast Cancer Res Treat 2014; 147:103-12. [PMID: 25106661 DOI: 10.1007/s10549-014-3090-8] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 07/29/2014] [Indexed: 12/20/2022]
Abstract
To define prognostic factors for breast cancer patients with brain metastases, compare their clinical courses and prognoses according to breast cancer subtypes, and analyze the causes of death in such patients. We retrospectively analyzed 1,466 patients diagnosed with brain metastases between April 1, 2001 and December 31, 2012, from 24 institutions of the Japan Clinical Oncology Group. Overall, 1,256 patients with brain metastases were included. The median overall survival (OS) was 8.7 months (95 % confidence interval [CI] 7.8-9.6 months). Univariate and multivariate analyses revealed that patients diagnosed with brain metastasis within 6 months of metastatic breast cancer diagnoses, asymptomatic brain disease, or HER2-positive/estrogen receptor-positive tumors had increased OS. Median OS after the development of brain metastases was 9.3 months (95 % CI 7.2-11.3) for the luminal type, 16.5 months (95 % CI 11.9-21.1) for the luminal-HER2 type, 11.5 months (95 % CI 9.1-13.8) for the HER2 type, and 4.9 months (95 % CI 3.9-5.9) for the triple-negative type. Luminal-HER2 type patients had significantly longer OS than patients with the luminal type (hazard ratio [HR] = 1.50, P < 0.0001) and triple-negative type (HR = 1.97, P < 0.0001); no significant differences were noted compared to HER2-type patients (HR = 1.19, P = 0.117). The prognosis and clinical course of patients with brain metastasis from breast cancer before and after developing brain metastases vary according to subtype. Focusing on the subtypes of breast cancer can optimize the prevention, early detection, and improved treatment of brain metastases.
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Affiliation(s)
- Naoki Niikura
- Department of Breast and Endocrine Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan,
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921
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Preusser M, Streubel B, Berghoff AS, Hainfellner JA, von Deimling A, Widhalm G, Dieckmann K, Wöhrer A, Hackl M, Zielinski C, Birner P. Amplification and overexpression of CMET is a common event in brain metastases of non-small cell lung cancer. Histopathology 2014; 65:684-92. [PMID: 25039982 DOI: 10.1111/his.12475] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 06/11/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND CMET represents an emerging therapy target for monoclonal antibodies and tyrosine kinase inhibitors in non-small cell lung cancer (NSCLC). METHODS We investigated CMET gene amplification status by fluorescence in-situ hybridization (FISH) and CMET protein expression by immunohistochemistry in a large series of 209 NSCLC brain metastases (BM; 165 adenocarcinoma, 20 squamous cell carcinoma, 11 adenosquamous carcinomas, 11 large cell carcinomas and two large cell neuroendocrine carcinomas) and correlated our results to clinic-pathological parameters and molecular data from previous studies. RESULTS We found CMET gene amplification in 36/167 (21.6%) and CMET protein expression in 87/196 (44.4%) of evaluable BM. There was a strong correlation between the presence of CMET gene amplification and CMET protein expression (P < 0.001, chi-square test). Furthermore, presence of CMET amplification correlated positively with presence of ALK amplifications (P = 0.039, chi-square test) and high HIF1 alpha index (P = 0.013, Mann-Whitney U-test). Neither CMET expression nor CMET gene amplification status correlated with patient outcome parameters or known prognostic factors. CONCLUSIONS CMET overexpression and CMET amplification are commonly found in NSCLC BM and may represent a promising therapeutic target.
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Affiliation(s)
- Matthias Preusser
- Department of Internal Medicine 1, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, CNS Unit, Medical University of Vienna, Vienna, Austria
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922
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Hepatocellular carcinoma specific graded prognostic assessment can predict outcomes for patients with brain metastases from hepatocellular carcinoma. J Neurooncol 2014; 120:199-207. [PMID: 25062667 DOI: 10.1007/s11060-014-1546-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 07/05/2014] [Indexed: 10/25/2022]
Abstract
Stratifying patients with brain metastasis (BM) from hepatocellular carcinoma (HCC) by prognostic factors can be useful when making treatment decisions. Nevertheless, a diagnosis-specific graded prognostic assessment (GPA) for HCC has not been well established. We retrospectively reviewed the data from 118 HCC patients newly diagnosed with BM at the Yonsei University Health System between 1985 and 2011. After univariate and multivariate analyses of prognostic factors, those shown to significantly affect survival were used to develop a HCC-specific GPA (HCC-GPA) index. The median overall survival after BM in all patients was 6.1 weeks (95% confidence interval 4.8-7.4 weeks). Using the prognostic factors identified via multivariate analysis, we developed a HCC-GPA index, including number of brain metastases (single: 0.5, multiple: 0 points), alpha-feto protein (<400 ng/mL: 0.5, ≥400 ng/mL: 0 points), and Child-Pugh-Score (A: 3, B: 2, C: 0 points). There were no survival differences for age, sex, performance status, and time interval from initial diagnosis to development of BM. Median survival times from BM were discriminable when applying the HCC-GPA scoring system: 1.7, 3.2, 7.9, and 27.0 weeks for HCC-GPA scores of 0-1.0 (N = 16), 1.5-2.5 (N = 32), 3.0-3.5 (N = 49), and 4.0 (N = 21), respectively (P < 0.001). Although the prognoses of patients with BM from HCC are dismal, the newly developed HCC-GPA index can be used to discriminate the expected prognoses thereof. Moreover, the index may hold value as a tool for selecting patients who may be good candidates for active local treatment.
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923
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Local control after fractionated stereotactic radiation therapy for brain metastases. J Neurooncol 2014; 120:339-46. [DOI: 10.1007/s11060-014-1556-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 07/05/2014] [Indexed: 10/25/2022]
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924
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Mak KS, Gainor JF, Niemierko A, Oh KS, Willers H, Choi NC, Loeffler JS, Sequist LV, Shaw AT, Shih HA. Significance of targeted therapy and genetic alterations in EGFR, ALK, or KRAS on survival in patients with non-small cell lung cancer treated with radiotherapy for brain metastases. Neuro Oncol 2014; 17:296-302. [PMID: 25053852 DOI: 10.1093/neuonc/nou146] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND We determined the impact of genetic alterations in EGFR, ALK, or KRAS on survival after radiotherapy for brain metastases in non-small cell lung cancer (NSCLC). METHODS Of 172 genotyped NSCLC patients treated with radiotherapy for brain metastases in 2005-2012, 54 had cancers with EGFR mutations, 12 had ALK rearrangements, 38 had KRAS mutations, and 68 were wild-type (WT). Overall survival (OS) was determined. RESULTS Median follow-up was 8.6 months. Median OS was 13.6 months for patients with EGFR mutations and 26.3 months for patients with ALK rearrangements, in contrast to 5.7 months for KRAS-mutant patients and 5.5 months for WT patients (P = .001). On multivariate analysis, adjusting for receipt of targeted therapy after cranial radiotherapy, ALK rearrangements were associated with improved OS (HR, 0.31; 95% CI, 0.13-0.74; P = .008). EGFR mutations were not significantly associated with improved OS on multivariate analysis (HR, 0.71; 95% CI, 0.37-1.38; P = .3). KRAS mutations were also not associated with improved OS (HR, 0.93; 95% CI, 0.59-1.47; P = .8). Receipt of targeted therapy after cranial radiotherapy was independently associated with improved OS (HR, 0.30; 95% CI, 0.17-0.54; P < .001). Receipt of chemotherapy after cranial radiotherapy, number of brain metastases, extracranial metastases, age, and performance status were also associated with OS. CONCLUSIONS NSCLC patients with genetic alterations in ALK have improved survival outcomes after radiotherapy for brain metastases compared with EGFR, KRAS, or WT. Subsequent receipt of targeted therapy was associated with additional improvement in OS.
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Affiliation(s)
- Kimberley S Mak
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts (K.S.M.); Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts (J.F.G.); Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (A.N., K.S.O., H.W., N.C.C., J.S.L., H.A.S.); Massachusetts General Hospital Cancer Center, Boston, Massachusetts (L.V.S., A.T.S.)
| | - Justin F Gainor
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts (K.S.M.); Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts (J.F.G.); Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (A.N., K.S.O., H.W., N.C.C., J.S.L., H.A.S.); Massachusetts General Hospital Cancer Center, Boston, Massachusetts (L.V.S., A.T.S.)
| | - Andrzej Niemierko
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts (K.S.M.); Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts (J.F.G.); Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (A.N., K.S.O., H.W., N.C.C., J.S.L., H.A.S.); Massachusetts General Hospital Cancer Center, Boston, Massachusetts (L.V.S., A.T.S.)
| | - Kevin S Oh
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts (K.S.M.); Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts (J.F.G.); Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (A.N., K.S.O., H.W., N.C.C., J.S.L., H.A.S.); Massachusetts General Hospital Cancer Center, Boston, Massachusetts (L.V.S., A.T.S.)
| | - Henning Willers
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts (K.S.M.); Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts (J.F.G.); Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (A.N., K.S.O., H.W., N.C.C., J.S.L., H.A.S.); Massachusetts General Hospital Cancer Center, Boston, Massachusetts (L.V.S., A.T.S.)
| | - Noah C Choi
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts (K.S.M.); Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts (J.F.G.); Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (A.N., K.S.O., H.W., N.C.C., J.S.L., H.A.S.); Massachusetts General Hospital Cancer Center, Boston, Massachusetts (L.V.S., A.T.S.)
| | - Jay S Loeffler
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts (K.S.M.); Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts (J.F.G.); Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (A.N., K.S.O., H.W., N.C.C., J.S.L., H.A.S.); Massachusetts General Hospital Cancer Center, Boston, Massachusetts (L.V.S., A.T.S.)
| | - Lecia V Sequist
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts (K.S.M.); Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts (J.F.G.); Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (A.N., K.S.O., H.W., N.C.C., J.S.L., H.A.S.); Massachusetts General Hospital Cancer Center, Boston, Massachusetts (L.V.S., A.T.S.)
| | - Alice T Shaw
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts (K.S.M.); Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts (J.F.G.); Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (A.N., K.S.O., H.W., N.C.C., J.S.L., H.A.S.); Massachusetts General Hospital Cancer Center, Boston, Massachusetts (L.V.S., A.T.S.)
| | - Helen A Shih
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts (K.S.M.); Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts (J.F.G.); Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (A.N., K.S.O., H.W., N.C.C., J.S.L., H.A.S.); Massachusetts General Hospital Cancer Center, Boston, Massachusetts (L.V.S., A.T.S.)
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925
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The Japanese Breast Cancer Society clinical practice guideline for radiotherapy of breast cancer. Breast Cancer 2014; 22:49-58. [PMID: 25022265 DOI: 10.1007/s12282-014-0548-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 06/16/2014] [Indexed: 12/25/2022]
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926
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Lin NU, Amiri-Kordestani L, Palmieri D, Liewehr DJ, Steeg PS. CNS metastases in breast cancer: old challenge, new frontiers. Clin Cancer Res 2014; 19:6404-18. [PMID: 24298071 DOI: 10.1158/1078-0432.ccr-13-0790] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Despite major therapeutic advances in the management of patients with breast cancer, central nervous system (CNS) metastases remain an intractable problem, particularly in patients with metastatic HER2-positive and triple-negative breast cancer. As systemic therapies to treat extracranial disease improve, some patients are surviving longer, and the frequency of CNS involvement seems to be increasing. Furthermore, in the early-stage setting, the CNS remains a potential sanctuary site for relapse. This review highlights advances in the development of biologically relevant preclinical models, including the development of brain-tropic cell lines for testing of agents to prevent and treat brain metastases, and summarizes our current understanding of the biology of CNS relapse. From a clinical perspective, a variety of therapeutic approaches are discussed, including methods to improve drug delivery, novel cytotoxic agents, and targeted therapies. Challenges in current trial design and endpoints are reviewed. Finally, we discuss promising new directions, including novel trial designs, correlative imaging techniques, and enhanced translational opportunities.
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Affiliation(s)
- Nancy U Lin
- Authors' Affiliations: Dana-Farber Cancer Institute, Boston, Massachusetts; Medical Oncology Branch, Center for Cancer Research, National Cancer Institute; Women's Cancers Section, Laboratory of Molecular Pharmacology; and Biostatistics and Data Management Section, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
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927
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Zimmermann S, Dziadziuszko R, Peters S. Indications and limitations of chemotherapy and targeted agents in non-small cell lung cancer brain metastases. Cancer Treat Rev 2014; 40:716-22. [DOI: 10.1016/j.ctrv.2014.03.005] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/20/2014] [Accepted: 03/30/2014] [Indexed: 12/22/2022]
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928
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Rogne SG, Helseth E, Brandal P, Scheie D, Meling TR. Are melanomas averse to cerebellum? Cerebellar metastases in a surgical series. Acta Neurol Scand 2014; 130:1-10. [PMID: 24313862 DOI: 10.1111/ane.12206] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To study the propensity of different cancers to metastasize to the cerebrum and cerebellum, and to study overall survival (OS) and prognostic factors for patients after surgical resection for cerebellar metastases. MATERIALS AND METHODS From a prospectively collected tumor database, all patients that underwent a craniotomy for intracranial metastases between 2003 and 2011 at Oslo University Hospital were included. RESULTS One hundred and forty patients underwent resection for cerebellar metastases. Most common primary tumor sites were lung, colon/rectum, and breast in 45%, 19%, and 14%, respectively. None were prostate cancers. Melanoma metastases were significantly underrepresented, and colorectal cancer metastases significantly overrepresented in cerebellum, compared to the overall proportion of cerebellar/supratentorial metastases surgically resected (P < 0.05). Thirty-day post-operative mortality rate was 4.3%. Median OS was 7.7 months (95% CI 6.0-9.5 months) irrespective of post-operative adjuvant therapy. Median OS was 51.8, 8.4, and 3.4 months, respectively, for recursive partitioning analysis class 1(n = 11), 2 (n = 78) and 3 (n = 34). Significant negative prognostic factors were age ≥65 years, Karnofsky performance score (KPS) <70, extracranial metastases and uncontrolled systemic disease. CONCLUSIONS Melanoma metastases were significantly underrepresented in cerebellum, whereas colorectal cancer metastases were significantly overrepresented. Surgical mortality and OS after surgical treatment of cerebellar metastases were similar to the results of supratentorial metastases.
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Affiliation(s)
- S. G. Rogne
- Department of Neurosurgery; Oslo University Hospital; Oslo Norway
| | - E. Helseth
- Department of Neurosurgery; Oslo University Hospital; Oslo Norway
- Faculty of Medicine; University of Oslo; Oslo Norway
| | - P. Brandal
- Department of Oncology; Oslo University Hospital; The Norwegian Radium Hospital; Oslo Norway
| | - D. Scheie
- Department of Pathology; Oslo University Hospital - Rikshospitalet; Oslo Norway
| | - T. R. Meling
- Department of Neurosurgery; Oslo University Hospital; Oslo Norway
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929
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Prasanna PGS, Ahmed MM, Stone HB, Vikram B, Mehta MP, Coleman CN. Radiation-induced brain damage, impact of Michael Robbins’ work and the need for predictive biomarkers. Int J Radiat Biol 2014; 90:742-52. [DOI: 10.3109/09553002.2014.925607] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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930
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Dyer MA, Arvold ND, Chen YH, Pinnell NE, Mitin T, Lee EQ, Hodi FS, Ibrahim N, Weiss SE, Kelly PJ, Floyd SR, Mahadevan A, Alexander BM. The role of whole brain radiation therapy in the management of melanoma brain metastases. Radiat Oncol 2014; 9:143. [PMID: 24954062 PMCID: PMC4132230 DOI: 10.1186/1748-717x-9-143] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 05/29/2014] [Indexed: 11/22/2022] Open
Abstract
Background Brain metastases are common in patients with melanoma, and optimal management is not well defined. As melanoma has traditionally been thought of as “radioresistant,” the role of whole brain radiation therapy (WBRT) in particular is unclear. We conducted this retrospective study to identify prognostic factors for patients treated with stereotactic radiosurgery (SRS) for melanoma brain metastases and to investigate the role of additional up-front treatment with whole brain radiation therapy (WBRT). Methods We reviewed records of 147 patients who received SRS as part of initial management of their melanoma brain metastases from January 2000 through June 2010. Overall survival (OS) and time to distant intracranial progression were calculated using the Kaplan-Meier method. Prognostic factors were evaluated using the Cox proportional hazards model. Results WBRT was employed with SRS in 27% of patients and as salvage in an additional 22%. Age at SRS > 60 years (hazard ratio [HR] 0.64, p = 0.05), multiple brain metastases (HR 1.90, p = 0.008), and omission of up-front WBRT (HR 2.24, p = 0.005) were associated with distant intracranial progression on multivariate analysis. Extensive extracranial metastases (HR 1.86, p = 0.0006), Karnofsky Performance Status (KPS) ≤ 80% (HR 1.58, p = 0.01), and multiple brain metastases (HR 1.40, p = 0.06) were associated with worse OS on univariate analysis. Extensive extracranial metastases (HR 1.78, p = 0.001) and KPS (HR 1.52, p = 0.02) remained significantly associated with OS on multivariate analysis. In patients with absent or stable extracranial disease, multiple brain metastases were associated with worse OS (multivariate HR 5.89, p = 0.004), and there was a trend toward an association with worse OS when up-front WBRT was omitted (multivariate HR 2.56, p = 0.08). Conclusions Multiple brain metastases and omission of up-front WBRT (particularly in combination) are associated with distant intracranial progression. Improvement in intracranial disease control may be especially important in the subset of patients with absent or stable extracranial disease, where the competing risk of death from extracranial disease is low. These results are hypothesis generating and require confirmation from ongoing randomized trials.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Brian M Alexander
- Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, MA, USA.
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931
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Berghoff AS, Sax C, Klein M, Furtner J, Dieckmann K, Gatterbauer B, Widhalm G, Rudas M, Zielinski CC, Bartsch R, Preusser M. Alleviation of brain edema and restoration of functional independence by bevacizumab in brain-metastatic breast cancer: a case report. ACTA ACUST UNITED AC 2014; 9:134-6. [PMID: 24944558 DOI: 10.1159/000360930] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Brain metastases (BM) are an increasing challenge in modern oncology, as treatment options especially after exhaustion of local treatment approaches are very limited. PATIENT AND METHODS A long-term surviving patient with brain-only metastatic breast cancer, who presented at our department with massive corticosteroid-refractory brain edema with serious neurological symptoms after exhaustion of all local therapy options, was started on bevacizumab. RESULTS Initiation of bevacizumab monotherapy led to rapid decrease of contrast-enhancing lesions and alleviation of brain edema, and allowed tapering and termination of corticosteroid administration. Neurological and neurocognitive function was restored and marked improvement in quality of life was observed. CONCLUSION Our case highlights that bevacizumab may represent a feasible and effective salvage treatment option in selected patients with BM.
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Affiliation(s)
- Anna S Berghoff
- Department of Medicine I, Medical University of Vienna, Austria ; Comprehensive Cancer Center, CNS Tumors Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria
| | - Cornelia Sax
- Department of Medicine I, Medical University of Vienna, Austria ; Comprehensive Cancer Center, CNS Tumors Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria
| | - Martin Klein
- Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands
| | - Julia Furtner
- Department of Neuroradiology, CNS Tumors Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria ; Comprehensive Cancer Center, CNS Tumors Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria
| | - Karin Dieckmann
- Department of Radiotherapy, CNS Tumors Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria ; Comprehensive Cancer Center, CNS Tumors Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria
| | - Brigitte Gatterbauer
- Department of Neurosurgery, CNS Tumors Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria ; Comprehensive Cancer Center, CNS Tumors Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria
| | - Georg Widhalm
- Department of Neurosurgery, CNS Tumors Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria ; Comprehensive Cancer Center, CNS Tumors Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria
| | - Margaretha Rudas
- Department of Pathology, CNS Tumors Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria
| | - Christoph C Zielinski
- Department of Medicine I, Medical University of Vienna, Austria ; Comprehensive Cancer Center, CNS Tumors Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria
| | - Rupert Bartsch
- Department of Medicine I, Medical University of Vienna, Austria ; Comprehensive Cancer Center, CNS Tumors Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria
| | - Matthias Preusser
- Department of Medicine I, Medical University of Vienna, Austria ; Comprehensive Cancer Center, CNS Tumors Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria
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932
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Aggressive therapy for patients with non-small cell lung carcinoma and synchronous brain-only oligometastatic disease is associated with long-term survival. Lung Cancer 2014; 85:239-44. [PMID: 24974152 DOI: 10.1016/j.lungcan.2014.06.001] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 05/05/2014] [Accepted: 06/01/2014] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Optimal therapy for patients with non-small cell lung carcinoma (NSCLC) presenting with synchronous brain-only oligometastases (SBO) is not well defined. We sought to analyze the effect of differing therapeutic paradigms in this subpopulation. MATERIALS AND METHODS We retrospectively analyzed NSCLC patients with 1-4 SBO diagnosed between 1/2000 and 1/2011 at our institution. Patients with T0 tumors or documented Karnofsky Performance Status <70 were excluded. Aggressive thoracic therapy (ATT) was defined as resection of the primary disease or chemoradiotherapy whose total radiation dose exceeded 45 Gy. Cox proportional hazards and competing risks models were used to analyze factors affecting survival and first recurrence in the brain. RESULTS Sixty-six patients were included. Median follow-up was 31.9 months. Intrathoracic disease extent included 9 stage I, 10 stage II and 47 stage III patients. Thirty-eight patients received ATT, 28 did not. Patients receiving ATT were younger (median age 55 vs. 60.5 years, p=0.027) but were otherwise similar to those who did not. Receipt of ATT was associated with prolonged median overall survival (OS) (26.4 vs. 10.5 months; p<0.001) with actuarial 2-year rates of 54% vs. 26%. ATT remained associated with OS after controlling for age, thoracic stage, performance status and initial brain therapy (HR 0.40, p=0.009). On multivariate analysis, the risk of first failure in the brain was associated with receipt of ATT (HR 3.62, p=0.032) and initial combined modality brain therapy (HR 0.34, p=0.046). CONCLUSION Aggressive management of thoracic disease in NSCLC patients with SBO is associated with improved survival. Careful management of brain disease remains important, especially for those treated aggressively.
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933
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Gonda DD, Khalessi AA, McCutcheon BA, Marcus LP, Noorbakhsh A, Chen CC, Chang DC, Carter BS. Long-term follow-up of unruptured intracranial aneurysms repaired in California. J Neurosurg 2014; 120:1349-57. [DOI: 10.3171/2014.3.jns131159] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Using a database that enabled longitudinal follow-up, the authors assessed the long-term outcomes of unruptured cerebral aneurysms repaired by clipping or coiling.
Methods
An observational analysis of the California Office of Statewide Health Planning and Development (OSHPD) database, which follows patients longitudinally in time and through multiple hospitalizations, was performed for all patients initially treated for an unruptured cerebral aneurysm in the period from 1998 to 2005 and with follow-up data through 2009.
Results
Nine hundred forty-four cases (36.5%) were treated with endovascular coiling, 1565 cases (60.5%) were surgically clipped, and 76 cases were treated with both coiling and clipping. There was no significant difference in any demographic variable between the two treatment groups except for age (median: 55 years for the clipped group, 58 years for the coiled group, p < 0.001). Perioperative (30-day) mortality was 1.1% in patients with coiled aneurysms compared with 2.3% in those with clipped aneurysms (p = 0.048). The median follow-up was 7 years (range 4–12 years). At the last follow-up, 153 patients (16.2%) in the coiled group had died compared with 244 (15.6%) in the clipped group (p = 0.693). The adjusted hazard ratio for death at the long-term follow-up was 1.14 (95% CI 0.9–1.4, p = 0.282) for patients with endovascularly treated aneurysms. The incidence of intracranial hemorrhage was similar in the two treatment groups (5.9% clipped vs 4.8% coiled, p = 0.276). One hundred ninety-three patients (20.4%) with coiled aneurysms underwent additional hospitalizations for aneurysm repair procedures compared with only 136 patients (8.7%) with clipped aneurysms (p < 0.001). Cumulative hospital costs per patient for admissions involving aneurysm repair procedures were greater in the clipped group (median cost $98,260 vs $81,620, p < 0.001) through the follow-up.
Conclusions
For unruptured cerebral aneurysms, an observed perioperative survival advantage for endovascular coiling relative to that for surgical clipping was lost on long-term follow-up, according to data from an administrative database of patients who were not randomly allocated to treatment type. A cost advantage of endovascular treatment was maintained even though endovascularly treated patients were more likely to undergo subsequent hospitalizations for additional aneurysm repair procedures. Rates of aneurysm rupture following treatment were similar in the two groups.
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Affiliation(s)
| | | | | | - Logan P. Marcus
- 2Department of Surgery, University of California, San Diego, California
| | | | | | - David C. Chang
- 2Department of Surgery, University of California, San Diego, California
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934
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Suleiman M, Mullane M. Oligometastatic Large Cell Neuroendocrine Carcinoma of the Brain Without Radiologically Detected Primary. World J Oncol 2014; 5:135-138. [PMID: 29147392 PMCID: PMC5649817 DOI: 10.14740/wjon805w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2014] [Indexed: 11/11/2022] Open
Abstract
A 60-year-old Polish male was admitted into our hospital with complaint of right-sided lower extremity weakness. CT of head showed a left frontal 2.6 × 1.5 cm mass. Staging work-up did not show any other associated lesions in the chest or abdomen. Brain tumor was resected with histology consistent with large cell neuroendocrine carcinoma with most likely lung primary because of TTF-1 positivity. Following recovery from surgery, he had external beam radiation therapy to the brain and systemic chemotherapy with four cycles of cisplatin/etoposide. Patient is alive and doing well 6 months post diagnosis with no evidence of recurrence.
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Affiliation(s)
- Moyosore Suleiman
- Department of Hematology and Oncology, John H Stroger Jr Hospital of Cook County, Chicago, IL 60612, USA
| | - Michael Mullane
- Department of Hematology and Oncology, John H Stroger Jr Hospital of Cook County, Chicago, IL 60612, USA
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935
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Bartolotti M, Franceschi E, Brandes AA. Treatment of brain metastases from HER-2-positive breast cancer: current status and new concepts. Future Oncol 2014; 9:1653-64. [PMID: 24156325 DOI: 10.2217/fon.13.90] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Breast cancer is the second most common source of brain metastases (BM). The incidence of BM in breast cancer patients has increased over the past decade, especially among patients with HER-2-positive breast cancer. This is probably due to how aggressive the HER-2-positive disease is but also to the prolongation of survival obtained with current treatments, which allow good control of extracranial disease but are unable to cross the blood-brain barrier. At present, whole-brain radiotherapy, surgery and radiosurgery/stereotactic radiotherapy represent the cornerstone of treatment for BM, while the role of pharmacological therapy remains uncertain. Lapatinib demonstrated activity against BM from HER-2-positive breast cancer in small Phase II and retrospective studies, mainly in combination with capecitabine, and cases of dramatic responses to such treatment are present in literature. In this review we focus on the available clinical data regarding the treatment of BM from HER-2-positive breast cancer and on new concepts about the treatment and evaluation of the CNS response.
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Affiliation(s)
- Marco Bartolotti
- Department of Medical Oncology, Azienda USL, Via Altura 3 40139, Bologna, Italy
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936
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Zhou L, Liu J, Xue J, Xu Y, Gong Y, Deng L, Wang S, Zhong R, Ding Z, Lu Y. Whole brain radiotherapy plus simultaneous in-field boost with image guided intensity-modulated radiotherapy for brain metastases of non-small cell lung cancer. Radiat Oncol 2014; 9:117. [PMID: 24884773 PMCID: PMC4035738 DOI: 10.1186/1748-717x-9-117] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 04/28/2014] [Indexed: 02/05/2023] Open
Abstract
Background Whole brain radiotherapy (WBRT) plus sequential focal radiation boost is a commonly used therapeutic strategy for patients with brain metastases. However, recent reports on WBRT plus simultaneous in-field boost (SIB) also showed promising outcomes. The objective of present study is to retrospectively evaluate the efficacy and toxicities of WBRT plus SIB with image guided intensity-modulated radiotherapy (IG-IMRT) for inoperable brain metastases of NSCLC. Methods Twenty-nine NSCLC patients with 87 inoperable brain metastases were included in this retrospective study. All patients received WBRT at a dose of 40 Gy/20 f, and SIB boost with IG-IMRT at a dose of 20 Gy/5 f concurrent with WBRT in the fourth week. Prior to each fraction of IG-IMRT boost, on-line positioning verification and correction were used to ensure that the set-up errors were within 2 mm by cone beam computed tomography in all patients. Results The one-year intracranial control rate, local brain failure rate, and distant brain failure rate were 62.9%, 13.8%, and 19.2%, respectively. The two-year intracranial control rate, local brain failure rate, and distant brain failure rate were 42.5%, 30.9%, and 36.4%, respectively. Both median intracranial progression-free survival and median survival were 10 months. Six-month, one-year, and two-year survival rates were 65.5%, 41.4%, and 13.8%, corresponding to 62.1%, 41.4%, and 10.3% of intracranial progression-free survival rates. Patients with Score Index for Radiosurgery in Brain Metastases (SIR) >5, number of intracranial lesions <3, and history of EGFR-TKI treatment had better survival. Three lesions (3.45%) demonstrated radiation necrosis after radiotherapy. Grades 2 and 3 cognitive impairment with grade 2 radiation leukoencephalopathy were observed in 4 (13.8%) and 4 (13.8%) patients. No dosimetric parameters were found to be associated with these late toxicities. Patients received EGFR-TKI treatment had higher incidence of grades 2–3 cognitive impairment with grade 2 leukoencephalopathy. Conclusions WBRT plus SIB with IG-IMRT is a tolerable and effective treatment for NSCLC patients with inoperable brain metastases. However, the results of present study need to be examined by the prospective investigations.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - You Lu
- Department of Thoracic Cancer, Cancer Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
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937
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938
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Gutenberg A, Nischwitz MD, Gunawan B, Enders C, Jung K, Bergmann M, Feiden W, Egensperger R, Keyvani K, Stolke D, Sure U, Schroeder HWS, Warzok R, Schober R, Meixensberger J, Paulus W, Wassmann H, Stummer W, Blumcke I, Buchfelder M, van Landeghem FKH, Vajkoczy P, Günther M, Bedke J, Giese A, Rohde V, Brück W, Füzesi L, Sander B. Predictive chromosomal clusters of synchronous and metachronous brain metastases in clear cell renal cell carcinoma. Cancer Genet 2014; 207:206-13. [PMID: 25027636 DOI: 10.1016/j.cancergen.2014.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 05/01/2014] [Accepted: 05/10/2014] [Indexed: 01/21/2023]
Abstract
Synchronous (early) and metachronous (late) brain metastasis (BM) events of sporadic clear cell renal cell carcinoma (ccRCC) (n = 148) were retrospectively analyzed using comparative genomic hybridization (CGH). Using oncogenetic tree models and cluster analyses, chromosomal imbalances related to recurrence-free survival until BM (RFS-BM) were analyzed. Losses at 9p and 9q appeared to be hallmarks of metachronous BM events, whereas an absence of detectable chromosomal changes at 3p was often associated with synchronous BM events. Correspondingly, k-means clustering showed that cluster 1 cases generally exhibited low copy number chromosomal changes that did not involve 3p. Cluster 2 cases had a high occurrence of -9p/-9q (94-98%) deletions, whereas cluster 3 cases had a higher frequency of copy number changes, including loss at chromosome 14 (80%). The higher number of synchronous cases in cluster 1 was also associated with a significantly shorter RFS-BM compared with clusters 2 and 3 (P = 0.02). Conversely, a significantly longer RFS-BM was observed for cluster 2 versus clusters 1 and 3 (P = 0.02). Taken together, these data suggest that metachronous BM events of ccRCC are characterized by loss of chromosome 9, whereas synchronous BM events may form independently of detectable genetic changes at chromosomes 9 and 3p.
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Affiliation(s)
- Angelika Gutenberg
- Department of Neurosurgery, Georg August University, Göttingen, Germany; Department of Neurosurgery, Johannes Gutenberg University, Mainz, Germany.
| | - Martin D Nischwitz
- Department of Gastroenteropathology, Georg August University, Göttingen, Germany
| | - Bastian Gunawan
- Department of Gastroenteropathology, Georg August University, Göttingen, Germany
| | - Christina Enders
- Department of Gastroenteropathology, Georg August University, Göttingen, Germany
| | - Klaus Jung
- Department of Medical Statistics, Georg August University, Göttingen, Germany
| | - Markus Bergmann
- Department of Neuropathology, Klinikum Bremen-Mitte, Bremen, Germany
| | - Wolfgang Feiden
- Departments of Gastroenteropathology and Neuropathology, University of the Saarland, Homburg, Germany
| | - Rupert Egensperger
- Institute of Neuropathology, University of Duisburg-Essen, Essen, Germany
| | - Kathy Keyvani
- Institute of Neuropathology, University of Duisburg-Essen, Essen, Germany
| | - Dietmar Stolke
- Department of Neurosurgery, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University of Duisburg-Essen, Essen, Germany
| | - Henry W S Schroeder
- Department of Neurosurgery, Ernst Moritz Arndt University, Greifswald, Germany
| | - Rolf Warzok
- Department of Neuropathology, Ernst Moritz Arndt University, Greifswald, Germany
| | - Ralf Schober
- Department of Neuropathology, University of Leipzig, Leipzig, Germany
| | | | - Werner Paulus
- Department of Neuropathology, Westphalian Wilhelm University, Münster, Germany
| | - Hansdetlef Wassmann
- Department of Neurosurgery, Westphalian Wilhelm University, Münster, Germany
| | - Wolfgang Stummer
- Department of Neurosurgery, Westphalian Wilhelm University, Münster, Germany
| | - Ingmar Blumcke
- Department of Neuropathology, University Hospital Erlangen, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Frank K H van Landeghem
- Department of Neuropathology, Charité University Medicine, Berlin, Germany; Department of Neuropathology, University of Alberta, Edmonton, Canada
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité University Medicine, Berlin, Germany
| | - Marlis Günther
- Department of Pathology, Health Care Center Brandenburg, Brandenburg, Germany
| | - Jens Bedke
- Department of Urology, Eberhard Karls University, Tübingen, Germany
| | - Alf Giese
- Department of Neurosurgery, Johannes Gutenberg University, Mainz, Germany
| | - Veit Rohde
- Department of Neurosurgery, Georg August University, Göttingen, Germany
| | - Wolfgang Brück
- Department of Neuropathology, Georg August University, Göttingen, Germany
| | - Laszlo Füzesi
- Department of Gastroenteropathology, Georg August University, Göttingen, Germany
| | - Bjoern Sander
- Stereology and Electron Microscopy Laboratory, Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
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939
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Dawe DE, Greenspoon JN, Ellis PM. Brain metastases in non-small-cell lung cancer. Clin Lung Cancer 2014; 15:249-57. [PMID: 24954227 DOI: 10.1016/j.cllc.2014.04.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 04/04/2014] [Accepted: 04/08/2014] [Indexed: 12/25/2022]
Abstract
Up to 50% of patients with advanced non-small-cell lung cancer will develop brain metastases at some point during their illness. These metastases cause a substantial burden in morbidity and mortality, which has motivated research and technological innovation over the past 2 decades. Surgery, radiotherapy, and systemic therapies have each played a role in management, with the greatest changes associated with the popularization of stereotactic radiosurgery. In this review, the evidence behind each modality used in the management of brain metastases for non-small-cell lung cancer patients is examined, and recommendations regarding the current standards of care and areas of future research focus are provided.
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Affiliation(s)
- David E Dawe
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
| | | | - Peter M Ellis
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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940
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3D radiation therapy boost improves the outcome of whole brain radiation therapy treated RPA II patients with one or two brain metastases. Int J Mol Sci 2014; 15:7554-62. [PMID: 24798750 PMCID: PMC4057690 DOI: 10.3390/ijms15057554] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 04/07/2014] [Accepted: 04/24/2014] [Indexed: 11/29/2022] Open
Abstract
Purpose to evaluate the role of whole brain radiotherapy (WBRT) and radiation boost (RB) for 208 patients recursive partitioning analysis (RPA) II with 1 or 2 brain metastases (BM) at a single institution. Methods and Materials the dose of WBRT was 30 Gy (10 fractions of 3 Gy). One hundred thirty-two patients (63.5%) benefited from RB of 9 Gy in 3 fractions of 3 Gy at the metastatic site. Patients had 1 or 2 BM in 122 (58.7%) and 86 cases (41.3%), respectively. Results patients with one or two metastases had similar survival (4.6 and 5.1 months, respectively) (p = 0.4). Median overall survival (OS) for patients treated with WBRT and RB, and with WBRT alone was 5.9 and 3.7 months, respectively (p = 0.03). The 6-, 12- and 24-month OS rates after WBRT and RB were 48.5%, 25% and 10.6%, respectively, while WBRT alone resulted in OS rates of 34%, 22.4% and 3.2%, respectively (p = 0.03). After WBRT and RB, the 6-, 12- and 24-month local control rates were 92%, 82% and 67%, respectively, while they were 81.2%, 75% and 37.5%, respectively, after WBRT alone (p = 0.03). The 6-, 12- and 24-month brain control rates after WBRT and RB were 88.7%, 75.8% and 62%, respectively, and after WBRT alone they were 78.5%, 59% and 37.7%, respectively (p = 0.03). Conclusion additional boost delivered with 3D conformal radiotherapy improves local and brain control rates significantly as well as overall survival for RPA II patients with 1 or 2 unresectable BM.
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941
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Kuremsky JG, Urbanic JJ, Petty WJ, Lovato JF, Bourland JD, Tatter SB, Ellis TL, McMullen KP, Shaw EG, Chan MD. Tumor histology predicts patterns of failure and survival in patients with brain metastases from lung cancer treated with gamma knife radiosurgery. Neurosurgery 2014; 73:641-7; discussion 647. [PMID: 23842552 DOI: 10.1227/neu.0000000000000072] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We review our experience with lung cancer patients with newly diagnosed brain metastases treated with Gamma Knife radiosurgery (GKRS). OBJECTIVE To determine whether tumor histology predicts patient outcomes. METHODS Between July 1, 2000, and December 31, 2010, 271 patients with brain metastases from primary lung cancer were treated with GKRS at our institution. Included in our study were 44 squamous cell carcinoma (SCC), 31 small cell carcinoma (SCLC), and 138 adenocarcinoma (ACA) patients; 47 patients with insufficient pathology to determine subtype were excluded. No non-small cell lung cancer (NSCLC) patients received whole-brain radiation therapy (WBRT) before their GKRS, and SCLC patients were allowed to have prophylactic cranial irradiation, but no previously known brain metastases. A median of 2 lesions were treated per patient with median marginal dose of 20 Gy. RESULTS Median survival was 10.2 months for ACA, 5.9 months for SCLC, and 5.3 months for SCC patients (P = .008). The 1-year local control rates were 86%, 86%, and 54% for ACA, SCC, and SCLC, respectively (P = .027). The 1-year distant failure rates were 35%, 63%, and 65% for ACA, SCC, and SCLC, respectively (P = .057). The likelihood of dying of neurological death was 29%, 36%, and 55% for ACA, SCC, and SCLC, respectively (P = .027). The median time to WBRT was 11 months for SCC and 24 months for ACA patients (P = .04). Multivariate analysis confirmed SCLC histology as a significant predictor of worsened local control (hazard ratio [HR]: 6.46, P = .025) and distant failure (HR: 3.32, P = .0027). For NSCLC histologies, SCC predicted for earlier time to salvage WBRT (HR: 2.552, P = .01) and worsened overall survival (HR: 1.77, P < .0121). CONCLUSION Histological subtype of lung cancer appears to predict outcomes. Future trials and prognostic indices should take these histology-specific patterns into account.
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Affiliation(s)
- J Griff Kuremsky
- Departments of ‡Radiation Oncology; §Internal Medicine, Hematology, and Oncology; ¶Neurosurgery, and ‖Public Health Sciences, Wake Forest University, Winston-Salem, North Carolina; †Deceased
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942
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Zakaria R, Das K, Bhojak M, Radon M, Walker C, Jenkinson MD. The role of magnetic resonance imaging in the management of brain metastases: diagnosis to prognosis. Cancer Imaging 2014; 14:8. [PMID: 25608557 PMCID: PMC4331840 DOI: 10.1186/1470-7330-14-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 02/11/2014] [Indexed: 11/20/2022] Open
Abstract
This article reviews the different MRI techniques available for the diagnosis, treatment and monitoring of brain metastases with a focus on applying advanced MR techniques to practical clinical problems. Topics include conventional MRI sequences and contrast agents, functional MR imaging, diffusion weighted MR, MR spectroscopy and perfusion MR. The role of radiographic biomarkers is discussed as well as future directions such as molecular imaging and MR guided high frequency ultrasound.
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Kocher M, Wittig A, Piroth MD, Treuer H, Seegenschmiedt H, Ruge M, Grosu AL, Guckenberger M. Stereotactic radiosurgery for treatment of brain metastases. A report of the DEGRO Working Group on Stereotactic Radiotherapy. Strahlenther Onkol 2014; 190:521-32. [PMID: 24715242 DOI: 10.1007/s00066-014-0648-7] [Citation(s) in RCA: 148] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 02/25/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND This report from the Working Group on Stereotaktische Radiotherapie of the German Society of Radiation Oncology (Deutsche Gesellschaft für Radioonkologie, DEGRO) provides recommendations for the use of stereotactic radiosurgery (SRS) on patients with brain metastases. It considers existing international guidelines and details them where appropriate. RESULTS AND DISCUSSION The main recommendations are: Patients with solid tumors except germ cell tumors and small-cell lung cancer with a life expectancy of more than 3 months suffering from a single brain metastasis of less than 3 cm in diameter should be considered for SRS. Especially when metastases are not amenable to surgery, are located in the brain stem, and have no mass effect, SRS should be offered to the patient. For multiple (two to four) metastases--all less than 2.5 cm in diameter--in patients with a life expectancy of more than 3 months, SRS should be used rather than whole-brain radiotherapy (WBRT). Adjuvant WBRT after SRS for both single and multiple (two to four) metastases increases local control and reduces the frequency of distant brain metastases, but does not prolong survival when compared with SRS and salvage treatment. As WBRT carries the risk of inducing neurocognitive damage, it seems reasonable to withhold WBRT for as long as possible. CONCLUSION A single (marginal) dose of 20 Gy is a reasonable choice that balances the effect on the treated lesion (local control, partial remission) against the risk of late side effects (radionecrosis). Higher doses (22-25 Gy) may be used for smaller (< 1 cm) lesions, while a dose reduction to 18 Gy may be necessary for lesions greater than 2.5-3 cm. As the infiltration zone of the brain metastases is usually small, the GTV-CTV (gross tumor volume-clinical target volume) margin should be in the range of 0-1 mm. The CTV-PTV (planning target volume) margin depends on the treatment technique and should lie in the range of 0-2 mm. Distant brain recurrences fulfilling the aforementioned criteria can be treated with SRS irrespective of previous WBRT.
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Affiliation(s)
- Martin Kocher
- Department of Radiation Oncology, University Hospital Cologne, Joseph-Stelzmann-Str. 9, 50924, Köln, Germany,
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Nieder C, Marienhagen K, Dalhaug A, Aandahl G, Haukland E, Pawinski A. Prognostic models predicting survival of patients with brain metastases: integration of lactate dehydrogenase, albumin and extracranial organ involvement. Clin Oncol (R Coll Radiol) 2014; 26:447-52. [PMID: 24702741 DOI: 10.1016/j.clon.2014.03.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 02/17/2014] [Accepted: 02/18/2014] [Indexed: 11/28/2022]
Abstract
AIMS To explore the role of expanded assessment of metastatic extracranial organ involvement, as well as albumin and lactate dehydrogenase (LDH), i.e. surrogates of disease extent, in survival prediction models for patients with brain metastases. MATERIALS AND METHODS A retrospective analysis of 189 patients treated with whole brain radiotherapy was carried out. Uni- and multivariate analyses included recursive partitioning analysis classes, basic score for brain metastases and diagnosis-specific graded prognostic assessment (DS-GPA). RESULTS Elevated LDH correlated significantly with extracranial organ involvement, low albumin with primary tumour type and primary tumour control. Elevated LDH, low albumin and a combination of both correlated significantly with overall survival. LDH, albumin and the number of extracranial organs involved (none, one, two or more harbouring metastases) were independent prognostic factors in multivariate analyses (if added to the three established scores mentioned above and also if added to individual parameters such as age, performance status, etc.). A combination of these three new prognostic factors predicted very short survival (median 0.7 months if all three were present). CONCLUSION We have previously defined patient groups in whom foregoing radiotherapy was unlikely to compromise survival. These were patients with a DS-GPA score of 0-1.5 points and age ≥75 years or Karnofsky performance status ≤50 or uncontrolled primary tumour with extracranial metastases to at least two organs. Patients with a combination of three new adverse features (elevated LDH plus low albumin plus extracranial metastases to at least two organs) might also be considered for best supportive care. Furthermore, it appears warranted to study whether scores such as DS-GPA can be optimised by integrating information on these three parameters.
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Affiliation(s)
- C Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway; Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway.
| | - K Marienhagen
- Department of Oncology, University Hospital of North Norway, Tromsø, Norway
| | - A Dalhaug
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway; Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - G Aandahl
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway
| | - E Haukland
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway
| | - A Pawinski
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway
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Prognostic Factors for stereotactic radiosurgery-treated patients with cerebral metastasis: Implications on randomised control trial design and inter-institutional collaboration. Eur J Cancer 2014; 50:1148-58. [DOI: 10.1016/j.ejca.2014.01.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 12/05/2013] [Accepted: 01/01/2014] [Indexed: 01/08/2023]
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946
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Clinical Outcome of Stereotactic Radiosurgery for Central Nervous System Metastases From Renal Cell Carcinoma. Clin Genitourin Cancer 2014; 12:111-6. [DOI: 10.1016/j.clgc.2013.10.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Accepted: 10/02/2013] [Indexed: 01/08/2023]
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947
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Gerber NK, Yamada Y, Rimner A, Shi W, Riely GJ, Beal K, Yu HA, Chan TA, Zhang Z, Wu AJ. Erlotinib versus radiation therapy for brain metastases in patients with EGFR-mutant lung adenocarcinoma. Int J Radiat Oncol Biol Phys 2014; 89:322-9. [PMID: 24679729 DOI: 10.1016/j.ijrobp.2014.02.022] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 02/12/2014] [Accepted: 02/13/2014] [Indexed: 12/13/2022]
Abstract
PURPOSE/OBJECTIVES Radiation therapy (RT) is the principal modality in the treatment of patients with brain metastases (BM). However, given the activity of EGFR tyrosine kinase inhibitors in the central nervous system, it is uncertain whether upfront brain RT is necessary for patients with EGFR-mutant lung adenocarcinoma with BM. METHODS AND MATERIALS Patients with EGFR-mutant lung adenocarcinoma and newly diagnosed BM were identified. RESULTS 222 patients were identified. Exclusion criteria included prior erlotinib use, presence of a de novo erlotinib resistance mutation, or incomplete data. Of the remaining 110 patients, 63 were treated with erlotinib, 32 with whole brain RT (WBRT), and 15 with stereotactic radiosurgery (SRS). The median overall survival (OS) for the whole cohort was 33 months. There was no significant difference in OS between the WBRT and erlotinib groups (median, 35 vs 26 months; P=.62), whereas patients treated with SRS had a longer OS than did those in the erlotinib group (median, 64 months; P=.004). The median time to intracranial progression was 17 months. There was a longer time to intracranial progression in patients who received WBRT than in those who received erlotinib upfront (median, 24 vs 16 months, P=.04). Patients in the erlotinib or SRS group were more likely to experience intracranial failure as a component of first failure, whereas WBRT patients were more likely to experience failure outside the brain (P=.004). CONCLUSIONS The survival of patients with EGFR-mutant adenocarcinoma with BM is notably long, whether they receive upfront erlotinib or brain RT. We observed longer intracranial control with WBRT, even though the WBRT patients had a higher burden of intracranial disease. Despite the equivalent survival between the WBRT and erlotinib group, this study underscores the role of WBRT in producing durable intracranial control in comparison with a targeted biologic agent with known central nervous system activity.
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Affiliation(s)
- Naamit K Gerber
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Weiji Shi
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Gregory J Riely
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Helena A Yu
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Timothy A Chan
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York.
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Nieder C, Marienhagen K, Dalhaug A, Aandahl G, Haukland E, Pawinski A. Impact of systemic treatment on survival after whole brain radiotherapy in patients with brain metastases. Med Oncol 2014; 31:927. [PMID: 24647787 DOI: 10.1007/s12032-014-0927-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 03/12/2014] [Indexed: 01/08/2023]
Abstract
Most patients with brain metastases have active extracranial disease, which limits survival unless effective systemic therapy can be administered. Available options have increased over the last 5 years. Therefore, we analyzed patient cohorts treated with or without systemic treatment after completion of whole brain radiotherapy (WBRT). This study included retrospective uni- and multivariate analyses of 189 patients. Two landmark analyses requiring minimum survival of 1 or 2 months from start of WBRT were performed. Age and Karnofsky performance status (KPS) requirements were also applied in order to resemble a prospective trial that would limit inclusion to patients with defined baseline characteristics such as adequate KPS. Irrespective of these different statistical scenarios, systemic treatment significantly improved survival. For example, the 2-month landmark analysis with upper age limit and inclusion of patients with KPS > 60 only showed median survival of 9.0 versus 3.7 months, p = 0.001. All patients alive after more than 2 years had received systemic treatment (chemotherapy, endocrine therapy, tyrosine kinase inhibitors or other drugs). After WBRT, systemic treatment is a prerequisite for long-term survival. The exact magnitude of improvement can only be assessed in randomized trials because retrospective cohort studies, even if carefully designed, are not able to correct for all potential imbalances.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway,
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Harter PN, Zinke J, Scholz A, Tichy J, Zachskorn C, Kvasnicka HM, Goeppert B, Delloye-Bourgeois C, Hattingen E, Senft C, Steinbach JP, Plate KH, Mehlen P, Schulte D, Mittelbronn M. Netrin-1 expression is an independent prognostic factor for poor patient survival in brain metastases. PLoS One 2014; 9:e92311. [PMID: 24647424 PMCID: PMC3960244 DOI: 10.1371/journal.pone.0092311] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 02/21/2014] [Indexed: 11/18/2022] Open
Abstract
The multifunctional molecule netrin-1 is upregulated in various malignancies and has recently been presented as a major general player in tumorigenesis leading to tumor progression and maintenance in various animal models. However, there is still a lack of clinico-epidemiological data related to netrin-1 expression. Therefore, the aim of our study was to elucidate the association of netrin-1 expression and patient survival in brain metastases since those constitute one of the most limiting factors for patient prognosis. We investigated 104 brain metastases cases for netrin-1 expression using in-situ hybridization and immunohistochemistry with regard to clinical parameters such as patient survival and MRI data. Our data show that netrin-1 is strongly upregulated in most cancer subtypes. Univariate analyses revealed netrin-1 expression as a significant factor associated with poor patient survival in the total cohort of brain metastasis patients and in sub-entities such as non-small cell lung carcinomas. Interestingly, many cancer samples showed a strong nuclear netrin-1 signal which was recently linked to a truncated netrin-1 variant that enhances tumor growth. Nuclear netrin-1 expression was associated with poor patient survival in univariate as well as in multivariate analyses. Our data indicate both total and nuclear netrin-1 expression as prognostic factors in brain metastases patients in contrast to other prognostic markers in oncology such as patient age, number of brain metastases or Ki67 proliferation index. Therefore, nuclear netrin-1 expression constitutes one of the first reported molecular biomarkers for patient survival in brain metastases. Furthermore, netrin-1 may constitute a promising target for future anti-cancer treatment approaches in brain metastases.
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Affiliation(s)
- Patrick N. Harter
- Edinger Institute, Institute of Neurology, University of Frankfurt am Main, Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jenny Zinke
- Edinger Institute, Institute of Neurology, University of Frankfurt am Main, Frankfurt am Main, Germany
| | - Alexander Scholz
- Edinger Institute, Institute of Neurology, University of Frankfurt am Main, Frankfurt am Main, Germany
| | - Julia Tichy
- Senckenberg Institute of Neurooncology, University of Frankfurt am Main, Frankfurt am Main, Germany
| | - Cornelia Zachskorn
- Edinger Institute, Institute of Neurology, University of Frankfurt am Main, Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Hans M. Kvasnicka
- German Cancer Consortium (DKTK), Heidelberg, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Senckenberg Institute of Pathology, University of Frankfurt am Main, Frankfurt am Main, Germany
| | - Benjamin Goeppert
- German Cancer Consortium (DKTK), Heidelberg, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
| | - Céline Delloye-Bourgeois
- Apoptosis, Cancer and Development Laboratory, Equipe labellisée ‘La Ligue’, LabEx DEVweCAN, Centre de Cancérologie de Lyon, INSERM U1052-CNRS UMR5286, Université de Lyon, Centre Léon Bérard, Lyon, France
| | - Elke Hattingen
- Institute of Neuroradiology, University of Frankfurt am Main, Frankfurt am Main, Germany
| | - Christian Senft
- Department of Neurosurgery, University of Frankfurt am Main, Frankfurt am Main, Germany
| | - Joachim P. Steinbach
- German Cancer Consortium (DKTK), Heidelberg, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Senckenberg Institute of Neurooncology, University of Frankfurt am Main, Frankfurt am Main, Germany
| | - Karl H. Plate
- Edinger Institute, Institute of Neurology, University of Frankfurt am Main, Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Patrick Mehlen
- Apoptosis, Cancer and Development Laboratory, Equipe labellisée ‘La Ligue’, LabEx DEVweCAN, Centre de Cancérologie de Lyon, INSERM U1052-CNRS UMR5286, Université de Lyon, Centre Léon Bérard, Lyon, France
| | - Dorothea Schulte
- Edinger Institute, Institute of Neurology, University of Frankfurt am Main, Frankfurt am Main, Germany
| | - Michel Mittelbronn
- Edinger Institute, Institute of Neurology, University of Frankfurt am Main, Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- * E-mail:
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950
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Berghoff AS, Ilhan-Mutlu A, Wöhrer A, Hackl M, Widhalm G, Hainfellner JA, Dieckmann K, Melchardt T, Dome B, Heinzl H, Birner P, Preusser M. Prognostic significance of Ki67 proliferation index, HIF1 alpha index and microvascular density in patients with non-small cell lung cancer brain metastases. Strahlenther Onkol 2014; 190:676-85. [PMID: 24577133 DOI: 10.1007/s00066-014-0639-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 11/25/2013] [Indexed: 01/06/2023]
Abstract
BACKGROUND Survival upon diagnosis of brain metastases (BM) in patients with non-small cell lung cancer (NSCLC) is highly variable and established prognostic scores do not include tissue-based parameters. METHODS Patients who underwent neurosurgical resection as first-line therapy for newly diagnosed NSCLC BM were included. Microvascular density (MVD), Ki67 tumor cell proliferation index and hypoxia-inducible factor 1 alpha (HIF-1 alpha) index were determined by immunohistochemistry. RESULTS NSCLC BM specimens from 230 patients (151 male, 79 female; median age 56 years; 199 nonsquamous histology) and 53/230 (23.0%) matched primary tumor samples were available. Adjuvant whole-brain radiation therapy (WBRT) was given to 153/230 (66.5%) patients after neurosurgical resection. MVD and HIF-1 alpha indices were significantly higher in BM than in matched primary tumors. In patients treated with adjuvant WBRT, low BM HIF-1 alpha expression was associated with favorable overall survival (OS), while among patients not treated with adjuvant WBRT, BM HIF-1 alpha expression did not correlate with OS. Low diagnosis-specific graded prognostic assessment score (DS-GPA), low Ki67 index, high MVD, low HIF-1 alpha index and administration of adjuvant WBRT were independently associated with favorable OS. Incorporation of tissue-based parameters into the commonly used DS-GPA allowed refined discrimination of prognostic subgroups. CONCLUSION Ki67 index, MVD and HIF-1 alpha index have promising prognostic value in BM and should be validated in further studies.
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Affiliation(s)
- A S Berghoff
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
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