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Sankey EW, Tsvankin V, Grabowski MM, Nayar G, Batich KA, Risman A, Champion CD, Salama AKS, Goodwin CR, Fecci PE. Operative and peri-operative considerations in the management of brain metastasis. Cancer Med 2019; 8:6809-6831. [PMID: 31568689 PMCID: PMC6853809 DOI: 10.1002/cam4.2577] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 09/07/2019] [Accepted: 09/09/2019] [Indexed: 12/24/2022] Open
Abstract
The number of patients who develop metastatic brain lesions is increasing as the diagnosis and treatment of systemic cancers continues to improve, resulting in longer patient survival. The role of surgery in the management of brain metastasis (BM), particularly multiple and recurrent metastases, remains controversial and continues to evolve. However, with appropriate patient selection, outcomes after surgery are typically favorable. In addition, surgery is the only means to obtain a tissue diagnosis and is the only effective treatment modality to quickly relieve neurological complications or life‐threatening symptoms related to significant mass effect, CSF obstruction, and peritumoral edema. As such, a thorough understanding of the role of surgery in patients with metastatic brain lesions, as well as the factors associated with surgical outcomes, is essential for the effective management of this unique and growing patient population.
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Affiliation(s)
- Eric W Sankey
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Vadim Tsvankin
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | | | - Gautam Nayar
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kristen A Batich
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Aida Risman
- School of Medicine, Medical College of Georgia, Augusta, GA, USA
| | - Cosette D Champion
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - April K S Salama
- Division of Medical Oncology, Duke University Medical Center, Durham, NC, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
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2
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Fecci PE, Champion CD, Hoj J, McKernan CM, Goodwin CR, Kirkpatrick JP, Anders CK, Pendergast AM, Sampson JH. The Evolving Modern Management of Brain Metastasis. Clin Cancer Res 2019; 25:6570-6580. [PMID: 31213459 DOI: 10.1158/1078-0432.ccr-18-1624] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/23/2019] [Accepted: 06/13/2019] [Indexed: 12/11/2022]
Abstract
The incidence of brain metastases is increasing as cancer therapies improve and patients live longer, providing new challenges to the multidisciplinary teams that care for these patients. Brain metastatic cancer cells possess unique characteristics that allow them to penetrate the blood-brain barrier, colonize the brain parenchyma, and persist in the intracranial environment. In addition, brain metastases subvert the innate and adaptive immune system, permitting evasion of the antitumor immune response. Better understanding of the above mechanisms will allow for development and delivery of more effective therapies for brain metastases. In this review, we outline the molecular mechanisms underlying development, survival, and immunosuppression of brain metastases. We also discuss current and emerging treatment strategies, including surgery, radiation, disease-specific and mutation-targeted systemic therapy, and immunotherapy.
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Affiliation(s)
- Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina.,Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
| | - Cosette D Champion
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina.,Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
| | - Jacob Hoj
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
| | - Courtney M McKernan
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina.,Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
| | - John P Kirkpatrick
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina.,Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina.,Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Carey K Anders
- Duke Cancer Institute, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Ann Marie Pendergast
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
| | - John H Sampson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina. .,Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
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She C, Wang R, Lu C, Sun Z, Li P, Yin Q, Liu Q, Wang P, Li W. Prognostic factors and outcome of surgically treated patients with brain metastases of non-small cell lung cancer. Thorac Cancer 2018; 10:137-142. [PMID: 30485664 PMCID: PMC6360214 DOI: 10.1111/1759-7714.12913] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/13/2018] [Accepted: 10/13/2018] [Indexed: 02/06/2023] Open
Abstract
Background Brain metastases (BM) are a common consequence of lung cancer and surgery is effective; however, the factors affecting survival after surgery are unclear. The aim of this study was to identify the outcomes and prognoses of post‐metastasectomy patients with BM from non‐small cell lung cancer (NSCLC) at a single institution over a 15‐year period. Methods NSCLC patients who had undergone BM surgery were retrospectively identified. Survival was analyzed using the Kaplan–Meier curve, and univariate and multivariate factors associated with survival were identified using the Cox proportional hazards model. Results The median overall survival was 9.8 months, 18 (14.8%) patients survived > 24 months, and 6 (4.9%) > 36 months. The one and two‐year survival rates were 41% and 18.6%, respectively. Univariate analysis revealed that recursive partitioning analysis (RPA) classification, Karnofsky Performance Scale (KPS) scores, BM number, extracranial metastasis status, different lesion locations, resection extent, postoperative treatment, and salvage therapy after recurrence significantly influenced patient survival. The different treatment modalities for primary lesions also affected postoperative survival. KPS ≥ 70, RPA class I/II, and postoperative chemotherapy were independent factors that decreased the risk of death from BM. Interestingly, the initial onset of intracranial lesions could increase the risk of death from BM. Conclusion A KPS score ≥ 70, RPA class I/II, and postoperative chemotherapy could benefit post‐metastasectomy patients with BM from NSCLC. Conversely, the initial onset of intracranial lesions is an unfavorable factor that increases the risk of death. These findings support the use of personalized therapy for patients with BM from NSCLC.
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Affiliation(s)
- Chunhua She
- Department of Neurosurgery and Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Ruixia Wang
- Department of Neurology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Changhong Lu
- Ultrasound Department, Binzhou People's Hospital, Binzhou, China
| | - Zengfeng Sun
- Department of Neurosurgery and Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Peng Li
- Department of Neurosurgery and Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Qiang Yin
- Department of Neurosurgery and Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Qun Liu
- Department of Neurosurgery and Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Peng Wang
- Department of Neurosurgery and Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Wenliang Li
- Department of Neurosurgery and Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
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Pojskic M, Bopp MHA, Schymalla M, Nimsky C, Carl B. Retrospective study of 229 surgically treated patients with brain metastases: Prognostic factors, outcome and comparison of recursive partitioning analysis and diagnosis-specific graded prognostic assessment. Surg Neurol Int 2017; 8:259. [PMID: 29184710 PMCID: PMC5680662 DOI: 10.4103/sni.sni_228_17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 08/26/2017] [Indexed: 01/18/2023] Open
Abstract
Background: Metastases are the most frequent tumors in the brain. Most often used scoring systems to predict the outcome are the RPA (Recursive Partitioning Analysis) classification and the DS-GPA (Diagnosis-Specific Graded Prognostic Assessment) score. The goal of our study was to determine prognostic factors which influence outcome in patients who undergo surgery for brain metastases and to compare different outcome scores. Methods: Two hundred and twenty-nine patients who underwent surgery for brain metastases in our institution between January 2005 and December 2014 were included in the study. Patient data were evaluated retrospectively. Results: The mean survival time was 19.2 months (median survival time, MST: 8 months), for patients with a single metastasis (n = 149) 17.6 months (MST: 8 months), and for patients with multiple metastases (n = 80) 17.9 months (MST: 6 months). Significant influence on MST had age <65 years (9 vs. 5 months, P = 0.002), female sex (10 vs. 6 months, P < 0.001), RPA Class I and II (11 vs. 4 months, P < 0.001), Karnofsky score >70% (11 vs. 4 months, P < 0.001), and postoperative radiotherapy (8 vs. 5 months, P < 0.002). To evaluate the diagnostic power of DS-GPA and RPA score in respect of survival, two Cox regressions were modeled, where the RPA classification showed a better predictive power. Conclusion: Favorable factors for prolonged survival were KPS >70%, RPA Class I and II, age <65 years, female sex, a DS-GPA Score of 2.5–3 and 3.5–4, and adjuvant radiotherapy. The RPA Classification was more accurate in predicting the outcome than the DS-GPA score.
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Affiliation(s)
- Mirza Pojskic
- Department of Neurosurgery, Philipps-University Marburg, Baldingerstraβe, Germany
| | - Miriam H A Bopp
- Department of Neurosurgery, Philipps-University Marburg, Baldingerstraβe, Germany
| | - Markus Schymalla
- Department of Radiotherapy and Radiation Oncology, Philipps-University Marburg, Baldingerstraβe, Germany
| | - Christopher Nimsky
- Department of Neurosurgery, Philipps-University Marburg, Baldingerstraβe, Germany
| | - Barbara Carl
- Department of Neurosurgery, Philipps-University Marburg, Baldingerstraβe, Germany
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Zhang Q, Wu YL. Surgery in oligometastatic NSCLC patients in the targeted therapy era. Lung Cancer Manag 2016; 5:141-153. [PMID: 30643558 DOI: 10.2217/lmt-2016-0012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/16/2016] [Indexed: 12/25/2022] Open
Abstract
More than 50% of NSCLC patients present with metastatic disease at first diagnosis, with a median survival of 8-11 months. However, selected patients with oligometastatic disease who receive appropriate local therapy for both the primary lesion and metastases enjoy long-term survival or are even cured. The new (eighth) edition of the tumor, node and metastasis classification of lung cancer suggests that patients with a single metastatic lesion in one distant organ should be placed into a new category, M1b, which will certainly lead to more applications of local therapy in such subpopulations. Moreover, as the applications of targeted therapy increase, surgery will play an evermore critical role in eliminating drug-resistant cancer clones of patients who exhibit mixed responses to tyrosine kinase inhibitors. The lung, brain and adrenal gland are the most common oligometastatic organs, and are reviewed separately.
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Affiliation(s)
- Qi Zhang
- Southern Medical University, Guangzhou, Guangdong 510515, PR China.,Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510515, PR China.,Southern Medical University, Guangzhou, Guangdong 510515, PR China.,Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510515, PR China
| | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510515, PR China.,Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510515, PR China
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Kim YH, Nagai H, Ozasa H, Sakamori Y, Mishima M. Therapeutic strategy for non-small-cell lung cancer patients with brain metastases (Review). Biomed Rep 2013; 1:691-696. [PMID: 24649011 DOI: 10.3892/br.2013.151] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 07/08/2013] [Indexed: 12/25/2022] Open
Abstract
Brain metastases are frequently encountered in patients with non-small-cell lung cancer (NSCLC) and are a significant cause of morbidity and mortality. Chemotherapy has been deemed ineffective under the hypothesis that the blood-brain barrier (BBB) limits the delivery of chemotherapeutic agents to the brain. Thus, radiotherapy and occasionally surgery have been selected for the treatment of brain metastases. However, recent clinical data suggested that chemotherapy may be an effective treatment option for patients with brain metastases, since patients who have developed brain metastases may have an inherently compromised BBB. The prognosis of NSCLC patients with brain metastases is generally poor and more effective treatment is required to improve their prognosis. Bevacizumab (Avastin) is a humanized monoclonal antibody that inhibits tumor angiogenesis by neutralizing the vascular endothelial growth factor. Preclinical data indicated that bevacizumab may be effective in preventing as well as treating preexisting brain metastases. Although safety concerns regarding intracranial hemorrhage have been a barrier for the use of bevacizumab in patients with brain metastases, safety data have gradually been accumulated through recent clinical trials. In this review, we aimed to summarize the currently available treatment options and present a therapeutic strategy for NSCLC patients with brain metastases, with a special emphasis on bevacizumab.
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Affiliation(s)
- Young Hak Kim
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Hiroki Nagai
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Hiroaki Ozasa
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Yuichi Sakamori
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Michiaki Mishima
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
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Stemmler HJ, Heinemann V. Central nervous system metastases in HER-2-overexpressing metastatic breast cancer: a treatment challenge. Oncologist 2008; 13:739-50. [PMID: 18614587 DOI: 10.1634/theoncologist.2008-0052] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
With improvements in diagnostic and therapeutic options and a corresponding improvement in survival, central nervous system (CNS) metastasis is becoming a more frequent diagnosis in breast cancer patients. It can be assumed that up to 30% of metastatic breast cancer (MBC) patients may experience CNS metastasis during the course of their disease. Moreover, it has been reported that patients with human epidermal growth factor receptor (HER)-2-overexpressing MBC are at a higher risk for CNS involvement. Whereas locoregional treatment modalities such as surgery, radiosurgery, and whole-brain radiotherapy still must be considered as the treatment of first choice, the armamentarium of systemic treatment modalities has been expanded by the introduction of small molecules such as the tyrosine kinase inhibitors. Rather than analyzing the risk factors for the development of CNS metastasis and reviewing the standard diagnostic and therapeutic approaches in patients with CNS involvement, this review focuses specifically on systemic treatment modalities in patients suffering from CNS metastasis from HER-2-overexpressing MBC.
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Affiliation(s)
- Hans-Joachim Stemmler
- Department of Haematology and Oncology, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany .
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Lung cancer with synchronous solitary brain metastasis: palliative or radical treatment? Clin Transl Oncol 2004. [DOI: 10.1007/bf02712369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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