Risk of brain metastases in patients with nonmetastatic lung cancer: Analysis of the Metropolitan Detroit Surveillance, Epidemiology, and End Results (SEER) data

Incidence and real-world burden of brain metastases from solid tumors and hematologic malignancies in Ontario: a population-based study

BACKGROUND

Although intracranial metastatic disease (IMD) is a frequent complication of cancer, most cancer registries do not capture these cases. Consequently, a data-gap exists, which thwarts system-level quality improvement efforts. The purpose of this investigation was to determine the real-world burden of IMD.

METHODS

Patients diagnosed with a non-CNS cancer between 2010 and 2018 were identified from the Ontario Cancer Registry. IMD was identified by scanning hospital administrative databases for cranial irradiation or coding for a secondary brain malignancy (ICD-10 code C793).

RESULTS

25,478 of 601,678 (4.2%) patients with a diagnosis of primary cancer were found to have IMD. The median time from primary cancer diagnosis to IMD was 5.2 (0.7, 15.4) months and varied across disease sites, for example, 2.1 months for lung, 7.3 months for kidney, and 22.8 months for breast. Median survival following diagnosis with IMD was 3.7 months. Lung cancer accounted for 60% of all brain metastases, followed by breast cancer (11%) and melanoma (6%). More advanced stage at diagnosis and younger age were associated with a higher likelihood of developing IMD (P < .0001). IMD was also associated with triple-negative breast cancers and ductal histology (P < .001), and with small-cell histology in patients with lung cancer (P < .0001). The annual incidence of IMD was 3,520, translating to 24.2 per 100,000 persons.

CONCLUSION

IMD represents a significant burden in patients with systemic cancers and is a significant cause of cancer mortality. Our findings support measures to actively capture incidents of brain metastasis in cancer registries.

The construction and validation of the model for predicting the incidence and prognosis of brain metastasis in lung cancer patients

BACKGROUND

Brain metastasis (BM) causes high morbidity and mortality rates in lung cancer (LC) patients. The present study aims to develop models for predicting the development and prognosis of BM using a large LC cohort.

METHODS

A total of 266,522 LC cases diagnosed between 2010 and 2016 were selected from the Surveillance, Epidemiology, and End Results (SEER) Program cohort. Risk factors for developing BM and prognosis were calculated by univariable and multivariable logistic and Cox regression analysis, respectively, and nomograms were constructed based on risk factors. Nomogram performance was evaluated with receiver operating characteristics (ROC) curve, or C-index and calibration curve.

RESULTS

The prevalence of BM was 13.33%. Associated factors for developing BM include: advanced age; Asian or Pacific Islander race; uninsured status; primary tumor site; higher T stage; higher N stage; poorly differentiated grade; the presence of lung, liver, and bone metastases; and adenocarcinoma histology. Median overall survival (OS) was 4 months; associated prognosis factors were similar to risk factors plus female gender, unmarried status, and surgery. The calibration curve showed good agreement between predicted and actual probability, and the AUC/C-index was 73.1% (95% CI: 72.6-73.6%) and 0.88 (95% CI: 0.87-0.89) for risk and prognosis predictive models, respectively.

CONCLUSIONS

BM was highly developed in LC patients, and homogeneous and heterogeneous factors were found between risk and prognosis for BM. The nomogram showed good performance in predicting BM development and prognosis.

The development and validation of a nomogram for predicting brain metastases in lung squamous cell carcinoma patients: an analysis of the Surveillance, Epidemiology, and End Results (SEER) database

Background

The incidence of brain metastasis (BM) in patients suffering from lung squamous cell carcinoma (LUSC) is lower than that in patients suffering from non-squamous cell carcinoma (NSCC) and there are few studies on BM of LUSC. The purpose of this investigation was to ascertain the risk factors of LUSC, as well as to establish a nomogram prognostic model to predict the incidence of BM in patients with LUSC.

Methods

Patients diagnosed with LUSC between 2010 and 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) database and the patient data were collated. All patients diagnosed from 2010–2012 were allocated into the training cohort, and the remaining patients diagnosed from 2013–2015 formed the test cohort. Using factors that were screened out through logistic regression analyses, the nomogram in the training cohort was established. It was then evaluated for discrimination and calibration using the test cohort. The performance of the nomogram was assessed by quantifying the area under the receiver operating characteristic (ROC) curve and evaluating the calibration curve.

Results

A total of 26,154 LUSC patients were included in the study. The training cohort consisted of 16,543 patients and there were 8611 patients in the test cohort. Age, marital status, insurance status, histological grade, tumor location, laterality, stage of the cancer, number of metastatic organs, chemotherapy, surgery, and radiotherapy were highly correlated with the incidence of BM. The area under the ROC curve (AUC) of the nomogram for the training cohort and the test cohort were 0.810 [95% confidence interval (CI): 0.796 to 0.823] and 0.805 (95% CI: 0.784 to 0.825), respectively. The slope of the calibration curve was close to 1.

Conclusions

The nomogram was able to accurately predict the incidence of BM. This may be beneficial for the early identification of high-risk LUSC patients and the establishment of individualized treatments.

Characteristics and Clinical Outcome of Breast Cancer Patients with Asymptomatic Brain Metastases

Background: Brain metastases (BM) have become a major challenge in patients with metastatic breast cancer. Methods: The aim of this analysis was to characterize patients with asymptomatic BM (n = 580) in the overall cohort of 2589 patients with BM from our Brain Metastases in Breast Cancer Network Germany (BMBC) registry. Results: Compared to symptomatic patients, asymptomatic patients were slightly younger at diagnosis (median age: 55.5 vs. 57.0 years, p = 0.01), had a better performance status at diagnosis (Karnofsky index 80-100%: 68.4% vs. 57%, p < 0.001), a lower number of BM (>1 BM: 56% vs. 70%, p = 0.027), and a slightly smaller diameter of BM (median: 1.5 vs. 2.2 cm, p < 0.001). Asymptomatic patients were more likely to have extracranial metastases (86.7% vs. 81.5%, p = 0.003) but were less likely to have leptomeningeal metastasis (6.3% vs. 10.9%, p < 0.001). Asymptomatic patients underwent less intensive BM therapy but had a longer median overall survival (statistically significant for a cohort of HER2-positive patients) compared to symptomatic patients (10.4 vs. 6.9 months, p < 0.001). Conclusions: These analyses show a trend that asymptomatic patients have less severe metastatic brain disease and despite less intensive local BM therapy still have a better outcome (statistically significant for a cohort of HER2-positive patients) than patients who present with symptomatic BM, although a lead time bias of the earlier diagnosis cannot be ruled out. Our analysis is of clinical relevance in the context of potential trials examining the benefit of early detection and treatment of BM.

Predictors of prognosis of synchronous brain metastases in small-cell lung cancer patients

Patients with small cell lung cancer (SCLC) are more likely to have synchronous brain metastasis (SBM) at the time of diagnosis than patients with any other extracranial primary malignancy. We sought to identify which factors predicted an increased risk of SBM in SCLC as well as which factors affected the prognosis of these patients. 38,956 Patients in the Surveillance, Epidemiology, and End Results (SEER) database with microscopically confirmed SCLC from 2010 to 2016 were identified. 6264 (16.1%) Patients with SCLC had SBM at the time of diagnosis. In the multivariable logistic regression, disease specific factors that were predictive of SBM were primary tumor size > 7 cm (adjusted OR = 1.14, 95% CI [1.02, 1.28], p = 0.02), synchronous lung metastases, and synchronous bone metastases. Demographic specific factors predictive of increased SBM risk in this model were younger age, male sex, and race (American Indian/Alaska Native and black patients). Patients insured through Medicaid were less likely to present with SBM. In the multivariate Cox proportional hazards model, lack of insurance was the strongest predictor of mortality (adjusted HR = 1.47, 95% CI [1.26, 1.73], p < 0.001). Other factors associated with an increased risk of mortality include male sex, older age, health insurance coverage through Medicaid, synchronous liver metastasis, synchronous lung metastasis, and primary tumor size > 7 cm. In contrast, Asian patients had a lower risk of mortality. This study identifies risk factors for SBM among patients with SCLC, as well as indicators of prognosis among this patient population.

Risk of brain metastases in T1-3N0 NSCLC: a population-based analysis

Aim:

Several consensus guidelines recommend against routine brain imaging at diagnosis of T1-3N0 non-small cell lung cancer (NSCLC).

Methods:

From the Surveillance, Epidemiology and End Results registry, patients with pathologically confirmed T1-3N0 NSCLC were identified. Risks of brain metastases at time of initial diagnosis were analyzed.

Results:

Patients selected to not undergo primary NSCLC resection had approximately tenfold greater incidence of brain metastases versus those who did. Younger age, adenocarcinoma histology, higher tumor stage and higher histologic grade were all significantly (p < 0.0001) associated with greater likelihood of presenting with brain metastases.

Conclusion:

Given the morbidity and mortality of brain metastases, routine brain screening after NSCLC diagnosis (particularly adenocarcinoma) may be justifiable, though more refined cost-benefit analyses are warranted.

Metastases to the central nervous system: Molecular basis and clinical considerations

BACKGROUND

Metastatic tumors are the most common malignancies of the central nervous system (CNS) in adults. CNS metastases are associated with unfavorable prognosis, high morbidity and mortality. Lung cancer is the most common source of brain metastases, followed by breast cancer and melanoma. Rising incidence is primarily due to improvements in systemic control of primary malignancies, prolonged survival and advances in cancer detection.

PURPOSE

To provide an overview of the metastatic cascade and the role of angiogenesis, neuroinflammation, metabolic adaptations, and clinical details about brain metastases from different primary tumors.

METHODS

A review of the literature on brain metastases was conducted, focusing on the pathophysiology and clinical aspects of the disease. PubMed was used to search for relevant articles published from January 1975 through December 2019 using the keywords brain metabolism, brain metastasis, metastatic cascade, molecular mechanisms, incidence, risk factors, and prognosis. 146 articles met the criteria and were included in this review.

DISCUSSION

Some primary tumors have a higher tendency to metastasize to the CNS. Establishing a suitable metastatic microenvironment is important in maintaining tumor cell growth and survival. Magnetic resonance imaging (MRI) is a widely used tool for diagnosis and treatment monitoring. Available treatments include surgery, radiotherapy, stereotactic radiosurgery, chemotherapy, immunotherapy, and systemic targeted therapies.

CONCLUSIONS

Prevention of metastases to the CNS remains a difficult challenge. Advances in screening of high-risk patients and future development of novel treatments may improve patient outcomes.

Icotinib is as efficacious as gefitinib for brain metastasis of EGFR mutated non-small-cell lung cancer

BACKGROUND

The prognosis of non-small-cell lung cancer (NSCLC) with brain metastases is very poor. Currently, therapeutic methods for this patient population include whole-brain radiation therapy (WBRT), surgery, radiosurgery and systemic treatment. Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) could be effective on cerebral metastases of mutated NSCLC. However, which EGFR-TKIs is more appropriate is still unknown.

METHODS

We conducted a retrospective analysis of advanced NSCLC patients with brain metastases for EGFR targeted therapy from November 2013 to April 2018 at Dongguan People's Hospital, Southern Medical University, China. A total of 43 patients were recruit in this study. Among them, 21 cases received icotinib (125 mg, thrice a day) and 22 cases received gefitinib (250 mg, once a day) until disease progression or unacceptable toxicity. The primary end point of this study was intracranial PFS (iPFS). The relationships between therapeutic arms and patients characteristics were performed using Pearson's chi-square test or Fisher's exact test. The differences in PFS among the two arms were analyzed using Kaplan-Meier curves and log rank tests.

RESULTS

There was no significant difference of intracranial ORR (66.6% versus 59.1%, P = 0.62) and DCR (85.7% versus 81.8%, P = 0.73) between the two arms. The median intracranial PFS (iPFS) for icotinib and gefitinib arms were 8.4 months (95% CI, 5.4 to 11.3 months) and 10.6 months (95% CI, 6.3 to 14.8 months), respectively (P = 0.17). Adverse events of the two study arms were generally mild. None of the patients experienced dose reduction of EGFR-TKIs.

CONCLUSIONS

Our study showed that icotinib and gefitinib had similar efficacy for brain metastasis of EGFR mutated NSCLC. Large randomized studies are suggested to further illuminate the effect of these two EGFR-TKIs on cerebral lesions of NSCLC.

Durable response to pulsatile icotinib for central nervous system metastases from EGFR-mutated non-small cell lung cancer: A case report

BACKGROUND

Central nervous system (CNS) metastases are a catastrophic complication of non-small cell lung cancer (NSCLC), including brain and leptomeningeal carcinomatosis, and are always accompanied by a poor prognosis. Despite the continuous development of existing treatments, the therapy of CNS metastases remains challenging.

CASE SUMMARY

We report a patient who was definitively diagnosed with brain and leptomeningeal metastases from NSCLC with a targeted mutation in epidermal growth factor receptor (EGFR). A standard dosage of icotinib (125 mg three times daily) was implemented but ineffective. CNS lesions developed despite stable systemic control, so pulsatile icotinib (1125 mg every 3 d) was administered. This new strategy for administration has lasted 25 mo so far, and resulted in complete remission of neurological symptoms, almost vanished lesions, and longer survival with no notable side effects.

CONCLUSION

This is the first successful example of pulsatile icotinib for treating isolated CNS progression from EGFR mutation-positive NSCLC, providing a new alternative for the local treatment of CNS metastases.

Stereotactic Radiation Therapy (SRT) for Brain Metastases of Multiple Primary Tumors: A Single Institution Retrospective Analysis

Purpose: To evaluate the efficiency and side effects of stereotactic radiation therapy (SRT) with or without other treatments for brain metastases (BM) from various primary tumors.

Methods: This was a retrospective analysis of 161 patients with brain metastases treated with SRT. Clinical data, EGFR mutation status and survival data were collected. Follow-up data was analyzed until December 2018. Kaplan-Meier and Cox proportional hazards regression analyses were used for the survival analysis.

Results: The median overall survival (OS) was 19 months. No difference was observed in OS between SRT group and SRT + whole brain radiation therapy (WBRT) groups (p = 0.717). Statistically significant factors of better OS after univariable analysis were no extracranial metastases (p = 0.016), BED₁₀-SRT≥50Gy (p = 0.049), oligometastases (1–3 brain metastases) (p < 0.001), GPA score≥2.5 (p = 0.003), RPA class I (p = 0.026), NSCLC tumor type (p = 0.006), targeted therapy (p < 0.001) and controlled extracranial disease (p = 0.011). Multivariate analysis indicated that higher BED₁₀-SRT (≥50Gy, HR = 0.504, p = 0.027), controlled extracranial disease (HR = 0.658, p = 0.039) and targeted therapy (HR = 0.157, <0.001) were independent favorable predictors for OS. Besides that, we also find that the median overall survival (OS) was 22 months in NSCLC patients and controlled extracranial disease (HR = 0.512, p = 0.012) and targeted therapy (HR = 0.168, < 0.001) were independent favorable predictors for OS.

Conclusion: For patients with brain metastases, stable extracranial disease, higher BED₁₀-SRT (≥50Gy) and targeted therapy may predict a favorable prognosis.

Temozolomide plus whole brain radiotherapy for the treatment of non-small-cell lung cancer patients with brain metastases: A protocol of an updated systematic review and meta-analysis

INTRODUCTION

Whole brain radiotherapy (WBRT) has been the mainstay treatment of brain metastases (BM) in non-small cell lung cancer (NSCLC) patients for years. Temozolomide (TMZ) could penetrate the blood-brain barrier and some studies showed that TMZ plus MBRT may improve clinical effectiveness. This meta-analysis is aim to evaluate the clinical effectiveness and safety of TMZ plus MBRT in the NSCLC patients with BM.

METHODS AND ANALYSIS

We systematically searched databases including PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and four Chinese databases (Chinese Biomedical Database, China National Knowledge Infrastructure, Wanfang Database and Chinese Scientific Journal Database) without language restrictions from inception until July 26, 2019. Randomized controlled trials (RCTs) which compared TMZ plus WBRT with single WBRT in the advanced NSCLC patients with BM were included. The outcomes analysis reported objective response rate (ORR), disease control rate (DCR), overall survival (OS), progression-free survival (PFS), quality of life (QOL), and adverse effects. Two reviewers will independently extract data from the selected studies and assess the quality of studies. Statistical analyses will be performed using Review manager 5.3 software. Random-effects or fixed models were used to estimate pooled hazard ratio and relative risk.

RESULTS

This systemic review and meta-analysis will evaluate the effects of TMZ plus MBRT in the NSCLC patients with BM in RCTs.

CONCLUSION

Our study will provide evidence to judge if TMZ plus MBRT are effective treatment for NSCLC patients with BM.

The impact of systemic treatment on brain metastasis in patients with non-small-cell lung cancer: A retrospective nationwide population-based cohort study

To compare the incidence of brain metastases of advanced non-small cell lung cancer (NSCLC) treated with systemic cytotoxic chemotherapy (CC) and targeted therapy (TT), we performed a large-scale, retrospective, nationwide, cohort study. The population data were extracted from the Health Insurance Review and Assessment Service of Korea database from January 1, 2011, to November 30, 2016. Of the 29,174 patients newly diagnosed with stage IIIB or IV NSCLC who received systemic treatment, we investigated the initial and subsequent incidence of brain metastases. Besides, among 22,458 patients without initial brain metastasis, the overall cumulative incidence of subsequent brain metastases was compared according to systemic treatment administered. In total, 1,126 (5.0%) patients subsequently developed brain metastasis. The overall cumulative incidence of brain metastasis was significantly higher in the TT group than in the CC group (1-year cumulative incidence: 8.7% vs. 3.8%; 3-year: 17.2% vs. 5.0%; P < 0.001). Younger age, female sex, and first-line TT were significant risk factors for subsequent brain metastasis. In conclusion, the overall cumulative incidence of brain metastasis was significantly higher in patients received TT as the first-line treatment than in those received CC.

Relationship between WBRT total dose, intracranial tumor control, and overall survival in NSCLC patients with brain metastases - a single-center retrospective analysis

Background

The relationship between whole brain radiotherapy (WBRT) dose with intracranial tumor control and overall survival (OS) in patients with non-small cell lung cancer (NSCLC) brain metastases (BM) is largely unknown.

Methods

We retrospectively analyzed 595 NSCLC BM patients treated consecutively at the Fourth Hospital of Hebei Medical University between 2013 to 2015. We assigned the patients into 4 dose groups of WBRT: none, < 30, 30–39, and ≥ 40 Gy and assessed their relationship with OS and intracranial progression-free survival (iPFS). Cox models were utilized. Covariates included sex, age, KPS, BM lesions, extracranial metastasis, BM and lung tumor resection, chemotherapy, targeted therapy, and focal radiotherapy modalities.

Results

Patients had a mean age of 59 years and were 44% female. Their median survival time (MST) of OS and iPFS were 9.3 and 8.9 months. Patients receiving none (344/58%), < 30 (30/5%), 30–39 (93/16%), and ≥ 40 (128/22%) Gy of WBRT had MST of OS (iPFS) of 7.3 (6.8), 6.0 (5.4), 10.3 (11.9) and 11.9 (11.9) months, respectively. Compared to none, other WBRT groups had adjusted HRs for OS - 1.23 (p > 0.20), 0.72 (0.08), 0.61 (< 0.00) and iPFS - 1.63 (0.03), 0.71 (0.06), 0.67 (< 0.01). Compared to 30–39 Gy, WBRT dose ≥40 Gy was not associated with improved OS and iPFS (all p > 0.40). Stratified analyses by 1–3 and ≥ 4 BM lesions and adjustment analyses by each prognostic index of RPA class, Lung-GPA and Lung-molGPA supported these relationships as well.

Conclusions

Compared to none, WBRT doses ≥30 Gy are invariably associated with improved intracranial tumor control and survival in NSCLC BM patients.

Fractionated stereotactic radiosurgery for locally recurrent brain metastases after failed stereotactic radiosurgery

AIMS AND BACKGROUND

There is scant data on the utility of repeated radiosurgery for management of locally recurrent brain metastases after upfront stereotactic radiosurgery (SRS). Most studies have used single-fraction SRS for repeated radiosurgery, and the use of fractionated stereotactic radiosurgery (f-SRS) in this setting has been poorly addressed. In this study, we assessed the utility of f-SRS for the management of locally recurrent brain metastases after failed upfront single-fraction SRS and report our single-center experience.

METHODS AND STUDY DESIGN

A total of 30 patients receiving f-SRS for locally recurrent brain metastases after upfront single-fraction SRS at our department between September 2011 and September 2017 were retrospectively evaluated for local control (LC), toxicity, and overall survival outcomes.

RESULTS

Median age and Karnofsky performance status were 57 (range: 38-78 years) and 80 (range: 70-100) at repeated radiosurgery (SRS2). The median time interval between the two radiosurgery applications was 13.5 months (range: 3.7-49 months). LC after SRS2 was 83.3%. Radionecrosis developed in 4 of the 30 lesions after SRS2, and total rate of radionecrosis was 13.3%. Statistical analysis revealed that the volume of planning target volume (PTV) at SRS2 was significantly associated with radionecrosis (P = 0.014). The volume of PTV was >13 cm³ at SRS2 in all patients with radionecrosis.

CONCLUSION

A repeated course of radiosurgery in the form of f-SRS may be a viable therapeutic option for the management of locally recurrent brain metastases after failed upfront SRS with high LC rates and an acceptable toxicity profile despite the need for further supporting evidence.

Prognostic assessment in patients with newly diagnosed small cell lung cancer brain metastases: results from a real-life cohort

Purposes

Brain metastases (BM) are a frequent complication in small cell lung cancer (SCLC), resulting in a reduced survival prognosis. Precise prognostic assessment is an important foundation for treatment decisions and clinical trial planning.

Methods

Patients with newly diagnosed SCLC BM were identified from the Vienna Brain Metastasis Registry and evaluated concerning prognostic factors.

Results

489 patients (male 62.2%, female 37.8%; median age 61 years) were included. Neurological symptoms were present in 297/489 (60.7%) patients. A- to oligosymptomatic patients (5 vs. 9 months, p = 0.030) as well as patients with synchronous diagnosis of BM and primary tumor (5 vs. 9 months, p = 0.008) presented with improved overall survival (OS) prognosis. RPA (HR 1.66; 95% CI 1.44–1.91; p < 0.001), GPA (HR 1.65; p < 0.001), DS-GPA (HR 1.60; p < 0.001) and LabBM score (HR 1.69; p < 0.001) were statistically significantly associated with OS. In multivariate analysis, DS-GPA (HR 1.59; p < 0.001), neurological deficits (HR 1.26; p = 0.021) and LabBM score (HR 1.57; p < 0.001) presented with statistical independent association with OS.

Conclusion

A- to oligosymptomatic BM as well as synchronous diagnosis of SCLC and BM were associated with improved OS. Established prognostic scores could be validated in this large SCLC BM real-life cohort.

Electronic supplementary material

The online version of this article (10.1007/s11060-019-03269-x) contains supplementary material, which is available to authorized users.

KRAS Exon 3 and PTEN Exon 7 Mutations in Small-cell Lung Cancer

Small cell lung cancer (SCLC) is recognized as one of the most aggressive and fatal malignant tumors. No significant improvement has been made to prolong the survival of SCLC patients. This study aimed to examine the mutation status of K-Ras (KRAS) and phosphatase and tensin homolog (PTEN) in SCLC patients in order to identify potential therapeutic targets for SCLC. Nineteen primary SCLC tumor specimens were enrolled in the study. Direct sequencing was performed to detect the mutations of KRAS exon 3 and PTEN exon 7 in the specimens. Kaplan- Meier and Cox regression analysis was performed to determine the overall survival (OS) of these SCLC patients. KRAS exon 3 mutation was found in 4 (21%) SCLC patients, and PTEN exon 7 mutation in only 1 (5%) SCLC patient. Kaplan Meier analysis showed that clinical stage and brain metastasis were significantly associated with OS (both P<0.05), but neither KRAS exon 3 mutation nor PTEN exon 7 mutation was significantly associated with OS (P>0.05). Cox proportional hazards regression model indicated that extensive stage of disease was the only independent negative prognostic factor for OS in SCLC patients. In conclusion, KRAS exon 3 and PTEN exon 7 mutations had no significant impact on OS of SCLC patients. Further study is still necessary to validate the molecular profiles of SCLC.

Standard dose osimertinib for erlotinib refractory T790M-negative EGFR-mutant non-small cell lung cancer with leptomeningeal disease

Background

Leptomeningeal spread in non-small cell lung cancer (NSCLC) patients with epidermal growth factor receptor (EGFR) mutations who experience disease progression on TKIs portends a poor prognosis. Mutation profiling of tumour DNA in cerebrospinal fluid (CSF) samples can be used to determine the presence of the EGFR T790M resistance mutation, indicating that osimertinib, a CNS-penetrating 3^rd generation TKI may be efficacious.

Methods

Eight patients on EGFR TKIs who progressed with cytology-proven leptomeningeal disease at our institution were studied. EGFR mutations were profiled in CSF using droplet digital PCR (ddPCR) and compared to matched plasma samples. Clinical characteristics and survival outcomes on subsequent therapies tailored to ddPCR analysis were reported.

Results

None of the four patients who developed leptomeningeal disease while receiving 1st generation EGFR TKIs developed the EGFR T790M mutation in CSF. One patient who did not have extra-cranial disease and was EGFR T790M-negative in both plasma and CSF was nevertheless treated with standard-dose osimertinib, and achieved a rapid and durable response lasting 9 months to date. Three patients developed leptomeningeal disease on osimertinib, with one patient developing the EGFR C797S mutation in a cis-allelic conformation with the EGFR T790M mutation in plasma.

Conclusions

Standard-dose osimertinib resulted in a clinically meaningful response in a patient with EGFR T790M-negative 1st generation EGFR TKI refractory leptomeningeal disease. Next generation sequencing and ddPCR has a role at identifying the C797S mutation and its allelic conformation with the T790M mutation with clinical implications.

Natural history, clinical course and predictors of interval time from initial diagnosis to development of subsequent NSCLC brain metastases

PURPOSE

Non-small cell lung cancer (NSCLC) brain metastases are associated with substantial morbidity and mortality. During recent years, accompanying dramatic improvements in systemic disease control, NSCLC brain metastases have emerged as an increasingly relevant clinical problem. However, optimal surveillance practices remain poorly defined. This purpose of this study was to further characterize the natural history, clinical course and risk factors associated with earlier development of subsequent NSCLC brain metastases to better inform clinical practice and help guide survivorship care.

METHODS

We retrospectively reviewed all institutional NSCLC brain metastasis cases treated with radiotherapy between 1997 and 2015. Exclusion criteria included presence of brain metastases at initial NSCLC diagnosis and incomplete staging information. Interval time to brain metastases and subsequent survival were characterized using Kaplan-Meier and multivariate Cox regression analyses.

RESULTS

Among 105 patients within this cohort, median interval time to development of brain metastases was 16 months. Median interval times were 29, 19, 16 and 13 months for Stage I-IV patients, respectively (P = 0.016). Additional independent predictors for earlier development of NSCLC brain metastases included non-adenocarcinomatous histopathology (HR 3.036, P < 0.001), no prior surgical resection (HR 1.609, P = 0.036) and no prior systemic therapy (HR 3.560, P = 0.004). Median survival following intracranial progression was 16 months. Delayed development of brain metastases was associated with better prognosis (HR 0.970, P < 0.001) but not survival following intracranial disease onset.

CONCLUSIONS

Collectively, our results provide valuable insights into the natural history of NSCLC brain metastases. NSCLC stage, histology, prior surgical resection and prior systemic therapy emerged as independent predictors for interval time to brain metastases.

From Whole-Brain Radiotherapy to Immunotherapy: A Multidisciplinary Approach for Patients with Brain Metastases from NSCLC

Non-small cell lung cancer patients with brain metastases have a multitude of treatment options, but there is currently no international and multidisciplinary consensus concerning their optimal treatment. Local therapies have the principal role, especially in symptomatic patients. Advances in surgery and radiation therapy manage considerable local control. Systemic treatments have shown effect in clinical trials and in real life clinical settings; yet, at present, this is restricted to patients with asymptomatic or stable intracranial lesions. Targeted agents can have a benefit only in patients with EGFR mutations or ALK rearrangement. Immunotherapy has shown impressive results in patients with PD-L1 expression in tumor cells. Its effects can be further enhanced by a synergy with radiotherapy, possibly by increasing the percentage of responders. The present review summarizes the need for more effective systemic treatments, so that the increased intracranial control achieved by local treatments can be translated in an increase in overall survival.

Incidence of brain metastasis in lung adenocarcinoma at initial diagnosis on the basis of stage and genetic alterations

OBJECTIVE

Patients with lung adenocarcinoma (ADC) are at higher risk of the development of brain metastasis (BM), and genetic alterations are associated with BM.

PATIENTS AND METHODS

A total of 598 patients with lung ADC in our institution between January 2014 and December 2014 were reviewed retrospectively. We evaluated the incidence of BM by stage and genetic alterations.

RESULTS

Of the 598 patients, 97 (16.2%) had BM, which occurred across all stages. The incidence of BM showed a tendency to increase as the stage increased (p < 0.001, trend test). Although patients with EGFR mutations had BM across all stages, those with ALK or K- mutations had BM only in stage III and IV diseases. Regardless of types of mutations, the incidence of BM showed a tendency to increase as the T or N staging increased (p < 0.001 for each of EGFR, ALK, and K-RAS mutations, trend test). Whereas BM incidence showed a tendency to increase as the M staging increased in patients with EGFR-mutant lung ADC (p < 0.001, trend test), there was no linear trend between M staging and ALK (p = 0.469, trend test) or K-RAS mutations (p = 0.066, trend test). After adjusting covariables, EGFR mutations were associated with BM in never-smokers (adjusted OR = 2.07, 95% CI = 1.02-4.34) and K-RAS mutations were risk factors for BM in males (adjusted OR = 3.86, 95% CI = 1.01-14.43).

CONCLUSIONS

BM occurred in approximately 16% of lung ADC patients, including 3% with stage I diseases. Whereas EGFR-mutant lung ADC had BM across all stages, ALK- or K-RAS-mutant lung ADC had BM only in advanced stages. EGFR mutations were risk factors for BM among never-smokers and K-RAS mutations were risk factors among males.

Prognostic impact of combining whole-body PET/CT and brain PET/MR in patients with lung adenocarcinoma and brain metastases

PURPOSE

The role of brain FDG-PET in patients with lung cancer and brain metastases remains unclear. Here, we sought to determine the prognostic significance of whole-body PET/CT plus brain PET/MR in predicting the time to neurological progression (nTTP) and overall survival (OS) in this patient group.

METHODS

Of 802 patients with non-small cell lung cancer who underwent primary staging by a single-day protocol of whole-body PET/CT plus brain PET/MR, 72 cases with adenocarcinoma and brain metastases were enrolled for a prognostic analysis of OS. On the basis of the available follow-up brain status, only 52 patients were eligible for prognostic analysis of nTTP. Metastatic brain tumors were identified on post-contrast MR imaging, and the tumor-to-brain ratio (TBR) was measured on PET images.

RESULTS

Multivariate analysis revealed that FDG-PET findings and eligibility for initial treatment with targeted therapy were significant independent predictors of nTTP and OS. A new index, termed the molecular imaging prognostic (MIP) score, was proposed to define three disease classes. MIP scores were significant predictors of both nTTP and OS (P < 0.001). Pre-existing prognostic indices such as Lung-molGPA scores were significant predictors of OS but did not predict nTTP.

CONCLUSIONS

When staging is performed with whole-body PET/CT plus brain PET/MR, our new prognostic index may be helpful to stratify the outcomes of patients with lung adenocarcinoma and brain metastases. The superior prognostic power of this index for nTTP might be used to select appropriate patients for intracranial control and thereby achieve better quality of life.

Pediatric lung adenocarcinoma presenting with brain metastasis: a case report

BACKGROUND

Diagnosis and treatment of primary lung adenocarcinoma in children remains challenging given its rarity. Here we highlight the clinical history, pathological evaluation, genomic findings, and management of a very young patient with metastatic lung adenocarcinoma.

CASE PRESENTATION

A 10-year-old white girl presented with brain metastases due to primary pulmonary adenocarcinoma. Next generation sequencing analysis with "Comprehensive Cancer Panel" highlighted the presence of multiple non-targetable mutations in the FLT4, UBR5, ATM, TAF1, and GUCY1A2 genes. She was treated aggressively with chemotherapy, surgery, and radiation therapy for local and distant recurrence. Eventually, therapy with nivolumab was started compassionately, and she died 23 months after diagnosis.

CONCLUSIONS

Extremely rare cancers in children such as lung adenocarcinoma need accurate and specific diagnosis in order to develop an optimal plan of treatment. It is also necessary to underline that "children are not little adults," thus implying that an adult-type cancer in the pediatric population might have a different etiopathogenesis. Diagnostic confirmation and primary treatment of such rare conditions should be centralized in reference centers, collaborative networks, or both, with multidisciplinary approaches and very specific expertise.

Brain metastases: epidemiology

Brain metastases (BM) are the most commonly diagnosed type of central nervous system tumor in the United States. Estimates of the frequency of BM vary significantly, as there is no nationwide reporting system for metastases. BM may be the first sign of a previously undiagnosed cancer, or occur years or decades after the primary cancer was diagnosed. Incidence of BM varies significantly by primary cancer site. Lung, breast, and melanoma continue to be the leading cause of BM. These tumors are increasingly more common as new therapeutics, advanced imaging, and improved screening have led to lengthened survival after primary diagnosis for cancer patients. BM are difficult to treat, and for most individuals the diagnosis of BM generally portends a poor prognosis.

Hematologic variables associated with brain failure in patients with small-cell lung cancer

BACKGROUND AND PURPOSE

We sought factors associated with the development of brain metastases after treatment of small cell lung cancer (SCLC) in patients without brain involvement at diagnosis.

METHODS

We analyzed 293 patients with SCLC without brain metastases who received chemotherapy, thoracic radiation therapy (TRT), or both in 2001-2015. Pretreatment hematologic markers (platelet count, neutrophil count, lymphocyte count, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and lactate dehydrogenase) and other clinical characteristics were evaluated for correlation with brain metastases-free survival (BMFS). Cutoffs were established with receiver operating characteristics curves. Factors significant in univariate analysis were used to build a multivariate Cox model for BMFS.

RESULTS

Median follow-up time was 14.3 months. Brain metastases developed in 115 patients (39%)-32% of those with low pretreatment platelet counts (PPC) (≤270 × 10⁹/L) and 46% of those with high PPC (>270 × 10⁹/L). Median BMFS time for all patients was 27.9 months. Two-year BMFS rates were worse for patients with high PPC (14.6% vs. 22.1% low, P = 0.009). High PPC was independently associated with inferior BMFS (P = 0.038), as were receipt of TRT <45 Gy and no prophylactic cranial irradiation (both P < 0.001).

CONCLUSIONS

High PPC was associated with increased rates of brain metastasis in patients with SCLC with no evidence of brain disease at diagnosis.

Outcomes of Surgery as Part of the Management of Metastatic Non-Small-Cell Lung Cancer: A Surveillance, Epidemiology and End Results Database Analysis

The role of local treatment in patients with oligometastatic non-small-cell lung cancer (NSCLC) is a subject of ongoing debate. This study assessed the survival impact of combined surgery to the primary tumor and metastatic disease in the management of metastatic NSCLC. Stage IV NSCLC patients at presentation, diagnosed from 2004 to 2013 were identified from the SEER (Surveillance, Epidemiology, and End Results) database. Propensity-matched analysis was performed considering baseline characteristics (age, gender, race, histology, TN stage, and site of metastases). A total of 144,334 patients were identified. The median age group was 65-70 years, and 1139 patients (0.8% of the patients) have received surgical treatment to both the primary tumor and metastatic disease. Both before and after propensity score matching, cancer-specific and overall survival were better in the surgical therapy group (P < 0.0001 for all). When the analysis was restricted to the subsets of patients with brain only M1 disease or isolated contra lateral nodule, overall survival was improved by combined surgery. However, in multivariate analysis of the overall population (postmatching), combined surgery was not associated with a better overall survival (0.576). Despite the apparently beneficial role of surgery in this study for some patients with metastatic disease, the absence of adequate information about systemic therapy as well as associated comorbidity hinders the generation of definite conclusions. Prospective studies are needed to confirm the role of surgery in the setting of metastatic disease.

Current progress and outcomes of clinical trials on using epidermal growth factor receptor-tyrosine kinase inhibitor therapy in non-small cell lung cancer patients with brain metastases

Non-small cell lung cancer (NSCLC) continues to be one of the major causes of cancer-related deaths worldwide, and brain metastases are the major cause of death in NSCLC patients. With recent advances in understanding the underlying molecular mechanism of NSCLC development and progression, mutations in epidermal growth factor receptor (EGFR) have been recognized as a key predictor of therapeutic sensitivity to EGFR tyrosine kinase inhibitors (TKIs). Using EGFR-TKI alone or in combination with standard treatments such as whole-brain radiotherapy and surgery has been an effective strategy for the management of brain metastasis. Particularly, a newer generation of EGFR-TKIs, including osimertinib and AZD3759, has been developed. These new EGFR-TKIs can cross the blood-brain barrier and potentially treat EGFR-TKI resistance and improve prognosis. In this article, current progress and outcomes of clinical trials on the use of EGFR-TKIs for treating NSCLC patients with brain metastasis will be reviewed.

Incidence and prognosis of patients with brain metastases at diagnosis of systemic malignancy: a population-based study

BACKGROUND

Brain metastases are associated with significant morbidity and mortality. Population-level data describing the incidence and prognosis of patients with brain metastases are lacking. The aim of this study was to characterize the incidence and prognosis of patients with brain metastases at diagnosis of systemic malignancy using recently released data from the Surveillance, Epidemiology, and End Results (SEER) program.

METHODS

We identified 1302166 patients with diagnoses of nonhematologic malignancies originating outside of the CNS between 2010 and 2013 and described the incidence proportion and survival of patients with brain metastases.

RESULTS

We identified 26430 patients with brain metastases at diagnosis of cancer. Patients with small cell and non-small cell lung cancer displayed the highest rates of identified brain metastases at diagnosis; among patients presenting with metastatic disease, patients with melanoma (28.2%), lung adenocarcinoma (26.8%), non-small cell lung cancer not otherwise specified/other lung cancer (25.6%), small cell lung cancer (23.5%), squamous cell carcinoma of the lung (15.9%), bronchioloalveolar carcinoma (15.5%), and renal cancer (10.8%) had an incidence proportion of identified brain metastases of >10%. Patients with brain metastases secondary to prostate cancer, bronchioloalveolar carcinoma, and breast cancer displayed the longest median survival (12.0, 10.0, and 10.0 months, respectively).

CONCLUSIONS

In this study we provide generalizable estimates of the incidence and prognosis for patients with brain metastases at diagnosis of a systemic malignancy. These data may allow for appropriate utilization of brain-directed imaging as screening for subpopulations with cancer and have implications for clinical trial design and counseling of patients regarding prognosis.

State-of-the-art considerations in small cell lung cancer brain metastases

BACKGROUND

Small cell lung cancer (SCLC) frequently leads to development of brain metastases. These unfortunately continue to be associated with short survival. Substantial advances have been made in our understanding of the underlying biology of disease. This understanding on the background of previously evaluated and currently utilized therapeutic treatments can help guide the next steps in investigations into this disease with the potential to influence future treatments.

DESIGN

A comprehensive review of the literature covering epidemiology, pathophysiology, imaging characteristics, prognosis, and therapeutic management of SCLC brain metastases was performed.

RESULTS

SCLC brain metastases continue to have a poor prognosis. Both unique aspects of SCLC brain metastases as well as features seen more universally across other solid tumor brain metastases are discussed. Systemic therapeutic studies and radiotherapeutic approaches are reviewed.

CONCLUSIONS

A clearer understanding of SCLC brain metastases will help lay the framework for studies which will hopefully translate into meaningful therapeutic options for these patients.

Validation of the graded prognostic assessment for lung cancer with brain metastases using molecular markers (lung-molGPA)

Background

Many patients with brain metastases from non-small cell lung cancer have limited survival, while others survive for several years, depending on patterns of spread, EGFR and ALK alterations, among others. The purpose of this study was to validate a new prognostic model (Lung-molGPA) originally derived from a North American database.

Patients and methods

This retrospective study included 269 German and Norwegian patients treated with individualized approaches, always including brain radiotherapy. Information about age, extracranial spread, number of brain metastases, performance status, histology, EGFR and ALK alterations was collected. The Lung-molGPA score was calculated as described by Sperduto et al.

Results

Median survival was 5.4 months. The score predicted survival in patients with adenocarcinoma histology and those with other types. For example, median survival was 3.0, 6.2, 14.7 and 25.0 months in the 4 different prognostic strata for adenocarcinoma. The corresponding figures were 2.4, 5.5 and 12.5 months in the 3 different prognostic strata for non-adenocarcinoma.

Conclusions

These results confirm the validity of the Lung-molGPA in an independent dataset from a different geographical region. However, median survival was shorter in 6 of 7 prognostic strata. Potential explanations include lead time bias and differences in treatment selection, both brain metastases-directed and systemically.

The TNM 8 M1b and M1c classification for non-small cell lung cancer in a cohort of patients with brain metastases

BACKGROUND AND PURPOSE

According to the recent TNM 8 classification, patients with metastatic non-small cell lung cancer (NSCLC) and single extrathoracic metastasis should be classified as stage M1b, while those with 2 or more metastases comprise stage M1c. The purpose of this study was to analyze the impact of this classification in patients with brain metastases.

MATERIALS AND METHODS

This retrospective study included 172 patients treated with individualized approaches. Actuarial survival was calculated. Uni- and multivariate analyses were performed.

RESULTS

Thirty patients (17%) were staged as M1b. Those with squamous cell cancer were more likely to harbor M1b disease (29%, adenocarcinoma 14%, other histology 17%, p = 0.16). Median survival was 5.4 months (8.0 months in case of M1b disease and 4.5 months in case of M1c disease, p = 0.001). Multivariate analysis confirmed the role of M1b stage. M1b patients managed with upfront surgery or radiosurgery had significantly longer median survival than those who received whole-brain irradiation (21.0 vs. 3.5 months, p = 0.0001) and the potential to survive beyond 5 years.

CONCLUSIONS

We found the M1b classification to provide clinically relevant information. The multivariate analysis suggested that patients with M1b disease, better performance status and younger age have better survival.

Dynamic contrast-enhanced MR imaging pharmacokinetic parameters as predictors of treatment response of brain metastases in patients with lung cancer

OBJECTIVES

To determine the diagnostic accuracy of pharmacokinetic parameters measured by dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) in predicting the response of brain metastases to antineoplastic therapy in patients with lung cancer.

METHODS

Forty-four consecutive patients with lung cancer, harbouring 123 newly diagnosed brain metastases prospectively underwent conventional 3-T MRI at baseline (within 1 month before treatment), during the early (7-10 weeks) and midterm (5-7 months) post-treatment period. An additional DCE MRI sequence was performed during baseline and early post-treatment MRI to evaluate baseline pharmacokinetic parameters (K ^trans, k _ep, v _e, v _p) and their early variation (∆K ^trans, ∆k _ep, ∆v _e, ∆v _p). The objective response was judged by the volume variation of each metastasis from baseline to midterm MRI. ROC curve analysis determined the best DCE MRI parameter to predict the objective response.

RESULTS

Baseline DCE MRI parameters were not associated with the objective response. Early ∆K ^trans, ∆v _e and ∆v _p were significantly associated with the objective response (p = 0.02, p = 0.001 and p = 0.02, respectively). The best predictor of objective response was ∆v _e with an area under the curve of 0.93 [95% CI = 0.87, 0.99].

CONCLUSIONS

DCE MRI and early ∆v _e may be a useful tool to predict the objective response of brain metastases in patients with lung cancer.

KEY POINTS

• DCE MRI could predict the response of brain metastases from lung cancer • ∆v _e was the best predictor of response • DCE MRI could be used to individualize patients' follow-up.

Pulsatile Erlotinib in EGFR-Positive Non-Small-Cell Lung Cancer Patients With Leptomeningeal and Brain Metastases: Review of the Literature

Patients with epidermal growth factor receptor (EGFR)-positive (EGFR⁺) non-small-cell lung cancer (NSCLC) show improved response rates when treated with tyrosine kinase inhibitors (TKIs) such as erlotinib. However, standard daily dosing of erlotinib often does not reach therapeutic concentrations within the cerebrospinal fluid (CSF), resulting in progression of central nervous system (CNS) disease. Intermittent, high-dose administration of erlotinib reaches therapeutic concentrations within the CSF and is well tolerated in patients. Experience with "pulsatile" dosing, however, is limited. We review the literature on the pharmacology and clinical outcomes of pulsatile erlotinib in the treatment of EGFR⁺ NSCLC with brain and leptomeningeal metastases, and include available data on the use of next-generation TKIs in CNS progression. We also provide our institution's experience with patients treated with pulsatile erlotinib for CNS metastasis, and propose clinical criteria for its use. Pulsatile erlotinib is a reasonable alternative in EGFR⁺ patients with new or worsening CNS disease, without evidence of systemic progression, and without confirmed T790M resistance mutations within the CNS.

Brain metastasis in lung cancer: Building a molecular and systems-level understanding to improve outcomes

Lung cancer is a clinically difficult disease with rising disease burden around the world. Unfortunately, most lung cancers present at a clinically advanced stage. Of these cancers, many also present with brain metastasis which complicates the clinical picture. This review summarizes current knowledge on the molecular basis of lung cancer brain metastases. We start from the clinical perspective, aiming to provide a clinical context for a significant problem that requires much deeper scientific investigation. We review new research governing the metastatic process, including tumor cell signaling, establishment of a receptive tumor niches in the brain and evaluate potential new therapeutic options that take advantage of these new scientific advances. Lung cancer remains the largest single cause of cancer mortality in the United States (Siegel et al., 2015). This continues to be the clinical picture despite significant advances in therapy, including the advent of targeted molecular therapies and newly adopted immunotherapies for certain subtypes of lung cancer. In the vast majority of cases, lung cancer presents as advanced disease; in many instances, this advanced disease state is intimately associated with micro and macrometastatic disease (Goldberg et al., 2015). For both non-small cell lung cancer and small cell lung cancer patients, the predominant metastatic site is the brain, with up to 68% of patients with mediastinal lymph node metastasis eventually demonstrating brain metastasis (Wang et al., 2009).The frequency (incidence) of brain metastasis is highest in lung cancers, relative to other common epithelial malignancies (Schouten et al., 2002). Other studies have attempted to predict the risk of brain metastasis in the setting of previously non-metastatic disease. One of the largest studies to do this, analyzing historical data from 1973 to 2011 using the SEER database revealed a 9% risk of patients with previously non-metastatic NSCLC developing brain metastasis over the course of their disease, while 18% of small cell lung cancer patients without previous metastasis went on to develop brain metastasis as their disease progressed (Goncalves et al., 2016).The reasons underlying this predilection for the central nervous system, as well as the recent increase in the frequency of brain metastasis identified in patients remain important questions for both clinicians and basic scientists. More than ever, the question of how brain metastasis develop and how they can be treated and managed requires the involvement of interdisciplinary teams-and more importantly-scientists who are capable of thinking like clinicians and clinicians who are capable of thinking like scientists. This review aims to present a translational perspective on brain metastasis. We will investigate the scope of the problem of brain metastasis and the current management of the metastatic disease process in lung cancer. From this clinical starting point, we will investigate the literature surrounding the molecular underpinnings of lung tumor metastasis and seek to understand the process from a biological perspective to generate new hypotheses.