1
|
Mannam SS, Bray DP, Nwagwu CD, Zhong J, Shu HK, Eaton B, Sudmeier L, Goyal S, Deibert C, Nduom EK, Olson J, Hoang KB. Examining the Effect of ALK and EGFR Mutations on Survival Outcomes in Surgical Lung Brain Metastasis Patients. Cancers (Basel) 2023; 15:4773. [PMID: 37835467 PMCID: PMC10572022 DOI: 10.3390/cancers15194773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/24/2023] [Accepted: 09/28/2023] [Indexed: 10/15/2023] Open
Abstract
In the context of the post-genomic era, where targeted oncological therapies like monoclonal antibodies (mAbs) and tyrosine-kinase inhibitors (TKIs) are gaining prominence, this study investigates whether these therapies can enhance survival for lung carcinoma patients with specific genetic mutations-EGFR-amplified and ALK-rearranged mutations. Prior to this study, no research series had explored how these mutations influence patient survival in cases of surgical lung brain metastases (BMs). Through a multi-site retrospective analysis, the study examined patients who underwent surgical resection for BM arising from primary lung cancer at Emory University Hospital from January 2012 to May 2022. The mutational statuses were determined from brain tissue biopsies, and survival analyses were conducted. Results from 95 patients (average age: 65.8 ± 10.6) showed that while 6.3% had anaplastic lymphoma kinase (ALK)-rearranged mutations and 20.0% had epidermal growth factor receptor (EGFR)-amplified mutations-with 9.5% receiving second-line therapies-these mutations did not significantly correlate with overall survival. Although the sample size of patients receiving targeted therapies was limited, the study highlighted improved overall survival and progression-free survival rates compared to earlier trials, suggesting advancements in systemic lung metastasis treatment. The study suggests that as more targeted therapies emerge, the prospects for increased overall survival and progression-free survival in lung brain metastasis patients will likely improve.
Collapse
Affiliation(s)
- Sneha Sai Mannam
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - David P. Bray
- Department of Neurosurgery, Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Chibueze D. Nwagwu
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Jim Zhong
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA (H.-K.S.)
| | - Hui-Kuo Shu
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA (H.-K.S.)
| | - Bree Eaton
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA (H.-K.S.)
| | - Lisa Sudmeier
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA (H.-K.S.)
| | - Subir Goyal
- Biostatistics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
| | - Christopher Deibert
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Edjah K. Nduom
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Jeffrey Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Kimberly B. Hoang
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| |
Collapse
|
2
|
Diehl CD, Giordano FA, Grosu AL, Ille S, Kahl KH, Onken J, Rieken S, Sarria GR, Shiban E, Wagner A, Beck J, Brehmer S, Ganslandt O, Hamed M, Meyer B, Münter M, Raabe A, Rohde V, Schaller K, Schilling D, Schneider M, Sperk E, Thomé C, Vajkoczy P, Vatter H, Combs SE. Opportunities and Alternatives of Modern Radiation Oncology and Surgery for the Management of Resectable Brain Metastases. Cancers (Basel) 2023; 15:3670. [PMID: 37509330 PMCID: PMC10377800 DOI: 10.3390/cancers15143670] [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: 04/18/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Postsurgical radiotherapy (RT) has been early proven to prevent local tumor recurrence, initially performed with whole brain RT (WBRT). Subsequent to disadvantageous cognitive sequalae for the patient and the broad distribution of modern linear accelerators, focal irradiation of the tumor has omitted WBRT in most cases. In many studies, the effectiveness of local RT of the resection cavity, either as single-fraction stereotactic radiosurgery (SRS) or hypo-fractionated stereotactic RT (hFSRT), has been demonstrated to be effective and safe. However, whereas prospective high-level incidence is still lacking on which dose and fractionation scheme is the best choice for the patient, further ablative techniques have come into play. Neoadjuvant SRS (N-SRS) prior to resection combines straightforward target delineation with an accelerated post-surgical phase, allowing an earlier start of systemic treatment or rehabilitation as indicated. In addition, low-energy intraoperative RT (IORT) on the surgical bed has been introduced as another alternative to external beam RT, offering sterilization of the cavity surface with steep dose gradients towards the healthy brain. This consensus paper summarizes current local treatment strategies for resectable brain metastases regarding available data and patient-centered decision-making.
Collapse
Affiliation(s)
- Christian D Diehl
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 80336 München, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Anca-L Grosu
- Department of Radiation Oncology, University Medical Center, Medical Faculty, 79106 Freiburg, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Klaus-Henning Kahl
- Department of Radiation Oncology, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Julia Onken
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- Berlin Institute of Health, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- German Cancer Consortium (DKTK), Partner Site Berlin, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, 37075 Göttingen, Germany
- Comprehensive Cancer Center Niedersachsen (CCC-N), 37075 Göttingen, Germany
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Arthur Wagner
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Jürgen Beck
- Department of Neurosurgery, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Stefanie Brehmer
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Marc Münter
- Department of Radiation Oncology, Klinikum Stuttgart Katharinenhospital, 70174 Stuttgart, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Veit Rohde
- Department of Neurosurgery, Universitätsmedizin Göttingen, 37075 Göttingen, Germany
| | - Karl Schaller
- Department of Neurosurgery, University of Geneva Medical Center & Faculty of Medicine, 1211 Geneva, Switzerland
| | - Daniela Schilling
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Elena Sperk
- Mannheim Cancer Center, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 80336 München, Germany
| |
Collapse
|
3
|
Kotecha R, Ahluwalia MS, Siomin V, McDermott MW. Surgery, Stereotactic Radiosurgery, and Systemic Therapy in the Management of Operable Brain Metastasis. Neurol Clin 2022; 40:421-436. [DOI: 10.1016/j.ncl.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
4
|
Mitchell D, Kwon HJ, Kubica PA, Huff WX, O’Regan R, Dey M. Brain metastases: An update on the multi-disciplinary approach of clinical management. Neurochirurgie 2022; 68:69-85. [PMID: 33864773 PMCID: PMC8514593 DOI: 10.1016/j.neuchi.2021.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/16/2021] [Accepted: 04/03/2021] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Brain metastasis (BM) is the most common malignant intracranial neoplasm in adults with over 100,000 new cases annually in the United States and outnumbering primary brain tumors 10:1. OBSERVATIONS The incidence of BM in adult cancer patients ranges from 10-40%, and is increasing with improved surveillance, effective systemic therapy, and an aging population. The overall prognosis of cancer patients is largely dependent on the presence or absence of brain metastasis, and therefore, a timely and accurate diagnosis is crucial for improving long-term outcomes, especially in the current era of significantly improved systemic therapy for many common cancers. BM should be suspected in any cancer patient who develops new neurological deficits or behavioral abnormalities. Gadolinium enhanced MRI is the preferred imaging technique and BM must be distinguished from other pathologies. Large, symptomatic lesion(s) in patients with good functional status are best treated with surgery and stereotactic radiosurgery (SRS). Due to neurocognitive side effects and improved overall survival of cancer patients, whole brain radiotherapy (WBRT) is reserved as salvage therapy for patients with multiple lesions or as palliation. Newer approaches including multi-lesion stereotactic surgery, targeted therapy, and immunotherapy are also being investigated to improve outcomes while preserving quality of life. CONCLUSION With the significant advancements in the systemic treatment for cancer patients, addressing BM effectively is critical for overall survival. In addition to patient's performance status, therapeutic approach should be based on the type of primary tumor and associated molecular profile as well as the size, number, and location of metastatic lesion(s).
Collapse
Affiliation(s)
- D Mitchell
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - HJ Kwon
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - PA Kubica
- Department of Neurosurgery, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA
| | - WX Huff
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - R O’Regan
- Department of Medicine/Hematology Oncology, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA
| | - M Dey
- Department of Neurosurgery, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA,Correspondence Should Be Addressed To: Mahua Dey, MD, University of Wisconsin School of Medicine & Public Health, 600 Highland Ave, Madison, WI 53792; Tel: 317-274-2601;
| |
Collapse
|
5
|
Nieblas-Bedolla E, Zuccato J, Kluger H, Zadeh G, Brastianos PK. Central Nervous System Metastases. Hematol Oncol Clin North Am 2021; 36:161-188. [PMID: 34711458 DOI: 10.1016/j.hoc.2021.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The proportion of patients developing central nervous system (CNS) metastasis is increasing. Most are identified once symptomatic. Surgical resection is indicated for solitary or symptomatic brain metastases, separation surgery for compressive radioresistant spinal metastases, and instrumentation for unstable spinal lesions. Surgical biopsies are performed when histological diagnoses are required. Stereotactic radiosurgery is an option for limited small brain metastases and radioresistant spinal metastases. Whole-brain radiotherapy is reserved for extensive brain metastases and leptomeningeal disease with approaches to reduce cognitive side effects. Radiosensitive and inoperable spinal metastases typically receive external beam radiotherapy. Systemic therapy is increasingly being utilized for CNS metastases.
Collapse
Affiliation(s)
- Edwin Nieblas-Bedolla
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Jeffrey Zuccato
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, 14-701, Toronto Medical Discovery Tower (TMDT), 101 College Street, Toronto, Ontario M5G 1L7, Canada
| | - Harriet Kluger
- Section of Medical Oncology-WWW211, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA
| | - Gelareh Zadeh
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, 14-701, Toronto Medical Discovery Tower (TMDT), 101 College Street, Toronto, Ontario M5G 1L7, Canada.
| | - Priscilla K Brastianos
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
| |
Collapse
|
6
|
Hulsbergen AFC, Abunimer AM, Ida F, Kavouridis VK, Cho LD, Tewarie IA, Mekary RA, Schucht P, Phillips JG, Verhoeff JJC, Broekman MLD, Smith TR. Neurosurgical resection for locally recurrent brain metastasis. Neuro Oncol 2021; 23:2085-2094. [PMID: 34270740 DOI: 10.1093/neuonc/noab173] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In patients with locally recurrent brain metastases (LRBMs), the role of (repeat) craniotomy is controversial. This study aimed to analyze long-term oncological outcomes in this heterogeneous population. METHODS Craniotomies for LRBM were identified from a tertiary neuro-oncological institution. First, we assessed overall survival (OS) and intracranial control (ICC) stratified by molecular profile, prognostic indices, and multimodality treatment. Second, we compared LRBMs to propensity score-matched patients who underwent craniotomy for newly diagnosed brain metastases (NDBM). RESULTS Across 180 patients, median survival after LRBM resection was 13.8 months and varied by molecular profile, with >24 months survival in ALK/EGFR+ lung adenocarcinoma and HER2+ breast cancer. Furthermore, 102 patients (56.7%) experienced intracranial recurrence; median time to recurrence was 5.6 months. Compared to NDBMs (n = 898), LRBM patients were younger, more likely to harbor a targetable mutation and less likely to receive adjuvant radiation (p < 0.05). After 1:3 propensity matching stratified by molecular profile, LRBM patients generally experienced shorter OS (hazard ratio 1.67 and 1.36 for patients with or without a mutation, p < 0.05) but similar ICC (hazard ratio 1.11 in both groups, p > 0.20) compared to NDBM patients with similar baseline. Results across specific molecular subgroups suggested comparable effect directions of varying sizes. CONCLUSIONS In our data, patients with LRBMs undergoing craniotomy comprised a subgroup of brain metastasis patients with relatively favorable clinical characteristics and good survival outcomes. Recurrent status predicted shorter OS but did not impact ICC. Craniotomy could be considered in selected, prognostically favorable patients.
Collapse
Affiliation(s)
- Alexander F C Hulsbergen
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Departments of Neurosurgery, Haaglanden Medical Center and Leiden University Medical Center, Leiden University, The Hague/Leiden, Zuid-Holland, The Netherlands
| | - Abdullah M Abunimer
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Fidelia Ida
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, MCPHS University, Boston, Massachusetts, United States
| | - Vasileios K Kavouridis
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
| | - Logan D Cho
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Icahn School of Medicine at Mount Sinai, New York City, New York, United States
| | - Ishaan A Tewarie
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Departments of Neurosurgery, Haaglanden Medical Center and Leiden University Medical Center, Leiden University, The Hague/Leiden, Zuid-Holland, The Netherlands
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, MCPHS University, Boston, Massachusetts, United States
| | - Philippe Schucht
- Department of Neurosurgery, University Hospital Bern, Kanton Bern, Switzerland
| | - John G Phillips
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Joost J C Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Utrecht, The Netherlands
| | - Marike L D Broekman
- Departments of Neurosurgery, Haaglanden Medical Center and Leiden University Medical Center, Leiden University, The Hague/Leiden, Zuid-Holland, The Netherlands.,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Timothy R Smith
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| |
Collapse
|
7
|
Przybylowski CJ, So V, DeTranaltes K, Walker C, Baranoski JF, Chapple K, Sanai N. Sterile Gelatin Film Reduces Cortical Injury Associated With Brain Tumor Re-Resection. Oper Neurosurg (Hagerstown) 2021; 20:383-388. [PMID: 33373437 PMCID: PMC7955982 DOI: 10.1093/ons/opaa448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 10/23/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Recurrent intracranial tumors frequently require re-resection. Dural adhesions to the cortex increase the morbidity and duration of these revision craniotomies. OBJECTIVE To describe the use of commercially available sterile gelatin film to prevent meningocerebral adhesions and decrease the rate of surgically induced ischemia from revision craniotomy. METHODS This retrospective cohort study examined patients with recurrent glioma, meningioma, and metastasis who underwent re-resection at least 30 d following their initial tumor resection. Cortical surface tissue ischemia after re-resection on diffusion-weighted magnetic resonance imaging was compared for patients with (gelatin film group) and without (nongelatin film group) a history of gelatin film placement at the conclusion of their initial tumor resection. RESULTS A total of 84 patients in the gelatin film group were compared to 86 patients in the nongelatin film group. Patient age, sex, tumor pathology, tumor volume, tumor eloquence, laterality of surgical approach, history of radiotherapy, and time interval between resections did not differ between groups. Radiographic evidence of cortical ischemia following reoperation was less prevalent in the gelatin film group (13.1% vs 32.6%; P < .01). In multivariate logistic regression analysis, no gelatin film (P < .01) and larger tumor size (P = .02) predicted cortical surface ischemia following revision craniotomy. Postoperative complications in the gelatin film and nongelatin film group otherwise did not differ. CONCLUSION Routine placement of commercially available sterile gelatin film on the cortex prior to dural closure is associated with decreased surgically induced tissue ischemia at the time of revision tumor craniotomy.
Collapse
Affiliation(s)
- Colin J Przybylowski
- Ivy Brain Tumor Research Center, Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Veronica So
- College of Medicine, University of Arizona, Phoenix, Arizona
| | | | - Corey Walker
- Ivy Brain Tumor Research Center, Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Jacob F Baranoski
- Ivy Brain Tumor Research Center, Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Kristina Chapple
- Department of Biostatistics, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Nader Sanai
- Ivy Brain Tumor Research Center, Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| |
Collapse
|
8
|
Proescholdt MA, Schödel P, Doenitz C, Pukrop T, Höhne J, Schmidt NO, Schebesch KM. The Management of Brain Metastases-Systematic Review of Neurosurgical Aspects. Cancers (Basel) 2021; 13:1616. [PMID: 33807384 PMCID: PMC8036330 DOI: 10.3390/cancers13071616] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 02/07/2023] Open
Abstract
The multidisciplinary management of patients with brain metastases (BM) consists of surgical resection, different radiation treatment modalities, cytotoxic chemotherapy, and targeted molecular treatment. This review presents the current state of neurosurgical technology applied to achieve maximal resection with minimal morbidity as a treatment paradigm in patients with BM. In addition, we discuss the contribution of neurosurgical resection on functional outcome, advanced systemic treatment strategies, and enhanced understanding of the tumor biology.
Collapse
Affiliation(s)
- Martin A. Proescholdt
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Petra Schödel
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Christian Doenitz
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Tobias Pukrop
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
- Department of Medical Oncology, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Julius Höhne
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Nils Ole Schmidt
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Karl-Michael Schebesch
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| |
Collapse
|
9
|
Shi S, Sandhu N, Jin MC, Wang E, Jaoude JA, Schofield K, Zhang C, Liu E, Gibbs IC, Hancock SL, Chang SD, Li G, Hayden-Gephart M, Adler JR, Soltys SG, Pollom EL. Stereotactic Radiosurgery for Resected Brain Metastases: Single-Institutional Experience of Over 500 Cavities. Int J Radiat Oncol Biol Phys 2020; 106:764-771. [DOI: 10.1016/j.ijrobp.2019.11.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/22/2019] [Accepted: 11/15/2019] [Indexed: 02/05/2023]
|
10
|
Palmer JD, Trifiletti DM, Gondi V, Chan M, Minniti G, Rusthoven CG, Schild SE, Mishra MV, Bovi J, Williams N, Lustberg M, Brown PD, Rao G, Roberge D. Multidisciplinary patient-centered management of brain metastases and future directions. Neurooncol Adv 2020; 2:vdaa034. [PMID: 32793882 PMCID: PMC7415255 DOI: 10.1093/noajnl/vdaa034] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The incidence of brain metastasis is increasing as improvements in systemic therapy lead to increased survival. This provides new and challenging clinical decisions for patients who are trying to balance the risk of recurrence or progression with treatment-related side effects, and it requires appropriate management strategies from multidisciplinary teams. Improvements in prognostic assessment and systemic therapy with increasing activity in the brain allow for individualized care to better guide the use of local therapies and/or systemic therapy. Here, we review the current landscape of brain-directed therapy for the treatment of brain metastasis in the context of recent improved systemic treatment options. We also discuss emerging treatment strategies including targeted therapies for patients with actionable mutations, immunotherapy, modern whole-brain radiation therapy, radiosurgery, surgery, and clinical trials.
Collapse
Affiliation(s)
- Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Neurosurgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M Trifiletti
- Departments of Radiation Oncology and Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Radiation Oncology Consultants LLC, Chicago, Illinois, USA
- Northwestern Medicine Chicago Proton Center Warrenville, Chicago, Illinois, USA
| | - Michael Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Giuseppe Minniti
- Radiation Oncology Unit, UPMC Hillman Cancer Center, San Pietro Hospital FBF, Rome, Italy
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic Scottsdale, Phoenix, Arizona, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joseph Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nicole Williams
- Department of Medical Oncology, The James Cancer Hospital and Solove Research Institute at The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Maryam Lustberg
- Department of Medical Oncology, The James Cancer Hospital and Solove Research Institute at The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ganesh Rao
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Roberge
- Department of Radiation Oncology, Centre Hospitalier de l’ Université de Montreal, Montreal, Quebec, Canada
| |
Collapse
|
11
|
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 PMCID: PMC8258430 DOI: 10.1158/1078-0432.ccr-18-1624] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [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.
Collapse
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
| |
Collapse
|
12
|
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] [MESH Headings] [Grants] [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.
Collapse
Affiliation(s)
- Eric W. Sankey
- Department of NeurosurgeryDuke University Medical CenterDurhamNCUSA
| | - Vadim Tsvankin
- Department of NeurosurgeryDuke University Medical CenterDurhamNCUSA
| | | | - Gautam Nayar
- Department of NeurosurgeryUniversity of Pittsburgh Medical CenterPittsburghPAUSA
| | | | - Aida Risman
- School of MedicineMedical College of GeorgiaAugustaGAUSA
| | | | | | - C. Rory Goodwin
- Department of NeurosurgeryDuke University Medical CenterDurhamNCUSA
| | - Peter E. Fecci
- Department of NeurosurgeryDuke University Medical CenterDurhamNCUSA
| |
Collapse
|
13
|
Guan Y, Wang C, Zhu H, Li J, Xu W, Sun L, Pan L, Dai J, Wang Y, Wang E, Wang X. Hypofractionated Radiosurgery Plus Bevacizumab for Locally Recurrent Brain Metastasis with Previously High-Dose Irradiation. World Neurosurg 2019; 133:e252-e258. [PMID: 31505283 DOI: 10.1016/j.wneu.2019.08.233] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Selection of appropriate treatment for patients with recurrent brain metastasis (BM) remains uncertain. Recent studies have demonstrated a significant response rate and acceptable toxicity using fractionated stereotactic radiosurgery (FSRS) in patients with locally recurrent large BM. The aim of this study was to evaluate efficacy and toxicity of FSRS with bevacizumab as a new salvage treatment for locally recurrent BM with previous high-dose irradiation. METHODS Patients with recurrent BM previously irradiated were enrolled. Salvage FSRS dose was 9.5-29 Gy (2-5 fractions) with 62%-75% isodose line by CyberKnife according to the brain tumor volume, site, and previous dose. Bevacizumab was prescribed for 4 cycles (5 mg/kg, every 3 weeks). The primary objective was to identify the overall survival after salvage treatment. Secondary objectives included clinical response (Karnofsky performance scale), imaging response (magnetic resonance imaging) and treatment-related adverse events. RESULTS From December 2009 to October 2016, 24 patients were enrolled. The 1-year overall survival after salvage stereotactic radiosurgery was 87.5%. Twenty-three (96%) patients had a positive imaging response with a T2 volume reduction range of 6-22 cm3 (median 14 cm3, P = 0.032, paired t test). Significant clinical improvement was achieved (best Karnofsky performance scale score, P < 0.05, paired t test). Grade 1/2 fatigue was observed in 8 (33%) patients. Grade 3 fatigue and headache occurred in 1 patient. CONCLUSIONS FSRS with adjuvant bevacizumab treatment showed favorable clinical and radiologic control as a salvage treatment regimen. The diagnoses of radiation necrosis and local recurrence after salvage FSRS warrant further study.
Collapse
Affiliation(s)
- Yun Guan
- Cyberknife Center, Department of Neurosurgery, Huashan Hospital, and Neurosurgical Institute, Fudan University, Shanghai, China
| | - Chaozhuang Wang
- Cyberknife Center, Department of Neurosurgery, Huashan Hospital, and Neurosurgical Institute, Fudan University, Shanghai, China
| | - Huaguang Zhu
- Cyberknife Center, Department of Neurosurgery, Huashan Hospital, and Neurosurgical Institute, Fudan University, Shanghai, China
| | - Jing Li
- Cyberknife Center, Department of Neurosurgery, Huashan Hospital, and Neurosurgical Institute, Fudan University, Shanghai, China
| | - Wenqian Xu
- Cyberknife Center, Department of Neurosurgery, Huashan Hospital, and Neurosurgical Institute, Fudan University, Shanghai, China
| | - Lei Sun
- Cyberknife Center, Department of Neurosurgery, Huashan Hospital, and Neurosurgical Institute, Fudan University, Shanghai, China
| | - Li Pan
- Cyberknife Center, Department of Neurosurgery, Huashan Hospital, and Neurosurgical Institute, Fudan University, Shanghai, China
| | - Jiazhong Dai
- Cyberknife Center, Department of Neurosurgery, Huashan Hospital, and Neurosurgical Institute, Fudan University, Shanghai, China
| | - Yang Wang
- Cyberknife Center, Department of Neurosurgery, Huashan Hospital, and Neurosurgical Institute, Fudan University, Shanghai, China
| | - Enmin Wang
- Cyberknife Center, Department of Neurosurgery, Huashan Hospital, and Neurosurgical Institute, Fudan University, Shanghai, China
| | - Xin Wang
- Cyberknife Center, Department of Neurosurgery, Huashan Hospital, and Neurosurgical Institute, Fudan University, Shanghai, China.
| |
Collapse
|
14
|
Survival and prognostic factors in surgically treated brain metastases. J Neurooncol 2019; 143:359-367. [DOI: 10.1007/s11060-019-03171-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/09/2019] [Indexed: 12/26/2022]
|
15
|
Liu Q, Tong X, Wang J. Management of brain metastases: history and the present. Chin Neurosurg J 2019; 5:1. [PMID: 32922901 PMCID: PMC7398203 DOI: 10.1186/s41016-018-0149-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/13/2018] [Indexed: 12/28/2022] Open
Abstract
Brain metastases are significant causes of morbidity or mortality for patients with metastatic cancer. With the application of novel systematic therapy and improvement of overall survival, the prevalence of brain metastases is increasing. The paradigm of treatment for brain metastases evolved rapidly during the last 30 years due to the development of technology and emergence of novel therapy. Brain metastases used to be regarded as the terminal stage of cancer and left life expectancy to only 1 month. The application of whole brain radiotherapy for patients with brain metastases increased the life expectancy to 4–6 months in the 1980s. Following studies established surgical resection followed by the application of whole brain radiotherapy the standard treatment for patients with single metastasis and good systematic performance. With the development of stereotactic radiosurgery, stereotactic radiosurgery plus whole brain radiotherapy provides an alternative modality with superior neurocognitive protection at the cost of overall survival. In addition, stereotactic radiosurgery combined with whole brain radiotherapy may offer a promising modality for patients with numerous multiple brain metastases who are not eligible for surgical resection. With the advancing understanding of molecular pathway and biological behavior of oncogenesis and tumor metastasis, novel targeted therapy including tyrosine-kinase inhibitors and immunotherapy are applied to brain metastases. Clinical trials had revealed the efficacy of targeted therapy. Furthermore, the combination of targeted therapy and radiotherapy or chemotherapy is the highlight of current investigation. Advancement in this area may further change the treatment paradigm and offer better modality for patients who are not suitable for surgical resection or radiosurgery.
Collapse
Affiliation(s)
- Qi Liu
- Department of neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Southern 4th Street, No.119, Beijing, 100071 China
| | - Xuezhi Tong
- Department of neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Southern 4th Street, No.119, Beijing, 100071 China
| | - Jiangfei Wang
- Department of neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Southern 4th Street, No.119, Beijing, 100071 China
| |
Collapse
|
16
|
Franchino F, Rudà R, Soffietti R. Mechanisms and Therapy for Cancer Metastasis to the Brain. Front Oncol 2018; 8:161. [PMID: 29881714 PMCID: PMC5976742 DOI: 10.3389/fonc.2018.00161] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/30/2018] [Indexed: 12/12/2022] Open
Abstract
Advances in chemotherapy and targeted therapies have improved survival in cancer patients with an increase of the incidence of newly diagnosed brain metastases (BMs). Intracranial metastases are symptomatic in 60–70% of patients. Magnetic resonance imaging (MRI) with gadolinium is more sensitive than computed tomography and advanced neuroimaging techniques have been increasingly used in the detection, treatment planning, and follow-up of BM. Apart from the morphological analysis, the most effective tool for characterizing BM is immunohistochemistry. Molecular alterations not always reflect those of the primary tumor. More sophisticated methods of tumor analysis detecting circulating biomarkers in fluids (liquid biopsy), including circulating DNA, circulating tumor cells, and extracellular vesicles, containing tumor DNA and macromolecules (microRNA), have shown promise regarding tumor treatment response and progression. The choice of therapeutic approaches is guided by prognostic scores (Recursive Partitioning Analysis and diagnostic-specific Graded Prognostic Assessment-DS-GPA). The survival benefit of surgical resection seems limited to the subgroup of patients with controlled systemic disease and good performance status. Leptomeningeal disease (LMD) can be a complication, especially in posterior fossa metastases undergoing a “piecemeal” resection. Radiosurgery of the resection cavity may offer comparable survival and local control as postoperative whole-brain radiotherapy (WBRT). WBRT alone is now the treatment of choice only for patients with single or multiple BMs not amenable to surgery or radiosurgery, or with poor prognostic factors. To reduce the neurocognitive sequelae of WBRT intensity modulated radiotherapy with hippocampal sparing, and pharmacological approaches (memantine and donepezil) have been investigated. In the last decade, a multitude of molecular abnormalities have been discovered. Approximately 33% of patients with non-small cell lung cancer (NSCLC) tumors and epidermal growth factor receptor mutations develop BMs, which are targetable with different generations of tyrosine kinase inhibitors (TKIs: gefitinib, erlotinib, afatinib, icotinib, and osimertinib). Other “druggable” alterations seen in up to 5% of NSCLC patients are the rearrangements of the “anaplastic lymphoma kinase” gene TKI (crizotinib, ceritinib, alectinib, brigatinib, and lorlatinib). In human epidermal growth factor receptor 2-positive, breast cancer targeted therapies have been widely used (trastuzumab, trastuzumab-emtansine, lapatinib-capecitabine, and neratinib). Novel targeted and immunotherapeutic agents have also revolutionized the systemic management of melanoma (ipilimumab, nivolumab, pembrolizumab, and BRAF inhibitors dabrafenib and vemurafenib).
Collapse
Affiliation(s)
- Federica Franchino
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| |
Collapse
|
17
|
Kamp MA, Fischer I, Dibué-Adjei M, Munoz-Bendix C, Cornelius JF, Steiger HJ, Slotty PJ, Turowski B, Rapp M, Sabel M. Predictors for a further local in-brain progression after re-craniotomy of locally recurrent cerebral metastases. Neurosurg Rev 2017; 41:813-823. [DOI: 10.1007/s10143-017-0931-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 11/01/2017] [Accepted: 11/20/2017] [Indexed: 01/01/2023]
|
18
|
Affiliation(s)
- Oliver Kennion
- School of Medical Education, Newcastle University, Newcastle Upon Tyne, UK
| | - Damian Holliman
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| |
Collapse
|
19
|
Lemjabbar-Alaoui H, Hassan OU, Yang YW, Buchanan P. Lung cancer: Biology and treatment options. BIOCHIMICA ET BIOPHYSICA ACTA 2015; 1856:189-210. [PMID: 26297204 PMCID: PMC4663145 DOI: 10.1016/j.bbcan.2015.08.002] [Citation(s) in RCA: 461] [Impact Index Per Article: 51.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 07/30/2015] [Accepted: 08/16/2015] [Indexed: 12/25/2022]
Abstract
Lung cancer remains the leading cause of cancer mortality in men and women in the U.S. and worldwide. About 90% of lung cancer cases are caused by smoking and the use of tobacco products. However, other factors such as radon gas, asbestos, air pollution exposures, and chronic infections can contribute to lung carcinogenesis. In addition, multiple inherited and acquired mechanisms of susceptibility to lung cancer have been proposed. Lung cancer is divided into two broad histologic classes, which grow and spread differently: small-cell lung carcinomas (SCLCs) and non-small cell lung carcinomas (NSCLCs). Treatment options for lung cancer include surgery, radiation therapy, chemotherapy, and targeted therapy. Therapeutic-modalities recommendations depend on several factors, including the type and stage of cancer. Despite the improvements in diagnosis and therapy made during the past 25 years, the prognosis for patients with lung cancer is still unsatisfactory. The responses to current standard therapies are poor except for the most localized cancers. However, a better understanding of the biology pertinent to these challenging malignancies, might lead to the development of more efficacious and perhaps more specific drugs. The purpose of this review is to summarize the recent developments in lung cancer biology and its therapeutic strategies, and discuss the latest treatment advances including therapies currently under clinical investigation.
Collapse
Affiliation(s)
- Hassan Lemjabbar-Alaoui
- Department of Surgery, Thoracic Oncology Division, University of CA, San Francisco 94143, USA
| | - Omer Ui Hassan
- Department of Surgery, Thoracic Oncology Division, University of CA, San Francisco 94143, USA
| | - Yi-Wei Yang
- Department of Surgery, Thoracic Oncology Division, University of CA, San Francisco 94143, USA
| | - Petra Buchanan
- Department of Surgery, Thoracic Oncology Division, University of CA, San Francisco 94143, USA
| |
Collapse
|
20
|
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.
Collapse
|
21
|
Bae MK, Yu WS, Byun GE, Lee CY, Lee JG, Kim DJ, Chung KY. Prognostic factors for cases with no extracranial metastasis in whom brain metastasis is detected after resection of non-small cell lung cancer. Lung Cancer 2015; 88:195-200. [PMID: 25770646 DOI: 10.1016/j.lungcan.2015.02.013] [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: 10/26/2014] [Revised: 02/12/2015] [Accepted: 02/14/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study aimed to determine prognostic factors associated with postrecurrence survival in cases with postoperative brain metastasis but with no extracranial metastasis in non-small cell lung cancer (NSCLC). MATERIAL AND METHODS Between 1992 and 2012, a total of 2832 patients underwent surgical resection for NSCLC. Among those, 86 patients had postoperative brain metastasis as the initial recurrence. Those patients were retrospectively reviewed. RESULTS The median follow-up time after the initial lung resection was 24.0 months (range, 2.0-126.0 months). The median overall survival after initial lung cancer resection was 25.0 months and the median overall postrecurrence survival was 11 months. An initial lesion of adenocarcinoma (hazard ratio, 0.548; 95% confidence interval, 0.318 to 0.946; p=0.031), non-pneumonectomy, and a disease-free interval longer than 10.0 months (hazard ratio, 0.565; 95% confidence interval, 0.321-0.995; p=0.048) from the initial lung resection to the diagnosis of brain metastasis positively related to a good postrecurrence survival. Solitary brain metastasis and a size of less than 3 cm for the largest brain lesion were also positive factors for postrecurrence survival. Systemic chemotherapy for brain metastasis (hazard ratio, 0.356; 95% confidence interval, 0.189-0.670; p=0.001) and local treatment of surgery and/or stereotactic radiosurgery (SRS) for brain lesions (hazard ratio, 0.321; 95% confidence interval, 0.138-0.747; p=0.008) were positive factors for better postrecurrence survival. CONCLUSION In patients with brain metastasis after resection for NSCLC with no extracranial metastasis, adenocarcinoma histologic type, longer disease-free interval, systemic chemotherapy for brain metastasis and local treatment of surgery and/or SRS for brain metastasis are independent positive prognostic factors for postrecurrence survival.
Collapse
Affiliation(s)
- Mi Kyung Bae
- Department of Thoracic and Cardiovascular Surgery, National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro, Ilsan-donggu, Goyang-si, Gyeonggi-do 410-719, Republic of Korea
| | - Woo Sik Yu
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea
| | - Go Eun Byun
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea
| | - Chang Young Lee
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea
| | - Jin Gu Lee
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea
| | - Dae Joon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea
| | - Kyung Young Chung
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea.
| |
Collapse
|
22
|
Chamberlain MC. Brain metastases: a medical neuro-oncology perspective. Expert Rev Neurother 2014; 10:563-73. [DOI: 10.1586/ern.10.30] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
23
|
Abstract
Neurologic complications of lung cancer are a frequent cause of morbidity and mortality. Tumor metastasis to the brain parenchyma is the single most common neurologic complication of lung cancer, of any histologic subtype. The goal of radiation therapy and in some cases surgical resection for patients with brain metastases is to improve or maintain neurologic function, and to achieve local control of the brain lesion(s). Metastasis of lung cancer to the spinal epidural space requires urgent evaluation and treatment. Early diagnosis and modern surgical and radiotherapy techniques improve neurologic outcome for most patients. Leptomeningeal metastasis is a less common but ominous occurrence in patients with lung cancer. Lung carcinomas can also occasionally metastasize to the brachial plexus, skull base, dura, or pituitary. Paraneoplastic neurologic disorders are uncommon but important complications of lung carcinoma, and are generally the presenting feature of the tumor. Paraneoplastic disorders are believed to be caused by an autoimmune humoral or cellular attack against shared "onconeural" antigens. The most frequent paraneoplastic disorders in patients with lung cancer are Lambert-Eaton myasthenic syndrome, and multifocal paraneoplastic encephalomyelitis, both mainly occurring in association with small-cell lung carcinoma. There is a variety of other paraneoplastic disorders affecting the central and peripheral nervous systems. Some affected patients have a good neurologic outcome, while others are left with severe permanent neurologic disability.
Collapse
Affiliation(s)
- Edward J Dropcho
- Department of Neurology, Indiana University Medical Center, Indianapolis, IN, USA.
| |
Collapse
|
24
|
Gempt J, Gerhardt J, Toth V, Hüttinger S, Ryang YM, Wostrack M, Krieg SM, Meyer B, Förschler A, Ringel F. Postoperative ischemic changes following brain metastasis resection as measured by diffusion-weighted magnetic resonance imaging. J Neurosurg 2013; 119:1395-400. [DOI: 10.3171/2013.9.jns13596] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Brain metastases occur in 10% to 40% of patients harboring cancer. In cases of neurosurgical metastasis resection, all postoperative neurological deterioration should be avoided. Reasons for postoperative deficits can be direct tissue damage due to resection, hemorrhage, venous congestive infarcts, or arterial ischemic events leading to tissue infarction. The aim of this study was to evaluate whether postoperative ischemic infarctions occur in surgery for brain metastasis and to determine their influence on new postoperative neurological deficits.
Methods
Patients who underwent resection of brain metastases and had preoperative and early postoperative (within 48 hours) MRI scans, including diffusion-weighted imaging sequences and apparent diffusion coefficient maps, between January 2009 and May 2012 were included in this study. Clinical and histopathological data (histopathological results, pre- and postoperative neurological status, and previous tumor-specific therapy) were recorded.
Results
One hundred twenty-two patients (56 male, 66 female) who underwent resection of brain metastases were included. The patients' mean age was 60 years (range 21–89 years). The mean time span from initial tumor diagnosis to resection of brain metastasis was 44 months (range 0–338 months). The mean preoperative Karnofsky Performance Status was 80% (exact mean 76% ± 17% [SD]), and the mean postoperative value was 80% (exact mean 78% ± 17%). Twelve (9.8%) of the 122 patients had postoperative permanent worsening of a neurological deficit or a new permanent neurological deficit; 44 (36.1%) of the 122 patients had postoperative ischemic lesions. When comparing patients with and without previous brain irradiation, 53.8% of patients with previous brain irradiation had ischemic lesions on postoperative imaging compared with 31.3% of patients without previous brain irradiation (p = 0.033). There was a significant association between ischemia and postoperative neurological status deterioration (transient or permanent); 13 (29.5%) of 44 patients with ischemic lesions had deterioration of their neurological status compared with 7 (9%) of the 78 patients who did not have ischemic lesions (p = 0.003).
Conclusions
This study demonstrates a high prevalence of vascular incidents in patients undergoing resection for metastatic brain disease. Patients harboring postoperative ischemic lesions detected by MRI have a higher rate of neurological deficits (transient or permanent). Patients who had previous irradiation therapy are at higher risk of developing postoperative ischemic lesions. A large number of postoperative neurological deficits are caused by ischemic incidents.
Collapse
Affiliation(s)
- Jens Gempt
- 1Neurochirurgische Klinik und Poliklinik and
| | | | - Vivien Toth
- 2Abteilung für Neuroradiologie, Klinikum rechts der Isar, Technische Universität München, Germany
| | | | - Yu-Mi Ryang
- 1Neurochirurgische Klinik und Poliklinik and
| | | | | | | | - Annette Förschler
- 2Abteilung für Neuroradiologie, Klinikum rechts der Isar, Technische Universität München, Germany
| | | |
Collapse
|
25
|
Surgery of recurrent brain metastases: retrospective analysis of 67 patients. Acta Neurochir (Wien) 2013; 155:1823-32. [PMID: 23913109 DOI: 10.1007/s00701-013-1821-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 07/03/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Treatment of patients with recurrent brain metastasis is one of the major challenges in neurooncology. Commonly, WBRT was applied after or as the initial treatment. Many patients received radiosurgery or their lesions were operated on. The question arises of what treatment modalities are appropriate and can be offered to the patients. In our retrospective analysis, we evaluated whether re-operation might be a useful measurement for the patients with respect to overall survival and quality of life. METHODS We included 67 patients who were treated between 1993 and 2008 in our department. The median age was 59 years. Metastases of 11 different primaries were diagnosed. The median OST was 7.5 months. RESULTS Statistically significant prognostic factors for OS were single lesions, completeness of resection, and time to recurrence, which was significantly influenced by WBRT after first operation. The one year survival rate correlated with the RPA classification: class I: 53.3 %, class II: 26.9 %, class III: 12.5 %. In 31.3 %, a second recurrence occurred which was treated by repeated surgery. Six patients survived as long-term survivors (25.7-132.2 months). CONCLUSION Surgery of recurrent brain metastasis is an important therapeutic option. A subgroup of patients, defined by prognostic factors, will profit with improvement of symptoms and prolongation of the overall survival time. Even long-term survivors can be expected.
Collapse
|
26
|
Intracerebral metastases of malignant melanoma and their recurrences—A clinical analysis. Clin Neurol Neurosurg 2013; 115:1721-8. [DOI: 10.1016/j.clineuro.2013.03.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 03/12/2013] [Accepted: 03/30/2013] [Indexed: 11/24/2022]
|
27
|
Hatiboglu MA, Wildrick DM, Sawaya R. The role of surgical resection in patients with brain metastases. Ecancermedicalscience 2013; 7:308. [PMID: 23634178 PMCID: PMC3628720 DOI: 10.3332/ecancer.2013.308] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Indexed: 11/09/2022] Open
Abstract
Brain metastasis is a devastating complication of systemic malignancy that affects a considerable number of cancer patients. The appearance of brain metastases is often considered to be a sign of poor prognosis; in patients with brain metastases poor survival time has been reported in the literature. Therefore, treatment of these brain lesions in cancer patients is important for quality of life, providing local tumour control, preventing death from neurological causes, and improving survival, although potentially only in a minority of patients. Surgical resection of brain metastases has been the cornerstone treatment in select patients. Careful patient selection, the use of appropriate surgical techniques, and surgical adjuncts are the major determinants of favourable outcome in patients undergoing resection of brain metastases. In this review, we explain the role of surgical resection in the treatment of patients with brain metastases with consideration of patient selection, surgical techniques and the use of intraoperative adjuncts.
Collapse
Affiliation(s)
- Mustafa Aziz Hatiboglu
- Department of Neurosurgery, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | | | | |
Collapse
|
28
|
Mut M. Surgical treatment of brain metastasis: A review. Clin Neurol Neurosurg 2012; 114:1-8. [PMID: 22047649 DOI: 10.1016/j.clineuro.2011.10.013] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 10/08/2011] [Accepted: 10/10/2011] [Indexed: 11/15/2022]
Affiliation(s)
- Melike Mut
- Hacettepe University, Department of Neurosurgery, Ankara, Turkey.
| |
Collapse
|
29
|
[Brain metastasis from breast cancer: who?, when? and special considerations about the role of technology in neurosurgery]. Bull Cancer 2011; 98:433-44. [PMID: 21540145 DOI: 10.1684/bdc.2011.1337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Questions about both the place and the role of surgery on brain metastasis from breast cancer are arising more and more frequently in practice due to the increase of brain metastasis in patients suffering from a form of cancer recognized as one of the most recurrent cancers in adults but also one of the most sensitive to general treatments of the systemic disease. With improvements in anaesthesia, in surgical instruments, and in global care, neurosurgery has taken advantage of new techniques such as pre- and even per-operative imagery and also neuronavigation. These techniques enable radical and effective surgical intervention with a high level of safety for the patient, making neurosurgery perfectly competitive with other therapeutic modalities, particularly on functional grounds. As for symptomatic treatments or other anti-metastasis treatments, most situations allow a reflection on the global therapeutic strategy which can be adapted to individual cases depending on the patient's general prognosis. In developing this global therapeutic strategy, surgical treatment is still as relevant as ever.
Collapse
|
30
|
Abd-El-Barr MM, Rahman M, Rao G. Investigational therapies for brain metastases. Neurosurg Clin N Am 2010; 22:87-96, vii. [PMID: 21109153 DOI: 10.1016/j.nec.2010.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Contrary to the incidence of primary cancers, the incidence of brain metastasis has been increasing. This increase is likely because of the effects of an aging population, improved neuroimaging surveillance, and better control of systemic cancer, allowing time for brain metastasis to occur. Unlike systemic cancers, for which chemotherapy is the mainstay of treatment, the therapeutic strategies available to treat brain metastasis have traditionally been limited to surgical resection, whole brain radiation therapy, or stereotactic radiosurgery, either individually or in combination. It is important to put the treatment in the context of the prognosis for patients with brain metastases.
Collapse
Affiliation(s)
- Muhammad M Abd-El-Barr
- Department of Neurosurgery, University of Florida, Box 100265, Gainesville, FL 32610, USA
| | | | | |
Collapse
|
31
|
Recurrent brain metastases from lung cancer: the impact of reoperation. Acta Neurochir (Wien) 2010; 152:1887-92. [PMID: 20617447 DOI: 10.1007/s00701-010-0721-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Accepted: 06/14/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The best treatment for solitary brain metastases from lung cancer is surgical resection followed by adjuvant treatment. However, about 50% of these patients develop recurrent brain metastases. There is no established treatment standard for this patient group. We therefore analyzed the survival, neurological function, and overall performance status of patients with recurrent solitary brain metastases from lung cancer after second microsurgical resection. MATERIALS AND METHODS Treatment outcome was analyzed in 25 patients (19 men, 6 women) with a mean age of 55.8 years (range, 38-78 years) who received a resection of recurrent solitary brain metastases. Eighty-four percent of all patients had non-small-cell lung cancer and 16% small cell lung cancer (SCLC). Eighty percent of the lesions were located supratentorially, 20% infratentorially. RESULTS The median overall survival after initial diagnosis was 26.9 months, 13.6 months after the first and 8.3 months after the second brain surgery, respectively. The median Karnofsky index improved significantly from 80 to 100 after the second brain surgery; 66.6% of all patients presenting with neurological impairment improved, and 50% regained normal function. No surgery-related morbidity or mortality was noted. Multivariate analysis indicated that the interval until first brain metastasis and between first and recurrent metastases was significantly predictive of survival. CONCLUSIONS The majority of patients in our study group showed significant functional benefit from surgical resection of recurrent brain metastases. This contributes to a better quality of life in this patient group showing a short overall survival time.
Collapse
|
32
|
Stark AM, Stöhring C, Hedderich J, Held-Feindt J, Mehdorn HM. Surgical treatment for brain metastases: Prognostic factors and survival in 309 patients with regard to patient age. J Clin Neurosci 2010; 18:34-8. [PMID: 20851611 DOI: 10.1016/j.jocn.2010.03.046] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Accepted: 03/23/2010] [Indexed: 10/19/2022]
Abstract
Brain metastases are the most common intracranial tumors. Overall, the only accepted prognostic factors are patient age and performance status. However, several other factors are considered before surgery. We performed a retrospective analysis of 309 patients who underwent surgical resection of newly diagnosed brain metastases between 1994 and 2004. Univariate survival analysis revealed age, performance status, extracranial metastases, complete resection, radiotherapy and re-craniotomy as prognostic indicators. Multivariate analysis determined that patient age, performance status, extracranial metastases, radiotherapy and re-craniotomy are independent factors of prolonged survival. We statistically estimated the age threshold separating patients with favorable outcomes from those with unfavorable prognoses. Using the Kaplan-Meier analysis this threshold can be set at 65 years. Multivariate analysis of patients >65 years revealed the presence of co-morbidities, the number of brain metastases, post-operative performance status and radiotherapy as independent prognostic factors.
Collapse
Affiliation(s)
- A M Stark
- Department of Neurosurgery, Schleswig-Holstein University Medical Center, Campus Kiel, Arnold-Heller-Strasse 3, Haus 41, D-24105 Kiel, Germany.
| | | | | | | | | |
Collapse
|
33
|
Current treatment strategies for brain metastasis and complications from therapeutic techniques: a review of current literature. Am J Clin Oncol 2010; 33:398-407. [PMID: 19675447 DOI: 10.1097/coc.0b013e318194f744] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Each year approximately 170,000 patients are diagnosed with brain metastasis in the United States, making this the most common intracranial tumor in adults. Historically, treatment strategies focused on the use of whole brain radiation therapy (WBRT) for palliation, yielding a median survival time of only 3 to 6 months. The possible effect of WBRT on cognitive function has generated much concern and debate regarding the use of this modality. Thus, the use of WBRT alone, or in conjunction with other treatment modalities should take into account both risks and benefits, to ensure the best patient outcome with regard to disease state and functional status. The advent of technologies permitting local dose-escalation have clearly increased local control rates, and in select patients, even survival, thereby, further intensifying the debate regarding the use of WBRT. Here, we review the use of WBRT, radiosurgery, and resection for the treatment of brain metastases. Further, we will review the use of radiation sensitizers and blood-brain barrier penetrating cytotoxics such as temozolomide. Finally, we will discuss current treatment strategies for possibly maintaining and improving cognitive function for these patients.
Collapse
|
34
|
Ammirati M, Cobbs CS, Linskey ME, Paleologos NA, Ryken TC, Burri SH, Asher AL, Loeffler JS, Robinson PD, Andrews DW, Gaspar LE, Kondziolka D, McDermott M, Mehta MP, Mikkelsen T, Olson JJ, Patchell RA, Kalkanis SN. The role of retreatment in the management of recurrent/progressive brain metastases: a systematic review and evidence-based clinical practice guideline. J Neurooncol 2009; 96:85-96. [PMID: 19957016 PMCID: PMC2808530 DOI: 10.1007/s11060-009-0055-6] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 11/08/2009] [Indexed: 12/19/2022]
Abstract
QUESTION What evidence is available regarding the use of whole brain radiation therapy (WBRT), stereotactic radiosurgery (SRS), surgical resection or chemotherapy for the treatment of recurrent/progressive brain metastases? TARGET POPULATION This recommendation applies to adults with recurrent/progressive brain metastases who have previously been treated with WBRT, surgical resection and/or radiosurgery. Recurrent/progressive brain metastases are defined as metastases that recur/progress anywhere in the brain (original and/or non-original sites) after initial therapy. RECOMMENDATION Level 3 Since there is insufficient evidence to make definitive treatment recommendations in patients with recurrent/progressive brain metastases, treatment should be individualized based on a patient's functional status, extent of disease, volume/number of metastases, recurrence or progression at original versus non-original site, previous treatment and type of primary cancer, and enrollment in clinical trials is encouraged. In this context, the following can be recommended depending on a patient's specific condition: no further treatment (supportive care), re-irradiation (either WBRT and/or SRS), surgical excision or, to a lesser extent, chemotherapy. Question If WBRT is used in the setting of recurrent/progressive brain metastases, what impact does tumor histopathology have on treatment outcomes? No studies were identified that met the eligibility criteria for this question.
Collapse
Affiliation(s)
- Mario Ammirati
- Department of Neurosurgery, Ohio State University Medical Center, Columbus, OH, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Shibamoto Y, Sugie C, Iwata H. Radiotherapy for metastatic brain tumors. Int J Clin Oncol 2009; 14:281-8. [DOI: 10.1007/s10147-009-0915-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Indexed: 12/15/2022]
|
36
|
Management of brain metastases: the indispensable role of surgery. J Neurooncol 2009; 92:275-82. [PMID: 19357955 DOI: 10.1007/s11060-009-9839-y] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Accepted: 02/23/2009] [Indexed: 10/20/2022]
Abstract
Brain metastases are the most common neurological complication of systemic cancer and carry a very poor prognosis. The management of patients with brain metastases has become more important recently because of the increased incidence of these tumors and the prolonged patient survival times that have accompanied increased control of systemic cancer. In this article, we review the current perspectives on surgical treatment of brain metastases in terms of patient selection criteria, intraoperative adjuncts, whole-brain radiation therapy (WBRT) as a postoperative adjuvant, reoperation for tumor recurrence, and resection of multiple and single metastases. Achieving the best outcome in treatment of brain metastasis requires the judicious and complementary use of surgical resection along with modalities such as whole-brain radiation therapy and stereotactic radiosurgery.
Collapse
|
37
|
Franzin A, Vimercati A, Picozzi P, Serra C, Snider S, Gioia L, Ferrari da Passano C, Bolognesi A, Giovanelli M. Stereotactic drainage and Gamma Knife radiosurgery of cystic brain metastasis. J Neurosurg 2008; 109:259-67. [PMID: 18671638 DOI: 10.3171/jns/2008/109/8/0259] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Treatment options for patients with brain metastasis include tumor resection, whole-brain radiation therapy, and radiosurgery. A single treatment is not useful in cases of multiple tumors, of which at least 1 is a cystic tumor. The purpose of this study was to assess the role of stereotactic drainage and Gamma Knife surgery (GKS) in the treatment of cystic brain metastasis. METHODS Between January 2001 and November 2005, 680 consecutive patients with brain metastases underwent GKS at our hospital, 30 of whom were included in this study (18 males and 12 females, mean age 60.6 +/- 11 years, range 38-75 years). Inclusion criteria were: 1) no prior whole-brain radiation therapy or resection procedure; 2) a maximum of 4 lesions on preoperative MR imaging; 3) at least 1 cystic lesion; 4) a Karnofsky Performance Scale score >or= 70; and 5) histological diagnosis of a malignant tumor. RESULTS Non-small cell lung carcinoma was the primary cancer in most patients (19 patients [63.3%]). A single metastasis was present in 13 patients (43.3%). There was a total of 81 tumors, 33 of which were cystic. Ten patients (33.3%) were in recursive partitioning analysis Class I, and 20 (66.6%) were in Class II. Before drainage the mean tumor volume was 21.8 ml (range 3.8-68 ml); before GKS the mean tumor volume was 10.1 ml (range 1.2-32 ml). The mean prescription dose to the tumor margin was 19.5 Gy (range 12-25 Gy). Overall median patient survival was 15 months. The 1- and 2-year survival rates were 54.7% (95% confidence interval 45.3-64.1%) and 34.2% (95% confidence interval 23.1-45.3%). Local tumor control was achieved in 91.3% of the patients. CONCLUSIONS The results of this study support the use of a multiple stereotactic approach in cases of multiple and cystic brain metastasis.
Collapse
Affiliation(s)
- Alberto Franzin
- Gamma Knife Unit, Department of Neurosurgery, IRCCS San Raffaele, University Vita-Salute, Milan, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Aprile G, Zanon E, Tuniz F, Iaiza E, De Pauli F, Pella N, Pizzolitto S, Buffoli A, Piga A, Skrap M, Fasola G. Neurosurgical management and postoperative whole-brain radiotherapy for colorectal cancer patients with symptomatic brain metastases. J Cancer Res Clin Oncol 2008; 135:451-7. [PMID: 18779977 DOI: 10.1007/s00432-008-0468-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2008] [Accepted: 08/19/2008] [Indexed: 12/19/2022]
Abstract
BACKGROUND New systemic treatments for advanced colorectal cancer have conferred a survival advantage, allowing patients to reach a median survival of almost 2 years. Due to this remarkable life extension, the incidence of brain metastases, though still low, is progressively increasing over time. There is little reported data on the optimal strategy to manage brain lesions from colorectal cancer. METHODS To explore the role of an aggressive approach to colorectal cancer brain metastases, we retrospectively collected and analyzed data from 30 patients who underwent neurosurgical resection + whole-brain radiotherapy between March 1998 and December 2006. Univariate (logrank) and multivariate (Cox's model) analyses were used to identify prognostic factors. RESULTS Median age at the time of surgery was 66 years, median ECOG PS was 1, most patients (87%) had concomitant lung and/or liver metastases. Median number of previous chemotherapies was two, with half of the patients being exposed both to oxaliplatin and irinotecan. A median of 27 Gy of radiotherapy were administered to 16 patients after resection. At the time of the analysis, 29 out of 30 patients had died, with a median survival time after brain metastasectomy of 167 days (8-682). Only one patient died within a month from surgery. Median survival was significantly longer in patients who received postsurgical radiotherapy (7.6 vs. 4.7 months, P = 0.014). CONCLUSIONS Neurosurgical management of symptomatic brain metastases from colorectal cancer is feasible, relatively safe, and offers a chance of prolonged survival. Patients who received radiotherapy after resection experienced a better outcome.
Collapse
|
39
|
Guillamo JS, Emery E, Busson A, Lechapt-Zalcman E, Constans JM, Defer GL. [Current management of brain metastases]. Rev Neurol (Paris) 2008; 164:560-8. [PMID: 18565355 DOI: 10.1016/j.neurol.2008.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2007] [Accepted: 03/20/2008] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Cerebral metastases occur in 15 to 20% of cancers and their incidence is increasing. The majority occur at an advanced stage of the disease, but metastasis may be the inaugural sign of cancer. The aim of treatments, which are often palliative, is to preserve the neurological status of the patient with the best quality of life. STATE OF ART Corticosteroids are widely used for symptomatic palliation, requiring close monitoring and regular dose adaptation. Antiepileptic drugs should be given only for patients who have had a seizure. In case of multiple cerebral metastases occurring at an advanced stage of the disease, whole brain radiation is the most effective therapy for rapid symptom control. However, radiotherapy moderately improves overall survival, which often depends on the progression of disseminated systemic disease. On the contrary, surgery is indicated in case of a solitary metastasis, particularly when the patient is young (less than 65 years), with good general status (Karnofsky greater than 70), and when the systemic disease is under control. Radiosurgery offers an attractive alternative for these patients with good prognostic factors and a small number of cerebral metastases (< or = 4). PERSPECTIVES Chemotherapy, considered in the past as not effective, is taking on a more important place in patients with multiple nonthreatening metastases from chemosensitive cancers (breast, testes...). Radiosurgery and whole brain radiotherapy are complementary techniques. Their respective role in the management of multiple metastases (< 4) remains to be further investigated. CONCLUSIONS Therapeutic options are increasingly effective to improve the functional prognosis of patients with cerebral metastases. Ideally, a multidisciplinary assessment offers the best choice of therapeutic modalities.
Collapse
Affiliation(s)
- J-S Guillamo
- Service de neurologie Dejerine, centre hospitalo-universitaire de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France.
| | | | | | | | | | | |
Collapse
|
40
|
Newton HB, Ray-Chaudhury A, Malkin MG. Overview of Pathology and Treatment of Metastatic Brain Tumors. HANDBOOK OF NEURO-ONCOLOGY NEUROIMAGING 2008:20-30. [DOI: 10.1016/b978-012370863-2.50005-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2023]
|
41
|
Surgery for brain metastases. Cancer Treat Res 2007. [PMID: 18078266 DOI: 10.1007/978-0-387-69222-7_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
|
42
|
|
43
|
Abstract
Brain metastases are the most common intracranial tumors in adults and source of the most common neurological complications of systemic cancer. The treatment approach to brain metastases differs essentially from treatment of systemic metastases due to the unique anatomical and physiological characteristics of the brain. Surgery and radiosurgery are important components in the complex treatment of brain metastases and can prolong survival and improve the quality of life (QOL). Aggressive intervention may be indicated for selected patients with well-controlled systemic cancer and good performance status in whom central nervous system (CNS) disease poses the greatest threat to functionality and survival. In this review the respective roles of surgery and radiosurgery, patient selection, general prognostic factors and tailoring of optimal surgical management strategies for cerebral metastases are discussed.
Collapse
Affiliation(s)
- Andrew A Kanner
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.
| | | | | | | |
Collapse
|
44
|
Siker ML, Mehta MP. Advances in the Treatment of Brain Metastases. Lung Cancer 2007. [DOI: 10.3109/9781420020359.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
45
|
Abstract
Metastatic brain tumors continue to increase in incidence as patients with cancer live longer. The options for management continue to evolve as well, with advances in radiation-based treatment, chemotherapy, and surgery. Although metastatic brain tumors are frequently treated without surgical intervention, there continues to be a significant role for surgery in caring for patients with these lesions. Study data have proven that surgery has a positive effect on survival and quality of life in properly selected patients. Those with a suitable age, functional status, systemic disease control, and several metastases may be suitable for surgical treatment. Advances in preoperative imaging and planning as well as intraoperative surgical adjuncts have lowered the morbidity associated with resection. With proper patient selection and operative and postoperative management, resection continues to play a significant and evolving role in the care of patients with metastatic brain tumor.
Collapse
Affiliation(s)
- Moksha G Ranasinghe
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania 17033, USA
| | | |
Collapse
|
46
|
Abstract
Brain metastasis is the most common intracranial malignancy in adults. Improvements in modern imaging techniques are detecting previously occult brain metastases, and more effective therapies are extending the survival of patients with invasive cancer who have historically died from extracranial disease before developing brain metastasis. This combination of factors along with increased life expectancy has led to the increased diagnosis of brain metastases. Conventional treatment has been whole brain radiotherapy, which can improve symptoms, but potentially results in neurocognitive deficits. Several strategies to improve the therapeutic ratio are currently under investigation to either enhance the radiation effect, thereby preventing tumor recurrence or progression as well as reducing collateral treatment-related brain injury. In this review article, we discuss new directions in the management of brain metastases, including the role of chemical modifiers, novel systemic agents, and the management and prevention of neurocognitive deficits.
Collapse
Affiliation(s)
- Rakesh R Patel
- Department of Human Oncology, University of Wisconsin, Madison, WI 53792, USA.
| | | |
Collapse
|
47
|
Affiliation(s)
- Malika L Siker
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
| | | |
Collapse
|
48
|
Stea B, Shaw E, Pintér T, Hackman J, Craig M, May J, Steffen RP, Suh JH. Efaproxiral red blood cell concentration predicts efficacy in patients with brain metastases. Br J Cancer 2006; 94:1777-84. [PMID: 16773073 PMCID: PMC2361352 DOI: 10.1038/sj.bjc.6603169] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Efaproxiral (Efaproxyn™, RSR13), a synthetic allosteric modifier of haemoglobin (Hb), decreases Hb-oxygen (O2) binding affinity and enhances oxygenation of hypoxic tumours during radiation therapy. This analysis evaluated the Phase 3, Radiation Enhancing Allosteric Compound for Hypoxic Brain Metastases; RT-009 (REACH) study efficacy results in relation to efaproxiral exposure (efaproxiral red blood cell concentration (E-RBC) and number of doses). Recursive partitioning analysis Class I or II patients with brain metastases from solid tumours received standard whole-brain radiation therapy (3 Gy/fraction × 10 days), plus supplemental O2 (4 l/min), either with efaproxiral (75 or 100 mg/kg daily) or without (control). Efaproxiral red blood cell concentrations were linearly extrapolated to all efaproxiral doses received. Three patient populations were analysed: (1) all eligible, (2) non-small-cell lung cancer (NSCLC) as primary cancer, and (3) breast cancer primary. Efficacy endpoints were survival and response rate. Brain metastases patients achieving sufficient E-RBC (⩾483 μg/ml) and receiving at least seven of 10 efaproxiral doses were most likely to experience survival and response benefits. Patients with breast cancer primary tumours generally achieved the target efaproxiral exposure and therefore gained greater benefit from efaproxiral treatment than NSCLC patients. This analysis defined the efaproxiral concentration-dependence in survival and response rate improvement, and provided a clearer understanding of efaproxiral dosing requirements.
Collapse
Affiliation(s)
- B Stea
- Department of Radiation Oncology, The University of Arizona Health Sciences Center, Tucson, 85724, USA.
| | | | | | | | | | | | | | | |
Collapse
|
49
|
Saito EY, Viani GA, Ferrigno R, Nakamura RA, Novaes PE, Pellizzon CA, Fogaroli RC, Conte MA, Salvajoli JV. Whole brain radiation therapy in management of brain metastasis: results and prognostic factors. Radiat Oncol 2006; 1:20. [PMID: 16808850 PMCID: PMC1526744 DOI: 10.1186/1748-717x-1-20] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2006] [Accepted: 06/29/2006] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To evaluate the prognostic factors associated with overall survival in patients with brain metastasis treated with whole brain radiotherapy (WBRT) and estimate the potential improvement in survival for patients with brain metastases, stratified by the Radiation Therapy Oncology Group (RTOG) recursive partitioning analysis (RPA) class. PATIENTS AND METHODS From January 1996 to December 2000, 270 medical records of patients with diagnosis of brain metastasis, who received WBRT in the Hospital do Cancer Sao Paulo A.C. Camargo in the period, were analyzed. The surgery followed by WBRT was used in 15% of patients and 85% of others patients were submitted at WBRT alone; in this cohort 134 patients (50%) received the fractionation schedule of 30 Gy in 10 fractions. The most common primary tumor type was breast (33%) followed by lung (29%), and solitary brain metastasis was present in 38.1% of patients. The prognostic factors evaluated for overall survival were: gender, age, Karnofsky Performance Status (KPS), number of lesions, localization of lesions, primary tumor site, surgery, chemotherapy, absence extracranial disease, RPA class and radiation doses and fractionation. RESULTS The OS in 1, 2 and 3 years was 25.1%, 10.4% and 4.3% respectively, and the median survival time was 4.6 months. The median survival time in months according to RPA class after WBRT was: 6.2 class I, 4.2 class II and 3.0 class III (p < 0.0001). In univariate analysis, the significant prognostic factors associated with better survival were: KPS higher than 70 (p < 0.0001), neurosurgery (p < 0.0001) and solitary brain metastasis (p = 0.009). In multivariate analysis, KPS higher than 70 (p < 0.001) and neurosurgery (p = 0.001) maintained positively associated with the survival. CONCLUSION In this series, the patients with higher perform status, RPA class I, and treated with surgery followed by whole brain radiotherapy had better survival. This data suggest that patients with cancer and a single metastasis to the brain may be treated effectively with surgical resection plus radiotherapy. The different radiotherapy doses and fractionation schedules did not altered survival.
Collapse
Affiliation(s)
- Elisa Y Saito
- Department of Radiation Oncology Hospital do Cancer, Sao Paulo, Brazil
| | - Gustavo A Viani
- Department of Radiation Oncology Hospital do Cancer, Sao Paulo, Brazil
| | - Robson Ferrigno
- Department of Radiation Oncology Hospital do Cancer, Sao Paulo, Brazil
| | | | - Paulo E Novaes
- Department of Radiation Oncology Hospital do Cancer, Sao Paulo, Brazil
| | | | | | - Maria A Conte
- Department of Radiation Oncology Hospital do Cancer, Sao Paulo, Brazil
| | - Joao V Salvajoli
- Department of Radiation Oncology Hospital do Cancer, Sao Paulo, Brazil
| |
Collapse
|
50
|
Khuntia D, Brown P, Li J, Mehta MP. Whole-brain radiotherapy in the management of brain metastasis. J Clin Oncol 2006; 24:1295-304. [PMID: 16525185 DOI: 10.1200/jco.2005.04.6185] [Citation(s) in RCA: 327] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Brain metastases are an important cause of morbidity and mortality, afflicting nearly 170,000 Americans annually. The prognosis for these patients is poor, with median survival times measured in months. In this review article, we present the standard treatment approach of whole-brain radiotherapy and discuss new directions, including the role of chemical modifiers and the management and prevention of neurocognitive deficits.
Collapse
|