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Shi W, Wang Y, Xia W, Liu B, Ni M, Shen J, Bai Y, Weng G, Liu W, Yuan S, Gao X. Brain metastases from small cell lung cancer and non-small cell lung cancer: comparison of spatial distribution and identification of metastatic risk regions. J Neurooncol 2023; 161:97-105. [PMID: 36520380 DOI: 10.1007/s11060-022-04211-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE This study aims to investigate the spatial distribution difference of brain metastases (BM) between small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC) and to identify the metastatic risk in brain regions. METHODS T1-enhanced MR images of 2997 BM from 728 eligible patients with SCLC and NSCLC were retrospectively reviewed by three independent medical institutions in China. All images were spatially normalised according to the Montreal Neurological Institute space, following BM delineation confirmed by three senior radiologists. The brain regions in the normalised images were identified based on the merged Anatomical Automatic Labeling atlas, and all BM locations were mapped onto these brain regions. Two-tailed proportional hypothesis testing was used to compare the BM observed rate with the expected rate based on the region's volume, and metastatic risk regions were finally identified. RESULTS In SCLC and NSCLC, BM was mainly present in the deep white matter (22.51% and 17.96%, respectively), cerebellar hemisphere (9.84% and 7.46%, respectively) and middle frontal gyrus (6.72% and 7.97%, respectively). The cerebellar hemisphere was a high-risk brain region in the SCLC. The precentral gyrus, middle frontal gyrus, paracentral lobule and cerebellar hemisphere were high-risk BM in the NSCLC. The inferior frontal gyrus and the temporal pole were a low-risk brain region in the SCLC and NSCLC, respectively. CONCLUSION The spatial BM distribution between SCLC and NSCLC is similar. Several critical brain regions had relatively low BM frequency in both SCLC and NSCLC, where a low-dose radiation distribution can be delivered due to adequate preoperative evaluations.
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Affiliation(s)
- Wei Shi
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, No. 88 Keling Road, Suzhou New District, Suzhou, 215163, Jiangsu, China.,Jinan Guoke Medical Engineering and Technology Development Co., Ltd., Pharmaceutical Valley New Drug Creation Platform, No. 3 Building, Jinan New District, Jinan, 250101, Shandong, China
| | - Yong Wang
- Shandong Cancer Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Wei Xia
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, No. 88 Keling Road, Suzhou New District, Suzhou, 215163, Jiangsu, China.,Jinan Guoke Medical Engineering and Technology Development Co., Ltd., Pharmaceutical Valley New Drug Creation Platform, No. 3 Building, Jinan New District, Jinan, 250101, Shandong, China
| | - Baoyan Liu
- Shandong Academy of Occupational Health and Occupational Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Meng Ni
- Shandong Cancer Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Jingyi Shen
- Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yujun Bai
- Shandong Cancer Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | | | - Wenju Liu
- Liaocheng People's Hospital, Liaocheng, Shandong, China
| | - Shuanghu Yuan
- Shandong Cancer Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China. .,Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China.
| | - Xin Gao
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, No. 88 Keling Road, Suzhou New District, Suzhou, 215163, Jiangsu, China. .,Jinan Guoke Medical Engineering and Technology Development Co., Ltd., Pharmaceutical Valley New Drug Creation Platform, No. 3 Building, Jinan New District, Jinan, 250101, Shandong, China.
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Würtemberger U, Rau A, Reisert M, Kellner E, Diebold M, Erny D, Reinacher PC, Hosp JA, Hohenhaus M, Urbach H, Demerath T. Differentiation of Perilesional Edema in Glioblastomas and Brain Metastases: Comparison of Diffusion Tensor Imaging, Neurite Orientation Dispersion and Density Imaging and Diffusion Microstructure Imaging. Cancers (Basel) 2022; 15:cancers15010129. [PMID: 36612127 PMCID: PMC9817519 DOI: 10.3390/cancers15010129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/12/2022] [Accepted: 12/24/2022] [Indexed: 12/28/2022] Open
Abstract
Although the free water content within the perilesional T2 hyperintense region should differ between glioblastomas (GBM) and brain metastases based on histological differences, the application of classical MR diffusion models has led to inconsistent results regarding the differentiation between these two entities. Whereas diffusion tensor imaging (DTI) considers the voxel as a single compartment, multicompartment approaches such as neurite orientation dispersion and density imaging (NODDI) or the recently introduced diffusion microstructure imaging (DMI) allow for the calculation of the relative proportions of intra- and extra-axonal and also free water compartments in brain tissue. We investigate the potential of water-sensitive DTI, NODDI and DMI metrics to detect differences in free water content of the perilesional T2 hyperintense area between histopathologically confirmed GBM and brain metastases. Respective diffusion metrics most susceptible to alterations in the free water content (MD, V-ISO, V-CSF) were extracted from T2 hyperintense perilesional areas, normalized and compared in 24 patients with GBM and 25 with brain metastases. DTI MD was significantly increased in metastases (p = 0.006) compared to GBM, which was corroborated by an increased DMI V-CSF (p = 0.001), while the NODDI-derived ISO-VF showed only trend level increase in metastases not reaching significance (p = 0.060). In conclusion, diffusion MRI metrics are able to detect subtle differences in the free water content of perilesional T2 hyperintense areas in GBM and metastases, whereas DMI seems to be superior to DTI and NODDI.
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Affiliation(s)
- Urs Würtemberger
- Department of Neuroradiology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Correspondence:
| | - Alexander Rau
- Department of Neuroradiology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Marco Reisert
- Department of Stereotactic and Functional Neurosurgery, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Department of Medical Physics, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Elias Kellner
- Department of Medical Physics, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Martin Diebold
- Institute of Neuropathology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- IMM-PACT Clinician Scientist Program, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Daniel Erny
- Institute of Neuropathology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Berta-Ottenstein-Program for Advanced Clinician Scientists, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Peter C. Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Fraunhofer Institute for Laser Technology, 52074 Aachen, Germany
| | - Jonas A. Hosp
- Department of Neurology and Neurophysiology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Marc Hohenhaus
- Department of Neurosurgery, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Theo Demerath
- Department of Neuroradiology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
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Mirmoeeni S, Azari Jafari A, Shah M, Salemi F, Hashemi SZ, Seifi A. The Clinical, Diagnostic, Therapeutic, and Prognostic Characteristics of Brain Metastases in Prostate Cancer: A Systematic Review. Prostate Cancer 2022; 2022:5324600. [PMID: 36474619 PMCID: PMC9719815 DOI: 10.1155/2022/5324600] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 08/19/2023] Open
Abstract
AIM Prostate cancer (PCa) is the second most common nonskin malignancy and the second most common cause of cancer-related deaths in men. The most common site of metastasis in PCa is the axial skeleton which may lead to back pain or pathological fractures. Hematogenous spread to the brain and involvement of the central nervous system (CNS) are a rare occurrence. However, failed androgen deprivation therapy (ADT) may facilitate such a spread resulting in an advanced metastatic stage of PCa, which carries a poor prognosis. METHODS In this systematic review, we searched the PubMed, Scopus, and Web of Science online databases based on the PRISMA guideline and used all the medical subject headings (MeSH) in terms of the following search line: ("Brain Neoplasms" OR "Central Nervous System Neoplasms") and ("Prostatic Neoplasms" OR "Prostate"). Related studies were identified and reviewed. RESULTS A total of 59 eligible studies (902 patients) were included in this systematic review. In order to gain a deeper understanding, we extracted and presented the data from included articles based on clinical manifestations, diagnostic methods, therapeutic approaches, and prognostic status of PCa patients having BMs. CONCLUSION We have demonstrated the current knowledge regarding the mechanism, clinical manifestations, diagnostic methods, therapeutic approaches, and prognosis of BMs in PCa. These data shed more light on the way to help clinicians and physicians to understand, diagnose, and manage BMs in PCa patients better.
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Affiliation(s)
| | | | - Muffaqam Shah
- Deccan College of Medical Sciences, P.O. Kanchanbagh, DMRL ‘X' Road, Santhosh Nagar, Hyderabad 500058, Telangana, India
| | - Fateme Salemi
- School of Medicine, Islamic Azad University of Medical Sciences, Yazd, Iran
| | - Seyedeh Zohreh Hashemi
- Researcher at the Research Center of Tehran University of Medical Sciences, Pharmacology Department, Tehran, Iran
| | - Ali Seifi
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio School of Medicine, San Antonio, TX, USA
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Barakeh DH, Alsolme E, Alqubaishi F, Almutairi A, Alhabeeb L, Al Abdulmohsen S, Almohsen SS, Alayed D, AlAnazi SR, AlZahrani M, Binowayn AM, AlOtaibi SS, Alkhureeb FA, Al Shakweer W, Al-Hindi H, Alassiri A, Robinson HA, Abedalthagafi M. Clinicopathologic and genomic characterizations of brain metastases using a comprehensive genomic panel. Front Med (Lausanne) 2022; 9:947456. [PMID: 36507516 PMCID: PMC9729258 DOI: 10.3389/fmed.2022.947456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 11/03/2022] [Indexed: 11/25/2022] Open
Abstract
Central nervous system (CNS) metastasis is the most common brain tumor type in adults. Compared to their primary tumors, these metastases undergo a variety of genetic changes to be able to survive and thrive in the complex tissue microenvironment of the brain. In clinical settings, the majority of traditional chemotherapies have shown limited efficacy against CNS metastases. However, the discovery of potential driver mutations, and the development of drugs specifically targeting affected signaling pathways, could change the treatment landscape of CNS metastasis. Genetic studies of brain tumors have so far focused mainly on common cancers in western populations. In this study, we performed Next Generation Sequencing (NGS) on 50 pairs of primary tumors, including but not limited to colorectal, breast, renal and thyroid tumors, along with their brain metastatic tumor tissue counterparts, from three different local tertiary centers in Saudi Arabia. We identified potentially clinically relevant mutations in brain metastases that were not detected in corresponding primary tumors, including mutations in the PI3K, CDK, and MAPK pathways. These data highlight the differences between primary cancers and brain metastases and the importance of acquiring and analyzing brain metastatic samples for further clinical management.
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Affiliation(s)
- Duna H. Barakeh
- Department of Pathology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia,Genomics Research Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ebtehal Alsolme
- Genomics Research Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Fatimah Alqubaishi
- Genomics Research Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Amal Almutairi
- Genomics Research Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Lamees Alhabeeb
- Genomics Research Department, King Fahad Medical City, Riyadh, Saudi Arabia,Department of Pathology, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | - Shahd S. Almohsen
- Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Doaa Alayed
- Department of Pathology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | | | - Malak AlZahrani
- Department of Pathology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | | | - Sarah S. AlOtaibi
- Genomics Research Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | - Wafa Al Shakweer
- Department of Pathology, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Hindi Al-Hindi
- Department of Pathology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ali Alassiri
- Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | | | - Malak Abedalthagafi
- Genomics Research Department, King Fahad Medical City, Riyadh, Saudi Arabia,Department of Pathology and Laboratory Medicine, Emory University Hospital, Atlanta, GA, United States,*Correspondence: Malak Abedalthagafi,
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55
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Tincknell G, Naveed A, Nankervis J, Mukhtiar A, Piper AK, Becker TM, Chantrill L, Aghmesheh M, Vine KL, Ranson M, Brungs D. HER2-Positive Gastroesophageal Cancers Are Associated with a Higher Risk of Brain Metastasis. Cancers (Basel) 2022; 14:cancers14235754. [PMID: 36497236 PMCID: PMC9735596 DOI: 10.3390/cancers14235754] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/09/2022] [Accepted: 11/17/2022] [Indexed: 11/25/2022] Open
Abstract
Brain metastasis from gastroesophageal adenocarcinomas (GOCs) is a rare but a devastating diagnosis. Human epidermal growth factor receptor 2 (HER2) is a prognostic and predictive biomarker in GOCs. The association of HER2 with GOC brain metastasis is not known. We performed a retrospective analysis of patients with GOCs with known HER2 status between January 2015 and November 2021. HER2 was assessed on either the primary tumour or metastasis by immunohistochemistry or in situ hybridization. The diagnosis of brain metastasis was made on standard imaging techniques in patients with symptoms or signs. HER2 results were available for 201 patients, with 34 patients (16.9%) HER2 positive. A total of 12 patients developed symptomatic brain metastasis from GOCs, of which 7 (58.3%) were HER2 positive. The development of symptomatic brain metastasis was significantly higher in the HER2-positive GOCs (OR8.26, 95%CI 2.09-35.60; p = 0.0009). There was no significant association of HER2 status and overall survival in patients with brain metastasis. Although the rate of brain metastasis remains low in GOCs, the incidence of symptomatic brain metastasis was significantly higher in patients with HER2-positive tumours.
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Affiliation(s)
- Gary Tincknell
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW 2522, Australia
- Illawarra Cancer Care Centre, Illawarra Shoalhaven Local Health District, Wollongong, NSW 2500, Australia
- School of Chemistry and Molecular Biosciences, University of Wollongong, Wollongong, NSW 2522, Australia
- School of Medicine, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Asma Naveed
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW 2522, Australia
- NSW Health Pathology, Wollongong, NSW 2522, Australia
- Southern IML, Wollongong, NSW 2500, Australia
| | | | | | - Ann-Katrin Piper
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW 2522, Australia
- School of Medicine, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Therese M. Becker
- Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia
- UNSW Medicine, University of New South Wales, Kensington, NSW 2052, Australia
- School of Medicine, Western Sydney University, Sydney, NSW 2560, Australia
| | - Lorraine Chantrill
- Illawarra Cancer Care Centre, Illawarra Shoalhaven Local Health District, Wollongong, NSW 2500, Australia
- School of Medicine, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Morteza Aghmesheh
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW 2522, Australia
- Illawarra Cancer Care Centre, Illawarra Shoalhaven Local Health District, Wollongong, NSW 2500, Australia
- School of Medicine, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Kara Lea Vine
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW 2522, Australia
- School of Chemistry and Molecular Biosciences, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Marie Ranson
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW 2522, Australia
- School of Chemistry and Molecular Biosciences, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Daniel Brungs
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW 2522, Australia
- Illawarra Cancer Care Centre, Illawarra Shoalhaven Local Health District, Wollongong, NSW 2500, Australia
- School of Medicine, University of Wollongong, Wollongong, NSW 2522, Australia
- Correspondence: ; Tel.: +61-2-4222-5200
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Jiang Q, Tan XP, Zhang CH, Li ZY, Li D, Xu Y, Liu YX, Wang L, Ma Z. Non-Coding RNAs of Extracellular Vesicles: Key Players in Organ-Specific Metastasis and Clinical Implications. Cancers (Basel) 2022; 14:cancers14225693. [PMID: 36428785 PMCID: PMC9688215 DOI: 10.3390/cancers14225693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/17/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
Extracellular vesicles (EVs) are heterogeneous membrane-encapsulated vesicles released by most cells. They act as multifunctional regulators of intercellular communication by delivering bioactive molecules, including non-coding RNAs (ncRNAs). Metastasis is a major cause of cancer-related death. Most cancer cells disseminate and colonize a specific target organ via EVs, a process known as "organ-specific metastasis". Mounting evidence has shown that EVs are enriched with ncRNAs, and various EV-ncRNAs derived from tumor cells influence organ-specific metastasis via different mechanisms. Due to the tissue-specific expression of EV-ncRNAs, they could be used as potential biomarkers and therapeutic targets for the treatment of tumor metastasis in various types of cancer. In this review, we have discussed the underlying mechanisms of EV-delivered ncRNAs in the most common organ-specific metastases of liver, bone, lung, brain, and lymph nodes. Moreover, we summarize the potential clinical applications of EV-ncRNAs in organ-specific metastasis to fill the gap between benches and bedsides.
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Affiliation(s)
- Qian Jiang
- Department of Gastroenterology, First Affiliated Hospital of Yangtze University, Health Science Center, Yangtze University, Jingzhou 434023, China
- Digestive Disease Research Institution of Yangtze University, Yangtze University, Jingzhou 434023, China
- Department of Cardiovascular Medicine, Honghu Hospital of Traditional Chinese Medicine, Honghu 433200, China
| | - Xiao-Ping Tan
- Department of Gastroenterology, First Affiliated Hospital of Yangtze University, Health Science Center, Yangtze University, Jingzhou 434023, China
- Digestive Disease Research Institution of Yangtze University, Yangtze University, Jingzhou 434023, China
| | - Cai-Hua Zhang
- School of Basic Medicine, Health Science Center, Yangtze University, Jingzhou 434023, China
| | - Zhi-Yuan Li
- Department of Cardiovascular Medicine, Honghu Hospital of Traditional Chinese Medicine, Honghu 433200, China
| | - Du Li
- School of Basic Medicine, Health Science Center, Yangtze University, Jingzhou 434023, China
| | - Yan Xu
- School of Basic Medicine, Health Science Center, Yangtze University, Jingzhou 434023, China
| | - Yu Xuan Liu
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117600, Singapore
| | - Lingzhi Wang
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117600, Singapore
- Cancer Science Institute of Singapore, National University of Singapore, Singapore 117599, Singapore
- NUS Centre for Cancer Research (N2CR), National University of Singapore, Singapore 117599, Singapore
- Correspondence: (Z.M.); (L.W.)
| | - Zhaowu Ma
- Department of Gastroenterology, First Affiliated Hospital of Yangtze University, Health Science Center, Yangtze University, Jingzhou 434023, China
- School of Basic Medicine, Health Science Center, Yangtze University, Jingzhou 434023, China
- Correspondence: (Z.M.); (L.W.)
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Klaas E, Mohamed S, Poe J, Reddy R, Dagra A, Lucke-Wold B. Innovative Approaches for Breast Cancer Metastasis to the Brain. ARCHIVES OF MEDICAL CASE REPORTS AND CASE STUDY 2022; 6:147. [PMID: 36468085 PMCID: PMC9717593 DOI: 10.31579/2692-9392/147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Breast cancer metastasis is a continued concern for patients with recent development in our understanding of disease progression. In this paper, we highlight the pathophysiology behind breast cancer metastasis. Blood brain barrier disruption plays a critical component in progression. We then investigate the current treatment strategies and recommended guidelines. This focuses on radiation and medical management. Finally, we address the role of surgical intervention. The data is organized into tables and figures to highlight key components. Finally, we address emerging treatments and pre-clinical data. The paper will serve as a user-friendly guide for clinicians and researchers to help formulate a strategy to manage breast cancer metastasis patients sufficiently.
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Affiliation(s)
| | | | - Jordan Poe
- College of Medicine, University of Florida
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Ono T, Nemoto K. Re-Whole Brain Radiotherapy May Be One of the Treatment Choices for Symptomatic Brain Metastases Patients. Cancers (Basel) 2022; 14:cancers14215293. [PMID: 36358712 PMCID: PMC9657612 DOI: 10.3390/cancers14215293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/20/2022] [Accepted: 10/26/2022] [Indexed: 02/03/2023] Open
Abstract
Generally, patients with multiple brain metastases receive whole brain radiotherapy (WBRT). Although, more than 60% of patients show complete or partial responses, many experience recurrence. Therefore, some institutions consider re-WBRT administration; however, there is insufficient information regarding this. Therefore, we aimed to review re-WBRT administration among these patients. Although most patients did not live longer than 12 months, symptomatic improvement was sometimes observed, with tolerable acute toxicities. Therefore, re-WBRT may be a treatment option for patients with symptomatic recurrence of brain metastases. However, physicians should consider this treatment cautiously because there is insufficient data on late toxicity, including radiation necrosis, owing to poor prognosis. A better prognostic factor for survival following radiotherapy administration may be the time interval of > 9 months between the first WBRT and re-WBRT, but there is no evidence supporting that higher doses lead to prolonged survival, symptom improvement, and tumor control. Therefore, 20 Gy in 10 fractions or 18 Gy in five fractions may be a reasonable treatment method within the tolerable total biological effective dose 2 ≤ 150 Gy, considering the biologically effective dose for tumors and normal tissues.
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Affiliation(s)
- Takashi Ono
- Correspondence: ; Tel.: +81-23-628-5386; Fax: +81-23-628-5389
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Intralesional TLR4 agonist treatment strengthens the organ defense against colonizing cancer cells in the brain. Oncogene 2022; 41:5008-5019. [PMID: 36224342 DOI: 10.1038/s41388-022-02496-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 08/31/2022] [Accepted: 09/30/2022] [Indexed: 11/08/2022]
Abstract
Brain metastasis in breast cancer remains difficult to treat and its incidence is increasing. Therefore, the development of new therapies is of utmost clinical relevance. Recently, toll-like receptor (TLR) 4 was correlated with IL6 expression and poor prognosis in 1 215 breast cancer primaries. In contrast, we demonstrated that TLR4 stimulation reduces microglia-assisted breast cancer cell invasion. However, the expression, prognostic value, or therapeutic potential of TLR signaling in breast cancer brain metastasis have not been investigated. We thus tested the prognostic value of various TLRs in two brain-metastasis gene sets. Furthermore, we investigated different TLR agonists, as well as MyD88 and TRIF-deficient microenvironments in organotypic brain-slice ex vivo co-cultures and in vivo colonization experiments. These experiments underline the ambiguous roles of TLR4, its adapter MyD88, and the target nitric oxide (NO) during brain colonization. Moreover, analysis of the gene expression datasets of breast cancer brain metastasis patients revealed associations of TLR1 and IL6 with poor overall survival. Finally, our finding that a single LPS application at the onset of colonization shapes the later microglia/macrophage reaction at the macro-metastasis brain-parenchyma interface (MMPI) and reduces metastatic infiltration into the brain parenchyma may prove useful in immunotherapeutic considerations.
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60
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Warren LEG, Niman SM, Remolano MC, Landry JM, Nakhlis F, Bellon JR, Aizer AA, Lin NU, Tolaney SM, Regan MM, Overmoyer BA, Lynce F. Incidence, characteristics, and management of central nervous system metastases in patients with inflammatory breast cancer. Cancer 2022; 128:4085-4094. [PMID: 36210737 DOI: 10.1002/cncr.34441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/25/2022] [Accepted: 05/12/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Patients with inflammatory breast cancer (IBC) have a high risk of central nervous system metastasis (mCNS). The purpose of this study was to quantify the incidence of and identify risk factors for mCNS in patients with IBC. METHODS The authors retrospectively reviewed patients diagnosed with IBC between 1997 and 2019. mCNS-free survival time was defined as the date from the diagnosis of IBC to the date of diagnosis of mCNS or the date of death, whichever occurred first. A competing risks hazard model was used to evaluate risk factors for mCNS. RESULTS A total of 531 patients were identified; 372 patients with stage III and 159 patients with de novo stage IV disease. During the study, there were a total of 124 patients who had mCNS. The 1-, 2-, and 5-year incidence of mCNS was 5%, 9%, and 18% in stage III patients (median follow-up: 5.6 years) and 17%, 30%, and 42% in stage IV patients (1.8 years). Multivariate analysis identified triple-negative tumor subtype as a significant risk factor for mCNS for stage III patients. For patients diagnosed with metastatic disease, visceral metastasis as first metastatic site, triple-negative subtype, and younger age at diagnosis of metastases were risk factors for mCNS. CONCLUSIONS Patients with IBC, particularly those with triple-negative IBC, visceral metastasis, and those at a younger age at diagnosis of metastatic disease, are at significant risk of developing mCNS. Further investigation into prevention of mCNS and whether early detection of mCNS is associated with improved IBC patient outcomes is warranted.
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Affiliation(s)
- Laura E G Warren
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA.,Inflammatory Breast Cancer Program, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Samuel M Niman
- Department of Data Science, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Marie C Remolano
- Inflammatory Breast Cancer Program, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jean M Landry
- Inflammatory Breast Cancer Program, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Faina Nakhlis
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Inflammatory Breast Cancer Program, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jennifer R Bellon
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA.,Inflammatory Breast Cancer Program, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Ayal A Aizer
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Meredith M Regan
- Department of Data Science, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA.,Inflammatory Breast Cancer Program, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Beth A Overmoyer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Inflammatory Breast Cancer Program, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Filipa Lynce
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Inflammatory Breast Cancer Program, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Klosko RC, Arnold JR, Murphy CV, Brimmer J, Hagy N, Exline MC, McLaughlin E, Elefritz JL. Early onset delirium incidence and risk factors in hematology oncology patients admitted to the intensive care unit: A retrospective cohort study. Int J Crit Illn Inj Sci 2022; 12:190-196. [PMID: 36779215 PMCID: PMC9910111 DOI: 10.4103/ijciis.ijciis_35_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/26/2022] [Accepted: 08/02/2022] [Indexed: 12/24/2022] Open
Abstract
Background Delirium occurs frequently in intensive care unit (ICU) patients; however, there are limited data evaluating its impact on critically ill hematology-oncology patients. We aimed to determine the incidence and risk factors for early-onset delirium development in hematology-oncology patients admitted to the ICU. Methods This single-center, retrospective cohort study evaluated the primary outcome of incident delirium within 7 days of ICU admission in adults admitted to the hematology-oncology medical or surgical ICU. Patients with delirium (DEL) were compared to those without (No-DEL) for evaluation of secondary endpoints including hospital mortality, ICU, and hospital length of stay (LOS). Multivariable logistic regression modeling was performed to identify independent risk factors for delirium. Results Delirium occurred in 125 (51.2%) of 244 patients. Inhospital mortality was significantly higher in the DEL vs. No-DEL group (32.8% vs. 15.1%, P = 0.002). Median (1st and 3rd quartiles) ICU and hospital LOS were significantly longer in the delirium group, respectively (6 [4-10] days vs. 3 [2-5] days, P < 0.001, and 21 [14-36] days vs. 12 [8-22] days, P < 0.001). Higher Sequential Organ Failure Assessment score, high-dose corticosteroids, mechanical ventilation (MV), and brain metastases were each independently, associated with an increased delirium risk. Conclusion Hematology-oncology patients admitted to the ICU frequently develop delirium. Consistent with literature in nonhematology-oncology critically ill patients, identified independent risk factors for delirium were MV and organ dysfunction. Risk factors unique to the critically ill hematology-oncology patient population include high-dose corticosteroids and brain metastases. Further research is needed to evaluate strategies to mitigate delirium development in this population based on risk assessment.
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Affiliation(s)
- Rachel C. Klosko
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Johnson City, NY
| | - Joshua R. Arnold
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, The United States of America
| | - Claire V. Murphy
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, The United States of America
| | - Jessica Brimmer
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, The United States of America
| | - Natalie Hagy
- College of Pharmacy, The Ohio State University, Columbus, Ohio, The United States of America
| | - Matthew C. Exline
- Division of Pulmonary Diseases, Critical Care Medicine, and Sleep, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, The United States of America
| | - Eric McLaughlin
- Center for Biostatistics, The Ohio State University, Columbus, Ohio, The United States of America
| | - Jessica L. Elefritz
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, The United States of America
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Wu J, Kang T, Lan X, Chen X, Wu Z, Wang J, Lin L, Cai C, Lin J, Ding X, Cai S. IMPULSED model based cytological feature estimation with U-Net: Application to human brain tumor at 3T. Magn Reson Med 2022; 89:411-422. [PMID: 36063493 DOI: 10.1002/mrm.29429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 07/06/2022] [Accepted: 08/08/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE This work introduces and validates a deep-learning-based fitting method, which can rapidly provide accurate and robust estimation of cytological features of brain tumor based on the IMPULSED (imaging microstructural parameters using limited spectrally edited diffusion) model fitting with diffusion-weighted MRI data. METHODS The U-Net was applied to rapidly quantify extracellular diffusion coefficient (Dex ), cell size (d), and intracellular volume fraction (vin ) of brain tumor. At the training stage, the image-based training data, synthesized by randomizing quantifiable microstructural parameters within specific ranges, was used to train U-Net. At the test stage, the pre-trained U-Net was applied to estimate the microstructural parameters from simulated data and the in vivo data acquired on patients at 3T. The U-Net was compared with conventional non-linear least-squares (NLLS) fitting in simulations in terms of estimation accuracy and precision. RESULTS Our results confirm that the proposed method yields better fidelity in simulations and is more robust to noise than the NLLS fitting. For in vivo data, the U-Net yields obvious quality improvement in parameter maps, and the estimations of all parameters are in good agreement with the NLLS fitting. Moreover, our method is several orders of magnitude faster than the NLLS fitting (from about 5 min to <1 s). CONCLUSION The image-based training scheme proposed herein helps to improve the quality of the estimated parameters. Our deep-learning-based fitting method can estimate the cell microstructural parameters fast and accurately.
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Affiliation(s)
- Jian Wu
- Department of Electronic Science, Fujian Provincial Key Laboratory of Plasma and Magnetic Resonance, Xiamen University, Xiamen, China
| | - Taishan Kang
- Department of Radiology, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Xinli Lan
- Department of Electronic Science, Fujian Provincial Key Laboratory of Plasma and Magnetic Resonance, Xiamen University, Xiamen, China
| | - Xinran Chen
- Department of Electronic Science, Fujian Provincial Key Laboratory of Plasma and Magnetic Resonance, Xiamen University, Xiamen, China
| | - Zhigang Wu
- MSC Clinical & Technical Solutions, Philips Healthcare, Beijing, China
| | - Jiazheng Wang
- MSC Clinical & Technical Solutions, Philips Healthcare, Beijing, China
| | - Liangjie Lin
- MSC Clinical & Technical Solutions, Philips Healthcare, Beijing, China
| | - Congbo Cai
- Department of Electronic Science, Fujian Provincial Key Laboratory of Plasma and Magnetic Resonance, Xiamen University, Xiamen, China
| | - Jianzhong Lin
- Department of Radiology, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Xin Ding
- Department of Pathology, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Shuhui Cai
- Department of Electronic Science, Fujian Provincial Key Laboratory of Plasma and Magnetic Resonance, Xiamen University, Xiamen, China
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Banga AR, Odiase P, Rachakonda K, Garg AP, Adunyah SE, Rachakonda G. Application of C-Terminal Clostridium Perfringens Enterotoxin in Treatment of Brain Metastasis from Breast Cancer. Cancers (Basel) 2022; 14:4309. [PMID: 36077843 PMCID: PMC9454751 DOI: 10.3390/cancers14174309] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Claudin-4 is part of the Claudin family of transmembrane tight junction (TJ) proteins found in almost all tissues and, together with adherens junctions and desmosomes, forms epithelial and endothelial junctional complexes. Although the distribution of Claudin-4 occurs in many cell types, the level of expression is cell-specific. Claudin proteins regulate cell proliferation and differentiation by binding cell-signaling ligands, and its expression is upregulated in several cancers. As a result, alterations in Claudin expression patterns or distribution are vital in the pathology of cancer. Profiling the genetic expression of Claudin-4 showed that Claudin-4 is also a receptor for the clostridium perfringens enterotoxin (CPE) and that Claudin-4 has a high sequence similarity with CPE's high-affinity receptor. CPE is cytolytic due to its ability to form pores in cellular membranes, and CPE treatment in breast cancer cells have shown promising results due to the high expression of Claudin-4. The C-terminal fragment of CPE (c-CPE) provides a less toxic alternative for drug delivery into breast cancer cells, particularly metastatic tumors in the brain, especially as Claudin-4 expression in the central nervous system (CNS) is low. Therefore, c-CPE provides a unique avenue for the treatment of breast-brain metastatic tumors.
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Affiliation(s)
- Amita R. Banga
- Department of Biotechnology, School of Biological Engineering & Sciences, Shobhit Institute of Engineering & Technology, Meerut 250110, India
- Department of Microbiology, Immunology and Physiology, Meharry Medical College, Nashville, TN 37208, USA
| | - Peace Odiase
- Department of Microbiology, Immunology and Physiology, Meharry Medical College, Nashville, TN 37208, USA
| | - Kartik Rachakonda
- Undergraduate Studies, School of Arts and Sciences, University of South Florida, Tampa, FL 33620, USA
| | - Amar P. Garg
- Department of Biotechnology, School of Biological Engineering & Sciences, Shobhit Institute of Engineering & Technology, Meerut 250110, India
| | - Samuel E. Adunyah
- Department of Biochemistry, Cancer Biology, Neuroscience & Pharmacology, Meharry Medical College, Nashville, TN 37208, USA
| | - Girish Rachakonda
- Department of Microbiology, Immunology and Physiology, Meharry Medical College, Nashville, TN 37208, USA
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Survival in patients with surgically treated dural based metastases: A single-center retrospective study. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Li Y, Lv X, Wang B, Xu Z, Wang Y, Gao S, Hou D. Differentiating EGFR from ALK mutation status using radiomics signature based on MR sequences of brain metastasis. Eur J Radiol 2022; 155:110499. [PMID: 36049410 DOI: 10.1016/j.ejrad.2022.110499] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/29/2022] [Accepted: 08/20/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE More and more small brain metastases (BMs) in asymptomatic patients can be detected even prior to their primary lung cancer with the development of MRI. The aim of this study was to develop a predictive radiomics model to identify epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) mutation status in BM and explore the optimal MR sequence for predication. METHODS This retrospective study included 186 patients with proven BM of lung cancer (training cohort: 70 patients with EGFR mutations and 65 patients with ALK rearrangements; testing cohort: 26 patients with EGFR mutations and 25 patients with ALK rearrangements). Radiomics features were separately extracted from contrast-enhanced T1-weighted imaging (T1-CE), T2 fluid-attenuated inversion recovery (T2-FLAIR) and T2WI sequences. The model for three MR sequences were constructed using a random forest classifier. ROC curves were used to validate the capability of the models in the training and testing cohorts. RESULTS The AUCs of the T2-FLAIR model were significantly higher than those of the T1-CE model in training cohort (0.991 versus 0.954) and testing cohort (0.950 versus 0.867) and much higher than those of the T2WI model in training cohort (0.991 versus 0.880) and testing cohort (0.950 versus 0.731). Besides, the F1 scores of the T1-CE model were slightly higher than the T2-FLAIR model and much higher than the T2WI model in two cohorts. CONCLUSION T2-FLAIR and T1-CE radiomics models that can be used as noninvasive tools for identifying EGFR and ALK mutation status are helpful to guide therapeutic strategies.
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Affiliation(s)
- Ye Li
- Department of Radiology, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
| | - Xinna Lv
- Department of Radiology, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
| | - Bing Wang
- Department of Radiology, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing 101149, China
| | - Zexuan Xu
- Department of Radiology, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
| | - Yichuan Wang
- Department of Radiology, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing 101149, China
| | - Shan Gao
- Department of Radiology, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing 101149, China
| | - Dailun Hou
- Department of Radiology, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China.
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Wu WF, Shen CW, Lai KM, Chen YJ, Lin EC, Chen CC. The Application of DTCWT on MRI-Derived Radiomics for Differentiation of Glioblastoma and Solitary Brain Metastases. J Pers Med 2022; 12:jpm12081276. [PMID: 36013225 PMCID: PMC9409920 DOI: 10.3390/jpm12081276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/17/2022] [Accepted: 07/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background: While magnetic resonance imaging (MRI) is the imaging modality of choice for the evaluation of patients with brain tumors, it may still be challenging to differentiate glioblastoma multiforme (GBM) from solitary brain metastasis (SBM) due to their similar imaging features. This study aimed to evaluate the features extracted of dual-tree complex wavelet transform (DTCWT) from routine MRI protocol for preoperative differentiation of glioblastoma (GBM) and solitary brain metastasis (SBM). Methods: A total of 51 patients were recruited, including 27 GBM and 24 SBM patients. Their contrast-enhanced T1-weighted images (CET1WIs), T2 fluid-attenuated inversion recovery (T2FLAIR) images, diffusion-weighted images (DWIs), and apparent diffusion coefficient (ADC) images were employed in this study. The statistical features of the pre-transformed images and the decomposed images of the wavelet transform and DTCWT were utilized to distinguish between GBM and SBM. Results: The support vector machine (SVM) showed that DTCWT images have a better accuracy (82.35%), sensitivity (77.78%), specificity (87.50%), and the area under the curve of the receiver operating characteristic curve (AUC) (89.20%) than the pre-transformed and conventional wavelet transform images. By incorporating DTCWT and pre-transformed images, the accuracy (86.27%), sensitivity (81.48%), specificity (91.67%), and AUC (93.06%) were further improved. Conclusions: Our studies suggest that the features extracted from the DTCWT images can potentially improve the differentiation between GBM and SBM.
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Affiliation(s)
- Wen-Feng Wu
- Department of Radiology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi 600, Taiwan; (W.-F.W.); (K.-M.L.)
| | - Chia-Wei Shen
- Department of Chemistry and Biochemistry, National Chung Cheng University, Chiayi 621, Taiwan; (C.-W.S.); (Y.-J.C.)
| | - Kuan-Ming Lai
- Department of Radiology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi 600, Taiwan; (W.-F.W.); (K.-M.L.)
- Department of Medical Imaging and Radiological Sciences, Central Taiwan University of Science and Technology, Taichung 406, Taiwan
| | - Yi-Jen Chen
- Department of Chemistry and Biochemistry, National Chung Cheng University, Chiayi 621, Taiwan; (C.-W.S.); (Y.-J.C.)
| | - Eugene C. Lin
- Department of Chemistry and Biochemistry, National Chung Cheng University, Chiayi 621, Taiwan; (C.-W.S.); (Y.-J.C.)
- Correspondence: (E.C.L.); (C.-C.C.); Tel.: +886-52-720-411 (ext. 66418) (E.C.L.); +886-52-765-041 (ext. 7521) (C.-C.C.)
| | - Chien-Chin Chen
- Department of Pathology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi 600, Taiwan
- Department of Cosmetic Science, Chia Nan University of Pharmacy and Science, Tainan 717, Taiwan
- Department of Biotechnology and Bioindustry Sciences, College of Bioscience and Biotechnology, National Cheng Kung University, Tainan 701, Taiwan
- Correspondence: (E.C.L.); (C.-C.C.); Tel.: +886-52-720-411 (ext. 66418) (E.C.L.); +886-52-765-041 (ext. 7521) (C.-C.C.)
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Keek SA, Beuque M, Primakov S, Woodruff HC, Chatterjee A, van Timmeren JE, Vallières M, Hendriks LEL, Kraft J, Andratschke N, Braunstein SE, Morin O, Lambin P. Predicting Adverse Radiation Effects in Brain Tumors After Stereotactic Radiotherapy With Deep Learning and Handcrafted Radiomics. Front Oncol 2022; 12:920393. [PMID: 35912214 PMCID: PMC9326101 DOI: 10.3389/fonc.2022.920393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionThere is a cumulative risk of 20–40% of developing brain metastases (BM) in solid cancers. Stereotactic radiotherapy (SRT) enables the application of high focal doses of radiation to a volume and is often used for BM treatment. However, SRT can cause adverse radiation effects (ARE), such as radiation necrosis, which sometimes cause irreversible damage to the brain. It is therefore of clinical interest to identify patients at a high risk of developing ARE. We hypothesized that models trained with radiomics features, deep learning (DL) features, and patient characteristics or their combination can predict ARE risk in patients with BM before SRT.MethodsGadolinium-enhanced T1-weighted MRIs and characteristics from patients treated with SRT for BM were collected for a training and testing cohort (N = 1,404) and a validation cohort (N = 237) from a separate institute. From each lesion in the training set, radiomics features were extracted and used to train an extreme gradient boosting (XGBoost) model. A DL model was trained on the same cohort to make a separate prediction and to extract the last layer of features. Different models using XGBoost were built using only radiomics features, DL features, and patient characteristics or a combination of them. Evaluation was performed using the area under the curve (AUC) of the receiver operating characteristic curve on the external dataset. Predictions for individual lesions and per patient developing ARE were investigated.ResultsThe best-performing XGBoost model on a lesion level was trained on a combination of radiomics features and DL features (AUC of 0.71 and recall of 0.80). On a patient level, a combination of radiomics features, DL features, and patient characteristics obtained the best performance (AUC of 0.72 and recall of 0.84). The DL model achieved an AUC of 0.64 and recall of 0.85 per lesion and an AUC of 0.70 and recall of 0.60 per patient.ConclusionMachine learning models built on radiomics features and DL features extracted from BM combined with patient characteristics show potential to predict ARE at the patient and lesion levels. These models could be used in clinical decision making, informing patients on their risk of ARE and allowing physicians to opt for different therapies.
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Affiliation(s)
- Simon A. Keek
- The D-Lab, Department of Precision Medicine, GROW- School for Oncology and Reproduction, Maastricht University, Maastricht, Netherlands
| | - Manon Beuque
- The D-Lab, Department of Precision Medicine, GROW- School for Oncology and Reproduction, Maastricht University, Maastricht, Netherlands
| | - Sergey Primakov
- The D-Lab, Department of Precision Medicine, GROW- School for Oncology and Reproduction, Maastricht University, Maastricht, Netherlands
| | - Henry C. Woodruff
- The D-Lab, Department of Precision Medicine, GROW- School for Oncology and Reproduction, Maastricht University, Maastricht, Netherlands
- Department of Radiology and Nuclear Medicine, GROW – School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Avishek Chatterjee
- The D-Lab, Department of Precision Medicine, GROW- School for Oncology and Reproduction, Maastricht University, Maastricht, Netherlands
| | - Janita E. van Timmeren
- Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Martin Vallières
- Medical Physics Unit, Department of Oncology, Faculty of Medicine, McGill University, Montréal, QC, Canada
- Department of Computer Science, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Lizza E. L. Hendriks
- Department of Pulmonary Diseases, GROW – School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Johannes Kraft
- Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
- Department of Radiation Oncology, University Hospital Würzburg, Würzburg, Germany
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Steve E. Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, United States
| | - Olivier Morin
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, United States
| | - Philippe Lambin
- The D-Lab, Department of Precision Medicine, GROW- School for Oncology and Reproduction, Maastricht University, Maastricht, Netherlands
- Department of Radiology and Nuclear Medicine, GROW – School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, Netherlands
- *Correspondence: Philippe Lambin,
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Health related quality of life trajectories after stereotactic radiosurgery for brain metastases: a systematic review. J Neurooncol 2022; 159:319-331. [PMID: 35788469 DOI: 10.1007/s11060-022-04067-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 06/10/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Health related quality of life (HRQoL) is often used as an outcome measure of cancer treatment. Stereotactic radiosurgery (SRS) is a mainstay treatment of brain metastases (BMs) with constantly improving treatment envelope. The goal of this systematic review was to evaluated HRQoL trajectories after SRS, identify important predictors of HRQoL after SRS, and to evaluate clinical importance of post-SRS HRQoL trajectories of BM patients treated with SRS. METHODS A systematic literature review according to the PRISMA guidelines analyzing HRQoL trajectories after SRS for BM published in the Pubmed/MEDLINE database before January, 2022. RESULTS We identified 18 studies that evaluated HRQoL before and at least once after SRS for BMs. The majority of studies were single-institution retrospective series and included patients with different cancer types. Different instruments were used to assess HRQoL. In the majority of studies (n = 10) at group level, there was no significant change in global HRQoL after SRS. Stability, improvement, and deterioration of HRQoL global and subscale scores at individual patient level were common. Post-SRS HRQoL deterioration was predicted by worse functional status, greater number of BMs, delayed SRS, symptomatic BMs, and presence of seizures and cognitive impairment. Shorter post-SRS survival and adverse radiation effects (AREs) were associated with worse HRQoL. CONCLUSIONS SRS for BMs is often associated with sustained preservation of HRQoL. Individual variation of HRQoL domains after SRS is common. Shorter survival and AREs are associated with worse HRQoL. Worse functional status and greater disease burden predict unfavorable HRQoL trajectories after SRS for BMs.
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Influence of the Timing of Leptomeningeal Metastasis on the Outcome of EGFR-Mutant Lung Adenocarcinoma Patients and Predictors of Detectable EGFR Mutations in Cerebrospinal Fluid. Cancers (Basel) 2022; 14:cancers14122824. [PMID: 35740489 PMCID: PMC9221267 DOI: 10.3390/cancers14122824] [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] [Received: 05/09/2022] [Revised: 06/05/2022] [Accepted: 06/06/2022] [Indexed: 11/26/2022] Open
Abstract
Simple Summary Leptomeningeal metastasis (LM) is a devastating complication of lung cancer, with a generally poor outcome. We conduct the present study to evaluate the association between clinical presentations, brain images, tumor cell counts of the cerebrospinal fluid (CSF), and the epidermal growth factor receptor (EGFR) mutation detection rate in CSF among EGFR-mutant lung adenocarcinoma patients with LM and accessed the influence of the timing of LM occurrence on patient outcomes. Tumor cell numbers were semi-quantified according to tumor cells per high power field of CSF cytological slides. Radiological burden was assessed using a four-point scoring system, which evaluated LM-involved areas on brain magnetic resonance imaging. Our results suggest the association between the radiological severity score of LM, CSF tumor cell counts, and EGFR mutation detection rate in CSF. Furthermore, LM prior to first-line EGFR-tyrosine kinase inhibitor treatment was associated with an independently worse outcome. Abstract Background: We aim to evaluate the influence of the timing of leptomeningeal metastasis (LM) occurrence on the outcome of EGFR-mutant lung adenocarcinoma and to explore the predictors of detectable EGFR mutation in the cerebrospinal fluid (CSF). Methods: EGFR-mutant lung adenocarcinoma patients with cytologically confirmed LM were included for analysis. EGFR mutation in CSF was detected by MALDI-TOF MS plus PNA. Results: A total of 43 patients was analyzed. Of them, 8 (18.6%) were diagnosed with LM prior to first-line EGFR-TKI treatment (early onset), while 35 patients (81.4%) developed LM after first-line EGFR-TKI treatment (late onset). Multivariate analysis suggested that both late-onset LM (aHR 0.31 (95% CI 0.10–0.94), p = 0.038) and a history of third-generation EGFR-TKI treatment (aHR 0.24 (95% CI 0.09–0.67), p = 0.006) independently predicted a favorable outcome. EGFR mutation detection sensitivity in CSF was 81.4%. The radiological burden of LM significantly correlated with CSF tumor cell counts (p = 0.013) with higher CSF tumor cell counts predicting a higher detection sensitivity of EGFR mutation (p = 0.042). Conclusions: Early onset LM was an independently poor prognostic factor. A higher radiological severity score of LM could predict higher tumor cell counts in CSF, which in turn were associated with a higher detection rate of EGFR mutation.
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Leyrat B, Khalill T, Lemaire JJ, Casile M, Molnar I, Dedieu V, Chassin V, Dupic G, Bellière A, Durando X, Lapeyre M, Verrelle P, Biau J. Local control and radionecrosis of brain metastases from non– small-cell lung cancer treated by hypofractionated stereotactic radiotherapy: Evaluation of predictive factors. Clin Transl Radiat Oncol 2022; 36:1-8. [PMID: 35733828 PMCID: PMC9207219 DOI: 10.1016/j.ctro.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 05/30/2022] [Accepted: 05/30/2022] [Indexed: 11/26/2022] Open
Abstract
First study on brain metastases 3-fraction SRT from a homogeneous population of NSCLC, according to French MF-SRT recommendations. MF-SRT with 3x7.7 Gy on the 70% isodose line and PTV = GTV + 2 mm leads to high local control rates in this population, with acceptable rates of radionecrosis. GTV Dmin ≥ 27.4 Gy leads to higher local control. Dyslipidemia could be involved in radionecrosis appearance.
Background The objective of our study was to report predictive factors of local control (LC) and radionecrosis (RN) of brain metastases (BM) of non-small cell lung carcinoma (NSCLC) treated by multifractionated stereotactic radiotherapy (MF-SRT) according to French recommendations. Method From 2012 to 2020, 87 patients with 101 BM were retrospectively included. The median age was 63 years (37–85). GTV was defined using contrast-enhanced T1w MRI and was isotropically extended by 2 mm to form PTV. Mean maximum BM diameter was 24.5 mm (10–46). Patients were treated with dynamic arctherapy from May 2012 to February 2016 and then with VMAT. The total prescribed dose was 23.1 Gy prescribed to the encompassing 70% isodose, in 3 fractions. Results LC rates at 6 months, 1 year and 2 years was 95.7%, 90.7% and 87.9% respectively. In multivariate analysis, high GTV Dmin (HR = 0.822, p = 0.012) was in favor of better LC whereas a large maximum diameter was predictive of poor LC (HR = 1.124, p = 0.02). GTV Dmin of 27.4 Gy was identified as a discriminant threshold of LC. In case of GTV Dmin ≥ 27.4 Gy, LC at 1 year was 95.3% versus 75.1% with GTV Dmin < 27.4 Gy. Cumulative incidence of RN at 6 months, 1 year and 2 years was 6.3%, 15.4% and 18.1%, respectively. In multivariate analysis, only dyslipidemia was predictive of RN (HR = 2.69, p = 0.03). No dosimetric predictive factor of RN was found in our study. Conclusion MF-SRT (3x7.7 Gy on 70% isodose line, with PTV = GTV + 2 mm; according to French recommendations) of BM from NSCLC gives high LC rates with acceptable RN rate. A GTV Dmin of at least 27.4 Gy could be proposed to optimize dosimetric objectives. No dosimetric predictive factors of RN were found in this study. However, dyslipidemia was identified as a potential predictive factor of RN.
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71
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A brain-enriched lncRNA shields cancer cells from immune-mediated killing for metastatic colonization in the brain. Proc Natl Acad Sci U S A 2022; 119:e2200230119. [PMID: 35617432 DOI: 10.1073/pnas.2200230119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
SignificanceBrain metastasis with current limited treatment options is a common complication in advanced cancer patients, and breast-to-brain metastasis (B2BM) is one of the major types. In this work, we report that brain metastasis oncogenic long noncoding RNA (BMOR) is a key brain-enriched long noncoding RNA for the development of B2BM. We demonstrate that BMOR allows B2BM cells to colonize the brain tissue by evading immune-mediated killing in the brain microenvironment. At the molecular level, BMOR binds and inactivates IRF3 in B2BM cells. Finally, BMOR silencer can effectively suppress the development of brain metastasis in vivo. Therefore, our findings reveal a way in which cancer cells evade immune-mediated killing in the brain microenvironment for brain metastasis development and establish therapeutic targets with potential targeted strategies against B2BM.
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72
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Aftahy AK, Barz M, Lange N, Baumgart L, Thunstedt C, Eller MA, Wiestler B, Bernhardt D, Combs SE, Jost PJ, Delbridge C, Liesche-Starnecker F, Meyer B, Gempt J. The Impact of Postoperative Tumor Burden on Patients With Brain Metastases. Front Oncol 2022; 12:869764. [PMID: 35600394 PMCID: PMC9114705 DOI: 10.3389/fonc.2022.869764] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 03/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background Brain metastases were considered to be well-defined lesions, but recent research points to infiltrating behavior. Impact of postoperative residual tumor burden (RTB) and extent of resection are still not defined enough. Patients and Methods Adult patients with surgery of brain metastases between April 2007 and January 2020 were analyzed. Early postoperative MRI (<72 h) was used to segment RTB. Survival analysis was performed and cutoff values for RTB were revealed. Separate (subgroup) analyses regarding postoperative radiotherapy, age, and histopathological entities were performed. Results A total of 704 patients were included. Complete cytoreduction was achieved in 487/704 (69.2%) patients, median preoperative tumor burden was 12.4 cm3 (IQR 5.2–25.8 cm3), median RTB was 0.14 cm3 (IQR 0.0–2.05 cm3), and median postoperative tumor volume of the targeted BM was 0.0 cm3 (IQR 0.0–0.1 cm3). Median overall survival was 6 months (IQR 2–18). In multivariate analysis, preoperative KPSS (HR 0.981982, 95% CI, 0.9761–0.9873, p < 0.001), age (HR 1.012363; 95% CI, 1.0043–1.0205, p = 0.0026), and preoperative (HR 1.004906; 95% CI, 1.0003–1.0095, p = 0.00362) and postoperative tumor burden (HR 1.017983; 95% CI; 1.0058–1.0303, p = 0.0036) were significant. Maximally selected log rank statistics showed a significant cutoff for RTB of 1.78 cm3 (p = 0.0022) for all and 0.28 cm3 (p = 0.0047) for targeted metastasis and cutoff for the age of 67 years (p < 0.001). (Stereotactic) Radiotherapy had a significant impact on survival (p < 0.001). Conclusions RTB is a strong predictor for survival. Maximal cytoreduction, as confirmed by postoperative MRI, should be achieved whenever possible, regardless of type of postoperative radiotherapy.
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Affiliation(s)
- Amir Kaywan Aftahy
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Melanie Barz
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Nicole Lange
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Lea Baumgart
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Cem Thunstedt
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Mario Antonio Eller
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Benedikt Wiestler
- Department of Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum Munich, Munich, Germany
| | - Philipp J Jost
- III. Medical Department of Hematology and Oncology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.,Clinical Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Claire Delbridge
- Department of Neuropathology, Institute of Pathology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Friederike Liesche-Starnecker
- Department of Neuropathology, Institute of Pathology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
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Deep-Learning-Based Automatic Detection and Segmentation of Brain Metastases with Small Volume for Stereotactic Ablative Radiotherapy. Cancers (Basel) 2022; 14:cancers14102555. [PMID: 35626158 PMCID: PMC9139632 DOI: 10.3390/cancers14102555] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/11/2022] [Accepted: 05/18/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary With advances in radiotherapy (RT) technique and more frequent use of stereotactic ablative radiotherapy (SABR), precise segmentation of all brain metastases (BM) including a small volume of BM is essential to choose an appropriate treatment modality. However, the process of detecting and manually delineating BM with small volumes often results in missing delineation and requires a great amount of labor. To address this issue, we present a useful deep learning (DL) model for the detection and segmentation of BMwith contrast-enhanced magnetic resonance images. Specifically, we applied effective training techniques to detect and segment a BM of less than 0.04 cc, which is relatively small compared to previous studies. The results of our DL model demonstrated that the proposed methods provide considerable benefit for BM, even small-volume BM, detection, and segmentation for SABR. Abstract Recently, several efforts have been made to develop the deep learning (DL) algorithms for automatic detection and segmentation of brain metastases (BM). In this study, we developed an advanced DL model to BM detection and segmentation, especially for small-volume BM. From the institutional cancer registry, contrast-enhanced magnetic resonance images of 65 patients and 603 BM were collected to train and evaluate our DL model. Of the 65 patients, 12 patients with 58 BM were assigned to test-set for performance evaluation. Ground-truth for BM was assigned to one radiation oncologist to manually delineate BM and another one to cross-check. Unlike other previous studies, our study dealt with relatively small BM, so the area occupied by the BM in the high-resolution images were small. Our study applied training techniques such as the overlapping patch technique and 2.5-dimensional (2.5D) training to the well-known U-Net architecture to learn better in smaller BM. As a DL architecture, 2D U-Net was utilized by 2.5D training. For better efficacy and accuracy of a two-dimensional U-Net, we applied effective preprocessing include 2.5D overlapping patch technique. The sensitivity and average false positive rate were measured as detection performance, and their values were 97% and 1.25 per patient, respectively. The dice coefficient with dilation and 95% Hausdorff distance were measured as segmentation performance, and their values were 75% and 2.057 mm, respectively. Our DL model can detect and segment BM with small volume with good performance. Our model provides considerable benefit for clinicians with automatic detection and segmentation of BM for stereotactic ablative radiotherapy.
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Faria CC, Cascão R, Custódia C, Paisana E, Carvalho T, Pereira P, Roque R, Pimentel J, Miguéns J, Cortes-Ciriano I, Barata JT. Patient-derived models of brain metastases recapitulate human disseminated disease. Cell Rep Med 2022; 3:100623. [PMID: 35584628 PMCID: PMC9133464 DOI: 10.1016/j.xcrm.2022.100623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 02/01/2022] [Accepted: 04/08/2022] [Indexed: 12/02/2022]
Abstract
Dissemination of cancer cells from primary tumors to the brain occurs in many cancer patients, increasing morbidity and death. There is an unmet medical need to develop translational platforms to evaluate therapeutic responses. Toward this goal, we established a library of 23 patient-derived xenografts (PDXs) of brain metastases (BMs) from eight distinct primary tumors. In vivo tumor formation correlates with patients’ poor survival. Mouse subcutaneous xenografts develop spontaneous metastases and intracardiac PDXs increase dissemination to the CNS, both models mimicking the dissemination pattern of the donor patient. We test the FDA-approved drugs buparlisib (pan-PI3K inhibitor) and everolimus (mTOR inhibitor) and show their efficacy in treating our models. Finally, we show by RNA sequencing that human BMs and their matched PDXs have similar transcriptional profiles. Overall, these models of BMs recapitulate the biology of human metastatic disease and can be valuable translational platforms for precision medicine. Established PDXs of brain metastasis from multiple cancers PDXs recapitulate the dissemination pattern of patient tumors Patient-derived models of brain metastases are valuable to test anticancer drugs Human brain metastases and their PDXs retain similar transcriptional profiles
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Affiliation(s)
- Claudia C Faria
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal; Department of Neurosurgery, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisboa, Portugal.
| | - Rita Cascão
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Carlos Custódia
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Eunice Paisana
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Tânia Carvalho
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Pedro Pereira
- Laboratory of Neuropathology, Neurology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisboa, Portugal
| | - Rafael Roque
- Laboratory of Neuropathology, Neurology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisboa, Portugal
| | - José Pimentel
- Laboratory of Neuropathology, Neurology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisboa, Portugal
| | - José Miguéns
- Department of Neurosurgery, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisboa, Portugal
| | - Isidro Cortes-Ciriano
- European Molecular Biology Laboratory, European Bioinformatics Institute, Hinxton, Cambridge CB10 1SD, UK
| | - João T Barata
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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Katano A, Yamashita H. Brain metastasis: Recent treatment modalities and future‑perspectives (Review). Oncol Lett 2022; 23:191. [DOI: 10.3892/ol.2022.13311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 04/12/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Atsuto Katano
- Department of Radiology, University of Tokyo Hospital, Bunkyo, Tokyo 113‑8655, Japan
| | - Hideomi Yamashita
- Department of Radiology, University of Tokyo Hospital, Bunkyo, Tokyo 113‑8655, Japan
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Wu KC, Cantalino JM, Dee EC, Hsu L, Harris TC, Rawal B, Juvekar PR, Mooney MA, Dunn IF, Aizer AA, Devlin PM, Bi WL. Salvage brachytherapy for multiply recurrent metastatic brain tumors: a matched-case analysis. Neurooncol Adv 2022; 4:vdac039. [PMID: 35571989 PMCID: PMC9092639 DOI: 10.1093/noajnl/vdac039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Patients with recurrent brain metastases who have exhausted external radiation options pose a treatment challenge in the setting of advances in systemic disease control which have improved quality of life and survival. Brachytherapy holds promise as salvage therapy given its ability to enforce surgical cytoreduction and minimize regional toxicity. This study investigates the role of salvage brachytherapy in maintaining local control for recurrent metastatic lesions. Methods We retrospectively reviewed our institution’s experience with brachytherapy in patients with multiply recurrent cerebral metastases who have exhausted external radiation treatment options (14 cases). The primary outcome of the study was freedom from local recurrence (FFLR). To capture the nuances of tumor biology, we compared FFLR achieved by brachytherapy to the preceding treatment for each patient. We further compared the response to brachytherapy in patients with lung cancer (8 cases) against a matched cohort of maximally radiated lung brain metastases (10 cases). Results Brachytherapy treatment conferred significantly longer FFLR compared to prior treatments (median 7.39 vs 5.51 months, P = .011) for multiply recurrent brain metastases. Compared to an independent matched cohort, brachytherapy demonstrated superior FFLR (median 8.49 vs 1.61 months, P = .004) and longer median overall survival (11.07 vs 5.93 months, P = .055), with comparable side effects. Conclusion Brachytherapy used as salvage treatment for select patients with a multiply recurrent oligometastatic brain metastasis in the setting of well-controlled systemic disease holds promise for improving local control in this challenging patient population.
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Affiliation(s)
- Kyle C Wu
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School
| | - Jonathan M Cantalino
- Department of Radiation Oncology, Brigham and Women’s Hospital, Harvard Medical School
| | - Edward C Dee
- Department of Radiation Oncology, Brigham and Women’s Hospital, Harvard Medical School
| | - Liangge Hsu
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School
| | - Thomas C Harris
- Department of Radiation Oncology, Brigham and Women’s Hospital, Harvard Medical School
| | - Bhupendra Rawal
- Department of Biostatistics and Computational Biology, Dana Farber Cancer Institute, Harvard Medical School
| | - Parikshit R Juvekar
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School
| | - Michael A Mooney
- Department of Neurosurgery, Barrow Neurologic Institute, Phoenix, Arizona
| | - Ian F Dunn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, University of Oklahoma College of Medicine
| | - Ayal A Aizer
- Department of Radiation Oncology, Brigham and Women’s Hospital, Harvard Medical School
| | - Phillip M Devlin
- Department of Radiation Oncology, Brigham and Women’s Hospital, Harvard Medical School
| | - Wenya Linda Bi
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School
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Blazquez R, Proescholdt MA, Klauser M, Schebesch KM, Doenitz C, Heudobler D, Stange L, Riemenschneider MJ, Bumes E, Rosengarth K, Schicho A, Schmidt NO, Brawanski A, Pukrop T, Wendl C. Breakouts-A Radiological Sign of Poor Prognosis in Patients With Brain Metastases. Front Oncol 2022; 12:849880. [PMID: 35444944 PMCID: PMC9015662 DOI: 10.3389/fonc.2022.849880] [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] [Received: 01/06/2022] [Accepted: 02/28/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose Brain metastases (BM) can present a displacing or infiltrating growth pattern, independent of the primary tumor type. Previous studies have shown that tumor cell infiltration at the macro-metastasis/brain parenchyma interface (MMPI) is correlated with poor outcome. Therefore, a pre-therapeutic, non-invasive detection tool for potential metastatic cell infiltration at the MMPI would be desirable to help identify patients who may benefit from a more aggressive local treatment strategy. The aim of this study was to identify specific magnetic resonance imaging (MRI) patterns at the MMPI in patients with BM and to correlate these patterns with patient outcome. Patients and Methods In this retrospective analysis of a prospective BM registry, we categorized preoperative MR images of 261 patients with BM according to a prespecified analysis system, which consisted of four MRI contrast enhancement (CE) patterns: two with apparently regularly shaped borders (termed “rim-enhancing” and “spherical”) and two with irregular delineation (termed “breakout” and “diffuse”). The primary outcome parameter was overall survival (OS). Additionally analyzed prognostic parameters were the Karnofsky Performance Index, tumor size, edema formation, extent of resection, and RPA class. Results OS of patients with a breakout pattern was significantly worse than OS of all other groups. Conclusion Our data show that BM with a breakout pattern have a highly aggressive clinical course. Patients with such a pattern potentially require a more aggressive local and systemic treatment strategy.
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Affiliation(s)
- Raquel Blazquez
- Department of Internal Medicine III, Hematology and Medical Oncology, University Hospital Regensburg, Regensburg, Germany
| | | | - Marlene Klauser
- Institute of Radiology, University Hospital Regensburg, Regensburg, Germany
| | | | - Christian Doenitz
- Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Daniel Heudobler
- Department of Internal Medicine III, Hematology and Medical Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Lena Stange
- Department of Neuropathology, University Hospital Regensburg, Regensburg, Germany
| | | | - Elisabeth Bumes
- Department of Neurology and Wilhelm Sander-NeuroOncology Unit, University Hospital Regensburg, Regensburg, Germany
| | | | - Andreas Schicho
- Institute of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - Nils-Ole Schmidt
- Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Alexander Brawanski
- Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Tobias Pukrop
- Department of Internal Medicine III, Hematology and Medical Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Christina Wendl
- Institute of Radiology, University Hospital Regensburg, Regensburg, Germany
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Sharma M, Bakshi AK, Mittapelly N, Gautam S, Marwaha D, Rai N, Singh N, Tiwari P, Aggarwal N, Kumar A, Mishra PR. Recent updates on innovative approaches to overcome drug resistance for better outcomes in cancer. J Control Release 2022; 346:43-70. [DOI: 10.1016/j.jconrel.2022.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 02/07/2023]
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79
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Liang R, Tomita D, Sasaki Y, Ginn J, Michino M, Huggins DJ, Baxt L, Kargman S, Shahid M, Aso K, Duggan M, Stamford AW, DeStanchina E, Liverton N, Meinke PT, Foley MA, Phillips RE. A Chemical Strategy toward Novel Brain-Penetrant EZH2 Inhibitors. ACS Med Chem Lett 2022; 13:377-387. [PMID: 35300079 PMCID: PMC8919293 DOI: 10.1021/acsmedchemlett.1c00448] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 01/24/2022] [Indexed: 12/14/2022] Open
Abstract
Aberrant gene-silencing through dysregulation of polycomb protein activity has emerged as an important oncogenic mechanism in cancer, implicating polycomb proteins as important therapeutic targets. Recently, an inhibitor targeting EZH2, the methyltransferase component of PRC2, received U.S. Food and Drug Administration approval following promising clinical responses in cancer patients. However, the current array of EZH2 inhibitors have poor brain penetrance, limiting their use in patients with central nervous system malignancies, a number of which have been shown to be sensitive to EZH2 inhibition. To address this need, we have identified a chemical strategy, based on computational modeling of pyridone-containing EZH2 inhibitor scaffolds, to minimize P-glycoprotein activity, and here we report the first brain-penetrant EZH2 inhibitor, TDI-6118 (compound 5). Additionally, in the course of our attempts to optimize this compound, we discovered TDI-11904 (compound 21), a novel, highly potent, and peripherally active EZH2 inhibitor based on a 7 member ring structure.
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Affiliation(s)
- Rui Liang
- Tri-Institutional Therapeutics Discovery Institute, 413 East 69th Street, New York, New York 10021, United States
| | - Daisuke Tomita
- Tri-Institutional Therapeutics Discovery Institute, 413 East 69th Street, New York, New York 10021, United States
| | - Yusuke Sasaki
- Tri-Institutional Therapeutics Discovery Institute, 413 East 69th Street, New York, New York 10021, United States
| | - John Ginn
- Tri-Institutional Therapeutics Discovery Institute, 413 East 69th Street, New York, New York 10021, United States
| | - Mayako Michino
- Tri-Institutional Therapeutics Discovery Institute, 413 East 69th Street, New York, New York 10021, United States
| | - David J Huggins
- Tri-Institutional Therapeutics Discovery Institute, 413 East 69th Street, New York, New York 10021, United States.,Department of Physiology and Biophysics, Weill Cornell Medical College, New York, New York 10021, United States
| | - Leigh Baxt
- Tri-Institutional Therapeutics Discovery Institute, 413 East 69th Street, New York, New York 10021, United States
| | - Stacia Kargman
- Tri-Institutional Therapeutics Discovery Institute, 413 East 69th Street, New York, New York 10021, United States
| | - Maaz Shahid
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States.,Epigenetics Program, Perelman School of Medicine, Philadelphia, Pennsylvania 19104, United States.,Abramson Cancer Center, Perelman School of Medicine, Philadelphia, Pennsylvania 19104, United States
| | - Kazuyoshi Aso
- Tri-Institutional Therapeutics Discovery Institute, 413 East 69th Street, New York, New York 10021, United States
| | - Mark Duggan
- LifeSci Consulting, LLC., 18243 SE Ridgeview Drive, Tequesta, Florida 33469, United States
| | - Andrew W Stamford
- Tri-Institutional Therapeutics Discovery Institute, 413 East 69th Street, New York, New York 10021, United States
| | - Elisa DeStanchina
- Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, New York 10065, United States
| | - Nigel Liverton
- Tri-Institutional Therapeutics Discovery Institute, 413 East 69th Street, New York, New York 10021, United States
| | - Peter T Meinke
- Tri-Institutional Therapeutics Discovery Institute, 413 East 69th Street, New York, New York 10021, United States.,Department of Pharmacology, Weill Cornell Medical College, New York, New York 10021, United States
| | - Michael A Foley
- Tri-Institutional Therapeutics Discovery Institute, 413 East 69th Street, New York, New York 10021, United States
| | - Richard E Phillips
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States.,Epigenetics Program, Perelman School of Medicine, Philadelphia, Pennsylvania 19104, United States.,Abramson Cancer Center, Perelman School of Medicine, Philadelphia, Pennsylvania 19104, United States
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80
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Rare pontine metastasis operated via endoscopic transsphenoidal transclival approach, a case report and brief review of literature. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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81
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Salvage Treatment for Progressive Brain Metastases in Breast Cancer. Cancers (Basel) 2022; 14:cancers14041096. [PMID: 35205844 PMCID: PMC8870695 DOI: 10.3390/cancers14041096] [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] [Received: 12/06/2021] [Revised: 01/31/2022] [Accepted: 02/17/2022] [Indexed: 11/24/2022] Open
Abstract
Simple Summary Thirty percent of patients with human epidermal growth factor receptor 2-positive breast cancer and triple-negative breast cancer, and 15% of patients with the remaining subtypes of breast cancer will develop brain metastases. Available treatment methods include surgery and radiotherapy. However, some individuals will experience intracranial progression despite prior local treatment. This situation remains a challenge. In the case of progressing lesions amenable to local therapy, the choice of a treatment method must consider performance status, cancer burden, possible toxicity, and previously applied therapy. Stereotactic radiosurgery or fractionated radiotherapy rather than whole-brain radiotherapy should be used only if feasible. If local therapy is unfeasible, selected patients, especially those with human epidermal growth factor receptor 2-positive breast cancer, may benefit from systemic therapy. Abstract Survival of patients with breast cancer has increased in recent years due to the improvement of systemic treatment options. Nevertheless, the occurrence of brain metastases is associated with a poor prognosis. Moreover, most drugs do not penetrate the central nervous system because of the blood–brain barrier. Thus, confirmed intracranial progression after local therapy is especially challenging. The available methods of salvage treatment include surgery, stereotactic radiosurgery (SRS), fractionated stereotactic radiotherapy (FSRT), whole-brain radiotherapy, and systemic therapies. This narrative review discusses possible strategies of salvage treatment for progressive brain metastases in breast cancer. It covers possibilities of repeated local treatment using the same method as applied previously, other methods of local therapy, and options of salvage systemic treatment. Repeated local therapy may provide a significant benefit in intracranial progression-free survival and overall survival. However, it could lead to significant toxicity. Thus, the choice of optimal methods should be carefully discussed within the multidisciplinary tumor board.
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82
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Wang ZN, Jiang XB, Lu J, Guo XY, He ZQ, Duan H, Liang L, Cui R, Hu HR, Zhang XH, Zhong S, Li C, Yu CW, Guo CC, Mou YG. Survival Benefit from Surgical Resection in Lung Cancer Patients with Brain Metastases: a Single-Center, Propensity-Matched Analysis Cohort Study. Ann Surg Oncol 2022; 29:3684-3693. [PMID: 35181815 DOI: 10.1245/s10434-022-11365-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/11/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Brain metastases (BMs) are the most serious complication of lung cancer, affecting the prognosis of lung cancer patients, and pose distinct clinical challenges. This study was designed to explore the prognostic factors related to lung cancer BM and the value of surgical resection in BMs from lung cancer. METHODS A retrospective analysis was performed on 714 patients with lung cancer BMs screened between January 2010 and January 2018 at the Sun Yat-sen University Cancer Center. A 1:1 propensity score matching analysis was performed to reduce the potential bias between the surgery and the nonsurgery group. In both the raw and the propensity-score matched dataset, univariate and multivariate Cox proportional hazards regression analyses were used to evaluate risk factors for survival. RESULTS After matching, 258 patients (129 surgery, 129 no surgery) were analyzed. Multivariate analyses after propensity score matching demonstrated that surgical resection was an independent protective factor for overall survival (OS), and older age, lower Karnofsky Performance Scale (KPS) score, and extracranial metastases were independent risk factors for worse OS. Patients without extracranial metastases, without synchronous BM and with a single BM had a better prognosis. CONCLUSIONS The findings showed that surgical resection, age, KPS score, and extracranial metastases are independent prognostic factors for predicting the OS of patients with lung cancer BMs, and surgical resection for brain metastatic lesions could significantly improve the OS. However, only certain groups of patients with BMs can benefit from intracranial lesion resection, such as no extracranial metastases and metachronous metastases.
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Affiliation(s)
- Zhen-Ning Wang
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Neurosurgery, Dongguan People's Hospital (Affiliated Dongguan Hospital, South Medical University), Dongguan, China
| | - Xiao-Bing Jiang
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Jie Lu
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Xiao-Yu Guo
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Neurosurgery, The First Affiliated Hospital of Ji'nan University, Guangzhou, China
| | - Zhen-Qiang He
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Hao Duan
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Lun Liang
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Run Cui
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Hong-Rong Hu
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Xiang-Heng Zhang
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Sheng Zhong
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Chang Li
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Cheng-Wei Yu
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Cheng-Cheng Guo
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.
| | - Yong-Gao Mou
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.
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83
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Surendran HP, Narmadha MP, Kalavagunta S, Sasidharan A, Dutta D. Preservation of cognitive function after brain irradiation. J Oncol Pharm Pract 2022:10781552221077037. [PMID: 35112915 DOI: 10.1177/10781552221077037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Approximately 50-90% of brain metastatic patients who receive radiation therapy (RT) exhibit cognitive decline which may affects the quality of life of cancer survivors. Hence preservation of cognitive functions in brain metastatic patients becomes important. This review aims to evaluates the pathology or mechanism of cognitive function impairment after brain irradiation and strategies available to preserve cognitive function after radiation therapy. DATA SOURCES Published articles evaluating the pathology behind radiation induced cognitive impairment and strategies to resolve or preserve cognitive impairment were searched for in scientific databases (eg: PubMed, Scopus, Cochrane database, Google scholar) using keywords including memantine, brain metastases, radiation therapy, pathophysiology, pathogenesis, mechanism and prevention. DATA SUMMARY Several hypotheses have been offered to explain the mechanism of radiation induced cognitive decline. Among them, vascular hypotheses play a significant role. Some pharmacological agents have been also tested in patients receiving radiotherapy, memantine was found beneficial based with the reference to existing data. CONCLUSION Future studies are required to evaluate the impact of memantine in different types of radiation therapy procedures and its effects on quality of life of brain metastatic survivors.
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Affiliation(s)
| | - M P Narmadha
- Department of Pharmacy Practice, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Sruthi Kalavagunta
- Department of Radiation Oncology, 29286Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Ajay Sasidharan
- Department of Radiation Oncology, 29286Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Debnarayan Dutta
- Department of Radiation Oncology, 29286Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
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84
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Wang L, Zeng D, Wang Q, Liu L, Lu T, Gao Y. Screening and Identification of Novel Potential Biomarkers for Breast Cancer Brain Metastases. Front Oncol 2022; 11:784096. [PMID: 35096583 PMCID: PMC8792448 DOI: 10.3389/fonc.2021.784096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/09/2021] [Indexed: 12/29/2022] Open
Abstract
Brain metastases represent a major cause of mortality among patients with breast cancer, and few effective targeted treatment options are currently available. Development of new biomarkers and therapeutic targets for breast cancer brain metastases (BCBM) is therefore urgently needed. In this study, we compared the gene expression profiles of the brain metastatic cell line MDA-MB-231-BR (231-BR) and its parental MDA-MB-231, and identified a total of 84 genes in the primary screening through a series of bioinformatic analyses, including construction of protein-protein interaction (PPI) networks by STRING database, identification of hub genes by applying of MCODE and Cytohubba algorithms, identification of leading-edge subsets of Gene Set Enrichment Analysis (GSEA), and identification of most up-regulated genes. Eight genes were identified as candidate genes due to their elevated expression in brain metastatic 231-BR cells and prognostic values in patients with BCBM. Then we knocked down the eight individual candidate genes in 231-BR cells and evaluated their impact on cell migration through a wound-healing assay, and four of them (KRT19, FKBP10, GSK3B and SPANXB1) were finally identified as key genes. Furthermore, the expression of individual key genes showed a correlation with the infiltration of major immune cells in the brain tumor microenvironment (TME) as analyzed by Tumor Immune Estimation Resource (TIMER) and Gene Expression Profiling Interactive Analysis (GEPIA), suggesting possible roles of them in regulation of the tumor immune response in TME. Therefore, the present work may provide new potential biomarkers for BCBM. Additionally, using GSEA, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) Enrichment Analysis, we determined the top enriched cellular functions or pathways in 231-BR cells, which may help better understand the biology governing the development and progression of BCBM.
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Affiliation(s)
- Lulu Wang
- Department of Human Anatomy, School of Basic Medical Sciences, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Beijing, China.,Cancer Institute of Capital Medical University, Beijing, China
| | - Dan Zeng
- Department of Human Anatomy, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Qi Wang
- Department of Human Anatomy, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Li Liu
- Department of Experimental Center for Basic Medical Teaching, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Tao Lu
- Department of Human Anatomy, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Yan Gao
- Department of Human Anatomy, School of Basic Medical Sciences, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Beijing, China.,Cancer Institute of Capital Medical University, Beijing, China
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85
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Cui G, Yang Y, Yin FF, Yoo D, Kim G, Duan J. Evaluation of two automated treatment planning techniques for multiple brain metastases using a single isocenter. JOURNAL OF RADIOSURGERY AND SBRT 2022; 8:47-54. [PMID: 35387403 PMCID: PMC8930061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 11/03/2021] [Indexed: 01/03/2023]
Abstract
Two automated treatment planning techniques were evaluated for multiple brain metastases using a single isocenter. One technique is knowledge-based planning (KBP) using a stereotactic radiosurgery (SRS) model in Eclipse treatment planning system (TPS); and the other is the Multiple Brain Mets (MBM) SRS technique in Brainlab Elements TPS. Eighteen plans each with 3-10 lesions were used for the study. Plan evaluation metrics included the planning target volume (PTV) coverage, conformity index (CI), total monitor units (MUs), plan optimization time, brain V12 Gy, V8 Gy, and V5 Gy. Both the KBP and MBM planning techniques produced comparable plans to the manually generated clinical plans in terms of PTV coverage and CI. For irregularly shaped lesions, the KBP plans provided more conformal dose distribution to the PTV than the MBM plans. The KBP plans took significantly longer time to plan but have fewer MUs than the MBM plans. The MBM plans spared normal brain tissues better than the KBP plans in terms of V5 Gy.
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Affiliation(s)
- Guoqiang Cui
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710 USA
| | - Yun Yang
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710 USA
| | - Fang-Fang Yin
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710 USA
| | - David Yoo
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710 USA
| | - Grace Kim
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710 USA
| | - Jun Duan
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710 USA
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86
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Ramos A, Giantini-Larsen A, Pannullo SC, Brandmaier A, Knisely J, Magge R, Wilcox JA, Pavlick AC, Ma B, Pisapia D, Ashamalla H, Ramakrishna R. A multidisciplinary management algorithm for brain metastases. Neurooncol Adv 2022; 4:vdac176. [PMID: 36532509 PMCID: PMC9749403 DOI: 10.1093/noajnl/vdac176] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
The incidence of brain metastases continues to present a management issue despite the advent of improved systemic control and overall survival. While the management of oligometastatic disease (ie, 1-4 brain metastases) with surgery and radiation has become fairly straightforward in the era of radiosurgery, the management of patients with multiple metastatic brain lesions can be challenging. Here we review the available evidence and provide a multidisciplinary management algorithm for brain metastases that incorporates the latest advances in surgery, radiation therapy, and systemic therapy while taking into account the latest in precision medicine-guided therapies. In particular, we argue that whole-brain radiation therapy can likely be omitted in most patients as up-front therapy.
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Affiliation(s)
- Alexander Ramos
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Alexandra Giantini-Larsen
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Susan C Pannullo
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Andrew Brandmaier
- Department of Radiation Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Jonathan Knisely
- Department of Radiation Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Rajiv Magge
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Jessica A Wilcox
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anna C Pavlick
- Department of Oncology, Weill Cornell Medicine, New York Presbyterian, New York, New York, USA
| | - Barbara Ma
- Department of Oncology, Weill Cornell Medicine, New York Presbyterian, New York, New York, USA
| | - David Pisapia
- Department of Pathology, Weill Cornell Medicine, New York Presbyterian, New York, New York, USA
| | - Hani Ashamalla
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Rohan Ramakrishna
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
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87
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Soni YS, Rich BJ, Kwon D, Zhao W, John DL, Seldon C, Meshman J, Benveniste R, Komotar RJ, de la Fuente M, Guillermo Prieto MDP, Azzam G, Mellon EA, Benjamin CG, Diwanji T. Factors associated with the use of salvage whole brain radiation therapy versus salvage stereotactic radiosurgery after initial stereotactic radiosurgery for brain metastases. JOURNAL OF RADIOSURGERY AND SBRT 2022; 8:85-94. [PMID: 36275132 PMCID: PMC9489072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 06/29/2022] [Indexed: 01/03/2023]
Abstract
Objectives Patients undergoing stereotactic radiosurgery (SRS) for brain metastases require additional radiation for relapse. Our objective is to determine the factors associated with salvage SRS versus whole brain radiation therapy (WBRT) for salvage of first intracranial failure (ICF) after upfront SRS. Method We identified a cohort of 110 patients with brain metastases treated with SRS in the definitive or postoperative setting followed by subsequent salvage WBRT or SRS at least one month after initial SRS. Clinical and demographic characteristics were retrospectively recorded. Results 78 Patients received SRS and 32 patients received WBRT at the time of first ICF. On multivariate analysis (MVA) factors associated with decreased use of salvage SRS were male gender (p=0.044) and local progression (p<0.001). Conclusions Local progression and male gender were the strongest factors associated with selection of salvage WBRT. Possible etiologies of this difference could be provider or patient driven, but warrant further exploration.
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Affiliation(s)
- Yash S. Soni
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Benjamin J. Rich
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Deukwoo Kwon
- Department of Public Health Sciences, Biostatistics and Bioinformatics Shared Resource, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Wei Zhao
- Department of Public Health Sciences, Biostatistics and Bioinformatics Shared Resource, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Danny L. John
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Crystal Seldon
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jessica Meshman
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ronald Benveniste
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ricardo J. Komotar
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Macarena de la Fuente
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Gregory Azzam
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eric A. Mellon
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Carolina G. Benjamin
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tejan Diwanji
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA, Department of Radiation Oncology, Mid-Atlantic Permanente Medical Group, Halethorpe, MD, USA
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88
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Mitchell D, Kwon HJ, Kubica PA, Huff WX, O’Regan R, Dey M. Brain metastases: An update on the multi-disciplinary approach of clinical management. Neurochirurgie 2022; 68:69-85. [PMID: 33864773 PMCID: PMC8514593 DOI: 10.1016/j.neuchi.2021.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/16/2021] [Accepted: 04/03/2021] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Brain metastasis (BM) is the most common malignant intracranial neoplasm in adults with over 100,000 new cases annually in the United States and outnumbering primary brain tumors 10:1. OBSERVATIONS The incidence of BM in adult cancer patients ranges from 10-40%, and is increasing with improved surveillance, effective systemic therapy, and an aging population. The overall prognosis of cancer patients is largely dependent on the presence or absence of brain metastasis, and therefore, a timely and accurate diagnosis is crucial for improving long-term outcomes, especially in the current era of significantly improved systemic therapy for many common cancers. BM should be suspected in any cancer patient who develops new neurological deficits or behavioral abnormalities. Gadolinium enhanced MRI is the preferred imaging technique and BM must be distinguished from other pathologies. Large, symptomatic lesion(s) in patients with good functional status are best treated with surgery and stereotactic radiosurgery (SRS). Due to neurocognitive side effects and improved overall survival of cancer patients, whole brain radiotherapy (WBRT) is reserved as salvage therapy for patients with multiple lesions or as palliation. Newer approaches including multi-lesion stereotactic surgery, targeted therapy, and immunotherapy are also being investigated to improve outcomes while preserving quality of life. CONCLUSION With the significant advancements in the systemic treatment for cancer patients, addressing BM effectively is critical for overall survival. In addition to patient's performance status, therapeutic approach should be based on the type of primary tumor and associated molecular profile as well as the size, number, and location of metastatic lesion(s).
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Affiliation(s)
- D Mitchell
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - HJ Kwon
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - PA Kubica
- Department of Neurosurgery, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA
| | - WX Huff
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - R O’Regan
- Department of Medicine/Hematology Oncology, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA
| | - M Dey
- Department of Neurosurgery, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA,Correspondence Should Be Addressed To: Mahua Dey, MD, University of Wisconsin School of Medicine & Public Health, 600 Highland Ave, Madison, WI 53792; Tel: 317-274-2601;
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89
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Schupper AJ, Price G, Hadjipanayis CG. Robotic-Assisted Digital Exoscope for Resection of Cerebral Metastases: A Case Series. Oper Neurosurg (Hagerstown) 2021; 21:436-444. [PMID: 34561708 DOI: 10.1093/ons/opab356] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 08/04/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Surgical resection is the primary treatment for cerebral metastases with safe complete resection as the goal. The robotically assisted digital surgical exoscope is a novel system with advanced visualization methods with recent applications in neurosurgery. OBJECTIVE To evaluate the outcomes for patients with cerebral metastases undergoing resection with the surgical exoscope. METHODS Data were retrospectively collected from patients with cerebral metastases where resection was achieved with using the surgical exoscope from 2016 to 2020. Demographics, clinical, imaging, and operative and outcome findings were collected. The relationship between perioperative data and discharge disposition as well as progression-free survival (PFS) and 12 mo overall survival (OS) was assessed. RESULTS A total of 31 patients (19 males) with a median patient age 63 yr (range 38-80) were included. Average pre- and postoperative volumes were 18.1 cc and 0.75 cc, respectively. Mean depth of the resected lesions was 0.6 cm (range 0-3.6 cm). Complete resection was achieved in 64.5% of patients. The mean extent of resection was 96.7%, with 71.0% achieving PFS at 6 mo. Overall PFS rate was 58.1% and the OS rate at 12 mo was 83.9%. Neurological complications included motor (35.5%) and sensory (12.9%) deficits, with 12 patients reporting no postoperative symptoms. CONCLUSION The surgical exoscope can delineate tumor tissues with high resolution, as shown by a gross total resection achieved for the majority of cases in our series. Postoperative complications and patient outcomes were similar to those reported with use of the operative microscope. Use of the exoscope can provide optimal visualization and delineation of cerebral metastases.
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Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Gabrielle Price
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Constantinos G Hadjipanayis
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
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90
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Marullo R, Castro M, Yomtoubian S, Calvo-Vidal MN, Revuelta MV, Krumsiek J, Cho A, Morgado PC, Yang S, Medina V, Roth BM, Bonomi M, Keshari KR, Mittal V, Navigante A, Cerchietti L. The metabolic adaptation evoked by arginine enhances the effect of radiation in brain metastases. SCIENCE ADVANCES 2021; 7:eabg1964. [PMID: 34739311 PMCID: PMC8570607 DOI: 10.1126/sciadv.abg1964] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Selected patients with brain metastases (BM) are candidates for radiotherapy. A lactatogenic metabolism, common in BM, has been associated with radioresistance. We demonstrated that BM express nitric oxide (NO) synthase 2 and that administration of its substrate l-arginine decreases tumor lactate in BM patients. In a placebo-controlled trial, we showed that administration of l-arginine before each fraction enhanced the effect of radiation, improving the control of BM. Studies in preclinical models demonstrated that l-arginine radiosensitization is a NO-mediated mechanism secondary to the metabolic adaptation induced in cancer cells. We showed that the decrease in tumor lactate was a consequence of reduced glycolysis that also impacted ATP and NAD+ levels. These effects were associated with NO-dependent inhibition of GAPDH and hyperactivation of PARP upon nitrosative DNA damage. These metabolic changes ultimately impaired the repair of DNA damage induced by radiation in cancer cells while greatly sparing tumor-infiltrating lymphocytes.
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Affiliation(s)
- Rossella Marullo
- Hematology and Oncology Division, Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Monica Castro
- Translational Research Unit, Angel Roffo Cancer Institute, University of Buenos Aires, Buenos Aires, Argentina
| | - Shira Yomtoubian
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, Cornell University, New York, NY, USA
- Department of Cell and Developmental Biology, Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - M. Nieves Calvo-Vidal
- Hematology and Oncology Division, Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Maria Victoria Revuelta
- Hematology and Oncology Division, Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Jan Krumsiek
- Department of Physiology and Biophysics, Institute for Computational Biomedicine, Weill Cornell Medicine, New York, NY, USA
| | - Andrew Cho
- Department of Biochemistry and Structural Biology, Weill Cornell Graduate School, New York, NY, USA
| | - Pablo Cresta Morgado
- Translational Research Unit, Angel Roffo Cancer Institute, University of Buenos Aires, Buenos Aires, Argentina
| | - ShaoNing Yang
- Hematology and Oncology Division, Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Vanina Medina
- Laboratory of Tumor Biology and Inflammation, Institute for Biomedical Research, School of Medical Sciences, Pontifical Catholic University of Argentina and National Scientific and Technical Research Council, Buenos Aires, Argentina
- Laboratory of Radioisotopes, School of Pharmacy and Biochemistry, University of Buenos Aires, Buenos Aires, Argentina
| | - Berta M. Roth
- Radiation and Imaging Department, Angel Roffo Cancer Institute, University of Buenos Aires, Buenos Aires, Argentina
| | - Marcelo Bonomi
- Hematology and Oncology Division, The Ohio State University, Columbus, OH, USA
| | - Kayvan R. Keshari
- Department of Biochemistry and Structural Biology, Weill Cornell Graduate School, New York, NY, USA
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vivek Mittal
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, Cornell University, New York, NY, USA
- Department of Cell and Developmental Biology, Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Alfredo Navigante
- Translational Research Unit, Angel Roffo Cancer Institute, University of Buenos Aires, Buenos Aires, Argentina
| | - Leandro Cerchietti
- Hematology and Oncology Division, Weill Cornell Medicine, Cornell University, New York, NY, USA
- Corresponding author.
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91
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Volumetric Response of Limited Brain Metastatic Disease to Focal Hypofractionated Radiation Therapy. Brain Sci 2021; 11:brainsci11111457. [PMID: 34827456 PMCID: PMC8615909 DOI: 10.3390/brainsci11111457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 11/25/2022] Open
Abstract
Background: This is a retrospective study aimed at assessing the volumetric response, morbidity and failure rates of hypofractionated radiation therapy (HFRT) for definitive focal management of limited brain metastasis. Methods: Patients managed with HFRT for unresected limited metastatic (≤10 lesions) brain disease were entered into an ethics-approved database. Included patients had been deemed unsuitable for surgical resection, and lesions managed with prior radiation therapy were excluded. HFRT was delivered using IMRT or VMAT with 25 Gy or 30 Gy in five fractions. Individual lesions had volumetric assessment performed at three timepoints. The primary endpoint was the change of volume from baseline (GTV0) to one month post-HFRT (GTV1) and to seven months post-HFRT (GTV7). Secondary endpoints were local failure, survival and rates of radiation necrosis. Results: One hundred and twenty-four patients with 233 lesions were managed with HFRT. Median follow-up was 23.5 months with 32 (25.8%) patients alive at censure. Median overall survival was 7.3 months with 36.3% survival at 12 months. Superior survival was predicted by smaller GTV0 (p = 0.003) and increased percentage of volumetric response (p < 0.001). Systemic therapy was delivered to 81.5% of patients. At one month post-HFRT, 206 metastases (88.4%) were available for assessment and at seven months post-HFRT, 118 metastases (50.6%) were available. Median metastasis volume at GTV0 was 1.6 cm3 (range: 0.1–19.1). At GTV1 and GTV7, this reduced to 0.7 cm3 (p < 0.001) and 0.3 cm3 (p < 0.001), respectively, correlating to percentage reductions of 54.9% and 83.3%. No significant predictors of volumetric response following HFRT were identified. Local failure was identified in 4.3% of lesions and radiation necrosis in 3.9%. Conclusion: HFRT is an effective therapy for limited metastatic disease in the brain to maximise initial volumetric response whilst minimising toxicity.
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Abstract
As novel systemic therapies yield improved survival in metastatic cancer patients, the frequency of brain metastases continues to increase. Over the years, management strategies have continued to evolve. Historically, stereotactic radiosurgery has been used as a boost to whole-brain radiotherapy (WBRT) but is increasingly being used as a replacement for WBRT. Given its capacity to treat both macro- and micro-metastases in the brain, WBRT has been an important management strategy for years, and recent research has identified technologic and pharmacologic approaches to delivering WBRT more safely. In this review, we outline the current landscape of radiotherapeutic treatment options and discuss approaches to integrating radiotherapy advances in the contemporary management of brain metastases.
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Affiliation(s)
- Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville and Proton Center, Warrenville, Illinois, USA
| | | | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
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93
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Yu W, Hu C, Gao H. Advances of nanomedicines in breast cancer metastasis treatment targeting different metastatic stages. Adv Drug Deliv Rev 2021; 178:113909. [PMID: 34352354 DOI: 10.1016/j.addr.2021.113909] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/20/2021] [Accepted: 07/28/2021] [Indexed: 02/07/2023]
Abstract
Breast cancer is the most common tumor in women, and the metastasis further increases the malignancy with extremely high mortality. However, there is almost no effective method in the clinic to completely inhibit breast cancer metastasis due to the dynamic multistep process with complex pathways and scattered occurring site. Nowadays, nanomedicines have been evidenced with great potential in treating cancer metastasis. In this review, we summarize the latest research advances of nanomedicines in anti-metastasis treatment. Strategies are categorized according to the metastasis dynamics, including primary tumor, circulating tumor cells, pre-metastatic niches and secondary tumor. In each different stage of metastasis process, nanomedicines are designed specifically with different functions. At the end of the review, we give our perspectives on current limitations and future directions in anti-metastasis therapy. We expect the review provides comprehensive understandings of anti-metastasis therapy for breast cancer, and boosts the clinical translation in the future to improve women's health.
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94
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Jünger ST, Reinecke D, Meissner AK, Goldbrunner R, Grau S. Resection of symptomatic non-small cell lung cancer brain metastasis in the setting of multiple brain metastases. J Neurosurg 2021:1-7. [PMID: 34715653 DOI: 10.3171/2021.7.jns211172] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Current guidelines primarily suggest resection of brain metastases (BMs) in patients with limited lesions. With a growing number of highly effective local and systemic treatment options, this view may be challenged. The purpose of this study was to evaluate the role of metastasectomy, disregarding BM count, in a comprehensive treatment setting. METHODS In this monocentric retrospective analysis, the authors included patients who underwent resection for at least 1 BM and collected demographic, clinical, and tumor-associated parameters. Prognostic factors for local control and overall survival (OS) were analyzed with the log-rank test and Cox proportional hazards analysis. RESULTS The authors analyzed 216 patients. One hundred twenty-nine (59.7%) patients were diagnosed with a single/solitary BM, whereas 64 (29.6%) patients had 2-3 BMs and the remaining 23 (10.6%) had more than 3 BMs. With resection of symptomatic BMs, a significant improvement in Karnofsky Performance Scale (KPS) was achieved (p < 0.001), thereby enabling adjuvant radiotherapy for 199 (92.1%) patients and systemic treatment for 119 (55.1%) patients. During follow-up, 83 (38.4%) patients experienced local recurrence. BM count did not significantly influence local control rates. By the time of analysis, 120 (55.6%) patients had died; the leading cause of death was systemic tumor progression. The mean (range) OS after surgery was 12.7 (0-88) months. In univariate analysis, the BM count did not influence OS (p = 0.844), but age < 65 years (p = 0.007), preoperative and postoperative KPS ≥ 70 (p = 0.002 and p = 0.005, respectively), systemic metastases other than BM (p = 0.004), adjuvant radiation therapy (p < 0.001), and adjuvant systemic treatment (p < 0.001) were prognostic factors. In regression analysis, the presence of extracranial metastases (HR 2.30, 95% CI 1.53-3.48, p < 0.001), adjuvant radiation therapy (HR 0.97, 95% CI 0.23-0.86, p = 0.016), and adjuvant systemic treatment (HR 0.37, 95% CI 0.25-0.55, p < 0.001) remained as independent factors for survival. CONCLUSIONS Surgery for symptomatic BM from non-small cell lung cancer may be indicated even for patients with multiple lesions in order to alleviate their neurological symptoms and to consequently facilitate further treatment.
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Affiliation(s)
- Stephanie T Jünger
- 1Centre for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; and.,2Centre for Integrated Oncology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - David Reinecke
- 1Centre for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; and.,2Centre for Integrated Oncology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Anna-Katharina Meissner
- 1Centre for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; and.,2Centre for Integrated Oncology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- 1Centre for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; and.,2Centre for Integrated Oncology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Stefan Grau
- 1Centre for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; and.,2Centre for Integrated Oncology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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95
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Kameda-Smith MM, Zhang E, Lannon M, Algird A, Reddy K, Lu JQ. Pituitary metastasis: From pathology to clinical and radiological considerations. J Clin Neurosci 2021; 93:231-240. [PMID: 34656254 DOI: 10.1016/j.jocn.2021.09.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/23/2021] [Accepted: 09/07/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE A review of the literature with respect to pituitary metastases (PM) with clinical and radiological considerations are summarized to facilitate clinical decision making in the management of PM METHODS: A review of literature associated with PM and tumour to tumour metastases in the English literature was reviewed and summarized RESULTS: Pituitary metastases account for 1.0-3.6% of all surgically treated pituitary lesions. Often identified in parallel with extensive disseminated disease, once diagnosed, the prognosis is generally poor, although survival is highly heterogeneous and dependent on the primary tumor histology. Within this anatomical region is also the observation of tumor-to-tumor metastases and collision tumours. Both the tumor macro- and microenvironment play central roles to the progression of disease with distinctive radiological features that may suggest a metastatic sellar lesion as opposed to a primary pituitary lesion. Surgical resection is the first line of therapy followed by adjuvant chemoradiotherapy and endocrinological evaluation for hormonal supplementation CONCLUSION: PMs are relatively rare but important oncological entities representing disseminated disease in the majority of cases. Careful consideration of the relevant clinical history and radiological features can aid the clinician differentiate between a metastatic lesion to the pituitary region and a primary pituitary tumor. While surgical resection is first line therapy, stereotactic radiosurgery in carefully selected patients is emerging as a viable alternative.
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Affiliation(s)
| | - E Zhang
- McMaster University, Canada; Diagnostic Imaging, Canada
| | - M Lannon
- McMaster University, Canada; Departments of Surgery, Canada
| | - A Algird
- McMaster University, Canada; Departments of Surgery, Canada
| | - K Reddy
- McMaster University, Canada; Departments of Surgery, Canada
| | - J-Q Lu
- McMaster University, Canada; Neuropathology, Canada
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96
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Holroyd KB, Rubin DB, Vaitkevicius H. Neurologic Complications in Patients with Cancer. Semin Neurol 2021; 41:588-605. [PMID: 34619783 DOI: 10.1055/s-0041-1733788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neurologic symptoms are commonly seen in patients with cancer and can be among the most challenging to diagnose and manage. It is often difficult to determine if new neurologic symptoms are secondary to direct effects of a malignant lesion, systemic complications of disease, paraneoplastic disorders, or side effects of cancer treatment itself. However, early diagnosis and treatment of each of these conditions can improve patients' quality of life and long-term functional outcomes. In this review, we describe a systematic approach to the diagnosis of new neurologic symptoms in patients with known malignancy. We have categorized the neurologic complications of cancer through a mechanistic approach, with an emphasis on ascertaining underlying pathophysiology to guide treatment choice. This review focuses on the acute neurologic complications of cancer that require hospital admission.
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Affiliation(s)
| | - Daniel B Rubin
- Department of Neurology, Massachusetts General Hospital, Brigham and Women's Hospital, Boston, Massachusetts
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97
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Zhang L, Yao R, Gao J, Tan D, Yang X, Wen M, Wang J, Xie X, Liao R, Tang Y, Chen S, Li Y. An Integrated Radiomics Model Incorporating Diffusion-Weighted Imaging and 18F-FDG PET Imaging Improves the Performance of Differentiating Glioblastoma From Solitary Brain Metastases. Front Oncol 2021; 11:732704. [PMID: 34527594 PMCID: PMC8435895 DOI: 10.3389/fonc.2021.732704] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/06/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND The effectiveness of conventional MRI (cMRI)-based radiomics in differentiating glioblastoma (GBM) from solitary brain metastases (SBM) is not satisfactory enough. Therefore, we aimed to develop an integrated radiomics model to improve the performance of differentiating GBM from SBM. METHODS One hundred patients with solitary brain tumors (50 with GBM, 50 with SBM) were retrospectively enrolled and randomly assigned to the training set (n = 80) or validation set (n = 20). A total of 4,424 radiomic features were obtained from contrast-enhanced T1-weighted imaging (CE-T1WI) with the contrast-enhancing and peri-enhancing edema region, T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI)-derived apparent diffusion coefficient (ADC), and 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) images. The partial least squares (PLS) regression with fivefold cross-validation is used to analyze the correlation between different radiomic features and different modalities. The cross-validity analysis was performed to judge whether a new principal component or a new feature dimension can significantly improve the final prediction effect. The principal components with effective interpretation in all radiomic features were projected to a low-dimensional space (2D in this study). The effective features of the new projection mapping were then sent to the random forest classifier to predict the results. The performance of differentiating GBM from SBM was compared between the integrated radiomics model and other radiomics models or nonradiomics methods using the area under the receiver operating characteristics curve (AUC). RESULTS Through the cross-validity analysis of partial least squares, hundreds of radiomic features were projected into a new two-dimensional space to complete the construction of radiomics model. Compared with the combined radiomics model using DWI + 18F-FDG PET (AUC = 0.93, p = 0.014), cMRI + DWI (AUC = 0.89, p = 0.011), cMRI + 8F-FDG PET (AUC = 0.91, p = 0.015), and single radiomics model using cMRI (AUC = 0.85, p = 0.018), DWI (AUC = 0.84, p = 0.017), and 18F-FDG PET (AUC = 0.85, p = 0.421), the integrated radiomics model (AUC = 0.98) showed more efficient diagnostic performance. The integrated radiomics model (AUC = 0.98) also showed significantly better performance than any single ADC, SUV, or TBR parameter (AUC = 0.57-0.71, p < 0.05). The integrated radiomics model showed better performance in the training (AUC = 0.98) and validation (AUC = 0.93) sets than any other models and methods, demonstrating robustness. CONCLUSIONS We developed an integrated radiomics model incorporating DWI and 18F-FDG PET, which improved the performance of differentiating GBM from SBM greatly.
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Affiliation(s)
- Liqiang Zhang
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rui Yao
- College of Computer & Information Science, Southwest University, Chongqing, China
| | - Jueni Gao
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Duo Tan
- College of Computer & Information Science, Southwest University, Chongqing, China
| | - Xinyi Yang
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ming Wen
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jie Wang
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiangxian Xie
- Department of Radiology, Chongqing United Medical Imaging Center, Chongqing, China
| | - Ruikun Liao
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Yao Tang
- Department of Oncology, People’s Hospital of Chongqing Hechuan, Chongqing, China
| | - Shanxiong Chen
- College of Computer & Information Science, Southwest University, Chongqing, China
| | - Yongmei Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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98
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González L, Castro S, Villa E, Zomosa G. Surgical resection versus stereotactic radiosurgery on local recurrence and survival for patients with a single brain metastasis: a systematic review and meta-analysis. Br J Neurosurg 2021; 35:703-713. [PMID: 34431733 DOI: 10.1080/02688697.2021.1950623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Brain metastases (BM) are the most frequent intracranial tumours in adults. In patients with solitary BM, surgical resection (SR) or stereotactic radiosurgery (SRS) is performed. There is limited evidence comparing one treatment over the other. OBJECTIVE To compare SR versus SRS on patients with solitary BMs, regarding local recurrence (LR) and overall survival (OS) conducting a systematic review and meta-analysis. METHODS Systematic review of literature following PRISMA guidelines, using the databases of Medline, Clinicaltrials.gov, Embase, Web of Science, Sciencedirect, CINAHL, Wiley Online Library, Springerlink and LILACS. Following study selection based on inclusion and exclusion criteria, data extraction and a critical analysis of the literature was performed according to the GRADE scale. For quantitative analysis, a random effects model was used. Data were synthetized and evaluated on a forest plot and funnel plot. RESULTS Two randomized clinical trials, four cohort studies and one case-control studies met our inclusion criteria for the qualitative analysis. None was excluded subsequently. Overall, 614 patients with single metastasis were included. Studies had high heterogeneity. Multiple significant variables affecting the outcome were signalized. Meta-analysis showed no significant differences for survival (HR, 1.10; 95% CI, 0.75-1.45) or LR (HR, 0.81; 95% CI, 0.42-1.20). CONCLUSIONS According to current evidence, in patients with a single small metastasis there is no statistically significant difference in OS or LR among the chosen techniques (SR or SRS). Multiple significant co-variables may affect both outcomes. Different outcomes better than OS should be evaluated in further randomized studies.
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Affiliation(s)
- Lucas González
- Faculty of Medicine, University of Chile, Santiago, Chile
| | | | - Eduardo Villa
- Faculty of Medicine, University of Chile, Santiago, Chile
| | - Gustavo Zomosa
- Department of Neurology & Neurosurgery, Hospital Clinico Universidad de Chile, Santiago, Chile
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Di Nunno V, Franceschi E, Tosoni A, Mura A, Minichillo S, Di Battista M, Gatto L, Maggio I, Lodi R, Bartolini S, Brandes AA. Is Molecular Tailored-Therapy Changing the Paradigm for CNS Metastases in Breast Cancer? Clin Drug Investig 2021; 41:757-773. [PMID: 34403132 DOI: 10.1007/s40261-021-01070-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2021] [Indexed: 11/28/2022]
Abstract
Breast cancer (BC) is the second most common tumour spreading to the central nervous system (CNS). The prognosis of patients with CNS metastases depends on several parameters including the molecular assessment of the disease. Although loco-regional treatment remains the best approach, systemic therapies are acquiring a role leading to remarkable long-lasting responses. The efficacy of these compounds diverges between tumours with different molecular assessments. Promising agents under investigation are drugs targeting the HER2 pathways such as tucatinib, neratinib, pyrotinib, trastuzumab deruxtecan. In addition, there are several promising agents under investigation for patients with triple-negative brain metastases (third-generation taxane, etirinotecan, sacituzumab, immune-checkpoint inhibitors) and hormone receptor-positive brain metastases (CDK 4/5, phosphoinositide-3-kinase-mammalian target of rapamycin [PI3K/mTOR] inhibitors). Also, the systemic treatment of leptomeningeal metastases, which represents a very negative prognostic site of metastases, is likely to change as several compounds are under investigation, some with interesting preliminary results. Here we performed a comprehensive review focusing on the current management of CNS metastases according to molecular subtypes, site of metastases (leptomeningeal vs brain), and systemic treatments under investigation.
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Affiliation(s)
- Vincenzo Di Nunno
- Department of Oncology, AUSL Bologna, Via Altura 3, 40139, Bologna, Italy.
| | - Enrico Franceschi
- Department of Oncology, AUSL Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Alicia Tosoni
- Department of Oncology, AUSL Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Antonella Mura
- Department of Oncology, AUSL Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Santino Minichillo
- Department of Oncology, AUSL Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Monica Di Battista
- Department of Oncology, AUSL Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Lidia Gatto
- Department of Oncology, AUSL Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Ilaria Maggio
- Department of Oncology, AUSL Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Raffaele Lodi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Stefania Bartolini
- Department of Oncology, AUSL Bologna, Via Altura 3, 40139, Bologna, Italy
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Lin YJ, Wei KC, Chen PY, Lim M, Hwang TL. Roles of Neutrophils in Glioma and Brain Metastases. Front Immunol 2021; 12:701383. [PMID: 34484197 PMCID: PMC8411705 DOI: 10.3389/fimmu.2021.701383] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/19/2021] [Indexed: 12/16/2022] Open
Abstract
Neutrophils, which are the most abundant circulating leukocytes in humans, are the first line of defense against bacterial and fungal infections. Recent studies have reported the role and importance of neutrophils in cancers. Glioma and brain metastases are the most common malignant tumors of the brain. The tumor microenvironment (TME) in the brain is complex and unique owing to the brain-blood barrier or brain-tumor barrier, which may prevent drug penetration and decrease the efficacy of immunotherapy. However, there are limited studies on the correlation between brain cancer and neutrophils. This review discusses the origin and functions of neutrophils. Additionally, the current knowledge on the correlation between neutrophil-to-lymphocyte ratio and prognosis of glioma and brain metastases has been summarized. Furthermore, the implications of tumor-associated neutrophil (TAN) phenotypes and the functions of TANs have been discussed. Finally, the potential effects of various treatments on TANs and the ability of neutrophils to function as a nanocarrier of drugs to the brain TME have been summarized. However, further studies are needed to elucidate the complex interactions between neutrophils, other immune cells, and brain tumor cells.
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Affiliation(s)
- Ya-Jui Lin
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Taiwan
- Graduate Institute of Natural Products, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Kuo-Chen Wei
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Neurosurgery, New Taipei Municipal TuCheng Hospital, Chang Gung Medical Foundation, New Taipei, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pin-Yuan Chen
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Neurosurgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Michael Lim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Tsong-Long Hwang
- Graduate Institute of Natural Products, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Research Center for Chinese Herbal Medicine, Research Center for Food and Cosmetic Safety, and Graduate Institute of Health Industry Technology, Chang Gung University of Science and Technology, Taoyuan, Taiwan
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Chemical Engineering, Ming Chi University of Technology, New Taipei City, Taiwan
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