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Phase II trial of sunitinib as adjuvant therapy after stereotactic radiosurgery in patients with 1-3 newly diagnosed brain metastases. J Neurooncol 2015; 124:485-91. [PMID: 26245136 DOI: 10.1007/s11060-015-1862-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 07/22/2015] [Indexed: 10/23/2022]
Abstract
Patients with 1-3 brain metastases (BM) often receive sterotactic radiosurgery (SRS) without whole brain radiotherapy (WBRT). SRS without WBRT carries a high rate of relapse in the central nervous system (CNS). This trial used sunitinib as an alternative to WBRT for post-SRS adjuvant therapy. Eligible patients with 1-3 newly diagnosed BM, RTOG RPA class 1-2, received sunitinib after SRS. Patients with controlled systemic disease were allowed to continue chemotherapy for their primary disease according to a list of published regimens (therapy + sunitinib) included in the protocol. Patients received sunitinib 37.5 or 50 mg/days 1-28 every 42 days until CNS progression. Neuropsychological testing and MRIs were obtained every two cycles. The primary endpoint was the rate of CNS progression at 6 months (PFS6) after SRS. Fourteen patients with a median age of 59 years were enrolled. Primary cancers included lung 43 %, breast 21 %, melanoma 14 %. Toxicity included grade 3 or higher fatigue in five patients and neutropenia in two patients. The CNS PFS6 and PFS12 were 43 ± 14 and 34 ± 14 %, respectively. Of the ten patients who completed >1 neurocognitive assessment, none showed cognitive decline. Sunitinib after SRS for 1-3 BM was well tolerated with a PFS6 of 43 %. The prevention of progressive brain metastasis after SRS requires the incorporation of chemotherapy regimens to control the patient's primary disease. Future trials should continue to explore the paradigm of secondary chemoprevention of BM after definitive local therapy.
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152
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Results of a Phase II Study of Short-Course Accelerated Radiation Therapy (SHARON) for Multiple Brain Metastases. Am J Clin Oncol 2015. [DOI: 10.1097/coc.0b013e3182a0e826] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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153
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Honda Y, Aruga T, Yamashita T, Miyamoto H, Horiguchi K, Kitagawa D, Idera N, Goto R, Kuroi K. Prolonged survival after diagnosis of brain metastasis from breast cancer: contributing factors and treatment implications. Jpn J Clin Oncol 2015; 45:713-8. [PMID: 25981620 DOI: 10.1093/jjco/hyv067] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 04/07/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The prognosis of breast cancer-derived brain metastasis is poor, but new drugs and recent therapeutic strategies have helped extend survival in patients. Prediction of therapeutic responses and outcomes is not yet possible, however. In a retrospective study, we examined prognostic factors in patients with breast cancer-derived brain metastasis, and we tested the prognostic utility of a breast cancer-specific Graded Prognostic Assessment in these patients. METHODS Sixty-three patients diagnosed with brain metastasis from breast cancer treated surgically and adjuvantly were included. We examined clinical variables per primary tumor subtype: ER+/HER2- (luminal), HER2+ (human epidermal growth factor receptor type 2-enriched) or ER-/PR-/HER2- (triple negative). We also categorized patients' breast cancer-specific Graded Prognostic Assessment scores and analyzed post-brain metastasis survival time in relation to these categories. RESULTS The breast cancers comprised the following subtypes: luminal, n = 18; human epidermal growth factor receptor type 2-enriched, n = 27 and triple-negative, n = 18; median survival per subtype was 11, 37 and 3 months, respectively. Survival of human epidermal growth factor receptor type 2-enriched patients was longer, though not significantly (P = 0.188), than that of luminal patients. Survival of triple-negative patients was significantly short (vs. human epidermal growth factor receptor type 2-enriched patients, P < 0.001). Karnofsky performance status, HER2 status and the disease-free interval (from initial treatment to first recurrence) were shown to be significant prognostic factors (Karnofsky performance status < 70: relative risk 2.08, P = 0.028; HER2+: relative risk 2.911, P = 0.004; disease-free interval < 24 months: relative risk 1.933, P = 0.011). Breast cancer-specific Graded Prognostic Assessment scores reflected disease-free intervals and survival times. CONCLUSIONS Our data indicate that breast cancer-specific Graded Prognostic Assessment-based prediction will be helpful in determining appropriate therapeutic strategies for patients with brain metastasis from breast cancer.
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Affiliation(s)
- Yayoi Honda
- Division of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Tomoyuki Aruga
- Division of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Toshinari Yamashita
- Division of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hiromi Miyamoto
- Division of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kazumi Horiguchi
- Division of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Dai Kitagawa
- Division of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Nami Idera
- Division of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Risa Goto
- Division of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Katsumasa Kuroi
- Division of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
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154
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155
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Clinical outcomes of palliative radiation therapy for children. Pract Radiat Oncol 2015; 5:183-187. [DOI: 10.1016/j.prro.2014.08.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 08/16/2014] [Accepted: 08/20/2014] [Indexed: 11/22/2022]
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The treatment of patients with 1-3 brain metastases: is there a place for whole brain radiotherapy alone, yet? A retrospective analysis. Radiol Med 2015; 120:1146-52. [PMID: 25917339 DOI: 10.1007/s11547-015-0542-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 04/16/2015] [Indexed: 10/23/2022]
Abstract
AIM To evaluate the efficacy of whole brain radiotherapy (WBRT) with or without other treatments in patients (pts) with 1-3 brain metastases (BM). MATERIALS AND METHODS Toxicities and survival of 134 pts treated between 2009 and 2013 with WBRT alone (58 pts), WBRT plus surgery (SUR-WBRT: 42 pts) or WBRT followed by stereotactic or integrated boost radiotherapy (SRT-WBRT: 34 pts) were analyzed. Differences in toxicity (acute and late) incidence and in overall (OS), disease-free (DFS) and disease-specific survival (DSS) were evaluated (χ(2)-test, uni- and multivariate analysis). RESULTS Pts given intensified treatments (SUR- and SBRT-WBRT) had better 3-month local response compared to WBRT alone group (p < 0.045). Better 1-year local control was evident only in SRT-WBRT pts (p < 0.035). Univariate OS analysis confirmed, as favorable prognostic factors, RPA class I (p < 0.001), GPA class III and IV (p < 0.001), single metastasis (p = 0.045), stable primary disease (p = 0.03), intensified treatment (p = 0.000), systemic therapy after radiotherapy (p = 0.04) and response of metastatic lesions (p = 0.002). At multivariate analysis, OS was better in RPA class I pts (p = 0.002), who had more aggressive radiotherapy treatments (p = 0.001), chemotherapy after radiotherapy (p < 0.001) and response to RT (p = 0.003). Response to radiotherapy (p = 0.002) and BM number (p < 0.001) resulted independently prognostic for DFS. About 60 % of patients had mild acute toxicity (G1), especially headache (51 %) and fatigue (34 %); only 2 patients (2 %) had severe (G3) headache and 5 patients (4 %) severe fatigue (G3) reversible with oral steroids. No differences were evident between the different treatment groups. Among 80 pts followed up with MRI, 12 (15 %) had leukoencephalopathy (equally distributed across subgroups) and 5 (6 %) radionecroses, 4/5 asymptomatic, 5/5 in pts given intensified treatments. CONCLUSIONS This analysis confirms the known prognostic factors for BM, emphasizing the importance of intensified treatments in a population with favorable features.
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157
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Chen IC, Lin CH, Jan IS, Cheng AL, Lu YS. Bevacizumab might potentiate the chemotherapeutic effect in breast cancer patients with leptomeningeal carcinomatosis. J Formos Med Assoc 2015; 115:243-8. [PMID: 25890495 DOI: 10.1016/j.jfma.2015.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 02/26/2015] [Accepted: 03/16/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND/PURPOSE Patients with leptomeningeal carcinomatosis (LC) from breast cancer is generally resistant to systemic chemotherapy. Bevacizumab may increase intratumor concentration of the chemotherapeutic agents through vascular normalization, although the overall clinical benefit of bevacizumab for metastatic breast cancer is under debate. METHODS Successful treatment of two breast cancer patients who developed LC after whole brain irradiation treatment for the brain metastases is reported here. Both patients have refractory disease to taxane and anthracycline, and both of them have disease progression under intrathecal methotrexate treatment for LC. RESULTS The two patients received systemic chemotherapy with bevacizumab (7.5 mg/kg infusion on Day 1), cisplatin (80 mg/m(2) infusion for 24 hours on Day 2), and etoposide (80 mg/m(2) infusion for 2 hours on Days 2-4) at 21-28 day intervals. Both patients achieved best response of negative cerebral spinal fluid cytology study and dramatic improvement of neurologic deficit after treatment. Their overall survival after development of LC was 8 months and 7.5 months respectively. CONCLUSION Bevacizumab plus etoposide and cisplatin might be a new option for breast cancer patients with LC. Further prospective study is warranted.
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Affiliation(s)
- I-Chun Chen
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Hung Lin
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - I-Shiow Jan
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ann-Lii Cheng
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yen-Shen Lu
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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158
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Hajdu SI, Vadmal M, Tang P. A note from history: Landmarks in history of cancer, part 7. Cancer 2015; 121:2480-513. [PMID: 25873516 DOI: 10.1002/cncr.29365] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 02/02/2015] [Indexed: 02/06/2023]
Abstract
In the 2 and half decades reviewed (1970-1995), research established that chromosomal translocation, deletion, and DNA amplification are prerequisites to cancerogenesis and that oncogenes, tumor-suppressor genes, growth factors, and cytokines play crucial roles in the pathomechanism of cancer. Human papillomavirus, human immunodeficiency virus, herpes virus, and hepatitis B virus were identified as cancer-causing viruses. Several laboratory tests were developed for the detection of primary and recurrent cancers, and cancer prevention by screening methods was popularized. Sonography, computerized tomography, magnetic resonance imaging, positron emission tomography, excision of sentinel lymph nodes, and immunohistochemical techniques became routine procedures. Clinicopathologic staging and classification of tumors were standardized. Limited surgery, adjuvant and neoadjuvant chemoradiation, and the therapeutic use of monoclonal antibodies, tumor vaccines, and targeted chemotherapy became routine practice. The decline in cancer incidence and mortality demonstrated that cancer prevention and advancement in oncology are pivotal to success in the crusade against cancer. Above all, it was clearly established that the care of patients with cancer can be accomplished best in a multidisciplinary setting involving surgical oncologists, radiologists, radiation therapists, medical oncologists, surgical pathologists, and laboratory scientists. In conclusion, the 25 years from 1970 and 1995 are the high-water mark in clinical oncology, and this is the period when oncology turned from art to science.
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Affiliation(s)
| | - Manjunath Vadmal
- Department of Dermatology, Los Angeles County-University of Southern California Medical Center, Los Angeles, California
| | - Ping Tang
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
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159
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De Ieso PB, Schick U, Rosenfelder N, Mohammed K, Ross GM. Breast cancer brain metastases - A 12 year review of treatment outcomes. Breast 2015; 24:426-33. [PMID: 25881974 DOI: 10.1016/j.breast.2015.03.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 03/11/2015] [Accepted: 03/18/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Breast cancer (BC) is the 2nd commonest cause of brain metastases (BM). This retrospective review investigates the applicability of prognostic scores and highlights different outcomes for patients with HER2 positive compared to triple negative (TN) subtypes. METHODS Two hundred and seventy four patients received whole brain radiotherapy for BC BM (01/2000-12/2011). The primary objective was to determine factors influencing overall survival (OS). All information relevant to primary BC, disease recurrence, treatment, outcome and cause of death (either neurological (NP) or systemic progression (SP)) were collected. Univariate (UV) and multivariate (MV) Cox regression analysis were used. RESULTS One hundred and forty four patients (53%) were ER positive, 104 (38%) HER2 positive and 57 (21%) TN. Median age at BM was 53 (27-81) years and median OS from BM diagnosis 7.3 (5.7-8.9) months. On MV analysis, Her2 status, RPA score, surgery, stereotactic radiotherapy, and absence of TN disease were independent prognostic factor for OS. NP was the cause of death in 69.2% of HER2 positive patients and 17.3% had SP. Of the TN patients, 29.8% had NP and 54.4% SP (p < 0.001). CONCLUSION A consistent OS advantage is noted for HER2 positive BM cases and inclusion of BC subtype in the breast GPA score should improve the prognostic factors' sensitivity. The unique presentations, response to treatment and causes of death for HER2 positive patients means more aggressive focal therapy should be considered and studied in the context of clinical trials. For TN BM patients with poor performance status, best supportive care may be appropriate.
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Affiliation(s)
- P B De Ieso
- Breast Clinical Oncology Unit, The Royal Marsden NHS Foundation Trust, Sutton and London, UK; NT Radiation Oncology, Alan Walker Cancer Centre, Rocklands Drive, Tiwi, NT 0810, Australia.
| | - U Schick
- Breast Clinical Oncology Unit, The Royal Marsden NHS Foundation Trust, Sutton and London, UK
| | - N Rosenfelder
- Breast Clinical Oncology Unit, The Royal Marsden NHS Foundation Trust, Sutton and London, UK
| | - K Mohammed
- Breast Clinical Oncology Unit, The Royal Marsden NHS Foundation Trust, Sutton and London, UK
| | - G M Ross
- Breast Clinical Oncology Unit, The Royal Marsden NHS Foundation Trust, Sutton and London, UK
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160
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Miura S, Kaira K, Kaira R, Akamatsu H, Ono A, Shukuya T, Tsuya A, Nakamura Y, Kenmotsu H, Naito T, Murakami H, Takahashi T, Endo M, Yamamoto N. The efficacy of amrubicin on central nervous system metastases originating from small-cell lung cancer: a case series of eight patients. Invest New Drugs 2015; 33:755-60. [DOI: 10.1007/s10637-015-0233-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 03/18/2015] [Indexed: 10/23/2022]
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161
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Abstract
Brain metastases are an important cause of morbidity and mortality, afflicting approximately 200,000 Americans annually. The prognosis for these patients is poor, with median survivals typically measured in months. In this review article, we present the standard treatment approaches with whole brain radiation and as well as novel approaches in the prevention of neurocognitive deficits.
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162
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Métellus P, Tallet A, Dhermain F, Reyns N, Carpentier A, Spano JP, Azria D, Noël G, Barlési F, Taillibert S, Le Rhun É. Stratégie globale de prise en charge des métastases cérébrales : une approche multidisciplinaire. Cancer Radiother 2015; 19:61-5. [DOI: 10.1016/j.canrad.2014.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 11/26/2014] [Indexed: 11/30/2022]
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163
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Hu N, Wang G, Wu YH, Chen SF, Liu GD, Chen C, Wang D, He ZS, Yang XQ, He Y, Xiao HL, Huang DD, Xiong KL, Wu Y, Huang M, Yang ZZ. LDA-SVM-based EGFR mutation model for NSCLC brain metastases: an observational study. Medicine (Baltimore) 2015; 94:e375. [PMID: 25654374 PMCID: PMC4602717 DOI: 10.1097/md.0000000000000375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Epidermal growth factor receptor (EGFR) activating mutations are a predictor of tyrosine kinase inhibitor effectiveness in the treatment of non-small-cell lung cancer (NSCLC). The objective of this study is to build a model for predicting the EGFR mutation status of brain metastasis in patients with NSCLC. Observation and model set-up. This study was conducted between January 2003 and December 2011 in 6 medical centers in Southwest China. The study included 31 NSCLC patients with brain metastases. Eligibility requirements were histological proof of NSCLC, as well as sufficient quantity of paraffin-embedded lung and brain metastases specimens for EGFR mutation detection. The linear discriminant analysis (LDA) method was used for analyzing the dimensional reduction of clinical features, and a support vector machine (SVM) algorithm was employed to generate an EGFR mutation model for NSCLC brain metastases. Training-testing-validation (3 : 1 : 1) processes were applied to find the best fit in 12 patients (validation test set) with NSCLC and brain metastases treated with a tyrosine kinase inhibitor and whole-brain radiotherapy. Primary and secondary outcome measures: EGFR mutation analysis in patients with NSCLC and brain metastases and the development of a LDA-SVM-based EGFR mutation model for NSCLC brain metastases patients. EGFR mutation discordance between the primary lung tumor and brain metastases was found in 5 patients. Using LDA, 13 clinical features were transformed into 9 characteristics, and 3 were selected as primary vectors. The EGFR mutation model constructed with SVM algorithms had an accuracy, sensitivity, and specificity for determining the mutation status of brain metastases of 0.879, 0.886, and 0.875, respectively. Furthermore, the replicability of our model was confirmed by testing 100 random combinations of input values. The LDA-SVM-based model developed in this study could predict the EGFR status of brain metastases in this small cohort of patients with NSCLC. Further studies with larger cohorts should be carried out to validate our findings in the clinical setting.
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Affiliation(s)
- Nan Hu
- From the Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University (NH, GW, CC, DW, X-QY, YW, Z-ZY); College of Computer Science, Chongqing University, Chongqing, P.R. China (Y-HW, Z-SH); Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA (S-FC); Eighth Department (G-DL); Department of Respiration (YH); Department of Pathology, Daping Hospital, (H-LX); Department of Nuclear Medicine, Southwest Hospital, (D-DH); Department of Radiology, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, P.R. China (K-LX); and Department of Minimally Invasive Interventional Radiology, Yunnan Tumor Hospital, Third Hospital Affiliated of Kunming Medical University, Kunming, P.R. China (MH)
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164
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Radiothérapie encéphalique en totalité des métastases cérébrales : intérêts et controverses dans le cadre d’un référentiel. Cancer Radiother 2015; 19:30-5. [DOI: 10.1016/j.canrad.2014.12.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 12/08/2014] [Indexed: 11/18/2022]
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165
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A proposal of postoperative follow-up pathways for lung cancer. Gen Thorac Cardiovasc Surg 2014; 63:231-8. [DOI: 10.1007/s11748-014-0506-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 12/04/2014] [Indexed: 11/27/2022]
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166
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White matter changes in breast cancer brain metastases patients who undergo radiosurgery alone compared to whole brain radiation therapy plus radiosurgery. J Neurooncol 2014; 121:583-90. [PMID: 25445836 DOI: 10.1007/s11060-014-1670-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 11/23/2014] [Indexed: 12/21/2022]
Abstract
Delayed toxicity after whole brain radiation therapy (WBRT) is of increasing concern in patients who survive more than one year with brain metastases from breast cancer. Radiation-related white matter toxicity is detected by magnetic resonance imaging (MRI) and has been correlated with neurocognitive dysfunction. This study assessed the risk of developing white matter changes (WMC) in breast cancer patients who underwent either WBRT plus stereotactic radiosurgery (SRS) or SRS alone. We retrospectively compared 35 patients with breast cancer brain metastases who received WBRT and SRS to 30 patients who only received SRS. All patients had evaluable imaging at a median of one year after their initial management. The development of white matter T2 prolongation as detected by T2 or FLAIR imaging was graded: grade 1 = little or no white matter T2 hyperintensity; grade 2 = limited periventricular hyperintensity; and grade 3 = diffuse white matter hyperintensity. After WBRT plus SRS, patients demonstrated a significantly higher incidence of WMC (p < 0.0001). After one year, 71.5 % of patients whose treatment included WBRT demonstrated WMC (42.9 % grade 2; 28.6 % grade 3). Only one patient receiving only SRS developed WMC. In long-term survivors of breast cancer, the risk of WMC was significantly reduced when SRS alone was used for management. Further prospective studies are necessary to determine how these findings correlate with neurocognitive toxicity. WBRT usage as initial management of limited brain disease should be replaced by SRS alone to reduce the risk of delayed white matter toxicity.
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167
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Management of Cerebral Brain Metastasis. CURRENT SURGERY REPORTS 2014. [DOI: 10.1007/s40137-014-0074-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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168
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Suh JH. Hippocampal-avoidance whole-brain radiation therapy: a new standard for patients with brain metastases? J Clin Oncol 2014; 32:3789-91. [PMID: 25349293 DOI: 10.1200/jco.2014.58.4367] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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169
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Owen S, Souhami L. The management of brain metastases in non-small cell lung cancer. Front Oncol 2014; 4:248. [PMID: 25309873 PMCID: PMC4164096 DOI: 10.3389/fonc.2014.00248] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 09/01/2014] [Indexed: 11/24/2022] Open
Abstract
Brain metastases (BM) are a common and lethal complication of non-small cell lung cancer (NSCLC), which portend a poor prognosis. In addition, their management implies several challenges including preservation of neurological and neurocognitive function during surgery or radiation-therapy, minimizing iatrogenic complications of supportive medications, and optimizing drug delivery across the blood–brain barrier. Despite these challenges, advancements in combined modality approaches can deliver hope of improved overall survival and quality of life for a subset of NSCLC patients with BM. Moreover, new drugs harnessing our greater understanding of tumor biology promise to build on this hope. In this mini-review, we revised the management of BM in NSCLC including advancements in neurosurgery, radiation therapy, as well as systemic and supportive therapy.
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Affiliation(s)
- Scott Owen
- Division of Medical Oncology, Department of Oncology, McGill University Health Centre , Montreal, QC , Canada
| | - Luis Souhami
- Division of Radiation Oncology, Department of Oncology, McGill University Health Centre , Montreal, QC , Canada
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170
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Sheehan JP, Yen CP, Lee CC, Loeffler JS. Cranial stereotactic radiosurgery: current status of the initial paradigm shifter. J Clin Oncol 2014; 32:2836-46. [PMID: 25113762 PMCID: PMC4152711 DOI: 10.1200/jco.2013.53.7365] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The concept of stereotactic radiosurgery (SRS) was first described by Lars Leksell in 1951. It was proposed as a noninvasive alternative to open neurosurgical approaches to manage a variety of conditions. In the following decades, SRS emerged as a unique discipline involving a collegial partnership among neurosurgeons, radiation oncologists, and medical physicists. SRS relies on the precisely guided delivery of high-dose ionizing radiation to an intracranial target. The focused convergence of multiple beams yields a potent therapeutic effect on the target and a steep dose fall-off to surrounding structures, thereby minimizing the risk of collateral damage. SRS is typically administered in a single session but can be given in as many as five sessions or fractions. By providing an ablative effect noninvasively, SRS has altered the treatment paradigms for benign and malignant intracranial tumors, functional disorders, and vascular malformations. Literature on extensive intracranial radiosurgery has unequivocally demonstrated the favorable benefit-to-risk profile that SRS affords for appropriately selected patients. In a departure from conventional radiotherapeutic strategies, radiosurgical principles have recently been extended to extracranial indications such as lung, spine, and liver tumors. The paradigm shift resulting from radiosurgery continues to alter the landscape of related fields.
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Affiliation(s)
- Jason P Sheehan
- Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, University of Virginia, Charlottesville, VA; Jay S. Loeffler, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Chun-Po Yen
- Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, University of Virginia, Charlottesville, VA; Jay S. Loeffler, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Cheng-Chia Lee
- Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, University of Virginia, Charlottesville, VA; Jay S. Loeffler, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jay S Loeffler
- Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, University of Virginia, Charlottesville, VA; Jay S. Loeffler, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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171
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Lukas RV, Gabikian P, Garza M, Chmura SJ. Treatment of brain metastases. Oncology 2014; 87:321-9. [PMID: 25227433 DOI: 10.1159/000362389] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 03/18/2014] [Indexed: 11/19/2022]
Abstract
Brain metastases are associated with substantial morbidity and mortality. Key prognostic classification systems for brain metastases are reviewed. The role of surgery, particularly for single brain metastases, is discussed. This is followed by an overview of radiation, both whole brain and focal, in the treatment of brain metastases. Finally, we review examples of important concepts regarding the role of systemic therapy in the treatment of brain metastases.
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Affiliation(s)
- Rimas V Lukas
- Department of Neurology,University of Chicago, Chicago, Ill., USA
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Cai L, Zhu JF, Zhang XW, Lin SX, Su XD, Lin P, Chen K, Zhang LJ. A comparative analysis of EGFR mutation status in association with the efficacy of TKI in combination with WBRT/SRS/surgery plus chemotherapy in brain metastasis from non-small cell lung cancer. J Neurooncol 2014; 120:423-30. [PMID: 25098700 PMCID: PMC4206296 DOI: 10.1007/s11060-014-1570-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Accepted: 07/22/2014] [Indexed: 11/28/2022]
Abstract
We proposed to identify the efficacy of an epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) using whole brain radiotherapy (WBRT)/stereotactic radiosurgery (SRS)/surgery in brain metastases from patients with non-small cell lung cancer (NSCLC) and clarify the association between treatment outcome and EGFR gene mutation status. A total of 282 patients with NSCLC brain metastases who underwent WBRT/SRS/surgery alone or in combination with TKI were enrolled in our study from 2003-2013. Amplification mutation refractory system technology was used to determine the EGFR mutation status in 109 tissue samples. EGFR mutation detection was performed in 109 patients with tumor tissues. The EGFR positive rate was 50 % (55/109), including 26 exon 19 deletions and 24 L858R mutations. The median follow-up time was 28 months. The median overall survival, median progression-free survival of intracranial disease, and median progression-free survival of extracranial disease was significantly longer for patients with TKI treatment (31.9 vs 17.0 months, P < 0.0001; 19.8 vs 12.0 months, P < 0.0001; and 19.6 vs 12.3 months, P < 0.0001; respectively). In subgroup analysis within the TKI group, patients harboring EGFR mutations had better extracranial disease control (20.4 vs 14.1 months, P = 0.032). Administration of TKI agents with conventional therapy compared with conventional therapy alone might be beneficial for overall survival, progression-free survival of intracranial disease and progression-free survival of extracranial disease in patients with brain metastases from NSCLC independent of EGFR mutations.
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Affiliation(s)
- Ling Cai
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, China
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Gangopadhyay A, Das J, Nath P, Maji T, Biswas J. Incidence of hospitalization in patients receiving short course palliative cranial radiotherapy on outpatient basis in a limited resource setting - Experience from a regional cancer center in India. Rep Pract Oncol Radiother 2014; 19:428-32. [PMID: 25337417 DOI: 10.1016/j.rpor.2014.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 02/05/2014] [Accepted: 04/05/2014] [Indexed: 10/25/2022] Open
Abstract
AIM To investigate incidence of toxicity and related hospitalization among patients treated at our institute by a short course of palliative cranial radiotherapy against a longer, widely established schedule. BACKGROUND Shorter schedule palliative cranial radiotherapy is more convenient for patients and reduce waiting times. Although many studies have established safety of short schedules, the need for hospitalization due to acute treatment toxicity remains under-explored. Hospital admissions are an economic burden both for the patient and healthcare system in a limited resource setting. Delivery of treatment on an outpatient basis and within shorter times is preferred by patients, caregivers and healthcare staff. MATERIALS AND METHODS This was a prospective study on 68 patients treated with palliative whole brain radiotherapy between November 2010 and October 2012. One group received 20 Gy in 5 fractions over 1 week and the other group, 30 Gy in 10 fractions over 2 weeks. Treatment toxicity due to cranial radiotherapy was assessed as per RTOG acute and late toxicity criteria. Need for hospitalization owing to acute toxicity was also noted. Significant differences in the study parameters between the two groups were calculated by Fisher's t-test. RESULTS Requirement for hospital stay due to acute toxicity was not significantly different between the two groups. Patients in both groups experienced similar toxicity both during and after treatment. CONCLUSIONS The shorter course entailed no significant increase in toxicity related admissions, suitable for limited resource settings where patient transport is difficult, there are financial constraints, and the healthcare system is overburdened.
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Affiliation(s)
- Aparna Gangopadhyay
- Dept. of Radiation Oncology, Chittaranjan National Cancer Institute, Kolkata, India
| | - Joydeep Das
- Dept. of Radiation Oncology, Chittaranjan National Cancer Institute, Kolkata, India
| | - Partha Nath
- Dept. of Medical Oncology, Chittaranjan National Cancer Institute, Kolkata, India
| | - Tapas Maji
- Dept. of Radiation Oncology, Chittaranjan National Cancer Institute, Kolkata, India
| | - Jaydip Biswas
- Dept. of Medical Oncology, Chittaranjan National Cancer Institute, Kolkata, India
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The diagnosis and treatment of pseudoprogression, radiation necrosis and brain tumor recurrence. Int J Mol Sci 2014; 15:11832-46. [PMID: 24995696 PMCID: PMC4139817 DOI: 10.3390/ijms150711832] [Citation(s) in RCA: 142] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 06/05/2014] [Accepted: 06/25/2014] [Indexed: 12/22/2022] Open
Abstract
Radiation therapy is an important modality used in the treatment of patients with brain metastatic disease and malignant gliomas. Post-treatment surveillance often involves serial magnetic resonance imaging. A challenge faced by clinicians is in the diagnosis and management of a suspicious gadolinium-enhancing lesion found on imaging. The suspicious lesion may represent post-treatment radiation effects (PTRE) such as pseudoprogression, radiation necrosis or tumor recurrence. Significant progress has been made in diagnostic imaging modalities to assist in differentiating these entities. Surgical and medical interventions have also been developed to treat PTRE. In this review, we discuss the pathophysiology, clinical presentation, diagnostic imaging modalities and provide an algorithm for the management of pseudoprogression, radiation necrosis and tumor recurrence.
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Lee SM, Lewanski CR, Counsell N, Ottensmeier C, Bates A, Patel N, Wadsworth C, Ngai Y, Hackshaw A, Faivre-Finn C. Randomized trial of erlotinib plus whole-brain radiotherapy for NSCLC patients with multiple brain metastases. J Natl Cancer Inst 2014; 106:dju151. [PMID: 25031274 PMCID: PMC4112798 DOI: 10.1093/jnci/dju151] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 04/23/2014] [Accepted: 04/28/2014] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Siow Ming Lee
- Affiliations of authors: Department of Oncology, University College London (UCL) Cancer Institute and UCL Hospitals, London, UK (SML, NP); Department of Oncology, Charing Cross Hospital, London, UK (CRL); Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute, London, UK (NC, CW, YN, AH); Department of Oncology, Southampton General Hospital, Southampton, UK (CO, AB); Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester (CFF), UK.
| | - Conrad R Lewanski
- Affiliations of authors: Department of Oncology, University College London (UCL) Cancer Institute and UCL Hospitals, London, UK (SML, NP); Department of Oncology, Charing Cross Hospital, London, UK (CRL); Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute, London, UK (NC, CW, YN, AH); Department of Oncology, Southampton General Hospital, Southampton, UK (CO, AB); Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester (CFF), UK
| | - Nicholas Counsell
- Affiliations of authors: Department of Oncology, University College London (UCL) Cancer Institute and UCL Hospitals, London, UK (SML, NP); Department of Oncology, Charing Cross Hospital, London, UK (CRL); Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute, London, UK (NC, CW, YN, AH); Department of Oncology, Southampton General Hospital, Southampton, UK (CO, AB); Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester (CFF), UK
| | - Christian Ottensmeier
- Affiliations of authors: Department of Oncology, University College London (UCL) Cancer Institute and UCL Hospitals, London, UK (SML, NP); Department of Oncology, Charing Cross Hospital, London, UK (CRL); Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute, London, UK (NC, CW, YN, AH); Department of Oncology, Southampton General Hospital, Southampton, UK (CO, AB); Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester (CFF), UK
| | - Andrew Bates
- Affiliations of authors: Department of Oncology, University College London (UCL) Cancer Institute and UCL Hospitals, London, UK (SML, NP); Department of Oncology, Charing Cross Hospital, London, UK (CRL); Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute, London, UK (NC, CW, YN, AH); Department of Oncology, Southampton General Hospital, Southampton, UK (CO, AB); Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester (CFF), UK
| | - Nirali Patel
- Affiliations of authors: Department of Oncology, University College London (UCL) Cancer Institute and UCL Hospitals, London, UK (SML, NP); Department of Oncology, Charing Cross Hospital, London, UK (CRL); Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute, London, UK (NC, CW, YN, AH); Department of Oncology, Southampton General Hospital, Southampton, UK (CO, AB); Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester (CFF), UK
| | - Christina Wadsworth
- Affiliations of authors: Department of Oncology, University College London (UCL) Cancer Institute and UCL Hospitals, London, UK (SML, NP); Department of Oncology, Charing Cross Hospital, London, UK (CRL); Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute, London, UK (NC, CW, YN, AH); Department of Oncology, Southampton General Hospital, Southampton, UK (CO, AB); Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester (CFF), UK
| | - Yenting Ngai
- Affiliations of authors: Department of Oncology, University College London (UCL) Cancer Institute and UCL Hospitals, London, UK (SML, NP); Department of Oncology, Charing Cross Hospital, London, UK (CRL); Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute, London, UK (NC, CW, YN, AH); Department of Oncology, Southampton General Hospital, Southampton, UK (CO, AB); Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester (CFF), UK
| | - Allan Hackshaw
- Affiliations of authors: Department of Oncology, University College London (UCL) Cancer Institute and UCL Hospitals, London, UK (SML, NP); Department of Oncology, Charing Cross Hospital, London, UK (CRL); Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute, London, UK (NC, CW, YN, AH); Department of Oncology, Southampton General Hospital, Southampton, UK (CO, AB); Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester (CFF), UK
| | - Corinne Faivre-Finn
- Affiliations of authors: Department of Oncology, University College London (UCL) Cancer Institute and UCL Hospitals, London, UK (SML, NP); Department of Oncology, Charing Cross Hospital, London, UK (CRL); Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute, London, UK (NC, CW, YN, AH); Department of Oncology, Southampton General Hospital, Southampton, UK (CO, AB); Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester (CFF), UK
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Lo SSM, Gore EM, Bradley JD, Buatti JM, Germano I, Ghafoori AP, Henderson MA, Murad GJA, Patchell RA, Patel SH, Robbins JR, Robins HI, Vassil AD, Wippold FJ, Yunes MJ, Videtic GMM. ACR Appropriateness Criteria® pre-irradiation evaluation and management of brain metastases. J Palliat Med 2014; 17:880-6. [PMID: 24971478 DOI: 10.1089/jpm.2014.9417] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Pretreatment evaluation is performed to determine the number, location, and size of the brain metastases and magnetic resonance imaging (MRI) is the recommended imaging technique, particularly in patients being considered for surgery or stereotactic radiosurgery. A contiguous thin-cut volumetric MRI with gadolinium with newer gadolinium-based agents can improve detection of small brain metastases. A systemic workup and medical evaluation are important, given that subsequent treatment for the brain metastases will also depend on the extent of the extracranial disease and on the age and performance status of the patient. Patients with hydrocephalus or impending brain herniation should be started on high doses of corticosteroids and evaluated for possible neurosurgical intervention. Patients with moderate symptoms should receive approximately 4-8 mg/d of dexamethasone in divided doses. The routine use of corticosteroids in patients without neurologic symptoms is not necessary. There is no proven benefit of anticonvulsants in patient without seizures. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Jezierska D, Adamska K, Liebert W. Evaluation of results of linac-based radiosurgery for brain metastases from primary lung cancer. Rep Pract Oncol Radiother 2014; 19:19-29. [PMID: 24936316 DOI: 10.1016/j.rpor.2013.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 04/13/2013] [Accepted: 06/23/2013] [Indexed: 11/18/2022] Open
Abstract
AIM The purpose of our review was to evaluate results of radiosurgery for patients with brain metastases from lung cancer. BACKGROUND Lung cancer is the leading cause of death from cancer and the most common source of brain metastases. Radiosurgery allows the precise focal delivery of a high single radiation dose to brain metastases and results in high rates of local control. MATERIALS AND METHODS 83 patients were treated between 2006 and 2008. We evaluated local control and outcome after radiosurgery and identified prognostic factors. RESULTS Median survival in the whole group was 7.8 months from radiosurgery and 11 months from diagnosis. Median survival in classes I, II and III was 13.2, 8.2 and 2.2 months. For 94% of patients symptoms improved or stabilised at the first follow-up visit and this status did not change during 7.1 months. According to the univariate analysis, factors associated with improved survival included: RPA class 1 compared with RPA 2 and 3, RPA class 2 compared with RPA 3, KPS > 70, control of the primary disease, radiosurgery performed more than once, level of haemoglobin >7 mmol/1, absence of extracranial metastases, volume of the biggest lesion <11 cm(3). The multivariate analysis confirmed a significant influence on survival for the following factors: RPA class 1 as compared with RPA 3, KPS > 70, absence of extracranial metastases, multiplicity of radiosurgery. CONCLUSIONS Stereotactic radiosurgery is a safe and effective treatment. It proved to be effective and safe in older patients. Selection of patients who are likely to benefit most should be based on prognostic factors. KPS proved to be the most important prognostic factor. In the RPA III group (patients with KPS < 70) survival time was similar to that achieved after symptomatic medical management.
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Affiliation(s)
- Dorota Jezierska
- Greater Poland Cancer Centre, Garbary 15 Str., 61-866 Poznań, Poland
| | - Krystyna Adamska
- Greater Poland Cancer Centre, Garbary 15 Str., 61-866 Poznań, Poland
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Zeng YC, Wu R, Wang SL, Chi F, Xing R, Cai WS, Fan GL, Fan YC, Zhong WZ, Wu LN, Chen XD, Chen HH, Xiao YP. Serum CA125 level predicts prognosis in patients with multiple brain metastases from non-small cell lung cancer before and after treatment of whole-brain radiotherapy. Med Oncol 2014; 31:48. [PMID: 24913812 DOI: 10.1007/s12032-014-0048-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 05/23/2014] [Indexed: 10/25/2022]
Abstract
This study was to evaluate the effect of serum CA125 level on the prognosis of patients with multiple brain metastases from non-small cell lung cancer before and after treatment of whole-brain radiotherapy. Sixty-six patients with multiple brain metastases from non-small cell lung cancer before and after treatment of radiotherapy were reviewed retrospectively. Radiotherapy was given to the whole brain using opposed 6MV lateral beams with a dose of 30 Gy in 15 fractions in 3 weeks. Elevated CA125 was defined as >35 U/mL. The survival rate was calculated using the Kaplan-Meier method, and the univariate and multivariate analyses were used to identify significant factors associated with prognosis, using a Cox proportional hazards model. During the median (range) follow-up of 1.25 (0.25-2.50) years, 62 patients died from non-small cell lung cancer; the 1-year cancer-specific survival (CSS) rate was 43.08 %. Thirty patients had a high CA125 level before chemoradiotherapy (>35U/mL), and their CSS rate was significantly worse than that in the remaining patients (P = 0.024). Multivariate analysis showed that CA125 level, number of metastases and total tumor volume were independent prognostic indicators for CSS, with a hazard ratio of 1.99, 1.67 and 2.02, respectively. The elevation of CA125 before treatment predicts a poor prognosis in patients with multiple brain metastases from non-small cell lung cancer before and after treatment of whole-brain radiotherapy.
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Affiliation(s)
- Yue-Can Zeng
- Department of Medical Oncology, Shengjing Hospital of China Medical University, 39 Huaxiang Road, Shenyang, 110022, China,
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Smith TR, Lall RR, Lall RR, Abecassis IJ, Arnaout OM, Marymont MH, Swanson KR, Chandler JP. Survival after surgery and stereotactic radiosurgery for patients with multiple intracranial metastases: results of a single-center retrospective study. J Neurosurg 2014; 121:839-45. [PMID: 24857242 DOI: 10.3171/2014.4.jns13789] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Patients with systemic cancer and a single brain metastasis who undergo treatment with resection plus radiotherapy live longer and have a better quality of life than those treated with radiotherapy alone. Historically, whole-brain radiotherapy (WBRT) has been the mainstay of radiation therapy; however, it is associated with significant delayed neurocognitive sequelae. In this study, the authors looked at survival in patients with single and multiple intracranial metastases who had undergone surgery and adjuvant stereotactic radiosurgery (SRS) to the tumor bed and synchronous lesions. METHODS The authors retrospectively reviewed the records from an 8-year period at a single institution for consecutive patients with brain metastases treated via complete resection of dominant lesions and adjuvant radiosurgery. The cohort was analyzed for time to local progression, synchronous lesion progression, new intracranial lesion development, systemic progression, and overall survival. The Kaplan-Meier method (stratified by age, sex, tumor histology, and number of intracranial lesions prior to surgery) was used to calculate both progression-free and overall survival. A Cox proportional-hazards regression model was also fitted with the number of intracranial lesions as the predictor and survival as the outcome controlling for disease severity, age, sex, and primary histology. RESULTS The median overall follow-up among the 150-person cohort eligible for analysis was 17 months. Patients had an average age of 46.2 years (range 16-82 years), and 62.7% were female. The mean (± standard deviation) number of intracranial lesions per patient was 2.5 ± 2.3. The mean time between surgery and stereotactic radiosurgery (SRS) was 3.2 ± 4.1 weeks. Primary cancers included lung cancer (43.3%), breast cancer (21.3%), melanoma (10.0%), renal cell carcinoma (6.7%), and colon cancer (6.7%). The average number of isocenters per treated lesion was 7.6 ± 6.6, and the average treatment dose was 17.8 ± 2.8 Gy. One-year survival for patients in this cohort was 52%, and the 1-year local control rate was 77%. The median (±standard error) overall survival was 13.2 ± 1.9 months. There was no difference in survival between patients with a single lesion and those with multiple lesions (p = 0.319) after controlling for age, sex, and histology of primary tumor. Patients with primary breast histology had the greatest overall median survival (22.9 ± 6.2 months); patients with colorectal cancer had the shortest overall median survival (5.3 ± 1.8 months). The most common cause of death in this series was systemic progression (79%). CONCLUSIONS These results confirm that 1-year survival for patients with multiple intracranial metastases treated with resection followed by SRS to both the tumor bed and synchronous lesions is similar to established outcomes for patients with a single intracranial metastasis.
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El Gantery MM, Abd El Baky HM, El Hossieny HA, Mahmoud M, Youssef O. Management of brain metastases with stereotactic radiosurgery alone versus whole brain irradiation alone versus both. Radiat Oncol 2014; 9:116. [PMID: 24884624 PMCID: PMC4035803 DOI: 10.1186/1748-717x-9-116] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 05/03/2014] [Indexed: 11/16/2022] Open
Abstract
Introduction This prospective randomized study aimed to evaluate the role of WBRT + SRS compared to SRS alone and to WBRT alone in improvement of overall survival, brain local control and neurologic manifestations. Patients and methods The trial included 60 patients with 1 to 3 brain metastases treated at the Radiotherapy Department, National Cancer Institute. 21 patients received WBRT + SRS, 18 patients received SRS alone and 21 patients received WBRT alone. Results Median local control was significantly better for WBRT + SRS compared to SRS alone & WBRT alone (10 vs 6 vs 5 months, respectively, P = 0.04). There was non significant survival benefit for WBRT + SRS compared to SRS alone & WBRT alone. Survival was significantly better for patients with controlled primary tumor who received WBRT + SRS compared to SRS alone & WBRT alone (median survival was 12 vs 5.5 vs 8 months, respectively. P = 0.027). Regardless of the treatment group, median survival and median local control were highly significantly better for single brain site involvement compared to multiple brain sites involvement (P = 0.003 & P = 0.001, respectively), and median brain local control was significantly better for single lesion compared to multiple lesions (P = 0.05). Conclusions WBRT + SRS is an effective, safe tool in treatment of patients with 1 to 3 brain metastses improving the brain local control, but further studies with larger number of patients is recommended.
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Affiliation(s)
| | - Hoda M Abd El Baky
- The Department of Radiation Oncology, National Cancer Institute, Cairo University, Cairo, Egypt.
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Rationale for the use of upfront whole brain irradiation in patients with brain metastases from breast cancer. Int J Mol Sci 2014; 15:8138-52. [PMID: 24815073 PMCID: PMC4057724 DOI: 10.3390/ijms15058138] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 04/22/2014] [Accepted: 04/25/2014] [Indexed: 01/28/2023] Open
Abstract
Breast cancer is the second most common cause of brain metastases and deserves particular attention in relation to current prolonged survival of patients with metastatic disease. Advances in both systemic therapies and brain local treatments (surgery and stereotactic radiosurgery) have led to a reappraisal of brain metastases management. With respect to this, the literature review presented here was conducted in an attempt to collect medical evidence-based data on the use of whole-brain radiotherapy for the treatment of brain metastases from breast cancer. In addition, this study discusses here the potential differences in outcomes between patients with brain metastases from breast cancer and those with brain metastases from other primary malignancies and the potential implications within a treatment strategy.
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182
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Komaki RU, Ghia AJ. Brain Metastasis from Lung Cancer. Lung Cancer 2014. [DOI: 10.1002/9781118468791.ch38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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183
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Prognostic Factors for stereotactic radiosurgery-treated patients with cerebral metastasis: Implications on randomised control trial design and inter-institutional collaboration. Eur J Cancer 2014; 50:1148-58. [DOI: 10.1016/j.ejca.2014.01.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 12/05/2013] [Accepted: 01/01/2014] [Indexed: 01/08/2023]
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184
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Owonikoko TK, Arbiser J, Zelnak A, Shu HKG, Shim H, Robin AM, Kalkanis SN, Whitsett TG, Salhia B, Tran NL, Ryken T, Moore MK, Egan KM, Olson JJ. Current approaches to the treatment of metastatic brain tumours. Nat Rev Clin Oncol 2014; 11:203-22. [PMID: 24569448 DOI: 10.1038/nrclinonc.2014.25] [Citation(s) in RCA: 192] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Metastatic tumours involving the brain overshadow primary brain neoplasms in frequency and are an important complication in the overall management of many cancers. Importantly, advances are being made in understanding the molecular biology underlying the initial development and eventual proliferation of brain metastases. Surgery and radiation remain the cornerstones of the therapy for symptomatic lesions; however, image-based guidance is improving surgical technique to maximize the preservation of normal tissue, while more sophisticated approaches to radiation therapy are being used to minimize the long-standing concerns over the toxicity of whole-brain radiation protocols used in the past. Furthermore, the burgeoning knowledge of tumour biology has facilitated the entry of systemically administered therapies into the clinic. Responses to these targeted interventions have ranged from substantial toxicity with no control of disease to periods of useful tumour control with no decrement in performance status of the treated individual. This experience enables recognition of the limits of targeted therapy, but has also informed methods to optimize this approach. This Review focuses on the clinically relevant molecular biology of brain metastases, and summarizes the current applications of these data to imaging, surgery, radiation therapy, cytotoxic chemotherapy and targeted therapy.
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Affiliation(s)
- Taofeek K Owonikoko
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA 30322, USA
| | - Jack Arbiser
- Department of Dermatology, Atlanta Veterans Administration Medical Center, Emory University, Atlanta, GA 30322, USA
| | - Amelia Zelnak
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA 30322, USA
| | - Hui-Kuo G Shu
- Department of Radiation Oncology, Emory University, Atlanta, GA 30322, USA
| | - Hyunsuk Shim
- Department of Radiation Oncology, Emory University, Atlanta, GA 30322, USA
| | - Adam M Robin
- Department of Neurosurgery, Henry Ford Health System, 2799 West Grand Boulevard, K-11, Detroit, MI 48202, USA
| | - Steven N Kalkanis
- Department of Neurosurgery, Henry Ford Health System, 2799 West Grand Boulevard, K-11, Detroit, MI 48202, USA
| | - Timothy G Whitsett
- Division of Cancer and Cell Biology, Translational Genomics Research Institute, 445 North 5th Street, Phoenix, AZ 85004, USA
| | - Bodour Salhia
- Division of Integrated Cancer Genomics, Translational Genomics Research Institute, 445 North 5th Street, Phoenix, AZ 85004, USA
| | - Nhan L Tran
- Division of Cancer and Cell Biology, Translational Genomics Research Institute, 445 North 5th Street, Phoenix, AZ 85004, USA
| | - Timothy Ryken
- Iowa Spine and Brain Institute, 2710 St Francis Drive, Suite 110, Waterloo, IA 50702, USA
| | - Michael K Moore
- Department of Neurosurgery, Emory University, Atlanta, GA 30322, USA
| | - Kathleen M Egan
- H. Lee Moffitt Cancer Center & Research Institute, University of South Florida, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University, Atlanta, GA 30322, USA
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Scharp M, Hauswald H, Bischof M, Debus J, Combs SE. Re-irradiation in the treatment of patients with cerebral metastases of solid tumors: retrospective analysis. Radiat Oncol 2014; 9:4. [PMID: 24387239 PMCID: PMC3904456 DOI: 10.1186/1748-717x-9-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Accepted: 12/26/2013] [Indexed: 12/05/2022] Open
Abstract
Background Goal of this retrospective analysis was to evaluate the role of repeat whole brain radiotherapy in the palliative care of patients with brain metastases due to solid tumors. Methods Data regarding demographic data, primary tumor, metastasis, radiotherapy and symptoms were compiled on 134 patients with cerebral metastases that received repeat whole brain radiotherapy (WBRT) in our clinic between 2002 and 2011. Results The analyzed group consisted of 63 (47%) women and 71 (53%) men with a median age of 57 at the start of re-irradiation. Most frequent primary site was the lung (87%). Sixty patients with lung cancer received the first WBRT prophylactically. At the time of re-WBRT 81% of all patients suffered from additional extracerebral metastases. Time between first and second WBRT was a median of 13.4 months. Full dose for the first WBRT was 30 Gy in 2.0 Gy single dose, for the second 20 Gy in 2.0 Gy single dose. At the start of the Re-WBRT 81 patients (60.4%) had mild, 32 (23.9%) severe neurological symptoms, 21 patients (15.7%) were asymptomatic. The median Karnofsky performance status was 70%. Overall, re-WBRT was tolerated satisfactorily. Main side effects were fatigue, erythema and focal alopecia, 10% of patients discontinued treatment before reaching the planned dose. Median survival was 2.8 months since the end of the re-WBRT with good performance status at the start of the re-irradiation being a key indicator for longer survival. Fifty-two patients (39%) showed a clinical improvement of neurological symptoms after the therapy, 59 patients (44%) remained stable, 23 patients (17%) showed worse symptoms. Conclusions From this large patient collective we were able to show that re-WBRT can be an important therapeutic option with low rate of acute side effects for patients in adequate general condition.
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Affiliation(s)
| | - Henrik Hauswald
- Department of Radiation Oncology, University of Heidelberg, Im Neuenheimer Feld 400, Heidelberg, Germany.
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187
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Witek M, Vahknenko Y, Siglin J, Harrison A, Xiao Y, Lui H, Andrews D, Shi W. Dose Reduction to the Scalp with Hippocampal Sparing Is Achievable with Intensity Modulated Radiotherapy. ACTA ACUST UNITED AC 2014; 3:176-182. [PMID: 29963335 PMCID: PMC6020831 DOI: 10.4236/ijmpcero.2014.33023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
We evaluated the feasibility of combined hippocampal- and scalp-sparing intensity-modulated radiotherapy (IMRT) plans. This study included 7 patients who received conventional palliative whole brain radiation treatment (WBRT) for brain metastasis. The brain, hippocampus, and scalp were contoured and replanned with intensity modulated radiation therapy. The prescription dose was 30 Gray (Gy) in 10 fractions with hippocampus and normal structure constraints per the Radiation Therapy Oncology Group (RTOG) 0933 protocol. Further planning was done to minimize the scalp dose while maintaining the dose constraints for the hippocampus. Dose volume histograms were obtained from conventional opposed lateral fields, IMRT and compared. Planning target volume (PTV) coverage for all plans fell within the RTOG 0933 critical structure acceptable variation category. When compared to traditional opposed lateral fields, the IMRT plan with combined hippocampal- and scalp-sparing constraints was able to significantly reduce the max and mean scalp dose as well as the percentage of scalp receiving 10 and 20 Gy by 46% and 35%, respectively, while maintaining acceptable RTOG 0933 hippocampal dose variations. We conclude that acceptable PTV coverage and sparing of the scalp and hippocampus can be accomplished using a 9-field non-coplanar IMRT plan. Prospective study is warranted to understand the impact on radiation induced alopecia.
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Affiliation(s)
- Matthew Witek
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Yelena Vahknenko
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Joshua Siglin
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Amy Harrison
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Ying Xiao
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Haison Lui
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - David Andrews
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, USA
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188
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Abstract
OPINION STATEMENT Brain metastases are a major clinical problem in patients with advanced breast cancer, lung cancer, melanoma, and renal cell carcinoma. Initial treatment for patients with brain metastases typically includes radiotherapy, either whole brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), or both. Surgical resection is generally reserved for good prognosis patients with limited/controlled extracranial metastases and a single brain lesion. Once patients progress through upfront treatment, the treatment approach is quite variable and there is no clearly defined standard-of-care. Over the past decade, the role of systemic therapies and in particular, targeted therapies has been increasingly explored in patients with brain metastases from solid tumors. For example, lapatinib has been studied as monotherapy, and in combination with capecitabine, in patients with HER2-positive breast cancer, and activity has been observed in both the upfront and refractory settings. In patients with nonsmall cell lung cancer (NSCLC), central nervous system (CNS) activity has been reported with gefinitib and erlotinib. Finally, in melanoma, the B-raf inhibitors vemurafenib and dabrafenib, and the immunomodulator, ipilumimab, have reported CNS activity. Moving forward, the challenge will be to understand how to optimize the activity of targeted agents in the CNS and how to best incorporate them into the current treatment paradigms in order to improve outcomes for this patient population.
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Affiliation(s)
- Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA,
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189
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Lukas RV, Lesniak MS, Salgia R. Brain metastases in non-small-cell lung cancer: better outcomes through current therapies and utilization of molecularly targeted approaches. CNS Oncol 2014; 3:61-75. [PMID: 25054901 PMCID: PMC6128200 DOI: 10.2217/cns.13.66] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Non-small-cell lung cancer (NSCLC) patients experience a high incidence of brain metastases, de novo and recurrent. We review the mechanisms of brain metastases and promising NSCLC molecular markers to delineate potential future therapeutic targets. Discussed are the current and previously utilized roles of surgery, radiation (both therapeutic and prophylactic), and systemic therapies in the treatment of NSCLC brain metastases. Future directions for treatment of NSCLC brain metastases will conclude our review.
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Affiliation(s)
- Rimas V Lukas
- Department of Neurology, University of Chicago, Chicago, IL, USA.
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190
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Abstract
Brain metastases are the most frequent neurological complication of cancer and the most common brain tumour type. Lung and breast cancers, and melanoma are responsible for up to three-quarters of metastatic brain lesions. Most patients exhibit either headache, seizures, focal deficits, cognitive or gait disorders, which severely impair the quality of life. Brain metastases are best demonstrated by MRI, which is sensitive but non-specific. The main differential diagnosis includes primary tumours, abscesses, vascular and inflammatory lesions. Overall prognosis is poor and depends on age, extent and activity of the systemic disease, number of brain metastases and performance status. In about half of the patients, especially those with widespread and uncontrolled systemic malignancy, death is heavily related to extra-neural lesions, and treatment of cerebral disease doesn't significantly improve survival. In such patients the aim is to improve or stabilize the neurological deficit and maintain quality of life. Corticosteroids and whole-brain radiotherapy usually fulfill this purpose. By contrast, patients with limited number of brain metastases, good performance status and controlled or limited systemic disease, may benefit from aggressive treatment as both quality of life and survival are primarily related to treatment of brain lesions. Several efficacious therapeutic options including surgery, radiotherapy and chemotherapy are available for these patients.
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Affiliation(s)
- Jaime Gállego Pérez-Larraya
- Department of Neurology and Neurosurgery, Clinic of the University of Navarra, University of Navarra, Pamplona, Spain; Fédération de Neurologie Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
| | - Jerzy Hildebrand
- Fédération de Neurologie Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
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191
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Tallet A. [Brain metastases from breast cancer]. Cancer Radiother 2013; 17:708-14. [PMID: 24210659 DOI: 10.1016/j.canrad.2013.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 09/19/2013] [Accepted: 09/24/2013] [Indexed: 11/29/2022]
Abstract
Breast cancer is the second leading cause of brain metastases and account for 15 % of metastatic breast cancer patients. Several patient- and tumor-related characteristics have been identified as risk factors for developing brain metastases. Treatment is based on local and/or systemic therapies, tailored to breast cancer brain metastases-specific prognostic factors. This article is an update on the current knowledge of the incidence, prognosis and prognostic factors, treatment and perspectives in brain metastases from breast cancer.
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Affiliation(s)
- A Tallet
- Département d'oncologie radiothérapie, institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13009 Marseille cedex 09, France.
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192
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Antoni D, Noël G. [Radiotherapy of brain metastases according to the GPA score (Graded Prognostic Assessment)]. Cancer Radiother 2013; 17:424-7. [PMID: 23973456 DOI: 10.1016/j.canrad.2013.06.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 05/28/2013] [Accepted: 06/10/2013] [Indexed: 11/25/2022]
Abstract
The management of patients with brain metastases remains a difficult and controversial subject. For years, the standard treatment has been whole-brain radiation therapy alone, but its validity is now under question because of improvements in surgery and the development of radiosurgery or novel targeted therapies and also because whole-brain radiation therapy is responsible for long term neurocognitive toxicity. Therefore it is important to assess diagnosis-specific prognostic factors and indexes when scheduling treatments. The GPA score (Graded Prognostic Assessment), established for various histologic tumor types, includes five prognostic factors: age, Karnofsky Performance Status, presence of extracranial metastases, number of brain metastases and also genetic subtype for breast cancer. We propose an adaptation of the management of brain metastases according to the GPA score.
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Affiliation(s)
- D Antoni
- Département universitaire de radiothérapie, centre de lutte contre le cancer Paul-Strauss, 3, rue de la Porte-de-l'Hôpital, BP 42, 67065 Strasbourg cedex, France.
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193
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Renfrow JJ, Lesser GJ. Molecular Subtyping of Brain Metastases and Implications for Therapy. Curr Treat Options Oncol 2013; 14:514-27. [DOI: 10.1007/s11864-013-0248-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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194
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Sperduto PW. In reply to Robins et al. Int J Radiat Oncol Biol Phys 2013; 86:810. [PMID: 23845833 DOI: 10.1016/j.ijrobp.2013.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 04/02/2013] [Indexed: 11/29/2022]
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195
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Sabsevitz DS, Bovi JA, Leo PD, Laviolette PS, Rand SD, Mueller WM, Schultz CJ. The role of pre-treatment white matter abnormalities in developing white matter changes following whole brain radiation: a volumetric study. J Neurooncol 2013; 114:291-7. [PMID: 23813291 DOI: 10.1007/s11060-013-1181-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 06/19/2013] [Indexed: 11/25/2022]
Abstract
White matter injury is a known complication of whole brain radiation (WBRT). Little is known about the factors that predispose a patient to such injury. The current study used MR volumetrics to examine risk factors, in particular the influence of pre-treatment white matter health, in developing white matter change (WMC) following WBRT. Thirty-four patients with unilateral metastatic disease underwent FLAIR MRI pre-treatment and at several time points following treatment. The volume of abnormal FLAIR signal in the white matter was measured in the hemisphere contralateral to the diseased hemisphere at each time point. Analyses were restricted to the uninvolved hemisphere to allow for the measurement of WBRT effects without the potential confounding effects of the disease on imaging findings. The relationship between select pre-treatment clinical variables and the degree of WMC following treatment was examined using correlational and regression based analyses. Age when treated and volume of abnormal FLAIR prior to treatment were significantly associated with WMC following WBRT; however, pre-treatment FLAIR volume was the strongest predictor of post-treatment WMCs. Age did not add any predictive value once white matter status was considered. No significant relationships were found between biological equivalent dose and select cerebrovascular risk factors (total glucose, blood pressure, BMI) and development of WMCs. The findings from this study identify pre-treatment white matter health as an important risk factor in developing WMC following WBRT. This information can be used to make more informed decisions and counsel patients on their risk for treatment effects.
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Affiliation(s)
- David S Sabsevitz
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI 53226-3596, USA.
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196
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Barani IJ, Larson DA, Berger MS. Future directions in treatment of brain metastases. Surg Neurol Int 2013; 4:S220-30. [PMID: 23717793 PMCID: PMC3656563 DOI: 10.4103/2152-7806.111299] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 02/11/2013] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Brain metastases affect up to 30% of patients with cancer. Management of brain metastases continues to evolve with ever increasing focus on cognitive preservation and quality of life. This manuscript reviews current state of brain metastases management and discusses various treatment controversies with focus on future clinical trials. Stereotactic radiosurgery (SRS) and whole-brain radiotherapy (WBRT) are discussed in context of multiple (4+ brain metastases) as well as new approaches combining radiation and targeted agents. A brief discussion of modified WBRT approaches, including hippocampal-avoidance WBRT (HA-WBRT) is included as well as a section on recently presented results of Radiation Therapy Oncology Group (RTOG) 0614, a randomized, double-blind, placebo-controlled trial of menantine for prevention of neurocognitive injury after WBRT. METHODS A search of selected studies relevant to management of brain metastases was performed in PubMed as well as in various published meeting abstracts. This data was collated and analyzed in context of contemporary management and future clinical trial plans. This data is presented in tabular form and discussed extensively in the text. RESULTS The published data demonstrate continued evolution of clinical trials and management strategies designed to minimize and/or prevent cognitive decline following radiation therapy management of brain metastases. Hippocampal avoidance whole-brain radiation therapy (HA-WBRT) and radiosurgery treatments for multiple brain metastases are discussed along with preliminary results of RTOG 0614, a trial of memantine therapy to prevent cognitive decline following WBRT. Trial results appear to support the use of memantine for prevention of cognitive decline. CONCLUSIONS Different management strategies for multiple brain metastases (>4 brain metastases) are currently being evaluated in prospective clinical trials to minimize the likelihood of cognitive decline following WBRT.
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Affiliation(s)
- Igor J. Barani
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - David A. Larson
- Department of Radiation Oncology and Neurological Surgery, University of California, San Francisco, CA, USA
| | - Mitchel S. Berger
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
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197
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McTyre E, Scott J, Chinnaiyan P. Whole brain radiotherapy for brain metastasis. Surg Neurol Int 2013; 4:S236-44. [PMID: 23717795 PMCID: PMC3656558 DOI: 10.4103/2152-7806.111301] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 03/08/2013] [Indexed: 12/25/2022] Open
Abstract
Whole brain radiotherapy (WBRT) is a mainstay of treatment in patients with both identifiable brain metastases and prophylaxis for microscopic disease. The use of WBRT has decreased somewhat in recent years due to both advances in radiation technology, allowing for a more localized delivery of radiation, and growing concerns regarding the late toxicity profile associated with WBRT. This has prompted the development of several recent and ongoing prospective studies designed to provide Level I evidence to guide optimal treatment approaches for patients with intracranial metastases. In addition to defining the role of WBRT in patients with brain metastases, identifying methods to improve WBRT is an active area of investigation, and can be classified into two general categories: Those designed to decrease the morbidity of WBRT, primarily by reducing late toxicity, and those designed to improve the efficacy of WBRT. Both of these areas of research show diversity and promise, and it seems feasible that in the near future, the efficacy/toxicity ratio may be improved, allowing for a more diverse clinical application of WBRT.
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Affiliation(s)
- Emory McTyre
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jacob Scott
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Prakash Chinnaiyan
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Experimental Therapeutics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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198
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Simoff MJ, Lally B, Slade MG, Goldberg WG, Lee P, Michaud GC, Wahidi MM, Chawla M. Symptom Management in Patients With Lung Cancer. Chest 2013; 143:e455S-e497S. [DOI: 10.1378/chest.12-2366] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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199
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Murphy JD, Nelson LM, Chang DT, Mell LK, Le QT. Patterns of care in palliative radiotherapy: a population-based study. J Oncol Pract 2013; 9:e220-7. [PMID: 23943892 DOI: 10.1200/jop.2012.000835] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Approximately one half of the radiotherapy (RT) prescribed in the United States is delivered with palliative intent. The purpose of this study was to investigate the patterns of delivery of palliative RT across the United States. METHODS Using the Surveillance, Epidemiology, and End Results-Medicare linked database, 51,610 patients were identified with incident stage IV breast, prostate, lung, or colorectal cancer diagnosed between 2000 and 2007 and observed through 2009. Multivariate logistic regression determined predictors of palliative RT. RESULTS Forty-one percent of the study population received palliative RT, including 53% of patients with lung cancer, followed by those with breast (42%), prostate (40%), and colorectal cancers (12%). Multivariate analysis revealed that older patients (P<.001) and those with higher Charlson comorbidity scores (P<.001) were less likely to receive palliative RT. Black patients with prostate cancer were 20% less likely (P<.001), and black patients with colorectal cancer were 28% less likely (P<.001), than white patients to receive palliative RT. Among those treated with RT, 23% of patients with lung cancer died within 2 weeks of completing treatment, followed by those with colorectal (12%), breast (11%), and prostate cancers (8%). In addition to tumor site, significant predictors (P<.05) of death within 2 weeks of receiving RT included increased age, increased comorbidity, and male sex. CONCLUSION Inequality in the receipt of palliative RT exists among the elderly and patients with comorbid conditions and varies with race. In addition, a significant number of patients die shortly after receiving RT. Understanding these patterns of care, along with further research into the underlying causes, will improve access and quality of palliative RT.
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Affiliation(s)
- James D Murphy
- Stanford University School of Medicine, Stanford; and University of California, San Diego, La Jolla, CA
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200
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Abstract
Brain metastases are the leading cause of intracranial malignancy and a major cause of mortality and morbidity. From 20 to 40% of cancer patients develop brain metastases. The irradiation of the whole brain remains the most commonly undertaken treatment, but should be discussed in relation to other therapeutic alternatives such as stereotactic radiotherapy or the use of new chemotherapy drugs. Its use according to pathology should be discussed. It can lead to a long-term neurocognitive toxicity that should be evaluated more precisely. This literature review aims to highlight the role of whole-brain radiotherapy used alone or in combination with other treatments.
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