Clinical predictors of metastatic disease to the brain from non-small cell lung carcinoma: primary tumor size, cell type, and lymph node metastases

Efficacy of afatinib, an irreversible ErbB family blocker, in the treatment of intracerebral metastases of non-small cell lung cancer in mice

Few effective therapeutic options are currently available for the treatment of non-small cell lung cancer (NSCLC) with brain metastases (BM). Recent evidence shows that NSCLC patients with BMs respond well to afatinib, but little is known about the underlying mechanisms. In this study, we evaluated the efficacy of afatinib in treatment of BMs in mice and investigated whether afatinib could actively penetrate the brain-blood barrier and bind to its target. NSCLC BM model was established in nude mice by intracerebral injection of PC-9.luc cells. The tumors were measured weekly using in vivo quantitative bioluminescence. The mice are administrated afatinib (15, 30 mg·kg^-1·d^-1, ig) for 14 d. The antitumor efficacy of afatinib was determined by tumor growth inhibition (TGI), which was calculated as [1-(change of tumor volume in treatment group/control group)×100]. Pharmacokinetic characteristics were measure in mice receiving a single dose of afatinib (30 mg/kg, ig). Pharmacodynamics of afatinib was also assessed by detecting the expression of pEGFR (Tyr1068) in brain tumor foci using immunohistochemistry. Administration of afatinib (15, 30 mg·kg^-1·d^-1) dose-dependently inhibited PC-9 tumor growth in the brain with a TGI of 90.2% and 105%, respectively, on d 14. After administration of afatinib (30 mg/kg), the plasma concentration of afatinib was 91.4±31.2 nmol/L at 0.5 h, reached a peak (417.1±119.9 nmol/L) at 1 h, and was still detected after 24 h. The cerebrospinal fluid (CSF) concentrations followed a similar pattern. The T_1/2 values of afatinib in plasma and CSF were 5.0 and 3.7 h, respectively. The AUC_{(0-24 h)} values for plasma and CSF were 2375.5 and 29.1 nmol/h, respectively. The plasma and CSF concentrations were correlated (r=0.844, P<0.01). Pharmacodynamics study showed that the expression levels of pEGFR were reduced by 90% 1 h after afatinib administration. The E_max was 86.5%, and the EC₅₀ was 0.26 nmol/L. A positive correlation between CSF concentrations and pEGFR modulation was revealed. Afatinib penetrates the BBB in NSCLC BM mice and contributes to the brain tumor response. The CSF exposure level is correlated with the plasma level, which in turn is correlated with the modulation of pEGFR in the tumor tissues. The results support for the potential application of afatinib in NSCLC patients with BMs.

Epidermal growth factor receptor tyrosine kinase inhibitors for the treatment of central nervous system metastases from non-small cell lung cancer: the present and the future

Lung cancer is one of the major causes of cancer related mortality worldwide. Brain metastases (BM) complicate clinical evolution of non-small cell lung cancer (NSCLC) in approximately 25-40% of cases, adversely influencing quality of life (QoL) and overall survival (OS). Systemic therapy remains the standard strategy for metastatic disease. Nevertheless, the blood-brain barrier (BBB) makes central nervous system (CNS) a sanctuary site. To date, the combination of chemotherapy with whole brain radiation therapy (WBRT), surgery and/or stereotactic radiosurgery (SRS) represents the most used treatment for patients (pts) with intracranial involvement. However, due to their clinical conditions, many pts are not able to undergo local treatments. Targeted therapies directed against epidermal growth factor receptor (EGFR), such as gefitinib, erlotinib and afatinib, achieved important improvements in EGFR mutated NSCLC with favorable toxicity profile. Although their role is not well defined, the reported objective response rate (ORR) and the good tolerance make EGFR-tyrosine kinase inhibitors (TKIs) an interesting valid alternative for NSCLC pts with BM, especially for those harboring EGFR mutations. Furthermore, new-generation TKIs, such as osimertinib and rociletinib, have already shown important activity on intracranial disease and several trials are still ongoing to evaluate their efficacy. In this review we want to highlight literature data about the use and the effectiveness of EGFR-TKIs in pts with BM from NSCLC.

Computed tomography protocols used in staging bronchopulmonary carcinoma: results of a national survey

OBJECTIVES

To know the protocols used for staging bronchopulmonary carcinoma by computed tomography in Spain.

MATERIAL AND METHODS

Radiologists in 129 hospitals were sent email questionnaires about the organization of their department, scanner type and manufacturer, study extension, techniques employed, and protocol for administering contrast material.

RESULTS

A total of 109 hospitals responded with data from 91 teams. Most hospitals were affiliated with a university, and most departments were organized by organ-systems. Scanners were from four manufacturers, and 68% had either 16 or 64 detectors. In 61% of the hospitals, the dose of contrast agent is modified only in patients with extreme body weights, and in 22% the dose is not individualized. Most hospitals do contrast-enhanced studies of the chest and upper abdomen, 42.4% through a single thoracoabdominal acquisition and 55.9% through independent chest and abdominal acquisitions; there was a significant association between these approaches and the scanner manufacturer's protocols and whether the hospital was affiliated with a university. The most commonly used technical parameters were 120kV with dose modulation and variable milliamperage.

CONCLUSION

There is very little variability among hospitals in the type of scanner used, the study extension, and the technical parameters used to stage bronchopulmonary carcinoma. Most centers individualize the dose of contrast agent only in extreme weights. There is a broad division between using one or two acquisitions to image the thorax and abdomen, and the number of acquisitions is related to the scanner manufacturer and whether the hospital is affiliated with a university.

Epidermal Growth Factor Receptor Mutational Status and Brain Metastases in Non-Small-Cell Lung Cancer

Introduction

Epidermal growth factor receptor (EGFR) mutations in non–small-cell lung cancers (NSCLC) may be more common in patients with brain metastases. Previous studies, however, did not adjust for effects of confounding variables.

Methods

This retrospective study included 1,522 consecutive patients with NSCLC, whose tumors were diagnosed and tested for EGFR mutations at the University of Nebraska Medical Center (Omaha, NE) and Tata Memorial Hospital (Mumbai, India). Multivariate logistic regression was used to identify any association between EGFR status and clinical factors.

Results

EGFR mutations were more common in females than males (38.7% v 24.8%), Asians than whites (31.3% v 13.4%), nonsmokers than smokers (40.2% v 14.6%), alcohol nonconsumers than users (32.4% v 15.8%), adenocarcinoma than other histology types (32.7% v 10.3%), and patients with brain metastases than extracranial or no metastases (39.4% v 29.8% v 15.1%; P < .001 for all comparisons). There was a higher likelihood of an EGFR mutation among patients with brain metastases (odds ratio, 1.8; P < .001). The median overall survival (OS) was 19.8 months. Patients with brain metastases had a shorter median OS (15 v 20.6 months; P = .02). However, in the cohort of EGFR mutation–positive patients, there was no difference in median OS between patients with and without brain metastases (20.8 v 25.1 months; P = .11).

Conclusion

There is a nearly two-fold higher incidence of EGFR mutations in NSCLC among patients with brain metastases at diagnosis. EGFR mutations did not predict for outcomes from brain metastases.

Preclinical Comparison of Osimertinib with Other EGFR-TKIs in EGFR-Mutant NSCLC Brain Metastases Models, and Early Evidence of Clinical Brain Metastases Activity

PURPOSE

Approximately one-third of patients with non-small cell lung cancer (NSCLC) harboring tumors with EGFR-tyrosine kinase inhibitor (TKI)-sensitizing mutations (EGFRm) experience disease progression during treatment due to brain metastases. Despite anecdotal reports of EGFR-TKIs providing benefit in some patients with EGFRm NSCLC brain metastases, there is a clinical need for novel EGFR-TKIs with improved efficacy against brain lesions.

EXPERIMENTAL DESIGN

We performed preclinical assessments of brain penetration and activity of osimertinib (AZD9291), an oral, potent, irreversible EGFR-TKI selective for EGFRm and T790M resistance mutations, and other EGFR-TKIs in various animal models of EGFR-mutant NSCLC brain metastases. We also present case reports of previously treated patients with EGFRm-advanced NSCLC and brain metastases who received osimertinib in the phase I/II AURA study (NCT01802632).

RESULTS

Osimertinib demonstrated greater penetration of the mouse blood-brain barrier than gefitinib, rociletinib (CO-1686), or afatinib, and at clinically relevant doses induced sustained tumor regression in an EGFRm PC9 mouse brain metastases model; rociletinib did not achieve tumor regression. Under positron emission tomography micro-dosing conditions, [¹¹C]osimertinib showed markedly greater exposure in the cynomolgus monkey brain than [¹¹C]rociletinib and [¹¹C]gefitinib. Early clinical evidence of osimertinib activity in previously treated patients with EGFRm-advanced NSCLC and brain metastases is also reported.

CONCLUSIONS

Osimertinib may represent a clinically significant treatment option for patients with EGFRm NSCLC and brain metastases. Further investigation of osimertinib in this patient population is ongoing. Clin Cancer Res; 22(20); 5130-40. ©2016 AACR.

FDA Approval: Alectinib for the Treatment of Metastatic, ALK-Positive Non-Small Cell Lung Cancer Following Crizotinib

On December 11, 2015, the FDA granted accelerated approval to alectinib (Alecensa; Genentech) for the treatment of patients with anaplastic lymphoma receptor tyrosine kinase (ALK)-positive, metastatic non-small cell lung cancer (NSCLC) who have progressed on or are intolerant to crizotinib. This approval was based on two single-arm trials including 225 patients treated with alectinib 600 mg orally twice daily. The objective response rates (ORR) by an independent review committee in these studies were 38% [95% confidence interval (CI), 28-49] and 44% (95% CI, 36-53); the median durations of response (DOR) were 7.5 months and 11.2 months. In a pooled analysis of 51 patients with measurable disease in the central nervous system (CNS) at baseline, the CNS ORR was 61% (95% CI, 46-74); the CNS DOR was 9.1 months. The primary safety analysis population included 253 patients. The most common adverse reactions were fatigue (41%), constipation (34%), edema (30%), and myalgia (29%). The most common laboratory abnormalities were anemia (56%), increased aspartate aminotransferase (51%), increased alkaline phosphatase (47%), increased creatine phosphokinase (43%), hyperbilirubinemia (39%), hyperglycemia (36%), increased alanine aminotransferase (34%), and hypocalcemia (32%). Dose reductions due to adverse reactions occurred in 12% of patients, whereas 27% of patients had alectinib dosing interrupted for adverse reactions. Permanent discontinuation of alectinib due to adverse reactions occurred in only 6% of patients. With the clinically meaningful ORR and DOR as well as the safety profile observed in these trials, alectinib was determined to have a favorable benefit-risk profile for the treatment of the indicated population. Clin Cancer Res; 22(21); 5171-6. ©2016 AACR.

Discordance of Mutation Statuses of Epidermal Growth Factor Receptor and K-ras between Primary Adenocarcinoma of Lung and Brain Metastasis

Mutations on epidermal growth factor receptor (EGFR) of adenocarcinomas of lung have been found to be associated with increased sensitivity to EGFR tyrosine kinase inhibitors and K-ras mutations may correlate with primary resistance. We aimed to explore the discordant mutation statuses of EGFR and K-ras between primary tumors and matched brain metastases in adenocarcinomas of lung. We used a sensitive Scorpion ARMS method to analyze EGFR mutation, and Sanger sequencing followed by allele-specific real-time polymerase chain reaction to analyze K-ras mutation. Forty-nine paired tissues with both primary adenocarcinoma of lung and matched brain metastasis were collected. Thirteen patients (26.5%) were discordant for the status of EGFR between primary and metastatic sites. K-ras gene could be checked in paired specimens from 33 patients, thirteen patients (39.6%) were discordant for the status of K-ras. In primary lung adenocarcinoma, there were 14 patients of mutant EGFR had mutant K-ras synchronously. This study revealed that the status of EGFR mutation in lung adenocarcinomas is relatively consistent between primary and metastatic sites compared to K-ras mutation. However, there are still a few cases of adenocarcinoma of lung showing discordance for the status of EGFR mutation. Repeated analysis of EGFR mutation is highly recommended if tissue from metastatic or recurrent site is available for the evaluation of target therapy.

Impact of whole brain radiation therapy on CSF penetration ability of Icotinib in EGFR-mutated non-small cell lung cancer patients with brain metastases: Results of phase I dose-escalation study

OBJECTIVES

Whole-brain radiation therapy (WBRT) and epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) are both treatment options for EGFR-mutated non-small cell lung cancer (NSCLC) patients with brain metastases. However, the dose-escalation toxicity and efficacy of combination therapy, and the effect of WBRT on cerebrospinal fluid (CSF) penetration of EGFR-TKIs are still unclear.

MATERIALS AND METHODS

EGFR-mutated NSCLC patients with brain metastases were enrolled in this study, and the cohorts were constructed with a 3+3 design. The patients received icotinib with escalating doses (125-625mg, tid), and the concurrent WBRT (37.5Gy/15f/3weeks) started a week later. The CSF penetration rates of icotinib were tested before, immediately after, and 4 weeks after WBRT, respectively. Potential toxicities and benefits from dose-escalation treatment were analyzed.

RESULTS

Fifteen patients were included in this study, 3 at each dose level from 125mg-375mg and 6 at 500mg with 3 occurred dose-limiting toxicities. The maximal tolerated dose of icotinib was 375mg tid in this combination therapy. There was a significant correlation between icotinib concentration in the CSF and plasma (R(2)=0.599, P<0.001). The CSF penetration rate of icotinib, from 1.2% to 9.7%, reached a maximum at 375mg (median, 6.1%). There was no significant difference for CSF penetration rates among the three test points (median, 4.1% vs. 2.8% vs. 2.8%, P=0.16). The intracranial objective response rate and median intracranial progression free survival are 80% and 18.9 months.

CONCLUSIONS

WBRT plus concurrent icotinib is well tolerated in EGFR-mutated NSCLC patients with brain metastases, up to an icotinib dose of 375mg tid. The icotinib CSF concentration seemed to have a potential ceiling effect with the dose escalation, and WBRT seemed to have no significant impact on CSF penetration of icotinib till 4 weeks after the treatment.

Radiation-enhancing effect of sodium glycididazole in patients suffering from non-small cell lung cancer with multiple brain metastases: A randomized, placebo-controlled study

PURPOSE

Median survival of patients with brain metastases from non-small cell lung cancer is poor. This study was to investigate the radiation-enhancing effect of sodium glycididazole combined with whole-brain radiotherapy of multiple brain metastases from non-small cell lung cancer.

PATIENTS AND METHODS

Sixty-four patients with multiple brain metastases from non-small cell lung cancer were included: the study group (n=32) received whole-brain radiotherapy combined with sodium glycididazole at a dose of 700mg/m(2) intravenous infusion 30minutes before radiotherapy, three times a week; the control group (n=32) only received whole-brain radiotherapy. The primary end point was central nervous system (CNS) progression-free survival and overall survival. The treatment-related toxicity was also recorded.

RESULTS

The CNS disease control rate was better (90.6% vs 65.6%, P=0.016) in the study group than in the control group at 3 month of follow-up. The median CNS progression-free survival time was longer in the study group than in the control group (7.0 months vs 4.0 months, P=0.038). There was no significant difference of the median overall survival time between the study group and the control group (11.0 months vs 9.0 months, P=0.418). On the other hand, the treatment-related toxicity showed no statistically significant difference between these two groups (P>0.05).

CONCLUSIONS

The study indicated that sodium glycididazole was an effective, promising radiation-enhancing agent that improved CNS disease control rate, extended the median CNS progression-free survival time and was well tolerated in patients suffering from non-small cell lung cancer with multiple brain metastases.

Brain Radiotherapy plus Concurrent Temozolomide versus Radiotherapy Alone for Patients with Brain Metastases: A Meta-Analysis

Objective

We performed a meta-analysis of randomized clinical trials to compare the efficacy of brain radiotherapy (RT) combined with temozolomide (TMZ) versus RT alone as first-line treatment for brain metastases (BM).

Methods

Medline, Embase, and Pubmed were used to search for relevant randomized controlled trials (RCTs). Two investigators reviewed the abstracts and independently rated the quality of trials and relevant data. The primary outcome was overall survival (OS). Secondary outcomes included progression-free survival (PFS), objective response rate (ORR), and adverse events.

Results

Seven studies were selected from the literature search. RT plus TMZ produced significant improvement in ORR with odds ratio (OR) of 2.27 (95% CI, 1.29 to 4.00; P = 0.005) compared with RT alone. OS and PFS were not significantly different between the two arms (OS: HR, 1.00; P = 0.959; PFS: HR, 0.73; P = 0.232). However, the RT plus TMZ arm was associated with significantly more grade 3 to 4 nausea and thrombocytopenia.

Conclusion

Concomitant RT and TMZ, compared to RT alone, significantly increases ORR in patients with BM, but yields increased toxicity and fails to demonstrate a survival advantage.

Incidence of Brain Metastasis at the Initial Diagnosis of Lung Squamous Cell Carcinoma on the Basis of Stage, Excluding Brain Metastasis

INTRODUCTION

Current National Comprehensive Cancer Network guidelines recommend routine brain magnetic resonance imaging (MRI) screening in patients with stage II to IV non-small cell carcinoma, regardless of histological subtype. This recommendation might not be universally applicable, however, because brain metastasis (BM) is seen less frequently in patients with lung squamous cell carcinoma (SCC) than in those with a histological diagnosis of nonsquamous cell carcinoma.

METHODS

The cases of 564 patients with lung SCC in our institution between January 2012 and December 2013 were reviewed prospectively for comprehensive staging. All subjects' lung SCC, but not their BM, was staged on the basis of the seventh edition of the guidelines of the American Joint Committee on Cancer. We evaluated the incidence of BM across the stages and clinical factors associated with BM.

RESULTS

Of the 564 patients, 28 (5.0%) had BM. BM did not occur in patients with stage Ia or Ib disease; however, it increased significantly as the disease progressed from stage IIa to IV (p < 0.001, trend test). Multivariate analysis showed that tumor involvement in N3 lymph nodes and distant metastasis other than BM (M1b) was independently associated with the development of BM.

CONCLUSIONS

Routine brain MRI screening in patients with lung SCC in stage II to IV can help to evaluate asymptomatic BM. By contrast, we did not find any evidence supporting routine brain MRI screening in patients with stage I disease.

Epidermal growth factor receptor tyrosine kinase inhibitors with conventional chemotherapy for the treatment of non-small cell lung cancer

We report a Chinese male patient with advanced stage lung squamous cell carcinoma who developed brain metastases after responding to treatment comprising six cycles of conventional chemotherapy with docetaxel and cisplatin. The patient was then treated with oral erlotinib (150 mg/day) and whole-brain radiation therapy followed by four cycles of docetaxel and carboplatin chemotherapy. The patient then received gefitinib (250 mg/day) as a maintenance therapy until the end of the follow-up period. In this patient, progression-free survival, defined as the interval from the initiation of first-line chemotherapy to the cessation of erlotinib due to progressive disease or death from any cause, was 3 months. Overall survival, defined as the interval from the initiation of first-line chemotherapy to death from any cause, was 75 months. Erlotinib was well tolerated in combination with whole-brain radiation therapy and a favorable objective response rate was observed. Furthermore, targeted drug treatment warrants consideration in patients with a negative epidermal growth factor receptor mutation status and male patients with a history of smoking.

AZD9291 in EGFR-mutant advanced non-small-cell lung cancer patients

Non-small-cell lung cancer (NSCLC) patients whose tumors have an EGFR-activating mutation develop acquired resistance after a median of 9–11 months from the beginning of treatment with erlotinib, gefitinib and afatinib. T790M mutation is the cause of this resistance in approximately 60% of cases. AZD9291 is an oral, irreversible, mutant-selective EGF receptor (EGFR) tyrosine kinase inhibitor (TKI) developed to have potency against EGFR mutations, including T790M mutation, while sparing wild-type EGFR. A Phase I trial of AZD9291 in EGFR-mutant NSCLC patients, demonstrated high activity, essentially among T790M-mutant tumors, with a manageable tolerability profile. Ongoing Phase III trials are evaluating AZD9291 in EGFR-mutant patients as first-line treatment compared with erlotinib and gefitinib; and as second-line treatment compared with chemotherapy after progression on EGFR TKI in T790M-mutant tumors. Better identification of T790M-mutant tumors post EGFR TKI relapse and mechanisms of resistance to AZD9291 are the future challenges. This article reviews the emerging data regarding AZD9291 in the treatment of patients with advanced NSCLC.

A phase II study of icotinib and whole-brain radiotherapy in Chinese patients with brain metastases from non-small cell lung cancer

PURPOSE

Icotinib is a new first-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors. A phase II study was conducted to evaluate the efficacy and safety of icotinib in combination with whole-brain radiotherapy (WBRT) in Chinese NSCLC patients with brain metastases (BMs); the cerebrospinal fluid (CSF)/plasma concentrations of icotinib were also investigated.

METHODS

Eligible patients had BMs from NSCLC, regardless of the EGFR status. Icotinib was administered at 125 mg orally 3 times/day until tumor progression or unacceptable toxicity, concurrently with WBRT (3.0 Gy per day, 5 days per week, to 30 Gy). CSF and plasma samples were collected simultaneously from 10 patients. Icotinib concentrations in the CSF and plasma were measured by high-performance liquid chromatography coupled with tandem mass spectrometry.

RESULTS

Twenty patients were enrolled. The median follow-up time was 20.0 months. The overall response rate was 80.0%. The median progression-free survival time was 7.0 months (95% CI 1.2-13.2 months), and the median survival time (MST) was 14.6 months (95% CI 12.5-16.7 months). Of the 18 patients with known EGFR status, the MST was 22.0 months for those with an EGFR mutation and was 7.5 months for those with wild-type EGFR (P = 0.0001). The CSF concentration and penetration rate of icotinib were 11.6 ± 9.1 ng/mL and 1.4 ± 1.1%, respectively. No patient experienced ≥grade 4 toxicity.

CONCLUSIONS

Icotinib was well tolerated in combination with WBRT and showed efficacy in patients with BMs from NSCLC. This clinical benefit was related to the presence of activating EGFR mutations.

Molecular determinants of lung cancer metastasis to the central nervous system

Lung cancer remains the leading cause of cancer-related mortality worldwide. The propensity for metastasis to the central nervous system (CNS) is a major clinical hurdle contributing to the low five-year survival rate of advanced disease. CNS metastases significantly outnumber primary brain tumors and carry a dismal prognosis in part due to the inability of therapeutic agents to cross the blood brain barrier. Standard treatment using radiation has been largely ineffective in improving mortality, suggesting the need for new agents targeting the critical metastatic drivers. The genetic and molecular events governing CNS metastasis from the lung are poorly understood at this time. This review highlights genetic events associated with CNS dissemination from the lung and molecular mechanisms associated with CNS metastasis. In vivo model systems that faithfully recapitulate escape from the lung and colonization of the CNS are described as tools for understanding the metastatic phenotype and for testing new therapeutic agents. A deeper understanding of the mechanisms of lung cancer metastasis to the CNS is needed to elucidate novel therapeutic avenues towards the improvement of the mortality associated with advanced stage lung cancer.

Potential toxicities of prophylactic cranial irradiation

Prophylactic cranial irradiation (PCI) with total doses of 20-30 Gy reduces the incidence of brain metastasis (BM) and increases survival of patients with limited and extensive-disease small-cell lung cancer (SCLC) that showed any response to chemotherapy. PCI is currently not applied in non-small-cell lung cancer (NSCLC) since it has not proven to significantly improve OS rates in stage IIIA/B, although novel data suggest that subgroups that could benefit may exist. Here we briefly review potential toxicities of PCI which have to be considered before prescribing PCI. They are mostly difficult to delineate from pre-existing risk factors which include preceding chemotherapy, patient age, paraneoplasia, as well as smoking or atherosclerosis. On the long run, this will force radiation oncologists to evaluate each patient separately and to estimate the individual risk. Where PCI is then considered to be of benefit, novel concepts, such as intensity-modulated radiotherapy and/or neuroprotective drugs with potential to lower the rates of side effects will eventually be superior to conventional therapy. This in turn will lead to a re-evaluation whether benefits might then outweigh the (lowered) risks.

EGFR-TKI therapy for patients with brain metastases from non-small-cell lung cancer: a pooled analysis of published data

Introduction

Brain metastases are one of the leading causes of death from non-small-cell lung cancer (NSCLC). The use of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) to treat brain metastases remains controversial. Thus, we performed a pooled analysis of published data to evaluate the efficacy of EGFR-TKIs in NSCLC patients with brain metastases, particularly for tumors with activating EGFR mutations.

Methods

Several data sources were searched, including PubMed, Web of Science, and ASCO Annual Meetings databases. The end points were intracranial overall response rate (ORR), disease control rate (DCR), progression-free survival (PFS), overall survival (OS), and adverse events. The pooled ORR, DCR, PFS, and OS with 95% confidence intervals (CIs) were calculated employing fixed- or random-effect models, depending on the heterogeneity of the included studies.

Results

Sixteen published studies were included in this analysis, with a total of 464 enrolled patients. The EGFR mutational status was unknown for 362 (unselected group), and 102 had activating EGFR mutations. The pooled intracranial ORR and DCR were 51.8% (95% CI: 45.8%–57.8%) and 75.7% (95% CI: 70.3%–80.5%), respectively. A higher ORR was observed in the EGFR mutation group than in the unselected group (85.0% vs 45.1%); a similar trend was observed for the DCR (94.6% vs 71.3%). The pooled median PFS and OS were 7.4 months (95% CI, 4.9–9.9) and 11.9 months (95% CI, 7.7–16.2), respectively, with longer PFS (12.3 months vs 5.9 months) and OS (16.2 months vs 10.3 months) in the EGFR mutation group than in the unselected group.

Conclusion

This pooled analysis strongly suggests that EGFR-TKIs are an effective treatment for NSCLC patients with brain metastases, particularly in those patients harboring EGFR mutations. Larger prospective randomized clinical trials are warranted to confirm our conclusion and identify the most appropriate treatment model.

Additional prognostic role of EGFR activating mutations in lung adenocarcinoma patients with brain metastasis: integrating with lung specific GPA score

OBJECTIVE

While several prognostic models have been presented in NSCLC patients with brain metastasis, none of these models have included molecular markers as an index. The aim of our study was to evaluate the prognostic value of EGFR mutations and to integrate these EGFR mutations into the prognostic index in NSCLC patients with brain metastasis.

MATERIALS AND METHODS

We analyzed retrospectively 292 lung adenocarcinoma patients with brain metastasis. Clinico-pathological features and overall survival (OS) were compared between patients with EGFR mutations and patients with EGFR wild type. EGFR mutation status was integrated with lung specific graded prognostic assessment (GPA) score.

RESULTS

Among 292 patients, EGFR mutation status was tested in 183 patients. One hundred and five patients (57.4%) had EGFR activating mutations, 14 (7.7%) had EGFR non-activating mutations and 64 (35.0%) had EGFR wild type. OS was significantly longer in patients with EGFR activating mutations than in those with EGFR wild type patients (20.4 vs. 10.1 months, p = 0.002). However, patients with EGFR non-activating mutations did not show superior OS compared with EGFR wild type patients (14.6 vs. 10.1 months, p = 0.83). Multivariate analysis revealed that the presence of EGFR activating mutation is an independent positive prognostic factor for OS (adjusted hazard ratio 0.56, p = 0.002).

CONCLUSIONS

EGFR activating mutations have a prognostic role in lung adenocarcinoma patients with brain metastasis that is independent of other known prognostic factors. The frequency of EGFR mutation was higher than expected. The presence of EGFR activating mutations should be included as an index in the prognostic models for lung adenocarcinoma patients with brain metastasis.

EGFR mutation and brain metastasis in pulmonary adenocarcinomas

BACKGROUND

This study aimed to explore the potential association of mutation in the epidermal growth factor receptor (EGFR) with brain metastases in patients with pulmonary adenocarcinoma.

METHODS

We analyzed clinical data on 314 patients who were tested for EGFR mutation and underwent brain magnetic resonance imaging at diagnosis. The relationship between EGFR mutation status and brain metastases at the initial presentation was analyzed. In addition, prognostic significance of EGFR mutational status on the risk of brain metastasis was evaluated in subgroups of surgically treated patients.

RESULTS

Of the 314 patients, 138 patients (43.9%) had EGFR mutations. The frequency of EGFR mutation was statistically higher for patients with brain metastases (64.7%, brain metastases; 39.8%, no metastases; 40.2%, extracranial metastases; p = 0.005). A strong association between EGFR mutation status and brain metastasis was observed (adjusted odds ratio = 3.83, p = 0.001), whereas no association was observed between EGFR mutation status and extracranial metastases (adjusted odds ratio = 1.73, p = 0.079). In addition, the number of brain metastases was significantly correlated with the EGFR mutation status (p = 0.029). Further analysis of 133 patients treated with surgical resection showed that EGFR mutation status was a poor prognostic factor for the risk of brain metastasis (hazard ratio = 4.49, p = 0.026) after adjustment for pathologic N stage.

CONCLUSIONS

We found a significant association between EGFR mutation and risk of brain metastases at the time of diagnosis and follow-up after curative resection for pulmonary adenocarcinoma. This result indicates the distinct clinical features of EGFR-mutated tumors in terms of brain metastases.

Antitumor activity of the selective ALK inhibitor alectinib in models of intracranial metastases

PURPOSE

The clinical efficacy of the anaplastic lymphoma kinase (ALK) inhibitor crizotinib has been demonstrated in ALK fusion-positive non-small cell lung cancer (NSCLC); however, brain metastases are frequent sites of initial failure in patients due to poor penetration of the central nervous system by crizotinib. Here, we examined the efficacy of a selective ALK inhibitor alectinib/CH5424802 in preclinical models of intracranial tumors.

METHODS

We established intracranial tumor implantation mouse models of EML4-ALK-positive NSCLC NCI-H2228 and examined the antitumor activity of alectinib in this model. Plasma distribution and brain distribution of alectinib were examined by quantitative whole-body autoradiography administrating a single oral dose of (14)C-labeled alectinib to rats. The drug permeability of alectinib was evaluated in Caco-2 cell.

RESULTS

Alectinib resulted in regression of NCI-H2228 tumor in mouse brain and provided a survival benefit. In a pharmacokinetic study using rats, alectinib showed a high brain-to-plasma ratio, and in an in vitro drug permeability study using Caco-2 cells, alectinib was not transported by P-glycoprotein efflux transporter that is a key factor in blood-brain barrier penetration.

CONCLUSIONS

We established intracranial tumor implantation models of EML4-ALK-positive NSCLC. Alectinib showed potent efficacy against intracranial EML4-ALK-positive tumor. These results demonstrated that alectinib might provide therapeutic opportunities for crizotinib-treated patients with brain metastases.

Brain metastases following radical surgical treatment of non-small cell lung cancer: is preoperative brain imaging important?

OBJECTIVES

There is a lack of good quality evidence or a clear consensus of opinion internationally regarding who should receive preoperative imaging of the brain prior to radical treatment for non-small cell lung cancer (NSCLC). We aimed to establish the proportion of patients who developed brain metastases following curative surgery and to estimate how many could have been detected by preoperative magnetic resonance imaging (MR).

METHODS

We performed a retrospective analysis of 646 patients who underwent surgery for lung cancer with curative intent at a regional thoracic surgical centre in the United Kingdom. We identified those who developed brain metastases in the postoperative period and, by using volume doubling times, estimated the size of the metastasis at the time of surgery. We then determined the proportion of metastases that would have been seen on preoperative MR brain at detection thresholds of 2 and 5mm diameter.

RESULTS

There was a 6.3% incidence of postoperative brain metastases, with the majority occurring within 12 months of surgery. Those who developed metastases were more likely to have adenocarcinoma and the majority had early stage malignancy (73% stage I or stage II). We estimate that 71% of those who developed cerebral metastases might have been detected had they undergone MR brain as part of their staging (4.4% of all patients).

CONCLUSION

Based on our findings we suggest that, in addition to standard staging investigations, patients have brain imaging (MR or equivalent) prior to curative surgery in NSCLC regardless of preoperative stage.

Serum starvation regulates E-cadherin upregulation via activation of c-Src in non-small-cell lung cancer A549 cells

E-cadherin is essential for the integrity of adherens junctions between lung epithelial cells, and the loss of E-cadherin allows cell motility and is thought to promote lung cancer metastasis. While the downregulation of E-cadherin expression has been well characterized and is seen with transforming growth factor-β1 (TGF-β1) exposure, few studies have focused on E-cadherin upregulation. Here, we show that serum starvation causes increased E-cadherin expression via the activation of c-Src kinase in non-small-cell lung cancer A549 cells. Serum starvation increased E-cadherin protein levels in a time- and dose-dependent manner. E-cadherin mRNA transcripts were unchanged with starvation, while protein translation inhibition with cycloheximide attenuated E-cadherin protein induction by starvation, suggesting that E-cadherin is regulated at the translational level by serum starvation. c-Src is a nonreceptor tyrosine kinase known to regulate protein translation machinery; serum starvation caused early and sustained activation of c-Src in A549 cells followed by E-cadherin upregulation. Furthermore, overexpression of a dominant negative c-Src attenuated the induction of E-cadherin by serum deprivation. Finally, we observed that TGF-β1 treatment attenuated the serum activation of c-Src as well as E-cadherin expression when cells were deprived of serum. In conclusion, our data demonstrate that the c-Src kinase is activated by serum starvation to increase E-cadherin expression in A549 cells, and these phenomena are antagonized by TGF-β1. These novel observations implicate the c-Src kinase as an upstream inducer of E-cadherin protein translation with serum starvation and TGF-β1 diametrically regulating c-Src kinase activity and thus E-cadherin abundance in A549 cells.

Evidence based imaging strategies for solitary pulmonary nodule

Solitary pulmonary nodule (SPN) is defined as a rounded opacity ≤3 cm in diameter surrounded by lung parenchyma. The majority of smokers who undergo thin-section CT have SPNs, most of which are smaller than 7 mm. In the past, multiple follow-up examinations over a two-year period, including CT follow-up at 3, 6, 12, 18, and 24 months, were recommended when such nodules are detected incidentally. This policy increases radiation burden for the affected population. Nodule features such as shape, edge characteristics, cavitation, and location have not yet been found to be accurate for distinguishing benign from malignant nodules. When SPN is considered to be indeterminate in the initial exam, the risk factor of the patients should be evaluated, which includes patients' age and smoking history. The 2005 Fleischner Society guideline stated that at least 99% of all nodules 4 mm or smaller are benign; when nodule is 5-9 mm in diameter, the best strategy is surveillance. The timing of these control examinations varies according to the nodule size (4-6, or 6-8 mm) and the type of patients, specifically at low or high risk of malignancy concerned. Noncalcified nodules larger than 8 mm diameter bear a substantial risk of malignancy, additional options such as contrast material-enhanced CT, positron emission tomography (PET), percutaneous needle biopsy, and thoracoscopic resection or videoassisted thoracoscopic resection should be considered.

Randomized trial of erlotinib plus whole-brain radiotherapy for NSCLC patients with multiple brain metastases

BACKGROUND

Median survival of non-small cell lung cancer (NSCLC) patients with brain metastases is poor. We examined concurrent erlotinib and whole brain radiotherapy (WBRT) followed by maintenance erlotinib in patients with untreated brain metastases, given the potential radiosensitizing properties of erlotinib and its direct effect on brain metastases and systemic activity.

METHODS

Eighty NSCLC patients with KPS of 70 and greater and multiple brain metastases were randomly assigned to placebo (n = 40) or erlotinib (100mg, n = 40) given concurrently with WBRT (20 Gy in 5 fractions). Following WBRT, patients continued with placebo or erlotinib (150 mg) until disease progression. The primary end point was neurological progression-free survival (nPFS); hazard ratios (HRs) were calculated using Cox regression. All P values were two-sided.

RESULTS

Fifteen patients (37.5%) from each arm were alive and without neurological progression 2 months after WBRT. Median nPFS was 1.6 months in both arms; nPFS HR 0.95 (95% CI = 0.59 to 1.54; P = .84). Median overall survival (OS) was 2.9 and 3.4 months in the placebo and erlotinib arms; HR 0.95 (95% CI = 0.58 to 1.55; P = .83). The frequency of epidermal growth factor receptor (EGFR) mutations was low with only 1 of 35 (2.9%) patients with available samples had activating EGFR-mutations. Grade 3/4 adverse event rates were similar between the two groups (70.0% in each arm), except for rash 20.0% (erlotinib) vs 5.0% (placebo), and fatigue 17.5% vs 35.0%. No statistically significant quality of life differences were found.

CONCLUSIONS

Our study showed no advantage in nPFS or OS for concurrent erlotinib and WBRT followed by maintenance erlotinib in patients with predominantly EGFR wild-type NSCLC and multiple brain metastases compared to placebo. Future studies should focus on the role of erlotinib with or without WBRT in patients with EGFR mutations.

Incidence of brain metastasis at initial presentation of lung cancer

BACKGROUND

No reliable estimates are available on the incidence of brain metastasis (BM) in cancer patients. This information is valuable for planning patient care and developing measures that may prevent or decrease the likelihood of metastatic brain disease.

METHODS

We report the first population-based analysis on BM incidence at cancer diagnosis using the Kentucky Cancer Registry (KCR) and Alberta Cancer Registry (ACR). All cancer cases with BM were identified from KCR and ACR, with subsequent focus on metastases from lung primaries; the annual number of BMs at initial presentation was derived. Comparisons were made between Kentucky and Alberta for the stage and site of organ involvement of lung cancer.

RESULTS

Low incidence of BM was observed in the United States until mandatory reporting began in 2010. Both the KCR and ACR recorded the highest incidence of BM from lung cancer, with total BM cases at initial presentation occurring at 88% and 77%, respectively. For lung cancer, stage IV was the most common stage at presentation for both registries and ranged from 45.9% to 57.2%. When BM from lung was identified, the most common synchronous organ site of metastasis was osseous, occurring at 28.4%.

CONCLUSION

Our analysis from the Kentucky and Alberta cancer registries similarly demonstrated the aggressive nature of lung cancer and its propensity for BM at initial presentation. Besides widespread organ involvement, no synchronous organ site predicted BM in lung cancer. BM is a common and important clinical outcome, and use of registry data is becoming more available.

Epidermal growth factor receptor tyrosine kinase inhibitors in the treatment of central nerve system metastases from non-small cell lung cancer

Brain metastases (BM) are common and disastrous occurrence in patients with non-small cell lung cancer (NSCLC). Currently increasing studies suggest remarkable efficacy and mild toxicity of the epidermal growth factor tyrosine kinase inhibitor (EGFR TKI) in these patients, making targeted therapy an attractive option to BM from NSCLC. We here present a review about the use of EGFR-TKIs in this context and the following questions would be discussed: Are TKIs capable of permeating across brain-blood barrier (BBB)? How to boost exposure of EGFR TKI in cerebrospinal fluid to overcome the resistance of refractory metastases? Would the combination with other treatment like radiotherapy bring about advanced effect? And which patients with BM is the fittest population to EGFR-TKI treatment? In fact, though the administration of EGFR TKI only could achieve certain effect with limited penetration across BBB, increasing dose and combined radiotherapy would carry out better outcome. Unsurprisingly EGFR mutations were still the most important predictor of the sensitivity.

Whole brain radiotherapy plus simultaneous in-field boost with image guided intensity-modulated radiotherapy for brain metastases of non-small cell lung cancer

Background

Whole brain radiotherapy (WBRT) plus sequential focal radiation boost is a commonly used therapeutic strategy for patients with brain metastases. However, recent reports on WBRT plus simultaneous in-field boost (SIB) also showed promising outcomes. The objective of present study is to retrospectively evaluate the efficacy and toxicities of WBRT plus SIB with image guided intensity-modulated radiotherapy (IG-IMRT) for inoperable brain metastases of NSCLC.

Methods

Twenty-nine NSCLC patients with 87 inoperable brain metastases were included in this retrospective study. All patients received WBRT at a dose of 40 Gy/20 f, and SIB boost with IG-IMRT at a dose of 20 Gy/5 f concurrent with WBRT in the fourth week. Prior to each fraction of IG-IMRT boost, on-line positioning verification and correction were used to ensure that the set-up errors were within 2 mm by cone beam computed tomography in all patients.

Results

The one-year intracranial control rate, local brain failure rate, and distant brain failure rate were 62.9%, 13.8%, and 19.2%, respectively. The two-year intracranial control rate, local brain failure rate, and distant brain failure rate were 42.5%, 30.9%, and 36.4%, respectively. Both median intracranial progression-free survival and median survival were 10 months. Six-month, one-year, and two-year survival rates were 65.5%, 41.4%, and 13.8%, corresponding to 62.1%, 41.4%, and 10.3% of intracranial progression-free survival rates. Patients with Score Index for Radiosurgery in Brain Metastases (SIR) >5, number of intracranial lesions <3, and history of EGFR-TKI treatment had better survival. Three lesions (3.45%) demonstrated radiation necrosis after radiotherapy. Grades 2 and 3 cognitive impairment with grade 2 radiation leukoencephalopathy were observed in 4 (13.8%) and 4 (13.8%) patients. No dosimetric parameters were found to be associated with these late toxicities. Patients received EGFR-TKI treatment had higher incidence of grades 2–3 cognitive impairment with grade 2 leukoencephalopathy.

Conclusions

WBRT plus SIB with IG-IMRT is a tolerable and effective treatment for NSCLC patients with inoperable brain metastases. However, the results of present study need to be examined by the prospective investigations.

Risk factors for brain metastases in locally advanced non-small cell lung cancer with definitive chest radiation

PURPOSE

We intended to identify risk factors that affect brain metastases (BM) in patients with locally advanced non-small cell lung cancer (LA-NSCLC) receiving definitive radiation therapy, which may guide the choice of selective prevention strategies.

METHODS AND MATERIALS

The characteristics of 346 patients with stage III NSCLC treated with thoracic radiation therapy from January 2008 to December 2010 in our institution were retrospectively reviewed. BM rates were analyzed by the Kaplan-Meier method. Multivariate Cox regression analysis was performed to determine independent risk factors for BM.

RESULTS

The median follow-up time was 48.3 months in surviving patients. A total of 74 patients (21.4%) experienced BM at the time of analysis, and for 40 (11.7%) of them, the brain was the first site of failure. The 1-year and 3-year brain metastasis rates were 15% and 28.1%, respectively. In univariate analysis, female sex, age ≤60 years, non-squamous cell carcinoma, T3-4, N3, >3 areas of lymph node metastasis, high lactate dehydrogenase and serum levels of tumor markers (CEA, NSE, CA125) before treatment were significantly associated with BM (P<.05). In multivariate analysis, age ≤60 years (P=.004, hazard ratio [HR] = 0.491), non-squamous cell carcinoma (P=.000, HR=3.726), NSE >18 ng/mL (P=.008, HR=1.968) and CA125 ≥ 35 U/mL (P=.002, HR=2.129) were independent risk factors for BM. For patients with 0, 1, 2, and 3 to 4 risk factors, the 3-year BM rates were 7.3%, 18.9%, 35.8%, and 70.3%, respectively (P<.001).

CONCLUSIONS

Age ≤60 years, non-squamous cell carcinoma, serum NSE >18 ng/mL, and CA125 ≥ 35 U/mL were independent risk factors for brain metastasis. The possibilities of selectively using prophylactic cranial irradiation in higher-risk patients with LA-NSCLC should be further explored in the future.

Brain metastasis effectively treated with erlotinib following the acquisition of resistance to gefitinib: a case report

Introduction

Non-small-cell lung cancer harboring an activated epidermal growth factor receptor mutation exhibits a good response to epidermal growth factor receptor-tyrosine kinase inhibitors; however, clinicians often experience treatment failure following the development of resistance to epidermal growth factor receptor-tyrosine kinase inhibitor.

Case presentation

We here report a case of a 56-year-old Japanese woman with non-small-cell lung carcinoma with a secondary T790M mutation associated with resistance to epidermal growth factor receptor-tyrosine kinase inhibitor that maintained sensitivity of brain metastases to epidermal growth factor receptor-tyrosine kinase inhibitor. An autopsy showed that the primary focus had a T790M mutation; however, no mutations of T790M were found in the brain metastases.

Conclusion

This case demonstrates the detection of T790M was associated with the clinical responsiveness to epidermal growth factor receptor-tyrosine kinase inhibitor.

Modeling and predicting the occurrence of brain metastasis from lung cancer by Bayesian network: a case study of Taiwan

The Bayesian network (BN) is a promising method for modeling cancer metastasis under uncertainty. BN is graphically represented using bioinformatics variables and can be used to support an informative medical decision/observation by using probabilistic reasoning. In this study, we propose such a BN to describe and predict the occurrence of brain metastasis from lung cancer. A nationwide database containing more than 50,000 cases of cancer patients from 1996 to 2010 in Taiwan was used in this study. The BN topology for studying brain metastasis from lung cancer was rigorously examined by domain experts/doctors. We used three statistical measures, namely, the accuracy, sensitivity, and specificity, to evaluate the performances of the proposed BN model and to compare it with three competitive approaches, namely, naive Bayes (NB), logistic regression (LR) and support vector machine (SVM). Experimental results show that no significant differences are observed in accuracy or specificity among the four models, while the proposed BN outperforms the others in terms of sampled average sensitivity. Moreover the proposed BN has advantages compared with the other approaches in interpreting how brain metastasis develops from lung cancer. It is shown to be easily understood by physicians, to be efficient in modeling non-linear situations, capable of solving stochastic medical problems, and handling situations wherein information are missing in the context of the occurrence of brain metastasis from lung cancer.

Does Immunohistochemistry Affect Response to Therapy and Survival of Inoperable Non–Small Cell Lung Carcinoma Patients? A Survey of 145 Stage III-IV Consecutive Cases

Whether non–small cell lung carcinoma (NSCLC) unveiled by immunohistochemistry (IHC) has the same clinical outcome as those typed by morphology is still matter of debate. A total of 145 stage III-IV, consecutive inoperable NSCLC patients treated by chemotherapy (133 cases) or EGFR tyrosine kinase inhibitor (12 cases) and including 100 biopsies, 11 surgical specimens, and 34 cytological samples had originally accounted for 120 adenocarcinomas (ADs), 19 squamous cell carcinomas (SQCs), and 6 adenosquamous carcinomas (ADSQCs) by integrating morphology and thyroid transcription factor-1 (TTF1)/p40 IHC. Thirty-two NSCLC–not otherwise specified (NSCLC-NOS) cases were identified by morphology revision of the original diagnoses, which showed solid growth pattern ( P < .001), 22 ADs, 5 SQCs, and 5 ADSQCs by IHC profiling ( P < .001), and 10 gene-altered tumors (3 EGFR, 5 KRAS, and 2 ALK). While no significant relationships were observed between response to therapy and original, morphology or IHC diagnoses, driver mutations and tumor differentiation by TTF1 expression, AD run better progression-free survival (PFS) or overall survival (OS) than other tumor types by morphology ( P = .010 and P = .047) and IHC ( P = .033 and P = .046), respectively. Furthermore, patients with NSCLC-NOS confirmed as AD by IHC tended to have poorer OS ( P = .179) and PFS ( P = .193) similar to that of ADSQC and SQC ( P = .702 and P = .540, respectively). A category of less differentiated AD with poorer prognosis on therapy could be identified by IHC, while there were no differences for SQC or ADSQC. The terminology of “NSCLC-NOS, favor by IHC” is appropriate to alert clinicians toward more aggressive tumors.

Identification of subgroup patients with stage IIIB/IV non-small cell lung cancer at higher risk for brain metastases

PURPOSE

Brain metastases (BM), a common occurrence in non-small cell lung cancer (NSCLC), usually lead to a poor prognosis. Recently, the selection of treatment modalities for BM has modestly improved patient survival and quality of life. Treatment choice is largely based on the number of BM, the presence of BM-related symptoms, and performance status. Therefore, early BM detection is crucial. In this study, we aimed to elucidate the factors associated with BM and identify subgroups of patients at higher risk for BM.

METHODS AND PATIENTS

The medical records of 596 consecutive patients with stage I-IV NSCLC were reviewed between January 2006 and November 2011. A multivariate logistic regression (MLR) model was used to identify factors associated with BM.

RESULTS

Among 482 eligible stage IIIB/IV NSCLC patients, 173 (36%) experienced BM during their disease course. On MLR analysis, female gender, age < 60 years and adenocarcinoma were associated with BM (OR = 1.71, 95% CI = 1.06-2.75, P = 0.028; OR = 2.11, 95% CI = 1.38-3.22, P = 0.001; and OR = 2.39, 95% CI = 1.16-4.92, P = 0.018, respectively). The actuarial incidence of BM varied widely from 14% to 59% in different subgroups; younger patients with adenocarcinoma tended to experience BM more than older patients with squamous cell carcinoma (OR = 6.88, 95% CI = 2.97-15.94, P < 0.001). Furthermore, the incidence of BM correlated closely with survival after NSCLC diagnosis, and it was 42%, 54% and 64% in patients who survived more than 3, 12 and 24 months, respectively. Notably, the number of BM, the size of the largest BM and the proportion of multiple BM, defined as more than 4 metastatic tumors in brain, were significantly different in NSCLC patients with and without BM-related symptoms or signs (4.0 ± 2.1 vs 2.7 ± 1.9, P < 0.001; 2.6 ± 1.5 vs 1.3 ± 1.0 CM, P < 0.001, and 50% vs 21%, P < 0.001, respectively).

CONCLUSION

We found that subgroups of NSCLC patients characterized by younger age, female gender and adenocarcinoma are at higher risks for BM. These findings might be helpful to detect BM earlier and facilitate the design of clinical trials aiming at their prevention.

Subtyping non-small cell lung cancer: relevant issues and operative recommendations for the best pathology practice

Morphology still remains the cornerstone in lung cancer classification and cytology and small biopsy samples should be interpreted by morphology, whenever feasible, according to shared and widely agreed-upon diagnostic schemes. However, as novel therapy strategies are being offered on the basis of the diverse tumor characteristics, pathologists are now challenged by the need to offer clinicians more detailed typing of non-small cell lung cancer, not otherwise specified (NSCLC-NOS), especially when dealing with limited diagnostic material or poorly differentiated tumors. Close integration of morphology, immunohistochemistry, and clinical data is highly warranted according to a multidisciplinary approach to limit the category of NSCLC-NOS as much as possible or exclude unsuspected metastases, so rendering more definite and clinically useful diagnoses. Among the many proposed immunohistochemical markers, which as a whole are more practical and diagnostically useful than cumbersome and expensive molecular assays, a 2-hit model including thyroid transcription factor-1 (TTF-1) and p40 (the latter more specific for squamous differentiation than p63) seems to be the most effective to basically highlight adenocarcinoma (positivity for TTF-1 regardless of p63) and squamous (always strongly and diffusely positive for p40 or p63 and negative for TTF-1) differentiation. This minimalist 2-hit diagnostic approach paves the way to novel perspectives in clinical trials on lung cancer, and it is also in keeping with the need of strategically preserving diagnostic material for molecular assays that are essential for personalizing therapies.

Phase II trial of erlotinib plus concurrent whole-brain radiation therapy for patients with brain metastases from non-small-cell lung cancer

PURPOSE

Brain metastasis (BM) is a leading cause of death from non-small-cell lung cancer (NSCLC). Reasoning that activation of the epidermal growth factor receptor (EGFR) contributes to radiation resistance, we undertook a phase II trial of the EGFR inhibitor erlotinib with whole-brain radiation therapy (WBRT) in an attempt to extend survival time for patients with BM from NSCLC. Additional end points were radiologic response and safety.

PATIENTS AND METHODS

Eligible patients had BM from NSCLC, regardless of EGFR status. Erlotinib was given at 150 mg orally once per day for 1 week, then concurrently with WBRT (2.5 Gy per day 5 days per week, to 35 Gy), followed by maintenance. EGFR mutation status was tested by DNA sequencing at an accredited core facility.

RESULTS

Forty patients were enrolled and completed erlotinib plus WBRT (median age, 59 years; median diagnosis-specific graded prognostic assessment score, 1.5). The overall response rate was 86% (n = 36). No increase in neurotoxicity was detected, and no patient experienced grade ≥ 4 toxicity, but three patients required dose reduction for grade 3 rash. At a median follow-up of 28.5 months (for living patients), median survival time was 11.8 months (95% CI, 7.4 to 19.1 months). Of 17 patients with known EGFR status, median survival time was 9.3 months for those with wild-type EGFR and 19.1 months for those with EGFR mutations.

CONCLUSION

Erlotinib was well tolerated in combination with WBRT, with a favorable objective response rate. The higher-than-expected rate of EGFR mutations in these unselected patients raises the possibility that EGFR-mutated tumors are prone to brain dissemination.

CXCR4/CXCL12 in non-small-cell lung cancer metastasis to the brain

Lung cancer represents the leading cause of cancer-related mortality throughout the world. Patients die of local progression, disseminated disease, or both. At least one third of the people with lung cancer develop brain metastases at some point during their disease, even often before the diagnosis of lung cancer is made. The high rate of brain metastasis makes lung cancer the most common type of tumor to spread to the brain. It is critical to understand the biologic basis of brain metastases to develop novel diagnostic and therapeutic approaches. This review will focus on the emerging data supporting the involvement of the chemokine CXCL12 and its receptor CXCR4 in the brain metastatic evolution of non-small-cell lung cancer (NSCLC) and the pharmacological tools that may be used to interfere with this signaling axis.

[Correlation between regional node metastasis and imageological characteristics in non-small cell lung cancer]

非小细胞肺癌（non-small cell lung cancer, NSCLC）局部淋巴结（N）分期是影响患者治疗方案选择的关键因素之一。目前临床所使用的无创和有创性N分期方法均有其局限性。研究发现NSCLC的某些影像学特点可预测淋巴结转移的危险性，包括大小、CT密度和氟代脱氧葡萄糖（fluorodeoxyglucose, FDG）标准化摄取值（standardized uptake value, SUV）等。期待系统性多因素分析，以发现影响肺癌淋巴结转移的关键因素。

Radiologic implications of the 2011 classification of adenocarcinoma of the lung

Now the leading subtype of lung cancer, adenocarcinoma received a new classification in 2011. For tumors categorized previously as bronchioloalveolar carcinoma (BAC), criteria and terminology had not been uniform, so the 2011 classification provided four new terms: (a) adenocarcinoma in situ (AIS), representing histopathologically a small (≤3-cm), noninvasive lepidic growth, which at computed tomography (CT) is usually nonsolid; (b) minimally invasive adenocarcinoma, representing histopathologically a small (≤3-cm) and predominantly lepidic growth that has 5-mm or smaller invasion, which at CT is mainly nonsolid but may have a central solid component of up to approximately 5 mm; (c) lepidic predominant nonmucinous adenocarcinoma, representing histopathologically invasive adenocarcinoma that shows predominantly lepidic nonmucinous growth, which at CT is usually part solid but may be nonsolid or occasionally have cystic components; and (d) invasive mucinous adenocarcinoma, histopathologically showing lepidic growth as its predominant component, which at CT varies widely from solid to mostly solid to part solid to nonsolid and may be single or multiple (when multifocal, it was formerly called multicentric BAC). In addition, new histopathologic subcategories of acinar, papillary, micropapillary, and solid predominant adenocarcinoma are now described, all as nonmucinous, predominantly invasive, may include a small lepidic component, and at CT are usually solid but may include a small nonsolid component. The micropapillary subtype has a poorer prognosis than the other subtypes. In addition, molecular genetic correlations for the subcategories of adenocarcinoma of the lung are now a topic of increasing interest. As the new classification enters common use, further descriptions of related correlations can be anticipated.

Risk factors of brain metastases in completely resected pathological stage IIIA-N2 non-small cell lung cancer

Background

Brain metastases (BM) is one of the most common failures of locally advanced non-small cell lung cancer (LA-NSCLC) after combined-modality therapy. The outcome of trials on prophylactic cranial irradiation (PCI) has prompted us to identify the highest-risk subset most likely to benefit from PCI. Focusing on patients with completely resected pathological stage IIIA-N2 (pIIIA-N2) NSCLC, we aimed to assess risk factors of BM and to define the highest-risk subset.

Methods

Between 2003 and 2005, the records of 217 consecutive patients with pIIIA-N2 NSCLC in our institution were reviewed. The cumulative incidence of BM was estimated using the Kaplan–Meier method, and differences between the groups were analyzed using log-rank test. Multivariate Cox regression analysis was applied to assess risk factors of BM.

Results

Fifty-three (24.4 %) patients developed BM at some point during their clinical course. On multivariate analysis, non-squamous cell cancer (relative risk [RR]: 4.13, 95 % CI: 1.86–9.19; P = 0.001) and the ratio of metastatic to examined nodes or lymph node ratio (LNR) ≥ 30 % (RR: 3.33, 95 % CI: 1.79–6.18; P = 0.000) were found to be associated with an increased risk of BM. In patients with non-squamous cell cancer and LNR ≥ 30 %, the 5-year actuarial risk of BM was 57.3 %.

Conclusions

In NSCLC, patients with completely resected pIIIA-N2 non-squamous cell cancer and LNR ≥ 30 % are at the highest risk for BM, and are most likely to benefit from PCI. Further studies are warranted to investigate the effect of PCI on this subset of patients.

[Selected arterial infusion chemotherapy combined with target drugs for non-small cell lung cancer with multiple brain metastase]

BACKGROUND AND OBJECTIVE

The aim of this study is to evaluate the efficacy of selected arterial infusion chemotherapy in treating non-small cell lung cancer (NSCLC) with multiple brain metastases and corresponding factors to influencing prognosis.

METHODS

From September 2008 to October 2011, a total of 31 patients of NSCLC with multiple brain metastases (≥3) received selected incranial, bronchial and corresponding target arterial infusion chemotherapy combined with EGFR-TKIs. Interventional treatment was performed every four weeks, two-six cycles with synchronized or sequential targeted drugs (erlotinib, gefitinib or icotinib). Follow-up CT and MRI were regularly finished at interval of four weeks after two cycles of interventional treatment were finished or during taking targeted drugs in order to evaluate efficacy of the therapy. The procedure was stopped for the tumor disease was worse or the patient could not tolerate the toxity of drugs any longer.

RESULTS

31 patients was performed two to six cycles of interventional therapy, 3 cycles at average. Response assessment showed that 5 (16.1%) patients got a complete response (CR), 7 (22.6%) had a partial response (PR), 11 (35.5%) had a stable disease (SD) and 8 (25.8%) had a progressive disease (PD). The objective response rate (ORR) was 38.7%, and the disease control rate was 74.2%. The median progression free survival (PFS) and overall survival (OS) were 13.1 months and 15.1 months. The 6-month survival rate, one-year survival rate and two-year survival rate were 79%, 61.1%, and 31.1%, respectively. The patients' OS and PFS were influenced by smoking state, tumor pathology, extracranial metastases, period of targeted drug taking and performance status, not by sex, age, before therapy and the total of brain metastases.

CONCLUSION

Selected arterial infusion chemotherapy with targeted drugs is one of the most effective and safe treatment to NSCLC with multiple brain metastases. Smoking status, tumor pathology, extracranial metastases, targeted drug taking and performance status are corresponding the patient's prognosis.

Impact of non-small cell lung cancer histology on survival predicted from the graded prognostic assessment for patients with brain metastases

INTRODUCTION

The Graded Prognostic Assessment (GPA) provides prognostic classification for patients with brain metastases (BM), based on Radiation Therapy Oncology Group (RTOG) data. Recent evidence suggests differential response and outcomes to chemotherapy for different non-small cell lung cancer (NSCLC) histologies. Using a large BM patient database, we assessed the impact of histologic subtypes on survival stratified by the GPA.

METHODS

From an IRB-approved database, we analyzed 780 patients with NSCLC BM treated from 1982 to 2004. GPA classification variables included age, KPS, number of BM, and presence of extracranial disease. Histology was identified for each patient. Median survival time (MST) based on GPA class and histology were calculated using Kaplan-Meier analysis. The log rank test was used to determine statistical differences.

RESULTS

MST, in months, by histology were: adenocarcinoma (AC) 6.2 (n=464), large cell (LC) 4.1 (n=98), squamous (SQ) 4.2 (n=108) (p=0.0549). For GPA 3.5-4.0, MSTs did not differ significantly by histology. Differences in MST by histology were noted for GPA 3.0 (p=0.04), GPA 1.5-2.5 (p=0.01), and GPA 0-1.0 (p=0.02). For all patients with brain metastases BM from NSCLC, MSTs by GPA score were: GPA 3.5-4.0, 12.6; GPA 3.0, 10.2; GPA 1.5-2.5, 5.8; and GPA 0-1.0, 2.7.

CONCLUSIONS

Adenocarcinoma showed a statistically significant higher MST than other histologies of NSCLC for patients with GPA 0-3.0. Using histology as a prognostic factor for BM from NSCLC warrants further investigation. Our cohort of NSCLC BM patients validates the GPA, with MST comparable to that of published data.

Limping man--unusual presentation of lung carcinoma

The authors report a case of a 61-year-old male smoker with primary adenocarcinoma of the lung with brain metastases. He presented with a 2 month history of a gradually worsening unilateral limp with no other local or systemic symptoms. History and examination findings suggested an upper motor neuron lesion but failed to indicate the level of the pathology. On further investigation, a mass was found in the upper lobe of the left lung and two ring-enhancing brain lesions. With surgical intervention ruled out, he was commenced on high dose dexamethasone and is currently undergoing palliative whole brain radiotherapy.

Non-small cell lung cancer histological subtype has prognostic impact in patients with brain metastases

In patients with brain metastases from non-small cell lung cancer, the prognostic impact of primary tumour histology, a feature with increasing implications for choice of systemic therapy, is not well defined. Therefore, a multi-institutional analysis was performed: retrospective uni- and multivariate analyses in 209 patients treated with different approaches including surgery and radiosurgery. While squamous cell and large cell carcinoma patients had comparable survival, those with adenocarcinoma survived significantly longer. In multivariate models, adenocarcinoma histology was confirmed as independent prognostic factor, which complements both recursive partitioning analysis (RPA) classes and diagnosis-specific graded prognostic assessment (GPA). When evaluated together with primary tumour control, extracranial metastases, number of brain metastases, age and performance status as individual covariates rather than RPA or GPA score, adenocarcinoma histology again emerged as significant prognostic factor. A significant but small survival advantage for patients with adenocarcinoma was evident already in the time period before drugs such as pemetrexed and epidermal growth factor receptor tyrosine kinase inhibitors were available. However, the gap has widened in recently treated patients. Comparable to patients without brain metastases, primary tumour histology should be taken into account when assessing patients' prognosis and recommending treatment strategy.

Baseline SUVmax at PET-CT in stage IIIA non-small-cell lung cancer patients undergoing surgery after neoadjuvant therapy: prognostic implication focused on histopathologic subtypes

RATIONALE AND OBJECTIVES

To evaluate the prognostic significance of maximum standardized uptake value (SUVmax) at (18)F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography in patients with stage IIIA non-small-cell lung cancer (NSCLC) who underwent surgical resection after neoadjuvant chemoradiotherapy, focused on the relationship between SUVmax values and tumor histology.

MATERIALS AND METHODS

We retrospectively evaluated the initial SUVmax of 205 patients (112 adenocarcinomas, 82 squamous cell carcinomas [SCCs], and 11 of other histology) with a stage IIIA NSCLC who underwent surgical resection after neoadjuvant chemoradiotherapy, and who were followed for up to 6 years. Clinical data, including histologic type, pathologic response, and treatment, were reviewed, and the relationship between the SUVmax and patient overall survival was examined.

RESULTS

Overall, the 2-year survival rate was 68%. Between the two histologic subtypes of adenocarcinoma and SCC, we noted significant differences in all variables of gender (male predominance in SCC), initial SUVmax (greater in SCC), pathologic response (more complete remission in SCC), and overall survival (better in SCC) (all P values, < .05). SUVmax remained as a sole independent factor for survival in multivariate analysis in whole series (SUVmax cutoff, 13; median survival, 3.0 years vs. 4.0 years; P = .016) and in adenocarcinomas (SUVmax cutoff, 11.5; median survival, 2.6 years vs. 3.6 years; P = .045), but not in SCCs.

CONCLUSION

The initial SUVmax is a sole significant prognostic factor in patients with a surgically resected NSCLC after neoadjuvant chemoradiotherapy, particularly in patients with an adenocarcinoma.

Intracranial hemorrhage from undiagnosed metastatic brain tumor during general anesthesia

A patient with endometrial cancer presented with intracranial hemorrhage from an undiagnosed metastatic brain tumor during abdominal radical hysterectomy. Since she was neurologically intact, a systematic examination for brain metastasis had not been performed preoperatively. After the surgery, she had delayed recovery from general anesthesia with right hemiplegia and aphasia. Computed tomography and magnetic resonance imaging showed left putaminal hemorrhage from brain metastasis.