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Ocaña-Tienda B, Pérez-Beteta J, Ortiz de Mendivil A, Asenjo B, Albillo D, Pérez-Romasanta LA, LLorente M, Carballo N, Arana E, Pérez-García VM. Morphological MRI features as prognostic indicators in brain metastases. Cancer Imaging 2024; 24:111. [PMID: 39164779 PMCID: PMC11334491 DOI: 10.1186/s40644-024-00753-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 08/07/2024] [Indexed: 08/22/2024] Open
Abstract
BACKGROUND Stereotactic radiotherapy is the preferred treatment for managing patients with fewer than five brain metastases (BMs). However, some lesions recur after irradiation. The purpose of this study was to identify patients who are at a higher risk of failure, which can help in adjusting treatments and preventing recurrence. METHODS In this retrospective multicenter study, we analyzed the predictive significance of a set of interpretable morphological features derived from contrast-enhanced (CE) T1-weighted MR images as imaging biomarkers using Kaplan-Meier analysis. The feature sets studied included the total and necrotic volumes, the surface regularity and the CE rim width. Additionally, we evaluated other nonmorphological variables and performed multivariate Cox analysis. RESULTS A total of 183 lesions in 128 patients were included (median age 61 [31-95], 64 men and 64 women) treated with stereotactic radiotherapy (57% single fraction, 43% fractionated radiotherapy). None of the studied variables measured at diagnosis were found to have prognostic value. However, the total and necrotic volumes and the CE rim width measured at the first follow-up after treatment and the change in volume due to irradiation can be used as imaging biomarkers for recurrence. The optimal classification was achieved by combining the changes in tumor volume before and after treatment with the presence or absence of necrosis (p < < 0.001). CONCLUSION This study demonstrated the prognostic significance of interpretable morphological features extracted from routine clinical MR images following irradiation in brain metastases, offering valuable insights for personalized treatment strategies.
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Affiliation(s)
- Beatriz Ocaña-Tienda
- Mathematical Oncology Laboratory (MOLAB), University of Castilla-La Mancha, Ciudad Real, Spain.
| | - Julián Pérez-Beteta
- Mathematical Oncology Laboratory (MOLAB), University of Castilla-La Mancha, Ciudad Real, Spain
| | | | - Beatriz Asenjo
- Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | | | | | | | | | - Víctor M Pérez-García
- Mathematical Oncology Laboratory (MOLAB), University of Castilla-La Mancha, Ciudad Real, Spain
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Nåhls NS, Anttonen A, Löyttyniemi E, Jekunen A, Akrén O, Saarto T. End-of-Life Care and Use of Hospital Resources in Radiotherapy-Treated Cancer Patients with Brain Metastases: A Single-Institution Retrospective Study. Palliat Med Rep 2024; 5:316-323. [PMID: 39144132 PMCID: PMC11319853 DOI: 10.1089/pmr.2024.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 08/16/2024] Open
Abstract
Purpose The aim of this single-institution retrospective study of patients treated with radiotherapy for brain metastases (BM) was to evaluate the timing of the palliative care (PC) decision, the use of health care services, i.e., emergency department (ED) visits and hospitalizations, and the implementation of radiotherapy at the end of life (EOL). Methods Data on all cancer patients with BM treated in Finland at the Vaasa Central Hospital Radiotherapy Department between March 2011 and November 2020 were retrospectively reviewed. The follow-up period lasted until November 2021. Altogether, 91 patients (54 men, mean age 67 years [range 23-91 years]) were analyzed. Data on timing of PC decision, visits to the PC outpatient unit, and ED and hospitalization periods were collected retrospectively from patients' records. Results The median overall survival from diagnosis of BM was 3.7 months (range 1-62 months) and, after radiotherapy, 2 months (0-61 months). Thirty-two percent of the patients received radiotherapy in the last month of life. During the last 30 days of life, 44 patients (48%) visited the ED and 38 (42%) were hospitalized. Patients with an early PC decision (>30 days before death) had fewer hospitalizations (22% vs. 53%; p = 0.005) and died less often during the hospitalization period (9% vs. 27%; p = 0.047) at EOL. No significant difference was found in ED visits (41% vs. 53%; p = 0.28). Conclusion For a large proportion of patients with BM, the prognosis is very poor. It is important to identify these patients and abstain from radiotherapy at EOL to reducing inappropriate health care utilization.
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Affiliation(s)
- Nelli-Sofia Nåhls
- Department of Oncology, Vaasa Central Hospital, The Wellbeing Services County of Ostrobothnia, Vaasa, Finland
- Department of Oncology, Comprehensive Cancer Centre, University of Helsinki, Helsinki, Finland
| | - Anu Anttonen
- Department of Radiotherapy, Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland
| | - Eliisa Löyttyniemi
- Department of Biostatistics, University of Turku and Turku University Hospital Turku, Turku Finland
| | - Antti Jekunen
- Department of Oncology, Vaasa Central Hospital, The Wellbeing Services County of Ostrobothnia, Vaasa, Finland
- Department of Oncology, Turku University, Vaasa, Finland
| | - Outi Akrén
- Palliative Center, Tyks Hospital Services, Turku University Hospital, Turku, Finland
- Department of General Medicine, University of Turku, Turku, Finland
| | - Tiina Saarto
- Department of Palliative Care, Comprehensive Cancer Center, Helsinki University Hospital, and Faculty of Medicine, Helsinki University, Helsinki, Finland
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3
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Pellerino A, Davidson TM, Bellur SS, Ahluwalia MS, Tawbi H, Rudà R, Soffietti R. Prevention of Brain Metastases: A New Frontier. Cancers (Basel) 2024; 16:2134. [PMID: 38893253 PMCID: PMC11171378 DOI: 10.3390/cancers16112134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/29/2024] [Accepted: 06/01/2024] [Indexed: 06/21/2024] Open
Abstract
This review discusses the topic of prevention of brain metastases from the most frequent solid tumor types, i.e., lung cancer, breast cancer and melanoma. Within each tumor type, the risk of brain metastasis is related to disease status and molecular subtype (i.e., EGFR-mutant non-small cell lung cancer, HER2-positive and triple-negative breast cancer, BRAF and NRAF-mutant melanoma). Prophylactic cranial irradiation is the standard of care in patients in small cell lung cancer responsive to chemotherapy but at the price of late neurocognitive decline. More recently, several molecular agents with the capability to target molecular alterations driving tumor growth have proven as effective in the prevention of secondary relapse into the brain in clinical trials. This is the case for EGFR-mutant or ALK-rearranged non-small cell lung cancer inhibitors, tucatinib and trastuzumab-deruxtecan for HER2-positive breast cancer and BRAF inhibitors for melanoma. The need for screening with an MRI in asymptomatic patients at risk of brain metastases is emphasized.
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Affiliation(s)
- Alessia Pellerino
- Division of Neuro-Oncology, Department of Neuroscience ‘Rita Levi Montalcini’, University and City of Health and Science Hospital, 10126 Turin, Italy;
| | - Tara Marie Davidson
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (T.M.D.); (H.T.)
| | - Shreyas S. Bellur
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL 33176, USA; (S.S.B.); (M.S.A.)
| | - Manmeet S. Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL 33176, USA; (S.S.B.); (M.S.A.)
| | - Hussein Tawbi
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (T.M.D.); (H.T.)
| | - Roberta Rudà
- Division of Neuro-Oncology, Department of Neuroscience ‘Rita Levi Montalcini’, University and City of Health and Science Hospital, 10126 Turin, Italy;
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Wasilewski D, Onken J, Höricke P, Bukatz J, Murad S, Früh A, Shaked Z, Misch M, Kühl A, Klein O, Ehret F, Kaul D, Radbruch H, Capper D, Vajkoczy P, Horst D, Frost N, Bischoff P. Predictive role of intracranial PD-L1 expression in a real-world cohort of NSCLC patients treated with immune checkpoint inhibition following brain metastasis resection. J Neurooncol 2024; 167:155-167. [PMID: 38358406 PMCID: PMC10978684 DOI: 10.1007/s11060-024-04590-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 01/27/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND Emerging evidence suggests that treatment of NSCLC brain metastases with immune checkpoint inhibitors (ICIs) is associated with response rates similar to those of extracranial disease. Programmed death-ligand 1 (PD-L1) tumor proportion score (TPS) serves as a predictive biomarker for ICI response. However, the predictive value of brain metastasis-specific (intracranial) PD-L1 TPS is not established. We investigated the role of intra- and extracranial PD-L1 TPS in NSCLC patients treated with ICI following brain metastasis resection. METHODS Clinical data from NSCLC patients treated with ICI following brain metastasis resection (n = 64) were analyzed. PD-L1 TPS of brain metastases (n = 64) and available matched extracranial tumor tissue (n = 44) were assessed via immunohistochemistry. Statistical analyses included cut point estimation via maximally selected rank statistics, Kaplan-Meier estimates, and multivariable Cox regression analysis for intracranial progression-free survival (icPFS), extracranial progression-free survival (ecPFS), and overall survival (OS). RESULTS PD-L1 expression was found in 54.7% of brain metastases and 68.2% of extracranial tumor tissues, with a median intra- and extracranial PD-L1 TPS of 7.5% (0 - 50%, IQR) and 15.0% (0 - 80%, IQR), respectively. In matched tissue samples, extracranial PD-L1 TPS was significantly higher than intracranial PD-L1 TPS (p = 0.013). Optimal cut points for intracranial and extracranial PD-L1 TPS varied according to outcome parameter assessed. Notably, patients with a high intracranial PD-L1 TPS (> 40%) exhibited significantly longer icPFS as compared to patients with a low intracranial PD-L1 TPS (≤ 40%). The cut point of 40% for intracranial PD-L1 TPS was independently associated with OS, icPFS and ecPFS in multivariable analyses. CONCLUSION Our study highlights the potential role of intracranial PD-L1 TPS in NSCLC, which could be used to predict ICI response in cases where extracranial tissue is not available for PD-L1 assessment as well as to specifically predict intracranial response.
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Affiliation(s)
- David Wasilewski
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany.
- Charité Comprehensive Cancer Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany.
- German Cancer Consortium (DKTK), Partner Site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Julia Onken
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- Charité Comprehensive Cancer Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- German Cancer Consortium (DKTK), Partner Site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Berlin Institute of Health (BIH) Charité, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Paul Höricke
- Institute of Pathology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Jan Bukatz
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Selin Murad
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Anton Früh
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) Charité, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Zoe Shaked
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Martin Misch
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- Charité Comprehensive Cancer Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Anja Kühl
- Berlin Institute of Health (BIH) Charité, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Oliver Klein
- Berlin Institute of Health (BIH) Charité, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Felix Ehret
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - David Kaul
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Helena Radbruch
- Institute of Neuropathology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - David Capper
- German Cancer Consortium (DKTK), Partner Site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Berlin Institute of Health (BIH) Charité, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Institute of Neuropathology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- Charité Comprehensive Cancer Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - David Horst
- Charité Comprehensive Cancer Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- German Cancer Consortium (DKTK), Partner Site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Institute of Pathology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Nikolaj Frost
- Charité Comprehensive Cancer Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- Department of Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Philip Bischoff
- German Cancer Consortium (DKTK), Partner Site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Berlin Institute of Health (BIH) Charité, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Institute of Pathology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
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Kojundzic I, Chehade R, Gonzalez CAC, Fritz J, Moravan V, Sahgal A, Warner E, Das S, Jerzak KJ. Brain Metastases in the Setting of Stable Versus Progressing Extracranial Disease Among Patients With Metastatic Breast Cancer. Clin Breast Cancer 2024; 24:156-161. [PMID: 38135543 DOI: 10.1016/j.clbc.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 10/18/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023]
Abstract
INTRODUCTION Women with metastatic breast cancer (BC) are at risk of developing brain metastases (BrM), which may result in significant morbidity and mortality. Given the emergence of systemic therapies with activity in the brain, more breast oncology clinical trials include patients with BrM, but most require extracranial disease progression for trial participation. METHODS We evaluated the proportion of patients with BC BrM who have intracranial disease progression in the setting of stable extracranial disease in a retrospective cohort study of 751 patients treated between 2008 and 2018 at the Sunnybrook Odette Cancer. Extracranial disease progression was defined as any progression outside of the brain within 4 weeks of a patient's local/regional treatment. Clinical/pathologic characteristics and outcomes were also abstracted from patients' medical records. RESULTS Of 752 patients in the cohort, 691 were included in our study. Sixty-one patients were excluded due to the presence of a second primary tumor or uncertain tissue origin of the BrM. BC subtype based on the primary tumor was known for 592 (85.6%) patients; 33.1% (n = 196) had HER2+ disease, 40% (n = 237) had HR+/HER2- disease, and 26.9% (n = 159) had triple negative BC. Extracranial disease status was available for 677 patients (98%); 41.1% (n = 284/691) had stable extracranial disease and 56.8% (n = 393/691) had extracranial disease progression within 4 weeks of treatment for BrM. DISCUSSION A high proportion of patients with BC BrM (41.1%) would be excluded from clinical trials due to stable extracranial disease. Efforts should be made to design trials for this patient population.
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Affiliation(s)
- Isabella Kojundzic
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Rania Chehade
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Carlos A Carmona Gonzalez
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jamie Fritz
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | | | - Arjun Sahgal
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ellen Warner
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sunit Das
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Katarzyna J Jerzak
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
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Gaebe K, Erickson AW, Li AY, Youssef AN, Sharma B, Chan KK, Lok BH, Das S. Re-examining prophylactic cranial irradiation in small cell lung cancer: a systematic review and meta-analysis. EClinicalMedicine 2024; 67:102396. [PMID: 38261885 PMCID: PMC10796984 DOI: 10.1016/j.eclinm.2023.102396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 01/25/2024] Open
Abstract
Background Patients with small cell lung cancer (SCLC) are at high risk for brain metastases. Prophylactic cranial irradiation (PCI) is recommended in this population to reduce the incidence of brain metastases and prolong survival. We aimed to assesses the efficacy of PCI in this population in the era of routine brain imaging. To our knowledge, this is the first systematic review and meta-analysis to examine the use among patients who were radiographically confirmed not to have brain metastases after completion of first-line therapy. Methods In this systematic review and meta-analysis, cohort studies and controlled trials reporting on the use of PCI for patients SCLC were identified in EMBASE, MEDLINE, CENTRAL, and grey literature sources. The literature search was conducted on November 12, 2023. Summary data were extracted. Random-effects meta-analyses pooled hazard ratios (HR) for the primary outcome of overall survival between PCI and no intervention groups. This study is registered with the Open Science Framework, DOI:10.17605/OSF.IO/BC359, and PROSPERO, CRD42021249466. Findings Of 4318 identified records, 223 were eligible for inclusion. 109 reported on overall survival in formats amenable to meta-analysis; PCI was associated with longer survival in all patients with SCLC (HR 0.59; 95% CI, 0.55-0.63; p < 0.001; n = 56,770 patients), patients with limited stage disease (HR 0.60; 95% CI, 0.55-0.65; p < 0.001; n = 78 studies; n = 27,137 patients), and patients with extensive stage disease (HR 0.59; 95% CI, 0.51-0.70; p < 0.001; n = 28 studies; n = 26,467 patients). Between-study heterogeneity was significant when pooled amongst all studies (I2 = 73.6%; 95% CI 68.4%-77.9%). Subgroup analysis did not reveal sources of heterogeneity. In a subgroup analysis on studies that used magnetic resonance imaging to exclude presence of brain metastases at restaging among all patients, overall survival did not differ significantly between patients who did or did not receive PCI (HR 0.74; 95% CI, 0.52-1.05; p = 0.08; n = 9 studies; n = 1384 patients). Interpretation Our findings suggested that administration of PCI is associated with a survival benefit, but not when considering studies that radiographically confirmed absence of brain metastases, suggesting that the survival benefit conferred by PCI might be therapeutic rather than prophylactic. Funding No funding.
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Affiliation(s)
- Karolina Gaebe
- Institute of Medical Science, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada
| | - Anders W. Erickson
- Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada
| | - Alyssa Y. Li
- Institute of Medical Science, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada
| | - Andrew N. Youssef
- Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada
| | - Bhagyashree Sharma
- Institute of Medical Science, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada
| | - Kelvin K.W. Chan
- Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Benjamin H. Lok
- Institute of Medical Science, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Sunit Das
- Institute of Medical Science, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, Canada
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7
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Jablonska PA, Muniz T, Ribeiro M, Liu ZA, Ye XY, Devaraja K, Laperriere N, Millar BA, Conrad T, Kongkham P, Butler M, Shultz DB. Toxicity and outcomes of melanoma brain metastases treated with stereotactic radiosurgery: the risk of subsequent symptomatic intralesional hemorrhage exceeds that of radiation necrosis. J Neurooncol 2023; 164:199-209. [PMID: 37552363 DOI: 10.1007/s11060-023-04404-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 07/19/2023] [Indexed: 08/09/2023]
Abstract
PURPOSE We aimed to assess the outcomes and patterns of toxicity in patients with melanoma brain metastases (MBM) treated with stereotactic radiosurgery (SRS) with or without immunotherapy (IO). METHODS From a prospective registry, we reviewed MBM patients treated with single fraction Gamma Knife SRS between 2008 and 2021 at our center. We recorded all systemic therapies (chemotherapy, targeted therapy, or immunotherapy) administered before, during, or after SRS. Patients with prior brain surgery were excluded. We captured adverse events following SRS, including intralesional hemorrhage (IH), radiation necrosis (RN) and local failure (LF), as well as extracranial disease status. Distant brain failure (DBF), extracranial progression-free survival (PFS) and overall survival (OS) were determined using a cumulative Incidence function and the Kaplan-Meier method. RESULTS Our analysis included 165 patients with 570 SRS-treated MBM. Median OS for patients who received IO was 1.41 years versus 0.79 years in patients who did not (p = 0.04). Ipilimumab monotherapy was the most frequent IO regimen (30%). In the absence of IO, the cumulative incidence of symptomatic (grade 2 +) RN was 3% at 24 months and remained unchanged with respect to the type or timing of IO. The incidence of post-SRS g2 + IH in patients who did not receive systemic therapy was 19% at 1- and 2 years compared to 7% at 1- and 2 years among patients who did (HR: 0.33, 95% CI 0.11-0.98; p = 0.046). Overall, neither timing nor type of IO correlated to rates of DBF, OS, or LF. Among patients treated with IO, the median time to extracranial PFS was 5.4 months (95% IC 3.2 - 9.1). CONCLUSION The risk of g2 + IH exceeds that of g2 + RN in MBM patients undergoing SRS, with or without IO. IH should be considered a critical adverse event following MBM treatments.
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Affiliation(s)
- Paola A Jablonska
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Thiago Muniz
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Mauricio Ribeiro
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Zhihui Amy Liu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Xiang Y Ye
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Kaviya Devaraja
- Department of Medical Science, University of Toronto Institute and Princess Margaret Cancer Research Tower, Toronto, Canada
| | - Normand Laperriere
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Barbara-Ann Millar
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Tatiana Conrad
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Paul Kongkham
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Canada
| | - Marcus Butler
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - David B Shultz
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.
- , 700 University Avenue, 7Th Floor (Room 7-401), Toronto, ON, M5G 1Z5, Canada.
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