Chemotherapy for brain metastases from small cell lung cancer

Development and validation of nomograms for predicting survival in small cell lung cancer patients with brain metastases: a SEER population-based analysis

OBJECTIVE

To develop prognostic nomograms for overall survival (OS) and cancer-specific survival (CSS) probabilities in small cell lung cancer (SCLC) patients with brain metastasis (BM).

METHODS

SCLC patients with BM from the Surveillance, Epidemiology, and End Results (SEER) database (2010-2015) were randomly allocated to training (n=1771) and validation (n=757) cohorts. Independent prognostic factors for OS and CSS were determined using univariate and multivariate Cox regression analyses in the training cohort, and prognostic nomograms for OS and CSS were constructed based on these factors. The efficacy of the nomograms was assessed using area under the receiver operating characteristic (ROC) curves (AUCs), calibration curves, decision curve analysis (DCA), net reclassification index (NRI), and integrated discrimination improvement (IDI), with the TNM staging model as a comparator.

RESULTS

Multivariate Cox analysis identified age, sex, race, tumor size, N staging, and presence of liver/bone/lung metastases, chemotherapy, and radiotherapy as independent prognostic factors for both OS and CSS. Prognostic nomograms were developed based on these factors. In both the training and validation cohorts, the AUC values of the nomograms for OS and CSS were significantly above 0.7, surpassing those for TNM staging. Calibration curves demonstrated a high degree of concordance between predicted and actual survival. The constructed nomograms showed superior clinical utility compared to the TNM staging system, as evidenced by NRI, IDI, and DCA.

CONCLUSIONS

This retrospective study successfully developed and validated prognostic nomograms for SCLC patients with BM, providing valuable tools for oncologists to enhance prognosis evaluation and guide clinical decision-making.

Efficacy and mechanism study of cordycepin against brain metastases of small cell lung cancer based on zebrafish

BACKGROUND

Small cell lung cancer (SCLC) is an aggressive tumor with high brain metastasis (BM) potential. There has been no significant progress in the treatment of SCLC for more than 30 years. Cordycepin has shown the therapeutic potential for cancer by modulating multiple cellular signaling pathways. However, the effect and mechanism of cordycepin on anti-SCLC BM remain unknown.

PURPOSE

In this study, we focused on the anti-SCLC BM effect of cordycepin in the zebrafish model and its potential mechanism.

STUDY DESIGN AND METHODS

A SCLC xenograft model based on zebrafish embryos and in vitro cell migration assay were established. Cordycepin was administrated by soaking and microinjection in the zebrafish model. RNA-seq assay was performed to analyze transcriptomes of different groups. Geno Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment were performed to reveal the underlying mechanism. Real-time qPCR was used to verify the effects of cordycepin on the key genes.

RESULTS

Cordycepin showed lower cytotoxicity in vitro compared with cisplatin, anlotinib and etoposide, but showed comparable anti-proliferation and anti-BM effects in zebrafish SCLC xenograft model. Cordycepin showed significant anti-SCLC BM effects when administrated by both soaking and microinjection. RNA-seq demonstrated that cordycepin was involved in vitamin D metabolism, lipid transport, and proteolysis in cellular protein catabolic process pathways in SCLC BM microenvironment in zebrafish, and was involved in regulating the expressions of key genes such as cyp24a1, apoa1a, ctsl. The anti-BM effect of cordycepin in SCLC was mediated by reversing the expression of these genes.

CONCLUSION

Our work is the first to describe the mechanism of cordycepin against SCLC BM from the perspective of regulating the brain microenvironment, providing new evidence for the anti-tumor effect of cordycepin.

Radiotherapy for brain metastases from small-cell lung cancer in distinct clinical indications and scenarios

Management of brain metastases (BM) from small-cell lung cancer (SCLC) is complex and not supported by a strong evidence from prospective clinical trials. Owing to the different clinical and pathological characteristics of SCLC, patients with this histology were not included in the prospective studies on the value of whole-brain radiotherapy (WBRT) and local surgical or ablative radiation treatment like stereotactic radiosurgery (SRS). Chemotherapy also represents a major part of the armamentarium against BM from SCLC due to the well-recognized chemoresponsiveness of this cancer and the frequent presentation of BM with extracranial progression. WBRT in combination with chemotherapy has long been a standard approach in this setting. However, data on the neurocognitive toxicity and the lack of documented impact on overall survival of WBRT in the management of BM from other solid tumors, as well as the increasing availability of the stereotactic radiotherapy technologies, has led to the increasing use of SRS with omission of WBRT also in SCLC. In the current review the use of different modalities of radiotherapy and ways of combining radiotherapy with chemotherapy for BM from SCLC will be presented for distinct clinical situations: presentation of BM synchronous with primary, metachronous presentation of BM—without previous prophylactic cranial irradiation (PCI) vs. after PCI, and asymptomatic BM found at the staging before PCI.

Pioneering Iodine-125-Labeled Nanoscale Covalent Organic Frameworks for Brachytherapy

Brachytherapy has been clinically used for the treatment of malignant solid tumors. However, the classic therapeutic radioactive ¹²⁵I seed must be surgically implanted directly into tumors. To avoid the surgery and prevent irrational radioactive distribution, radioiodine-loaded nanomaterials are ever-developing for brachytherapy. Hence, it is still a notable challenge to obtain an advanced material that simultaneously incorporates features of high radiolabeling rate, short labeling time, good radiolabeling stability, and long tumor retention time. Covalent organic frameworks (COFs), which are crystalline polymers with ordered pores, are widely applied in guest delivery of drugs based on their high porosity and modifiable skeleton. Herein, we developed a functionalized nanoscale PEG-COF-Ag material, which could rapidly capture radioiodine reaching a 94% radiolabeling yield in 30 s. In addition, more than 95% ¹²⁵I was maintained after 24 h in PBS (phosphate-buffered saline) as well as in serum and over 90% for nearly 1 week. PEG-COF-Ag-¹²⁵I (¹²⁵I-COF) demonstrated excellent cancer cell killing performance in vitro, and further experiments in vivo revealed a long tumor retention time and effective tumor treatment during the radiotherapy. The results indicate that radioiodine-labeled PEG-COF-Ag could be potentially applied in brachytherapy with a promising therapeutic effect.

Best Supportive Care Versus Whole-Brain Irradiation, Chemotherapy Alone, or WBRT Plus Chemotherapy in Patients With Brain Metastases From Small-Cell Lung Cancer: A Case-Controlled Analysis

Background

WBRT and systemic chemotherapy are the mainstay treatments for small-cell lung cancer (SCLC) brain metastases (BM). However, current recommendations are mainly based on evidence from retrospective analyses. A recent randomized trial found no benefits from WBRT compared with best supportive care (BSC) in patients with more than three BM from non-small-cell lung cancer (NSCLC). Herein, we aimed to evaluate the roles of WBRT and chemotherapy further in the management of BM from SCLC.

Materials and Methods

There were 698 patients with BM from SCLC included. Of these, 580 received anti cancer treatment (Group 1), including 178 who received WBRT only (Group 1a), 129 who received chemotherapy only (Group 1b), and 273 who received WBRT plus chemotherapy (Group 1c). The other 118 received BSC (Group 2). Propensity score matching (PSM) analysis was used to compare Group 2 with each of the other groups.

Results

After PSM, compared with Group 2 (n = 118), patients in Group 1 (n = 440) had a prolonged overall survival (OS) in both univariate and multivariate tests, with a median survival time of 10 months (95% CI = 9-11) in Group 1 and 3.5 months (95% CI = 2-7) in Group 2 (p < 0.001). In subgroup analyses, patients who received WBRT plus chemotherapy were more likely to benefit from treatment (p < 0.001). Chemotherapy alone or WBRT alone did not show survival benefits.

Conclusion

WBRT plus chemotherapy improved OS in patients with BM from SCLC as compared to BSC. Chemotherapy alone and WBRT alone did not show survival benefits. This retrospective study suggests that SCLC patients with BM who receive WBRT combined with chemotherapy have a better outcome than those receiving BSC alone.

Two case reports of brain metastases in patients with pancreatobiliary neuroendocrine carcinoma

Brain metastases are extremely rare in patients with pancreatobiliary neuroendocrine caricnoma (PB-NEC). In this case report, we report two rare cases of brain metastases in patients with PB-NEC. Each patient was diagnosed with brain metastases five and ten months after the initial diagnosis of PB-NEC. It is noteworthy that the serum tumor marker neuron-specific enolase (NSE) or pro-gastrin-releasing peptide (Pro-GRP) was elevated, although the primary and metastatic lesions other than in the brain were under control with systemic chemotherapy. Moreover, the patients complained of no neurological symptoms until they were diagnosed with brain metastases. Although the incidence of brain metastases of PB-NEC is exceedingly low, it is important to keep in mind the possibility of brain metastases during the course of treatment for PB-NEC. In addition, we discuss a strategy of treatment and screening for brain metastases of PB-NEC in this case report.

Combinatorial Effect of Cold Atmosphere Plasma (CAP) and the Anticancer Drug Cisplatin on Oral Squamous Cell Cancer Therapy

Cold atmospheric plasma (CAP) has been extensively investigated in the local treatment of cancer due to its potential of reactive oxygen species (ROS) generation in biological systems. In this study, we examined the synergistic effect of combination of CAP and cisplatin-mediated chemotherapy of oral squamous cell carcinoma (OSCC) in vitro. SCC-15 OSCC cells and human gingival fibroblasts (HGF-1) cells were treated with cisplatin, and then, the cells were irradiated with CAP. Following this, viability and apoptosis behavior of the cells were investigated. The viability of SCC-15 cells was inhibited by cisplatin with a dose-dependent manner and CAP treatment time. HGF-1 cells also showed decreased viability by treatment with cisplatin and CAP. Combination of 1 μM cisplatin plus 3 min of CAP treatment or 3 μM cisplatin plus 1 min of CAP treatment showed a synergistic anticancer effect with appropriate cytotoxicity against normal cells. ROS generation and dead cell staining were also increased by the increase in CAP treatment time. Furthermore, tumor-suppressor proteins and apoptosis-related enzymes also increased according to the treatment time of CAP. We showed the synergistic effect of cisplatin and CAP treatment against SCC-15 cells with low cytotoxicity against normal cells.

Copper Complexes as Anticancer Agents Targeting Topoisomerases I and II

Organometallics, such as copper compounds, are cancer chemotherapeutics used alone or in combination with other drugs. One small group of copper complexes exerts an effective inhibitory action on topoisomerases, which participate in the regulation of DNA topology. Copper complexes inhibitors of topoisomerases 1 and 2 work by different molecular mechanisms, analyzed herein. They allow genesis of DNA breaks after the formation of a ternary complex, or act in a catalytic mode, often display DNA intercalative properties and ROS production, and sometimes display dual effects. These amplified actions have repercussions on the cell cycle checkpoints and death effectors. Copper complexes of topoisomerase inhibitors are analyzed in a broader synthetic view and in the context of cancer cell mutations. Finally, new emerging treatment aspects are depicted to encourage the expansion of this family of highly active anticancer drugs and to expend their use in clinical trials and future cancer therapy.

Systemic therapy for brain metastases

Metastases from cells outside of the central nervous system are the most common cancer found in the brain and are commonly associated with poor prognosis. Although cancer treatment is improving overall, central nervous system metastases are becoming more prevalent and require finesse to properly treat. Physicians must consider the biology of the primary tumor and the complex neurological environment that the metastasis resides in. This can be further complicated by the fact that the practice of cancer management is constantly evolving and therapy that works outside of the blood-brain barrier may not be effective inside of it. Therefore, this review seeks to update the reader on recent advancements made on the three most common sources of brain metastases: lung cancer, breast cancer, and melanoma. Each of these malignancies has been the subject of intriguing and novel avenues of therapy which are reviewed here.

Survival outcomes after whole brain radiotherapy for brain metastases in older adults with newly diagnosed metastatic small cell carcinoma: A national cancer database (NCDB) analysis

BACKGROUND

Small cell lung cancer (SCLC) is an aggressive malignancy with a tendency to affect older adults and also metastasize to the brain. Older adults tolerate whole brain radiotherapy (WBRT) poorly with marginal survival benefit. We utilized the national cancer database (NCDB) to evaluate the survival outcomes following WBRT in older adults with SCLC and brain metastases.

METHODS

We identified 1615 patients ≥75 years old diagnosed with SCLC and brain metastases. Patients were categorized by type of therapy: chemotherapy + WBRT (n = 576), chemotherapy alone (n = 238), WBRT alone (n = 360) and no chemotherapy or WBRT (n = 441). Clinical and demographic characteristics were reported for each treatment cohort with a subsequent multivariable regression analysis for survival.

RESULTS

Median patient age was 79 years. WBRT median dose was 30 Gy. At time of analysis, 1530 of the cohort had died, yielding a median OS of 2.9 months and 6 month survival of 31% for patients that received chemotherapy. For patients treated without chemotherapy, median OS with WBRT was 1.9 months compared to 1.2 months without (p < .0001). For patients receiving chemotherapy with, and without WBRT, median OS was 5.6 months and 6.4 months, respectively (p = .43). Multivariable cox regression revealed age > 80, extracranial disease, male sex, and rural location as predictors of increased risk of death.

CONCLUSION

In older adult patients with SCLC brain metastasis, WBRT was associated with a modest increase in survival in patients not fit for chemotherapy, and there was no association with increased survival over chemotherapy alone.

State-of-the-art considerations in small cell lung cancer brain metastases

BACKGROUND

Small cell lung cancer (SCLC) frequently leads to development of brain metastases. These unfortunately continue to be associated with short survival. Substantial advances have been made in our understanding of the underlying biology of disease. This understanding on the background of previously evaluated and currently utilized therapeutic treatments can help guide the next steps in investigations into this disease with the potential to influence future treatments.

DESIGN

A comprehensive review of the literature covering epidemiology, pathophysiology, imaging characteristics, prognosis, and therapeutic management of SCLC brain metastases was performed.

RESULTS

SCLC brain metastases continue to have a poor prognosis. Both unique aspects of SCLC brain metastases as well as features seen more universally across other solid tumor brain metastases are discussed. Systemic therapeutic studies and radiotherapeutic approaches are reviewed.

CONCLUSIONS

A clearer understanding of SCLC brain metastases will help lay the framework for studies which will hopefully translate into meaningful therapeutic options for these patients.

A study on different therapies and prognosis-related factors for 101 patients with SCLC and brain metastases

OBJECTIVE

There is a need to explore multi-discipline general treatment modes to improve the survival period of patients with SCLC and brain metastases undergoing standard radiotherapy treatment.

METHODS

A total of 101 patients with SCLC and brain metastases were included into this study. These patients were classified into 4 groups, based on different treatment modes: chemotherapy group, brain radiotherapy group, brain radiotherapy combined with sequential chemotherapy, and chemotherapy combined with sequential brain radiotherapy. Recent and long-term curative effects were compared among the 4 groups.

RESULTS

A RR of 42.57% was determined for all 4 groups, and median PFS and OS was 11.56 and 17.32 months, respectively. After SCLC with brain metastases manifested in the limited stage, the difference in median survival period was not statistically significant among the 4 treatment groups (P = 0.29). At the extensive stage of SCLC, survival period was superior in the brain radiotherapy combined with sequential chemotherapy group, compared with other groups (P<0.05). Furthermore, median survival period in the brain radiotherapy combined with sequential chemotherapy group was 15.5 ± 1.03 months. This was followed by 12.0 ± 3.06 months in the chemotherapy combined with sequential brain radiotherapy group, 8.0 ± 1.49 months in the chemotherapy group, and 8.0 ± 0.43 months in the brain radiotherapy group.

CONCLUSION

Combining chemotherapy with brain radiotherapy is a better treatment mode compared with single therapy for treating SCLC with brain metastases. Furthermore, it is recommended for patients in the extensive stage to initially receive brain radiotherapy.

Clinical outcomes of WBRT plus EGFR-TKIs versus WBRT or TKIs alone for the treatment of cerebral metastatic NSCLC patients: a meta-analysis

Whether WBRT plus EGFR-TKIs has a greater survival benefit than EGFR-TKIs alone or WBRT alone remains controversial in NSCLC patients with multiple brain metastases. To rectify this, we conducted a systematic meta-analysis based on 9 retrospective studies and 1 randomized controlled study published between 2012 and 2016, comprising 1041 patients. Five studies were included in the comparison of WBRT plus EGFR-TKIs and EGFR-TKIs alone. The combined HR for OS of patients with EGFR mutation was 1.25 [95% CI 0.98–2.15; P = 0.08] and for intracranial PFS was 1.30 [95% CI 1.03–1.65; P = 0.03], which revealed that EGFR-TKIs alone produced a superior intracranial PFS than WBRT plus EGFR-TKIs. Five studies were included in the comparison of WBRT plus EGFR-TKIs and WBRT alone. The combined HR for OS, intracranial PFS and extracranial PFS were 0.52 [95% CI 0.37–0.75; P = 0.0004], 0.36 [95% CI 0.24–0.53; P < 0.001] and 0.52 [95% CI 0.38–0.71; P < 0.001], respectively, which revealed a significant benefit of WBRT plus EGFR-TKIs compared with WBRT alone. The results indicated that EGFR-TKIs alone should be the first option for the treatment of NSCLC patients with multiple BM, especially with EGFR mutation, since it provides similar OS and extracranial PFS but superior intracranial PFS compared with WBRT plus EGFR-TKIs.

Perilesional edema in brain metastasis from non-small cell lung cancer (NSCLC) as predictor of response to radiosurgery (SRS)

Radiosurgery (SRS) is widely used in the treatment of brain oligo-metastases from NSCLC. The aim of present study is to evaluate the extent of perilesional edema in brain metastases as predictive factor of treatment response. This single center retrospective study included 42 consecutive patients (January 2011-December 2014) with 1-2 brain metastasis from NSCLC treated with Radiosurgery (SRS). Extent of perilesional edema was measured as maximal extension from the edge of lesion and classified as minor (<10 mm) or major (≥10 mm). We analyzed Modality of Brain Recurrence (MBR), classified as in-field or out-of- field, and Brain Progression Free-Survival (BPFS) after treatment stratified according to extent of perilesional edema. Analyzing modality of brain recurrence and BPFS, after a median follow-up of 6 months, we found that patients with minor edema had a better radiological response to SRS with none in-field recurrences and a lower risk of the onset of new brain lesions (out-of-field recurrence). Instead, patients group with major edema had a worse response rate of lesions treated, further, a higher risk of out-of-field brain relapse. Extent of perilesional edema in brain metastasis from NSCLC could be a predictive factor of response and brain progression after SRS treatment alone.

Prognostic Value of MR Imaging Texture Analysis in Brain Non-Small Cell Lung Cancer Oligo-Metastases Undergoing Stereotactic Irradiation

BACKGROUND : Stereotactic irradiation is widely used in brain oligo-metastases treatment. The aim of this study is to evaluate the prognostic value of magnetic resonance imaging (MRI) texture analysis (TA) of brain metastases (BM) of non-small cell lung cancer (NSCLC). MATERIALS AND METHODS : This study included thirty-eight consecutive patients undergoing stereotactic irradiation, that is, stereotactic fractionated radiotherapy (SRT) or radiosurgery (SRS), from January 2011 to December 2014 for 1-2 brain BM from NSCLC. Whole-brain radiotherapy (WBRT) was not delivered. The diagnostic MRI DICOM (Digital Imaging and Communications in Medicine) images were collected and analyzed with a homemade ImageJ macro, and typical TA parameters (mean, standard deviation, skewness, kurtosis, entropy, and uniformity) were evaluated for: brain progression-free survival; modality of brain metastatic progression (local progression or/and new metastases); and overall survival, after SRT/SRS.

RESULTS

After SRT/SRS 14 patients (36.8%) experienced recurrence in the brain, with a recurrence in the irradiated site (five patients, 13.2%), new metastases (11 patients, 28.9%), local recurrence and new metastases (two patients, 5.25%). Nineteen patients (50%) died of tumor progression or other causes. Entropy and uniformity were significantly associated with local progression, whereas kurtosis was significantly associated with both local progression and new brain metastases. CONCLUSIONS : These results appear promising, since the knowledge of factors correlated with the modality of brain progression after stereotactic irradiation of brain oligo-metastatic foci of NSCLC might help in driving the best treatment in these patients (association of SRT/SRS with WBRT? Increase of SRT/SRS dose?). Our preliminary data needs confirmation in large patient series.

Role of stereotactic radiosurgery in patients with more than four brain metastases

For patients presenting with brain metastases, two methods of radiation treatment currently exist: stereotactic radiosurgery (SRS) and whole-brain radiation therapy (WBRT). SRS is a minimally invasive to noninvasive technique that delivers a high dose of ionizing radiation to a precisely defined focal target volume, whereas WBRT involves multiple smaller doses of radiation delivered to the whole brain. Evidence exists from randomized controlled trials for SRS in the treatment of patients with one to four brain metastases. Patients with more than four brain metastases generally receive WBRT, which can effectively treat undetected metastases and protect against intracranial relapse. However, WBRT has been associated with an increased potential for toxic neurocognitive side effects, including memory loss and early dementia, and does not provide 100% protection against relapse. For this reason, physicians at many medical centers are opting to use SRS as first-line treatment for patients with more than four brain metastases, despite evidence showing an increased rate of intracranial relapse compared with WBRT. In light of the evolving use of SRS, this review will examine the available reports on institutional trials and outcomes for patients with more than four brain metastases treated with SRS alone as first-line therapy.

Voluntary exercise prevents cisplatin-induced muscle wasting during chemotherapy in mice

Loss of muscle mass related to anti-cancer therapy is a major concern in cancer patients, being associated with important clinical endpoints including survival, treatment toxicity and patient-related outcomes. We investigated effects of voluntary exercise during cisplatin treatment on body weight, food intake as well as muscle mass, strength and signalling. Mice were treated weekly with 4 mg/kg cisplatin or saline for 6 weeks, and randomized to voluntary wheel running or not. Cisplatin treatment induced loss of body weight (29.8%, P < 0.001), lean body mass (20.6%, P = 0.001), as well as anorexia, impaired muscle strength (22.5% decrease, P < 0.001) and decreased glucose tolerance. In addition, cisplatin impaired Akt-signalling, induced genes related to protein degradation and inflammation, and reduced muscle glycogen content. Voluntary wheel running during treatment attenuated body weight loss by 50% (P < 0.001), maintained lean body mass (P < 0.001) and muscle strength (P < 0.001), reversed anorexia and impairments in Akt and protein degradation signalling. Cisplatin-induced muscular inflammation was not prevented by voluntary wheel running, nor was glucose tolerance improved. Exercise training may preserve muscle mass in cancer patients receiving cisplatin treatment, potentially improving physical capacity, quality of life and overall survival.