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Amouzegar A, Haig S, Kahn AM, Tawbi HA, Jones JA, Goldberg SB. Navigating the Complexities of Brain Metastases Management. Am Soc Clin Oncol Educ Book 2024; 44:e433694. [PMID: 38781565 DOI: 10.1200/edbk_433694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
The management of brain metastases, a potentially devastating complication of advanced cancers, has become increasingly complex with advancements in local and systemic therapies. Improved outcomes and extended survival for patients with metastatic solid tumors have led to a surge in the prevalence and possibly incidence of brain metastases, affecting up to 40% of individuals with solid tumors. Enhanced imaging technologies contribute to more accurate and early detection, shaping the understanding of the intricate landscape of this condition. Traditionally, surgery and radiation stood as the mainstays of treatment because of the limited efficacy of systemic therapies within the brain. However, emerging clinical data, particularly in melanoma, lung, and breast cancers, reveal promising results with novel systemic treatments such as immunotherapy and targeted therapies. Despite the historical exclusion of patients with active brain metastases from clinical trials, a shift is occurring toward a more inclusive approach. This chapter delves into the multifaceted challenges associated with managing brain metastases, with a focus on the evolving landscape of systemic approaches as well as the intricacies of shared decision making, providing a comprehensive overview of the current state and future directions in navigating the complexities of brain metastases management.
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Affiliation(s)
- Afsaneh Amouzegar
- Department of Melanoma Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shannon Haig
- Lake Erie College of Osteopathic Medicine, Greensburg, PA
| | - Adriana M Kahn
- Section of Medical Oncology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Hussein A Tawbi
- Department of Melanoma Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joshua A Jones
- Department of Oncology, Division of Radiation Oncology and Division of Palliative Medicine, Rochester Regional Health System, Rochester, NY
| | - Sarah B Goldberg
- Section of Medical Oncology, Department of Medicine, Yale School of Medicine, New Haven, CT
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Tang HKC, Rao A, Peters C, Ambulkar T, Ho MFX, Wang B, Patel P. 'Immunotherapeutic Strategies for Intra-cranial Metastatic Melanoma - a Meta-analysis and Systematic Review'. J Cancer 2024; 15:3495-3509. [PMID: 38817862 PMCID: PMC11134445 DOI: 10.7150/jca.93306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 03/27/2024] [Indexed: 06/01/2024] Open
Abstract
Immune-activating anti-CTLA4 and anti-PD1 monoclonal antibodies (alone or in combination) are being used to treat advanced melanoma patients and can lead to durable remissions, and long-term overall survival may be achieved in between 50-60% of patients. Although intracranial metastases are very common in melanoma (about 50-75% of all patients with advanced disease), most of the pivotal prospective clinical trials exclude patients with intra-cranial metastases, certainly if their lesions are symptomatic and steroid-requiring and the degree of sensitivity of intra-cranial melanoma to immunotherapy remains uncertain, and requires further investigation especially in view of the demonstrable activity of RAF-MEK inhibitors in this clinical setting and the emergence of stereotactic radiotherapy. Our study aimed to evaluate the efficacy and toxicity of immunotherapy against advanced melanoma patients with brain metastases. In terms of comparative studies, only retrospective analyses could be identified. Based on 3 retrospective studies, treatment of patients with melanoma brain metastases with immunotherapeutic approaches improves overall survival substantially compared with supportive measures alone (no active anticancer treatment). The efficacy of targeted therapy appeared to be comparable to that of immune therapy in terms of overall survival, based on a small number of patients. The combination of concurrent radiation therapy to the brain and systemic immunotherapy led to improved overall survival compared to radiotherapy alone, suggesting potential synergism between the approaches, and combination treatment could be delivered safely. Our review supports the use of immunotherapeutic strategies for these patients although treatment efficacy appears to be lower for symptomatic lesions. In view of the extremely high efficacy of stereotactic radiotherapy approaches in the brain, understanding the interaction between radiotherapy and immunotherapy is vital and should be an area of active investigation.
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Affiliation(s)
- Hiu Kwan Carolyn Tang
- Department of Oncology, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, United Kingdom
| | - Ankit Rao
- Department of Oncology, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, United Kingdom
| | - Christina Peters
- Department of Oncology, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, United Kingdom
| | - Tanvi Ambulkar
- Department of Oncology, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, United Kingdom
| | - Michael FX Ho
- Department of Oncology, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, United Kingdom
| | - Bo Wang
- Trinity Hall, University of Cambridge, Cambridge, CB2 1TJ, United Kingdom
| | - Poulam Patel
- Department of Oncology, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, United Kingdom
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Gallitto M, Pan PC, Chan MD, Milano MT, Wang TJC. The role of radiotherapy in immunotherapy strategies in the central nervous system. Neuro Oncol 2024; 26:S66-S75. [PMID: 38437664 PMCID: PMC10911795 DOI: 10.1093/neuonc/noad184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
The clinical efficacy and relative tolerability of adverse effects of immune checkpoint immunotherapy have led to its increasingly routine use in the management of multiple advanced solid malignancies. Radiation therapy (RT) is well-known to have both local and distant immunomodulatory effects, which has led to extensive investigation into the synergism of these 2 therapies. While the central nervous system (CNS) has historically been thought to be a sanctuary site, well-protected by the blood-brain barrier from the effects of immunotherapy, over the last several years studies have shown the benefits of these drugs, particularly in metastatic disease involving the CNS. This review explores current progress and the future of combination therapy with immune checkpoint inhibitors and RT.
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Affiliation(s)
- Matthew Gallitto
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York, USA
| | - Peter C Pan
- Division of Neuro-Oncology, Columbia University Irving Medical Center, New York, New York , USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York, USA
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York, USA
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Mehkri Y, Windermere SA, Still MEH, Yan SC, Goutnik M, Melnick K, Doonan B, Ghiaseddin AP, Rahman M. The Safety and Efficacy of Concurrent Immune Checkpoint Blockade and Stereotactic Radiosurgery Therapy with Practitioner and Researcher Recommendations. World Neurosurg 2024; 181:e133-e153. [PMID: 37739175 DOI: 10.1016/j.wneu.2023.09.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have shown growing promise in the treatment of brain metastases, especially combined with stereotactic radiosurgery (SRS). The combination of ICIs with SRS has been studied for efficacy as well as increasing radiation necrosis risks. In this review, we compare clinical outcomes of radiation necrosis, intracranial control, and overall survival between patients with brain metastases treated with either SRS alone or SRS-ICI combination therapy. METHODS A literature search of PubMed, Scopus, Embase, Web of Science, and Cochrane was performed in May 2023 for articles comparing the safety and efficacy of SRS/ICI versus SRS-alone for treating brain metastases. RESULTS The search criteria identified 1961 articles, of which 48 met inclusion criteria. Combination therapy with SRS and ICI does not lead to significant increases in incidence of radiation necrosis either radiographically or symptomatically. Overall, no difference was found in intracranial control between SRS-alone and SRS-ICI combination therapy. Combination therapy is associated with increased median overall survival. Notably, some comparative studies observed decreased neurologic deaths, challenging presumptions that improved survival is due to greater systemic control. The literature supports SRS-ICI administration within 4 weeks of another for survival but remains inconclusive, requiring further study for other outcome measures. CONCLUSIONS Combination SRS-ICI therapy is associated with significant overall survival benefit for patients with brain metastases without significantly increasing radiation necrosis risks compared to SRS alone. Although intracranial control rates appear to be similar between the 2 groups, timing of treatment delivery may improve control rates and demands further study attention.
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Affiliation(s)
- Yusuf Mehkri
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | | | - Megan E H Still
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Sandra C Yan
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Michael Goutnik
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Kaitlyn Melnick
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Bently Doonan
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Ashley P Ghiaseddin
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Maryam Rahman
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
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Badrigilan S, Meola A, Chang SD, Rezaeian S, Nemati H, Almasi T, Rostampour N. Stereotactic radiosurgery with immune checkpoint inhibitors for brain metastases: a meta-analysis study. Br J Neurosurg 2023; 37:1533-1543. [PMID: 34979828 DOI: 10.1080/02688697.2021.2022098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 12/20/2021] [Indexed: 11/02/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are an emerging tool in the treatment of brain metastases (BMs), Stereotactic radiosurgery (SRS), traditionally used for BMs, elicits an immune brain response and can act synergistically with ICIs. We aim to investigate the efficacy of ICI administered with SRS and determine the impact of timing on BM response. METHODS A systematical search was performed to identify potential studies concerning BMs managed with SRS alone or with SRS + ICI with relative timing administration (ICI concurrent with SRS, ICI nonconcurrent with SRS, SRS before ICI, SRS after ICI). The overall survival (OS), 12-month OS, local progression-free survival (LPFS), 12-month local brain control (LBC), distant progression-free survival (DPFS), 12-month distant brain control (DBC), and adverse events (intracranial hemorrhage, radionecrosis) were analyzed using the random-effects model. RESULTS A total of 16 retrospective studies with 1356 BM patients were included. Compared to nonconcurrent therapy, concurrent therapy revealed a significantly longer OS (HR= 1.43; p = 0.008) and 12-months LBC (HR = 1.91; p = 0.04), a similar 12-months DBC (HR = 1.12; p = 0.547) and higher complication rate (R = 0.77; p = 0.346). Concurrent therapy leads to a significantly higher OS compared to ICI before SRS (HR = 2.55; p = 0.0003). CONCLUSION The combination of SRS with ICI improves patients' clinical and radiological outcomes. The effectiveness of the combination is subject to the identification of an optimal therapeutic window.
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Affiliation(s)
- Samireh Badrigilan
- Department of Medical Physics, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Antonio Meola
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Steven D Chang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Shahab Rezaeian
- Research Center for Environmental Determinants of Health (RCEDH), Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Hossein Nemati
- Department of Epidemiology, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Tinoosh Almasi
- Department of Medical Physics, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Nima Rostampour
- Department of Medical Physics, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Yu Y, Chen H, Tian Z, Zhang Q, Shui Y, Shen L, Hu Q, Huang Z, Zhu S, Jiang H, Wei Q. Improved survival outcome with not-delayed radiotherapy and immediate PD-1/PD-L1 inhibitor for non-small-cell lung cancer patients with brain metastases. J Neurooncol 2023; 165:127-137. [PMID: 37848757 PMCID: PMC10638122 DOI: 10.1007/s11060-023-04459-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/20/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE To investigate the impact of radiotherapy (RT) and immune checkpoint inhibitor (ICI) sequence on the survival outcome in NSCLC patients with brain metastasis, and decide the best time to initiate RT. METHODS Patients were managed with delayed RT (ICI delivered over 2 weeks prior to RT), concurrent RT (ICI delivered within 2 weeks prior to or after RT), or upfront RT (RT delivered over 2 weeks prior to ICI). Overall survival (OS), intracranial local progression-free survival (iLPFS), and intracranial distant progression-free survival (iDPFS) were assessed. A meta-analysis was performed to analyze the association between survival outcome and RT/ICI sequence. RESULTS A total of 73 NSCLC patients were identified with a median follow-up of 13.9 months. Patients who receive delayed RT demonstrated shorter iLPFS (P = 0.0029), iDPFS (P = 0.016), and OS (P < 0.001). A meta-analysis was conducted and a total of 4 studies, 254 patients were included. The HR was 0.44 for iDPFS (P = 0.03), 0.41 for OS (P < 0.01) when compared concurrent with delayed RT, 0.21 for iDPFS (P < 0.01), 0.32 for OS (P < 0.01) when compared upfront with delayed RT, consistent with our conclusion that delayed RT brought with worst iDPFS and OS. More importantly, the best overall response rate (BOR) decreased in cases with longer RT and ICI intervals. Patients who receive intervals of RT and ICI within 7 days achieve the best median BOR of - 53%. CONCLUSIONS Delayed RT brought poor survival outcomes including iLPFS, iDPFS, and OS in NSCLC patients. The shorter interval of RT and ICI is associated with better BOR.
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Affiliation(s)
- Yaner Yu
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Cancer, Cancer Center of Zhejiang University, Hangzhou, China
| | - Haiyan Chen
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Cancer, Cancer Center of Zhejiang University, Hangzhou, China
- Anhui Campus of the Second Affiliated Hospital, Zhejiang University School of Medicine, Bengbu, 233000, China
| | - Zhifeng Tian
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Radiotherapy, Lishui Municipal Central Hospital, Lishui, China
| | - Qun Zhang
- Department of Radiation Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233000, China
| | - Yongjie Shui
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Cancer, Cancer Center of Zhejiang University, Hangzhou, China
| | - Li Shen
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Cancer, Cancer Center of Zhejiang University, Hangzhou, China
| | - Qiongge Hu
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Cancer, Cancer Center of Zhejiang University, Hangzhou, China
| | - Zhifei Huang
- Department of Radiation Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233000, China
| | - Shuangqiu Zhu
- Department of Radiation Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233000, China
| | - Hao Jiang
- Department of Radiation Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233000, China.
| | - Qichun Wei
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
- Zhejiang Provincial Clinical Research Center for Cancer, Cancer Center of Zhejiang University, Hangzhou, China.
- Anhui Campus of the Second Affiliated Hospital, Zhejiang University School of Medicine, Bengbu, 233000, China.
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Yoo KH, Park DJ, Choi JH, Marianayagam NJ, Lim M, Meola A, Chang SD. Optimizing the synergy between stereotactic radiosurgery and immunotherapy for brain metastases. Front Oncol 2023; 13:1223599. [PMID: 37637032 PMCID: PMC10456862 DOI: 10.3389/fonc.2023.1223599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/24/2023] [Indexed: 08/29/2023] Open
Abstract
Solid tumors metastasizing to the brain are a frequent occurrence with an estimated incidence of approximately 30% of all cases. The longstanding conventional standard of care comprises surgical resection and whole-brain radiotherapy (WBRT); however, this approach is associated with limited long-term survival and local control outcomes. Consequently, stereotactic radiosurgery (SRS) has emerged as a potential alternative approach. The primary aim of SRS has been to improve long-term control rates. Nevertheless, rare observations of abscopal or out-of-field effects have sparked interest in the potential to elicit antitumor immunity via the administration of high-dose radiation. The blood-brain barrier (BBB) has traditionally posed a significant challenge to the efficacy of systemic therapy in managing intracranial metastasis. However, recent insights into the immune-brain interface and the development of immunotherapeutic agents have shown promise in preclinical and early-phase clinical trials. Researchers have investigated combining immunotherapy with SRS to enhance treatment outcomes in patients with brain metastasis. The combination approach aims to optimize long-term control and overall survival (OS) outcomes by leveraging the synergistic effects of both therapies. Initial findings have been encouraging in the management of various intracranial metastases, while further studies are required to determine the optimal order of administration, radiation doses, and fractionation regimens that have the potential for the best tumor response. Currently, several clinical trials are underway to assess the safety and efficacy of administering immunotherapeutic agents concurrently or consecutively with SRS. In this review, we conduct a comprehensive analysis of the advantages and drawbacks of integrating immunotherapy into conventional SRS protocols for the treatment of intracranial metastasis.
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Affiliation(s)
| | | | | | | | | | | | - Steven D. Chang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
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Dohm AE, Tang JD, Mills MN, Liveringhouse CL, Sandoval ML, Perez BA, Robinson TJ, Creelan BC, Gray JE, Etame AB, Vogelbaum MA, Forsyth P, Yu HHM, Oliver DE, Ahmed KA. Clinical outcomes of non-small cell lung cancer brain metastases treated with stereotactic radiosurgery and immune checkpoint inhibitors, EGFR tyrosine kinase inhibitors, chemotherapy and immune checkpoint inhibitors, or chemotherapy alone. J Neurosurg 2023; 138:1600-1607. [PMID: 36681988 DOI: 10.3171/2022.9.jns221896] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/30/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Immune checkpoint inhibitors (ICIs) and epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) are commonly used in the systemic management of non-small cell lung cancer (NSCLC) brain metastases (BMs). However, optimizing control of NSCLC BM with stereotactic radiosurgery (SRS) and various systemic therapies remains an area of investigation. METHODS Between 2016 and 2019, the authors identified 171 NSCLC BM patients with 646 BMs treated with single-fraction SRS within 3 months of receiving treatment with ICIs (n = 56; 33%), EGFR-TKI (n = 30; 18%), chemotherapy and ICIs (n = 23; 14%), or standard chemotherapy alone (n = 62; 36%). Time-to-event analysis was conducted, and outcomes included distant intracranial control (DIC), local control (LC), and overall survival from SRS. RESULTS The median follow-up from BM diagnosis was 8.9 months (range 0.3-127 months). The 12-month Kaplan-Meier DIC rates were 37%, 53%, 41%, and 21% (p = 0.047) for the ICI, EGFR-TKI, ICI and chemotherapy, and chemotherapy-alone groups, respectively. On multivariate analysis, DIC was improved with EGFR-TKI (HR 0.4, 95% CI 0.3-0.8, p = 0.005) compared with conventional chemotherapy and treatment with SRS before systemic therapy (HR 0.5, 95% CI 0.3-0.9, p = 0.03) compared with after; and LC was improved with SRS before (HR 0.4, 95% CI 0.2-0.9, p = 0.03) or concurrently (HR 0.3, 95% CI 0.1-0.6, p = 0.003) compared with after. No differences in radionecrosis were noted by timing or type of systemic therapy. CONCLUSIONS The authors' analysis showed significant differences in DIC based on receipt of systemic therapy and treatment with SRS before systemic therapy improved DIC. Prospective evaluation of the potential synergism between systemic therapy and SRS in NSCLC BM management is warranted.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Peter Forsyth
- 4Neuro-Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Fenioux C, Troussier I, Amelot A, Borius PY, Canova CH, Blais E, Mazeron JJ, Maingon P, Valéry CA. Long duration of immunotherapy before radiosurgery might improve intracranial control of melanoma brain metastases. Cancer Radiother 2023; 27:206-213. [PMID: 37149466 DOI: 10.1016/j.canrad.2022.11.004] [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: 09/13/2022] [Revised: 11/12/2022] [Accepted: 11/19/2022] [Indexed: 05/08/2023]
Abstract
PURPOSE Despite significant advances that have been made in management of metastatic melanoma with immune checkpoint therapy, optimal timing of combination immune checkpoint therapy and stereotactic radiosurgery is unknown. We have reported toxicity and efficiency outcomes of patients treated with concurrent immune checkpoint therapy and stereotactic radiosurgery. PATIENTS AND METHODS From January 2014 to December 2016, we analyzed 62 consecutive patients presenting 296 melanoma brain metastases, treated with gamma-knife and receiving concurrent immune checkpoint therapy with anti-CTLA4 or anti-PD1 within the 12 weeks of SRS procedure. Median follow-up time was 18 months (mo) (13-22). Minimal median dose delivered was 18 gray (Gy), with a median volume per lesion of 0.219 cm3. RESULTS The 1-year control rate per irradiated lesion was 89% (CI 95%: 80.41-98.97). Twenty-seven patients (43.5%) developed distant brain metastases after a median time of 7.6 months (CI 95% 1.8-13.3) after gamma-knife. In multivariate analysis, positive predictive factors for intracranial tumor control were: delay since the initiation of immunotherapy exceeding 2 months before gamma-knife procedure (P=0.003) and use of anti-PD1 (P=0.006). Median overall survival (OS) was 14 months (CI 95%: 11-NR). Total irradiated tumor volume<2.1 cm3 was a positive predictive factor for overall survival (P=0.003). Ten patients (16.13%) had adverse events following irradiation, with four grade≥3. Predictive factors of all grade toxicity were: female gender (P=0.001) and previous treatment with MAPK (P=0.05). CONCLUSION A long duration of immune checkpoint therapy before stereotactic radiosurgery might improve intracranial tumor control, but this relationship and its ideal timing need to be assessed in prospective trials.
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Affiliation(s)
- C Fenioux
- Service de radiothérapie oncologique, hôpital de la Pitié-Salpêtrière, Paris, France
| | - I Troussier
- Service de radiothérapie oncologique, hôpital de la Pitié-Salpêtrière, Paris, France
| | - A Amelot
- Service de neurochirurgie, hôpital de la Pitié-Salpêtrière, Paris, France
| | - P Y Borius
- Service de neurochirurgie, hôpital de la Pitié-Salpêtrière, Paris, France; Unité de radiochirurgie gamma-knife, hôpital de la Pitié-Salpêtrière, Paris, France
| | - C H Canova
- Service de radiothérapie oncologique, hôpital de la Pitié-Salpêtrière, Paris, France
| | - E Blais
- Service de radiothérapie oncologique, hôpital de la Pitié-Salpêtrière, Paris, France
| | - J J Mazeron
- Service de radiothérapie oncologique, hôpital de la Pitié-Salpêtrière, Paris, France
| | - P Maingon
- Service de radiothérapie oncologique, hôpital de la Pitié-Salpêtrière, Paris, France
| | - C A Valéry
- Service de neurochirurgie, hôpital de la Pitié-Salpêtrière, Paris, France; Unité de radiochirurgie gamma-knife, hôpital de la Pitié-Salpêtrière, Paris, France.
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Eckstein J, Gogineni E, Sidiqi B, Lisser N, Parashar B. Effect of Immunotherapy and Stereotactic Body Radiation Therapy Sequencing on Local Control and Survival in Patients With Spine Metastases. Adv Radiat Oncol 2023; 8:101179. [PMID: 36896213 PMCID: PMC9991541 DOI: 10.1016/j.adro.2023.101179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 01/09/2023] [Indexed: 01/17/2023] Open
Abstract
Purpose Stereotactic body radiation therapy (SBRT) is commonly used to treat spinal metastases in combination with immunotherapy (IT). The optimal sequencing of these modalities is unclear. This study aimed to investigate whether sequencing of IT and SBRT was associated with differences in local control (LC), overall survival (OS), and toxicity when treating spine metastases. Methods and Materials All patients at our institution who received spine SBRT from 2010 to 2019 with systemic therapy data available were reviewed retrospectively. The primary endpoint was LC. Secondary endpoints were toxicity (fracture and radiation myelitis) and OS. Kaplan-Meier analysis was used to determine whether IT sequencing (before versus after SBRT) and use of IT were associated with LC or OS. Results A total of 191 lesions in 128 patients met inclusion criteria with 50 (26%) lesions in 33 (26%) patients who received IT. Fourteen (11%) patients with 24 (13%) lesions received the first IT dose before SBRT, whereas 19 (15%) patients with 26 (14%) lesions received the first dose after SBRT. LC did not differ between lesions treated with IT before SBRT versus after SBRT (1 year 73% versus 81%, log rank = 0.275, P = .600). Fracture risk was not associated with IT timing (χ2 = 0.137, P = .934) or receipt of IT (χ2 = 0.508, P = .476), and no radiation myelitis events occurred. Median OS was 31.8 versus 6.6 months for the IT after SBRT versus IT before SBRT cohorts, respectively (log rank = 13.193, P < .001). On Cox univariate analysis and multivariate analysis, receipt of IT before SBRT and Karnofsky performance status <80 were associated with worse OS. IT treatment versus none was not associated with any difference in LC (log rank = 1.063, P = .303) or OS (log rank = 1.736, P = .188). Conclusions Sequencing of IT and SBRT was not associated with any difference in LC or toxicity, but delivering IT after SBRT versus before SBRT was associated with improved OS.
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Affiliation(s)
- Jacob Eckstein
- Department of Radiation Medicine, Zucker School of Medicine, Hofstra, Northwell Health, New York, New York
| | - Emile Gogineni
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Baho Sidiqi
- Department of Radiation Medicine, Zucker School of Medicine, Hofstra, Northwell Health, New York, New York
| | - Noah Lisser
- Department of Radiation Medicine, Zucker School of Medicine, Hofstra, Northwell Health, New York, New York
| | - Bhupesh Parashar
- Department of Radiation Medicine, Zucker School of Medicine, Hofstra, Northwell Health, New York, New York
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11
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Tracz JA, Donnelly BM, Ngu S, Vojnic M, Wernicke AG, D'Amico RS. The abscopal effect: inducing immunogenicity in the treatment of brain metastases secondary to lung cancer and melanoma. J Neurooncol 2023; 163:1-14. [PMID: 37086369 DOI: 10.1007/s11060-023-04312-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/11/2023] [Indexed: 04/23/2023]
Abstract
PURPOSE The phenomenon of radiation therapy (RT) causing regression of targeted lesions as well as lesions outside of the radiation field is known as the abscopal effect and is thought to be mediated by immunologic causes. This phenomena has been described following whole brain radiation (WBRT) and stereotactic radiosurgery (SRS) of brain metastasis (BM) in advanced melanoma and non-small-cell lung cancer (NSCLC). We systematically reviewed the available literature to identify which radiation modality and immunotherapy (IT) combination may elicit the abscopal effect, the optimal timing of RT and IT, and potential adverse effects inherent to the combination of RT and IT. METHODS Using PRISMA guidelines, a search of PubMed, Medline, and Web of Science was conducted to identify studies demonstrating the abscopal effect during treatment of NSCLC or melanoma with BM. RESULTS 598 cases of irradiated BM of melanoma or NSCLC in 18 studies met inclusion criteria. The most commonly administered ITs included PD-1 or CTLA-4 immune checkpoint inhibitors (ICI), with RT most commonly administered within 3 months of ICI. Synergy between ICI and RT was described in 16 studies including evidence of higher tumor response within and outside of the irradiated field. In the 12 papers (n = 232 patients) that reported objective response rate (ORR) in patients with BM treated with RT and concurrent systemic IT, the non-weighted mean ORR was 49.4%; in the 5 papers (n = 110 patients) that reported ORR for treatment with RT or IT alone, the non-weighted mean ORR was 27.8%. No studies found evidence of significantly increased toxicity in patients receiving RT and ICI. CONCLUSION The combination of RT and ICIs may enhance ICI efficacy and induce more durable responses via the abscopal effect in patients with brain metastases of melanoma or NSCLC.
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Affiliation(s)
- Jovanna A Tracz
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, 10075, USA
| | - Brianna M Donnelly
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, 11549, USA
| | - Sam Ngu
- Department of Hematology and Oncology, Lenox Hill Hospital, New York, NY, 10075, USA
| | - Morana Vojnic
- Department of Hematology and Oncology, Lenox Hill Hospital, New York, NY, 10075, USA
| | | | - Randy S D'Amico
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, 10075, USA.
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, 11549, USA.
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12
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Tian W, Chu X, Tanzhu G, Zhou R. Optimal timing and sequence of combining stereotactic radiosurgery with immune checkpoint inhibitors in treating brain metastases: clinical evidence and mechanistic basis. J Transl Med 2023; 21:244. [PMID: 37020242 PMCID: PMC10077682 DOI: 10.1186/s12967-023-04089-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/25/2023] [Indexed: 04/07/2023] Open
Abstract
Recent evidence has shown that immune checkpoint inhibitors (ICIs) are efficacious for treating brain metastases of various primary tumors. However, the immunosuppressive tumor microenvironment and the blood-brain barrier (BBB) or blood-tumor barrier (BTB) essentially restrict the efficacy of ICIs. Stereotactic radiosurgery (SRS) can be a powerful ally to ICIs due to its trait of disrupting the BBB/BTB and increasing the immunogenicity of brain metastases. The combination of SRS + ICI has shown synergy in brain metastases in several retrospective studies. Nevertheless, the optimal schedule for the combination of SRS and ICI in brain metastases is yet to be determined. In this review, we summarized the current clinical and preclinical evidence on the timing and sequence of SRS + ICI to provide insight into the current state of knowledge about this important area in patient care.
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Affiliation(s)
- Wentao Tian
- Department of Oncology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Kaifu District, Changsha, 410008, China
| | - Xianjing Chu
- Department of Oncology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Kaifu District, Changsha, 410008, China
| | - Guilong Tanzhu
- Department of Oncology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Kaifu District, Changsha, 410008, China
| | - Rongrong Zhou
- Department of Oncology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Kaifu District, Changsha, 410008, China.
- Xiangya Lung Cancer Center, Xiangya Hospital, Central South University, Changsha, 410008, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, China.
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13
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Leu J, Akerman M, Mendez C, Lischalk JW, Carpenter T, Ebling D, Haas JA, Witten M, Barbaro M, Duic P, Tessler L, Repka MC. Time interval from diagnosis to treatment of brain metastases with stereotactic radiosurgery is not associated with radionecrosis or local failure. Front Oncol 2023; 13:1132777. [PMID: 37091181 PMCID: PMC10113671 DOI: 10.3389/fonc.2023.1132777] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/07/2023] [Indexed: 04/09/2023] Open
Abstract
IntroductionBrain metastases are the most common intracranial tumor diagnosed in adults. In patients treated with stereotactic radiosurgery, the incidence of post-treatment radionecrosis appears to be rising, which has been attributed to improved patient survival as well as novel systemic treatments. The impacts of concomitant immunotherapy and the interval between diagnosis and treatment on patient outcomes are unclear.MethodsThis single institution, retrospective study consisted of patients who received single or multi-fraction stereotactic radiosurgery for intact brain metastases. Exclusion criteria included neurosurgical resection prior to treatment and treatment of non-malignant histologies or primary central nervous system malignancies. A univariate screen was implemented to determine which factors were associated with radionecrosis. The chi-square test or Fisher’s exact test was used to compare the two groups for categorical variables, and the two-sample t-test or Mann-Whitney test was used for continuous data. Those factors that appeared to be associated with radionecrosis on univariate analyses were included in a multivariable model. Univariable and multivariable Cox proportional hazards models were used to assess potential predictors of time to local failure and time to regional failure.ResultsA total of 107 evaluable patients with a total of 256 individual brain metastases were identified. The majority of metastases were non-small cell lung cancer (58.98%), followed by breast cancer (16.02%). Multivariable analyses demonstrated increased risk of radionecrosis with increasing MRI maximum axial dimension (OR 1.10, p=0.0123) and a history of previous whole brain radiation therapy (OR 3.48, p=0.0243). Receipt of stereotactic radiosurgery with concurrent immunotherapy was associated with a decreased risk of local failure (HR 0.31, p=0.0159). Time interval between diagnostic MRI and first treatment, time interval between CT simulation and first treatment, and concurrent immunotherapy had no impact on incidence of radionecrosis or regional failure.DiscussionAn optimal time interval between diagnosis and treatment for intact brain metastases that minimizes radionecrosis and maximizes local and regional control could not be identified. Concurrent immunotherapy does not appear to increase the risk of radionecrosis and may improve local control. These data further support the safety and synergistic efficacy of stereotactic radiosurgery with concurrent immunotherapy.
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Affiliation(s)
- Justin Leu
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
| | - Meredith Akerman
- Division of Health Services Research, New York University (NYU) Long Island School of Medicine, Mineola, NY, United States
| | - Christopher Mendez
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University (NYU) Long Island, Mineola, NY, United States
| | - Jonathan W. Lischalk
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University (NYU) Long Island, Mineola, NY, United States
- NYCyberKnife at Perlmutter Cancer Center – Manhattan, New York, NY, United States
| | - Todd Carpenter
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University (NYU) Long Island, Mineola, NY, United States
| | - David Ebling
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University (NYU) Long Island, Mineola, NY, United States
| | - Jonathan A. Haas
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University (NYU) Long Island, Mineola, NY, United States
- NYCyberKnife at Perlmutter Cancer Center – Manhattan, New York, NY, United States
| | - Matthew Witten
- Department of Medical Physics, Perlmutter Cancer Center at New York University (NYU) Long Island, Mineola, NY, United States
| | - Marissa Barbaro
- Department of Neurology, New York University (NYU) Long Island School of Medicine, Mineola, NY, United States
| | - Paul Duic
- Department of Neurology, New York University (NYU) Long Island School of Medicine, Mineola, NY, United States
| | - Lee Tessler
- Department of Neurosurgery, Perlmutter Cancer Center at New York University (NYU) Long Island, Mineola, NY, United States
| | - Michael C. Repka
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, United States
- *Correspondence: Michael C. Repka,
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14
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King ALO, Lee V, Yu B, Mirza FN, Zogg CK, Yang DX, Tran T, Leventhal J, An Y. Factors associated with the use of adjuvant radiation therapy in stage III melanoma. Front Oncol 2023; 13:1005930. [PMID: 36816935 PMCID: PMC9929351 DOI: 10.3389/fonc.2023.1005930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/18/2023] [Indexed: 02/04/2023] Open
Abstract
Objective The role of radiation therapy (RT) in melanoma has historically been limited to palliative care, with surgery as the primary treatment modality. However, adjuvant RT can be a powerful tool in certain cases and its application in melanoma has been increasingly explored in recent years. The aim of this study is to explore national patterns of care and associations surrounding the use of adjuvant RT for stage III melanoma. Methods The National Cancer Data Base (NCDB) was used to identify patients who were diagnosed with stage III melanoma between 2004 and 2014. Exclusion criteria included those with distant metastatic disease, in-situ histology, no confirmed positive nodes, palliative intent therapy, and dosing regimens inconsistent with National Comprehensive Cancer Network (NCCN) guidelines for adjuvant RT in melanoma. Patients treated with and without adjuvant RT were compared and factors associated with use of adjuvant RT were identified using multivariable logistic regression analyses. Results A total of 7,758 cases of stage III melanoma were analyzed, of which 11.7% received adjuvant RT. The mean age of the overall cohort was 58.5 years, and the majority of patients were male (64.7%), white (96.6%), on private insurance (51.3%), and presented to a non-high-volume facility (90.3%). Multivariable regression analyses revealed that patients who present to the hospital in 2009-2014 as compared to 2004-2008 (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.36-1.92), had 4 or more positive nodes (OR 4.30, 95% CI 3.67-5.04), and had microscopic residual tumor (OR 2.11, 95% CI 1.46-3.04) were more likely to receive adjuvant RT. Factors that were negatively associated with receiving adjuvant RT included female gender (OR 0.72, 95% CI 0.61-0.85) and median income of at least $63,000 (OR 0.66, 95% CI 0.52-0.83). Conclusions This study demonstrates the rising use of RT for stage III melanoma in recent years and identifies demographic, social, clinical, and hospital-specific factors associated with patients receiving adjuvant RT. Further investigation is needed to explore disease benefits to improve guidance on the utilization of RT in melanoma.
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Affiliation(s)
- Amber L. O. King
- Department of Dermatology, Yale School of Medicine, New Haven, CT, United States
| | - Victor Lee
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, United States
| | - Beverly Yu
- Department of Dermatology, Yale School of Medicine, New Haven, CT, United States
| | - Fatima N. Mirza
- Department of Dermatology, Yale School of Medicine, New Haven, CT, United States
| | - Cheryl K. Zogg
- Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Daniel X. Yang
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, United States
| | - Thuy Tran
- Department of Medicine (Medical Oncology), Yale School of Medicine, New Haven, CT, United States
| | - Jonathan Leventhal
- Department of Dermatology, Yale School of Medicine, New Haven, CT, United States
| | - Yi An
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, United States
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15
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Amin S, Baine M, Lin C. Immunotherapy plus stereotactic body radiation therapy or whole-brain radiation therapy in brain metastases. Immunotherapy 2023; 15:163-174. [PMID: 36748364 DOI: 10.2217/imt-2022-0051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Aim: To investigate the association of stereotactic radiation therapy (SRT) or whole-brain radiation therapy (WBRT) plus immunotherapy with the overall survival (OS) of cancer patients with brain metastases (BMs) regardless of the primary cancer. Patients & methods: Patients diagnosed with BMs were identified from the National Cancer Database. Results: A total of 34,286 patients were included. SRT plus immunotherapy was associated with improved OS compared with SRT without immunotherapy (hazard ratio: 0.774; 95% CI: 0.687-0.872; p < 0.001), and WBRT plus immunotherapy was associated with improved OS compared with WBRT without immunotherapy (hazard ratio: 0.724; 95% CI; 0.673-0.779; p < 0.001). Conclusion: SRT plus immunotherapy was associated with improved OS compared with SRT. WBRT plus immunotherapy was associated with improved OS compared with WBRT in cancer patients who had BMs at the time of primary cancer diagnosis.
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Affiliation(s)
- Saber Amin
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Michael Baine
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Chi Lin
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
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16
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Karz A, Dimitrova M, Kleffman K, Alvarez-Breckenridge C, Atkins MB, Boire A, Bosenberg M, Brastianos P, Cahill DP, Chen Q, Ferguson S, Forsyth P, Glitza Oliva IC, Goldberg SB, Holmen SL, Knisely JPS, Merlino G, Nguyen DX, Pacold ME, Perez-Guijarro E, Smalley KSM, Tawbi HA, Wen PY, Davies MA, Kluger HM, Mehnert JM, Hernando E. Melanoma central nervous system metastases: An update to approaches, challenges, and opportunities. Pigment Cell Melanoma Res 2022; 35:554-572. [PMID: 35912544 PMCID: PMC10171356 DOI: 10.1111/pcmr.13059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/29/2022] [Indexed: 01/27/2023]
Abstract
Brain metastases are the most common brain malignancy. This review discusses the studies presented at the third annual meeting of the Melanoma Research Foundation in the context of other recent reports on the biology and treatment of melanoma brain metastases (MBM). Although symptomatic MBM patients were historically excluded from immunotherapy trials, efforts from clinicians and patient advocates have resulted in more inclusive and even dedicated clinical trials for MBM patients. The results of checkpoint inhibitor trials were discussed in conversation with current standards of care for MBM patients, including steroids, radiotherapy, and targeted therapy. Advances in the basic scientific understanding of MBM, including the role of astrocytes and metabolic adaptations to the brain microenvironment, are exposing new vulnerabilities which could be exploited for therapeutic purposes. Technical advances including single-cell omics and multiplex imaging are expanding our understanding of the MBM ecosystem and its response to therapy. This unprecedented level of spatial and temporal resolution is expected to dramatically advance the field in the coming years and render novel treatment approaches that might improve MBM patient outcomes.
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Affiliation(s)
- Alcida Karz
- Department of Pathology, NYU Grossman School of Medicine, New York, USA.,Interdisciplinary Melanoma Cooperative Group, Perlmutter Cancer Center, NYU Langone Health, New York, USA
| | - Maya Dimitrova
- Interdisciplinary Melanoma Cooperative Group, Perlmutter Cancer Center, NYU Langone Health, New York, USA.,Department of Medicine, NYU Grossman School of Medicine, New York, USA
| | - Kevin Kleffman
- Department of Pathology, NYU Grossman School of Medicine, New York, USA.,Interdisciplinary Melanoma Cooperative Group, Perlmutter Cancer Center, NYU Langone Health, New York, USA
| | | | - Michael B Atkins
- Georgetown-Lombardi Comprehensive Cancer Center and Department of Oncology, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Adrienne Boire
- Human Oncology and Pathogenesis Program, Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Marcus Bosenberg
- Laboratory of Cancer Biology and Genetics, Center for Cancer Research NCI, NIH, USA
| | - Priscilla Brastianos
- MGH Cancer Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel P Cahill
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Qing Chen
- Immunology, Microenvironment and Metastasis Program, The Wistar Institute, Philadelphia, Pennsylvania, USA
| | - Sherise Ferguson
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Peter Forsyth
- Department of Neuro-Oncology and Tumor Biology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Isabella C Glitza Oliva
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sarah B Goldberg
- Department of Medicine (Medical Oncology), Yale School of Medicine, New Haven, Connecticut, USA
| | - Sheri L Holmen
- Huntsman Cancer Institute and Department of Surgery, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Jonathan P S Knisely
- Meyer Cancer Center and Department of Radiation Oncology, Weill Cornell Medicine, New York, New York, USA
| | - Glenn Merlino
- Laboratory of Cancer Biology and Genetics, Center for Cancer Research NCI, NIH, USA
| | - Don X Nguyen
- Department of Pathology, Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael E Pacold
- Department of Radiation Oncology, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
| | - Eva Perez-Guijarro
- Laboratory of Cancer Biology and Genetics, Center for Cancer Research NCI, NIH, USA
| | - Keiran S M Smalley
- Department of Tumor Biology, Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Hussein A Tawbi
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, United States, Boston, Massachusetts, USA
| | - Michael A Davies
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Harriet M Kluger
- Department of Medicine (Medical Oncology), Yale School of Medicine, New Haven, Connecticut, USA
| | - Janice M Mehnert
- Interdisciplinary Melanoma Cooperative Group, Perlmutter Cancer Center, NYU Langone Health, New York, USA.,Department of Medicine, NYU Grossman School of Medicine, New York, USA
| | - Eva Hernando
- Department of Pathology, NYU Grossman School of Medicine, New York, USA.,Interdisciplinary Melanoma Cooperative Group, Perlmutter Cancer Center, NYU Langone Health, New York, USA
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17
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Koide Y, Nagai N, Miyauchi R, Kitagawa T, Aoyama T, Shimizu H, Tachibana H, Kodaira T. Radiotherapy or systemic therapy versus combined therapy in patients with brain metastases: a propensity-score matched study. J Neurooncol 2022; 160:191-200. [DOI: 10.1007/s11060-022-04132-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/07/2022] [Indexed: 11/30/2022]
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18
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Matsui JK, Perlow HK, Raj RK, Nalin AP, Lehrer EJ, Kotecha R, Trifiletti DM, McClelland S, Kendra K, Williams N, Owen DH, Presley CJ, Thomas EM, Beyer SJ, Blakaj DM, Ahluwalia MS, Raval RR, Palmer JD. Treatment of Brain Metastases: The Synergy of Radiotherapy and Immune Checkpoint Inhibitors. Biomedicines 2022; 10:2211. [PMID: 36140312 PMCID: PMC9496359 DOI: 10.3390/biomedicines10092211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/31/2022] [Accepted: 09/02/2022] [Indexed: 11/27/2022] Open
Abstract
Brain metastases are a devastating sequela of common primary cancers (e.g., lung, breast, and skin) and have limited effective therapeutic options. Previously, systemic chemotherapy failed to demonstrate significant benefit in patients with brain metastases, but in recent decades, targeted therapies and more recently immune checkpoint inhibitors (ICIs) have yielded promising results in preclinical and clinical studies. Furthermore, there is significant interest in harnessing the immunomodulatory effects of radiotherapy (RT) to synergize with ICIs. Herein, we discuss studies evaluating the impact of RT dose and fractionation on the immune response, early studies supporting the synergistic interaction between RT and ICIs, and ongoing clinical trials assessing the benefit of combination therapy in patients with brain metastases.
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Affiliation(s)
| | - Haley K. Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Rohit K. Raj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Ansel P. Nalin
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | | | - Shearwood McClelland
- Departments of Radiation Oncology and Neurological Surgery, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Kari Kendra
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Nicole Williams
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Dwight H. Owen
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Carolyn J. Presley
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Evan M. Thomas
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Sasha J. Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Manmeet S. Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Raju R. Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Joshua D. Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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19
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Radiation therapy for melanoma brain metastases: a systematic review. Radiol Oncol 2022; 56:267-284. [PMID: 35962952 PMCID: PMC9400437 DOI: 10.2478/raon-2022-0032] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 06/17/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Radiation therapy (RT) for melanoma brain metastases, delivered either as whole brain radiation therapy (WBRT) or as stereotactic radiosurgery (SRS), is an established component of treatment for this condition. However, evidence allowing comparison of the outcomes, advantages and disadvantages of the two RT modalities is scant, with very few randomised controlled trials having been conducted. This has led to considerable uncertainty and inconsistent guideline recommendations. The present systematic review identified 112 studies reporting outcomes for patients with melanoma brain metastases treated with RT. Three were randomised controlled trials but only one was of sufficient size to be considered informative. Most of the evidence was from non-randomised studies, either specific treatment series or disease cohorts. Criteria for determining treatment choice were reported in only 32 studies and the quality of these studies was variable. From the time of diagnosis of brain metastasis, the median survival after WBRT alone was 3.5 months (IQR 2.4-4.0 months) and for SRS alone it was 7.5 months (IQR 6.7-9.0 months). Overall patient survival increased over time (pre-1989 to 2015) but this was not apparent within specific treatment groups. CONCLUSIONS These survival estimates provide a baseline for determining the incremental benefits of recently introduced systemic treatments using targeted therapy or immunotherapy for melanoma brain metastases.
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20
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Radiotherapy and Immunotherapy, Combined Treatment for Unresectable Mucosal Melanoma with Vaginal Origin. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12157734] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Gynecologic melanomas are uncommon and malignant mucosal melanomas with vaginal origin are extremely rare, treatment strategies are limited and extrapolated from those of cutaneous melanoma. A better understanding of the vulvovaginal melanoma’s biology and its risk factors is needed. Therapeutic strategies include surgery, systemic therapy and radiotherapy. For vulvovaginal melanoma, surgery is selected as the primary treatment. Immunotherapy and target treatment have recently enhanced the systemic therapy for cutaneous melanoma (CM). Immunotherapy and new target agents demonstrated a better survival of melanoma and might be considered as treatment of vulvovaginal melanoma. Radiotherapy is included in the therapeutic arsenal for mucosal melanoma and may be performed on selected patients who may receive concurrent checkpoints and inhibition neoadjuvant radiotherapy with the purpose of reducing morbidity and mortality.
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Tagliaferri L, Lancellotta V, Fionda B, Mangoni M, Casà C, Di Stefani A, Pagliara MM, D’Aviero A, Schinzari G, Chiesa S, Mazzarella C, Manfrida S, Colloca GF, Marazzi F, Morganti AG, Blasi MA, Peris K, Tortora G, Valentini V. Immunotherapy and radiotherapy in melanoma: a multidisciplinary comprehensive review. Hum Vaccin Immunother 2022; 18:1903827. [PMID: 33847208 PMCID: PMC9122308 DOI: 10.1080/21645515.2021.1903827] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Melanoma is an extremely aggressive tumor and is considered to be an extremely immunogenic tumor because compared to other cancers it usually presents a well-expressed lymphoid infiltration. The aim of this paper is to perform a multidisciplinary comprehensive review of the evidence available about the combination of radiotherapy and immunotherapy for melanoma. Radiation, in fact, can increase tumor antigens visibility and promote priming of T cells but can also exert immunosuppressive action on tumor microenvironment. Combining radiotherapy with immunotherapy provides an opportunity to increase immunostimulatory potential of radiation. We therefore provide the latest clinical evidence about radiobiological rationale, radiotherapy techniques, timing, and role both in advanced and systemic disease (with a special focus on ocular melanoma and brain, liver, and bone metastases) with a particular attention also in geriatric patients. The combination of immunotherapy and radiotherapy seems to be a safe therapeutic option, supported by a clear biological rationale, even though the available data confirm that radiotherapy is employed more for metastatic than for non-metastatic disease. Such a combination shows promising results in terms of survival outcomes; however, further studies, hopefully prospective, are needed to confirm such evidence.
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Affiliation(s)
- Luca Tagliaferri
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Valentina Lancellotta
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Bruno Fionda
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
- CONTACT Bruno Fionda UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli, 8, Roma00168, Italy
| | - Monica Mangoni
- Sezione di Radioterapia Oncologica, Dipartimento di Scienze Biomediche Sperimentali e Cliniche, Università di Firenze, Florence, Italy
| | - Calogero Casà
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Alessandro Di Stefani
- UOC Dermatologia, Dipartimento di Scienze mediche e chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Monica Maria Pagliara
- UOC Oncologia Oculare, Dipartimento di Scienze dell'Invecchiamento, neurologiche ortopediche e della testa collo, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Andrea D’Aviero
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Giovanni Schinzari
- UOC Oncologia Medica, Comprehensive Cancer Center, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Silvia Chiesa
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Ciro Mazzarella
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Stefania Manfrida
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Giuseppe Ferdinando Colloca
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Fabio Marazzi
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Alessio Giuseppe Morganti
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Settore Scientifico Disciplinare, Università di Bologna, Bologna, Italy
| | - Maria Antonietta Blasi
- UOC Oncologia Oculare, Dipartimento di Scienze dell'Invecchiamento, neurologiche ortopediche e della testa collo, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Ketty Peris
- UOC Dermatologia, Dipartimento di Scienze mediche e chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Giampaolo Tortora
- UOC Oncologia Medica, Comprehensive Cancer Center, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Vincenzo Valentini
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
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22
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The role of stereotactic radiotherapy in addition to immunotherapy in the management of melanoma brain metastases: results of a systematic review. Radiol Med 2022; 127:773-783. [PMID: 35606609 PMCID: PMC9308608 DOI: 10.1007/s11547-022-01503-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/06/2022] [Indexed: 11/12/2022]
Abstract
Aim of this study was to systematically review the literature to assess efficacy and safety of stereotactic radiotherapy (SRT) in combination with immunotherapy for the treatment of melanoma brain metastases (MBM). The literature was searched using PubMed, Scopus, and Embase. Studies comparing SRT plus immunotherapy versus SRT or immunotherapy alone were deemed eligible for inclusion. Two studies showed improved overall survival after SRT plus immunotherapy in melanoma cancer patients with brain metastases. Three studies reported data on LC and DFS showing as SRT plus immunotherapy did not improve local control and DFS rates. G3-G4 toxicity was reported in only one study (20% in the SRT plus immunotherapy group versus 23% in the immunotherapy group). Despite SRT plus concurrent immunotherapy seems associated with possible survival advantage and low ≥ G3 late toxicity rates, the quality of evidence is very low. Therefore, in patients with brain metastases from melanoma, SRT plus immunotherapy should be evaluated on an individual basis after discussion by a multidisciplinary team.
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Melanoma Brain Metastases: An Update on the Use of Immune Checkpoint Inhibitors and Molecularly Targeted Agents. Am J Clin Dermatol 2022; 23:523-545. [PMID: 35534670 DOI: 10.1007/s40257-022-00678-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 11/01/2022]
Abstract
Brain metastases from melanoma are no longer uniformly associated with dismal outcomes. Impressive tumor tissue-based (craniotomy) translational research has consistently shown that distinct patient subgroups may have a favorable prognosis. This review provides a historical overview of the standard-of-care treatments until the early 2010s. It subsequently summarizes more recent advances in understanding the biology of melanoma brain metastases (MBMs) and treating patients with MBMs, mainly focusing upon prospective clinical trials of BRAF/MEK and PD-1/CTLA-4 inhibitors in patients with previously untreated MBMs. These additional systemic treatments have provided effective complementary treatment approaches and/or alternatives to radiation and craniotomy. The current role of radiation therapy, especially in conjunction with systemic therapies, is also discussed through the lens of various retrospective studies. The combined efficacy of systemic treatments with radiation has improved overall survival over the last 10 years and has sparked considerable research interest regarding optimal dosing and sequencing of radiation treatments with systemic treatments. Finally, the review describes ongoing clinical trials in patients with MBMs.
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Gaebe K, Li AY, Park A, Parmar A, Lok BH, Sahgal A, Chan KKW, Erickson AW, Das S. Stereotactic radiosurgery versus whole brain radiotherapy in patients with intracranial metastatic disease and small-cell lung cancer: a systematic review and meta-analysis. Lancet Oncol 2022; 23:931-939. [DOI: 10.1016/s1470-2045(22)00271-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 12/14/2022]
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25
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State of the Art in Combination Immuno/Radiotherapy for Brain Metastases: Systematic Review and Meta-Analysis. Curr Oncol 2022; 29:2995-3012. [PMID: 35621634 PMCID: PMC9139474 DOI: 10.3390/curroncol29050244] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/03/2022] [Accepted: 04/17/2022] [Indexed: 01/10/2023] Open
Abstract
Objectives: Common origins for brain metastases (BMs) are melanoma, lung, breast, and renal cell cancers. BMs account for a large share of morbidity and mortality caused by these cancers. The advent of new immunotherapeutic treatments has made a revolution in the treatment of cancer patients and particularly, as a new concept, if it is combined with radiotherapy, may lead to considerably longer survival. This systematic review and meta-analysis aimed to evaluate the survival rate and toxicities of such a combination in brain metastases. Methods: To perform a systematic review of the literature until January 2021 using electronic databases such as PubMed, Cochrane Library, and Embase; the Newcastle–Ottawa Scale was used to evaluate the quality of cohort studies. For data extraction, two reviewers extracted the data blindly and independently. Hazard ratio with 95% confidence interval (CI), fixed-effect model, and inverse-variance method was calculated. The meta-analysis has been evaluated with the statistical software Stata/MP v.16 (The fastest version of Stata). Results: In the first step, 494 studies were selected to review the abstracts, in the second step, the full texts of 86 studies were reviewed. Finally, 28 studies were selected consisting of 1465 patients. The addition of IT to RT in the treatment of brain metastasis from melanoma and non-small-cell lung carcinoma was associated with a 39% reduction in mortality rate and has prolonged overall survival, with an acceptable toxicity profile. The addition of IT to RT compared with RT alone has a hazard ratio of 0.39(95% CI 0.34–0.44). Conclusions: A combination of immuno/radiotherapy (IR) for the treatment of patients with BMs from melanoma and non-small-cell lung carcinoma has prolonged overall survival and reduced mortality rate, with acceptable toxicity. In terms of timing, RT seems to have the best effect on the result when performed before or simultaneously with immunotherapy.
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26
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Li AY, Gaebe K, Jerzak KJ, Cheema PK, Sahgal A, Das S. Intracranial Metastatic Disease: Present Challenges, Future Opportunities. Front Oncol 2022; 12:855182. [PMID: 35330715 PMCID: PMC8940535 DOI: 10.3389/fonc.2022.855182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/16/2022] [Indexed: 11/13/2022] Open
Abstract
Intracranial metastatic disease (IMD) is a prevalent complication of cancer that significantly limits patient survival and quality of life. Over the past half-century, our understanding of the epidemiology and pathogenesis of IMD has improved and enabled the development of surveillance and treatment algorithms based on prognostic factors and tumor biomolecular characteristics. In addition to advances in surgical resection and radiation therapy, the treatment of IMD has evolved to include monoclonal antibodies and small molecule antagonists of tumor-promoting proteins or endogenous immune checkpoint inhibitors. Moreover, improvements in the sensitivity and specificity of imaging as well as the development of new serological assays to detect brain metastases promise to revolutionize IMD diagnosis. In this review, we will explore current treatment principles in patients with IMD, including the emerging role of targeted and immunotherapy in select primary cancers, and discuss potential areas for further investigation.
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Affiliation(s)
- Alyssa Y Li
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Karolina Gaebe
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Katarzyna J Jerzak
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Oncology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Parneet K Cheema
- Division of Oncology, William Osler Health System, Brampton, ON, Canada
| | - Arjun Sahgal
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Sunit Das
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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27
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Burke AM, Carrasquilla M, Jean WC, Collins BT, Anaizi AN, Atkins MB, Gibney GT, Collins SP. Volume of Disease as a Predictor for Clinical Outcomes in Patients With Melanoma Brain Metastases Treated With Stereotactic Radiosurgery and Immune Checkpoint Therapy. Front Oncol 2022; 11:794615. [PMID: 35096594 PMCID: PMC8789649 DOI: 10.3389/fonc.2021.794615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/15/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose/Objectives Clinical trials of anti-Programmed cell death protein 1 (PD-1) and cytotoxic T-lymphocyte-associated protein (CTLA-4) therapies have demonstrated a clinical benefit with low rates of neurologic adverse events in patients with melanoma brain metastases (MBMs). While the combined effect of these immunotherapies (ITs) and stereotactic radiosurgery (SRS) has yielded impressive results with regard to local control (LC) and overall survival (OS), it has also been associated with increased rates of radiation necrosis (RN) compared to historical series of SRS alone. We retrospectively reviewed patients treated with IT in combination with SRS to report on predictors of clinical outcomes. Materials and Methods Patients were included if they had MBMs treated with SRS within 1 year of receiving anti-PD-1 and/or CTLA-4 therapy. Clinical outcomes including OS, LC, intracranial death (ID), and RN were correlated with type and timing of IT with SRS, radiation dose, total volume, and size and number of lesions treated. Results Twenty-nine patients with 171 MBMs were treated between May 2012 and May 2018. Patients had a median of 5 lesions treated (median volume of 6.5 cm3) over a median of 2 courses of SRS. The median dose was 21 Gy. Most patients were treated with ipilimumab (n = 13) or nivolumab-ipilimumab (n = 10). Most patients underwent SRS concurrently or within 3 months of receiving immunotherapy (n = 21). Two-year OS and LC were 54.4% and 85.5%, respectively. In addition, 14% of patients developed RN; however, only 4.7% of the total treated lesions developed RN. The median time to development of RN was 9.5 months. Patients with an aggregate tumor volume >6.5 cm3 were found to be at increased risk of ID (p = 0.05) and RN (p = 0.03). There was no difference in OS, ID, or RN with regard to type of IT, timing of SRS and IT, number of SRS courses, SRS dose, or number of cumulative lesions treated. Conclusions In our series, patients treated with SRS and IT for MBMs had excellent rates of OS and LC; however, patients with an aggregate tumor volume >6.5 cm3 were found to be at increased risk of ID and RN. Given the efficacy of combined anti-PD-1/CTLA-4 therapy for MBM management, further study of optimal selection criteria for the addition of SRS is warranted.
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Affiliation(s)
- Aidan M Burke
- Department of Radiation Oncology, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - Michael Carrasquilla
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Walter C Jean
- George Washington University Hospital, Washington, DC, United States
| | - Brian T Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Amjad N Anaizi
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Michael B Atkins
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, United States
| | - Geoffrey T Gibney
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
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28
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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).
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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;
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29
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Wang J, Tawbi HA. Emergent immunotherapy approaches for brain metastases. Neurooncol Adv 2021; 3:v43-v51. [PMID: 34859232 PMCID: PMC8633738 DOI: 10.1093/noajnl/vdab138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Brain metastases from solid tumors are increasing in incidence, especially as outcomes of systemic therapies continue to extend patients’ overall survival. The long-held notion that the brain is an immune sanctuary has now been largely refuted with increasing evidence that immunotherapy can induce durable responses in brain metastases. Single agent immune checkpoint inhibition with anti-CTLA4 and anti-PD1 antibodies induces durable responses in 15%–20% in melanoma brain metastases as long as patients are asymptomatic and do not require corticosteroids. The combination of anti-CTLA4 with anti-PD-1 antibodies induces an intracranial response in over 50% of asymptomatic melanoma patients, and much lower rate of otherwise durable responses (20%) in symptomatic patients or those on steroids. Data in other cancers, such as renal cell carcinoma, are accumulating indicating a role for immunotherapy. Emerging immunotherapy approaches will have to focus on increasing response rates, decreasing toxicity, and decreasing steroid dependency. The path to those advances will have to include a better understanding of the mechanisms of response and resistance to immunotherapy in brain metastases, the use of novel agents such as anti-LAG3 checkpoint inhibitors, targeted therapy (oncogene directed or TKIs), and possibly surgery and SRS to improve the outcomes of patients with brain metastases.
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Affiliation(s)
- Jianbo Wang
- Department of Genitourinary Malignancies, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Hussein A Tawbi
- Department of Melanoma Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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30
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Anvari A, Sasanpour P, Rajabzadeh Kheradmardi M. Radiotherapy and immunotherapy in melanoma brain metastases. Hematol Oncol Stem Cell Ther 2021; 16:1-20. [PMID: 36634277 DOI: 10.1016/j.hemonc.2021.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 10/29/2021] [Accepted: 11/14/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Melanoma brain metastasis (MBM) generally portends a dismal prognosis. Simultaneous use of radiotherapy (RT) and immune checkpoint inhibitor (ICI) therapy demonstrated tremendous promise and emerged as the new standard. This meta-analysis was conducted to evaluate survival outcomes and toxicities of this combination in patients with MBM. Data analyses were performed using Comprehensive Meta-Analysis software (version 2) and IBM SPSS software (version 27). METHODS A systematic literature search of PubMed, EMBASE, and the Cochrane Library (via Wiley) was conducted using PICOS/PRISMA selection protocol and included studies to evaluate survival and safety-associated outcomes of ICI + RT for the treatment of MBM. RESULTS A total 44 studies involving 2498 patients were reviewed. The pooled effect size (ES) for overall survival (OS) to compare the ICI + RT arm and ICI alone arm (HR: 0.693 [0.526-0.913, p = .001]), and compare the ICI + RT arm and brain RT alone (HR: 0.595 [0.489-0.723, p < .001)] indicated better survival outcomes in ICI + RT versus RT alone and ICI alone arms. Comparing central nervous system toxicity in the ICI + RT arm and RT alone arm, the pooled ES Grade ≥ 3 neurologic adverse events (NAEs) risk ratio ([RR] = 1.425; 95% confidence interval [CI]: 0.485-4.183; p = .519) indicated that ICI + RT nonsignificantly increased Grade 3-4 NAEs. Comparing Grade ≥ 3 radiation necrosis in the ICI + RT arm and RT alone arm, the pooled ES RR (RR = 2.73; 95% CI: 0.59-12.59; p = .199) indicated that ICI + RT nonsignificantly increased Grade ≥ 3 radiation necrosis. CONCLUSION Concurrent administration of RT and ICI evinced favorable OS outcomes and acceptable safety profile in MBM patients. Planned prospective trials are required to demonstrate the issue.
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Affiliation(s)
- Amir Anvari
- Department of Radiation Oncology, Imam Hussein Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Pegah Sasanpour
- Department of Radiation Oncology, Imam Ali Hospital, Zahedan University of Medical Science, Zahedan, Iran
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31
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Li AR, Valdebran M, Reuben DY. Emerging Developments in Management of Melanoma During the COVID-19 Era. Front Med (Lausanne) 2021; 8:769368. [PMID: 34820401 PMCID: PMC8606631 DOI: 10.3389/fmed.2021.769368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/15/2021] [Indexed: 12/04/2022] Open
Abstract
In March 2020, the designation of the COVID-19 outbreak as a worldwide pandemic marked the beginning of an unprecedented era in modern medicine. Facing the possibility of resource precincts and healthcare rationing, leading dermatological and cancer societies acted expeditiously to adapt their guidelines to these contingencies. Melanoma is a lethal and aggressive skin cancer necessitating a multidisciplinary approach to management and is associated with significant healthcare and economic cost in later stages of disease. In revisiting how the pandemic transformed guidelines from diagnosis and surveillance to surgical and systemic management of melanoma, we appraise the evidence behind these decisions and their enduring implications.
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Affiliation(s)
- Andraia R Li
- Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Manuel Valdebran
- Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, SC, United States.,Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Daniel Y Reuben
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
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32
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Naik GS, Buchbinder EI, Cohen JV, Manos MP, Johnson AEW, Bowling P, Aizer AA, Schoenfeld JD, Lawrence DP, Haq R, Hodi FS, Sullivan RJ, Ott PA. Long-term Overall Survival and Predictors in Anti-PD-1-naive Melanoma Patients With Brain Metastases Treated With Immune Checkpoint Inhibitors in the Real-world Setting: A Multicohort Study. J Immunother 2021; 44:307-318. [PMID: 34406158 DOI: 10.1097/cji.0000000000000385] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/29/2021] [Indexed: 01/09/2023]
Abstract
Long-term survival outcomes among melanoma patients with brain metastases treated with immune checkpoint inhibitors are limited. In this retrospective study at 2 centers, metastatic melanoma patients with radiographic evidence of brain metastases who received anti-programmed death-1 (PD-1) monotherapy or nivolumab in combination with ipilimumab between 2014 and 2017 were included. Overall survival (OS) was assessed in diagnosis-specific graded prognostic assessment (ds-GPA) and melanoma-molecular graded prognostic assessment (molGPA) prognostic risk groups. Baseline clinical covariates were used to identify predictors of OS in univariate/multivariable Cox proportional-hazards models. A total of 84 patients (58 monotherapy, 26 combination) were included with a median duration of follow-up of 43.4 months (maximum: 5.1 y). The median OS [95% confidence interval (CI)] was 3.1 months (1.8, 7) for ds-GPA 0-1, 22.1 months [5.4, not reached (NR)] for ds-GPA 2 and NR (24.9, NR) for ds-GPA 3-4 in the monotherapy cohort [hazard ratio (HR) for ds-GPA 3-4 vs. 0-1: 0.13 (95% CI: 0.052, 0.32); 0.29 (95% CI: 0.12, 0.63) for ds-GPA 2 vs. 0-1]. The median OS was 1.1 months (95% CI: 0.3, NR) for ds-GPA 0-1, 11.8 months (95% CI: 2.9, 23.3) for ds-GPA 2 and 24.4 months (95% CI: 3.4, NR) for ds-GPA 3-4 in the combination cohort [HR for 3-4 vs. 0-1: 0.013 (95% CI: 0.0012, 0.14); HR for ds-GPA 2 vs. 0-1: 0.033 (0.0035, 0.31)]. Predictors associated with longer survival included ds-GPA or molGPA>1 (among prognostic indices), neutrophil-to-lymphocyte ratio (<4 vs. ≥4), while high lactate dehydrogenase, neurological symptoms, and leptomeningeal metastases were associated with shorter survival. Baseline ds-GPA/molGPA>1 and neutrophil-to-lymphocyte ratio <4 were strong predictors of long-term survival to anti-PD-1-based immune checkpoint inhibitors in melanoma brain metastases patients previously naive to anti-PD-1 therapy in a real-world clinical setting treated at independent centers.
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Affiliation(s)
- Girish S Naik
- Department of Medical Oncology, Dana-Farber Cancer Institute
- Harvard Medical School
| | - Elizabeth I Buchbinder
- Department of Medical Oncology, Dana-Farber Cancer Institute
- Harvard Medical School
- Brigham and Women's Hospital
| | - Justine V Cohen
- Harvard Medical School
- Center for Melanoma, Massachusetts General Hospital, Boston
| | - Michael P Manos
- Department of Medical Oncology, Dana-Farber Cancer Institute
| | - Alistair E W Johnson
- Institute of Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA
| | - Peter Bowling
- Department of Medical Oncology, Dana-Farber Cancer Institute
| | - Ayal A Aizer
- Harvard Medical School
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center
| | - Jonathan D Schoenfeld
- Harvard Medical School
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center
| | - Donald P Lawrence
- Harvard Medical School
- Center for Melanoma, Massachusetts General Hospital, Boston
| | - Rizwan Haq
- Department of Medical Oncology, Dana-Farber Cancer Institute
- Harvard Medical School
- Brigham and Women's Hospital
| | - Frank Stephen Hodi
- Department of Medical Oncology, Dana-Farber Cancer Institute
- Harvard Medical School
- Brigham and Women's Hospital
| | - Ryan J Sullivan
- Harvard Medical School
- Center for Melanoma, Massachusetts General Hospital, Boston
| | - Patrick A Ott
- Department of Medical Oncology, Dana-Farber Cancer Institute
- Harvard Medical School
- Brigham and Women's Hospital
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Tonse R, Tom MC, Mehta MP, Ahluwalia MS, Kotecha R. Integration of Systemic Therapy and Stereotactic Radiosurgery for Brain Metastases. Cancers (Basel) 2021; 13:cancers13153682. [PMID: 34359583 PMCID: PMC8345095 DOI: 10.3390/cancers13153682] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/16/2021] [Accepted: 07/20/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary In the multi-modal treatment of brain metastasis (BM), the role of systemic therapy has undergone a recent revolution. Due to the development of multiple agents with modest central nervous system penetration of the blood-brain barrier, targeted therapies and immune checkpoint inhibitors are increasingly being utilized alone or in combination with radiation therapy. However, the adoption of sequential or concurrent strategies varies considerably, and treatment strategies employed in clinical practice have rapidly outpaced evidence development. Therefore, this review critically analyzes the data regarding combinatorial approaches for a variety of systemic therapeutics with stereotactic radiosurgery and provides an overview of ongoing clinical trials. Abstract Brain metastasis (BM) represents a common complication of cancer, and in the modern era requires multi-modal management approaches and multi-disciplinary care. Traditionally, due to the limited efficacy of cytotoxic chemotherapy, treatment strategies are focused on local treatments alone, such as whole-brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), and resection. However, the increased availability of molecular-based therapies with central nervous system (CNS) penetration now permits the individualized selection of tailored systemic therapies to be used alongside local treatments. Moreover, the introduction of immune checkpoint inhibitors (ICIs), with demonstrated CNS activity has further revolutionized the management of BM patients. The rapid introduction of these cancer therapeutics into clinical practice, however, has led to a significant dearth in the published literature about the optimal timing, sequencing, and combination of these systemic therapies along with SRS. This manuscript reviews the impact of tumor biology and molecular profiles on the management paradigm for BM patients and critically analyzes the current landscape of SRS, with a specific focus on integration with systemic therapy. We also discuss emerging treatment strategies combining SRS and ICIs, the impact of timing and the sequencing of these therapies around SRS, the effect of corticosteroids, and review post-treatment imaging findings, including pseudo-progression and radiation necrosis.
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Affiliation(s)
- Raees Tonse
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (R.T.); (M.C.T.); (M.P.M.)
| | - Martin C. Tom
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (R.T.); (M.C.T.); (M.P.M.)
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA;
| | - Minesh P. Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (R.T.); (M.C.T.); (M.P.M.)
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA;
| | - Manmeet S. Ahluwalia
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA;
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (R.T.); (M.C.T.); (M.P.M.)
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA;
- Correspondence: ; Tel.: +1-(786)-596-2000
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Knispel S, Stang A, Zimmer L, Lax H, Gutzmer R, Heinzerling L, Weishaupt C, Pföhler C, Gesierich A, Herbst R, Kaehler KC, Weide B, Berking C, Loquai C, Utikal J, Terheyden P, Kaatz M, Schlaak M, Kreuter A, Ulrich J, Mohr P, Dippel E, Livingstone E, Becker JC, Weichenthal M, Chorti E, Gronewold J, Schadendorf D, Ugurel S. Impact of a preceding radiotherapy on the outcome of immune checkpoint inhibition in metastatic melanoma: a multicenter retrospective cohort study of the DeCOG. J Immunother Cancer 2021; 8:jitc-2019-000395. [PMID: 32371460 PMCID: PMC7228559 DOI: 10.1136/jitc-2019-000395] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2020] [Indexed: 12/16/2022] Open
Abstract
Background Immune checkpoint inhibition (ICI) is an essential treatment option in melanoma. Its outcome may be improved by a preceding radiation of metastases. This study aimed to investigate the impact of a preceding radiotherapy on the clinical outcome of ICI treatment. Methods This multicenter retrospective cohort study included patients who received anti-cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) or anti-programmed cell death protein 1 (PD-1) ICI with or without preceding radiotherapy for unresectable metastatic melanoma. ICI therapy outcome was measured as best overall response (BOR), progression-free (PFS) and overall survival (OS). Response and survival analyses were adjusted for confounders identified by directed acyclic graphs. Adjusted survival curves were calculated using inverse probability treatment weighting. Results 835 patients who received ICI (anti-CTLA-4, n=596; anti-PD-1, n=239) at 16 centers were analyzed, whereof 235 received a preceding radiotherapy of metastatic lesions in stage IV disease. The most frequent organ sites irradiated prior to ICI therapy were brain (51.1%), lymph nodes (17.9%) and bone (17.9%). After multivariable adjustment for confounders, no relevant differences in ICI therapy outcome were observed between cohorts with and without preceding radiotherapy. BOR was 8.7% vs 13.0% for anti-CTLA-4 (adjusted relative risk (RR)=1.47; 95% CI=0.81 to 2.65; p=0.20), and 16.5% vs 25.3% for anti-PD-1 (RR=0.93; 95% CI=0.49 to 1.77; p=0.82). Survival probabilities were similar for cohorts with and without preceding radiotherapy, for anti-CTLA-4 (PFS, adjusted HR=1.02, 95% CI=0.86 to 1.25, p=0.74; OS, HR=1.08, 95% CI=0.81 to 1.44, p=0.61) and for anti-PD-1 (PFS, HR=0.84, 95% CI=0.57 to 1.26, p=0.41; OS, HR=0.73, 95% CI=0.43 to 1.25, p=0.26). Patients who received radiation last before ICI (n=137) revealed no better survival than those who had one or more treatment lines between radiation and start of ICI (n=86). In 223 patients with brain metastases, we found no relevant survival differences on ICI with and without preceding radiotherapy. Conclusions This study detected no evidence for a relevant favorable impact of a preceding radiotherapy on anti-CTLA-4 or anti-PD-1 ICI treatment outcome in metastatic melanoma.
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Affiliation(s)
- Sarah Knispel
- Department of Dermatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Andreas Stang
- Center of Clinical Epidemiology, Institute for Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | - Lisa Zimmer
- Department of Dermatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Hildegard Lax
- Center of Clinical Epidemiology, Institute for Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | - Ralf Gutzmer
- Skin Cancer Center Hannover, Department of Dermatology, Hannover Medical School, Hannover, Germany
| | - Lucie Heinzerling
- Department of Dermatology, University Hospital Erlangen, Erlangen, Germany
| | - Carsten Weishaupt
- Department of Dermatology, University Hospital Münster, Münster, Germany
| | - Claudia Pföhler
- Department of Dermatology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Anja Gesierich
- Department of Dermatology, University Hospital Würzburg, Würzburg, Germany
| | - Rudolf Herbst
- Department of Dermatology, Helios Klinikum Erfurt, Erfurt, Germany
| | | | - Benjamin Weide
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Carola Berking
- Department of Dermatology, Ludwig-Maximilians University Munich, Munich, Germany
| | - Carmen Loquai
- Department of Dermatology, University Medical Center Mainz, Mainz, Germany
| | - Jochen Utikal
- Skin Cancer Unit, German Cancer Research Center (DKFZ) and Department of Dermatology, Venereology and Allergology, niversity Medical Center Mannheim, Ruprecht-Karl University of Heidelberg, Mannheim, Germany
| | - Patrick Terheyden
- Department of Dermatology, University Hospital Lübeck, Lübeck, Germany
| | - Martin Kaatz
- Department of Dermatology, Wald-Klinikum Gera, Gera, Germany
| | - Max Schlaak
- Department of Dermatology, Ludwig-Maximilians University Munich, Munich, Germany.,Department of Dermatology, Skin Cancer Center at CIO Koeln/Bonn, University Hospital Cologne, Cologne, Germany
| | - Alexander Kreuter
- Department of Dermatology, Helios St. Elisabeth Hospital Oberhausen, University of Witten-Herdecke, Oberhausen, Germany
| | - Jens Ulrich
- Department of Dermatology, Klinikum Quedlinburg, Quedlinburg, Germany
| | - Peter Mohr
- Department of Dermatology, Elbe-Klinikum Buxtehude, Buxtehude, Germany
| | - Edgar Dippel
- Department of Dermatology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Elisabeth Livingstone
- Department of Dermatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Jürgen C Becker
- Department of Dermatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.,Translational Skin Cancer Research, Deutsches Konsortium für Translationale Krebsforschung (DKTK), Deutsches Konsortium für Translationale Krebsforschung (DKTK), Essen, Germany
| | | | - Eleftheria Chorti
- Department of Dermatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Janine Gronewold
- Department of Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Selma Ugurel
- Department of Dermatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Fares J, Ulasov I, Timashev P, Lesniak MS. Emerging principles of brain immunology and immune checkpoint blockade in brain metastases. Brain 2021; 144:1046-1066. [PMID: 33893488 PMCID: PMC8105040 DOI: 10.1093/brain/awab012] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/12/2022] Open
Abstract
Brain metastases are the most common type of brain tumours, harbouring an immune microenvironment that can in principle be targeted via immunotherapy. Elucidating some of the immunological intricacies of brain metastases has opened a therapeutic window to explore the potential of immune checkpoint inhibitors in this globally lethal disease. Multiple lines of evidence suggest that tumour cells hijack the immune regulatory mechanisms in the brain for the benefit of their own survival and progression. Nonetheless, the role of the immune checkpoint in the complex interplays between cancers cells and T cells and in conferring resistance to therapy remains under investigation. Meanwhile, early phase trials with immune checkpoint inhibitors have reported clinical benefit in patients with brain metastases from melanoma and non-small cell lung cancer. In this review, we explore the workings of the immune system in the brain, the immunology of brain metastases, and the current status of immune checkpoint inhibitors in the treatment of brain metastases.
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Affiliation(s)
- Jawad Fares
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Ilya Ulasov
- Group of Experimental Biotherapy and Diagnostics, Institute for Regenerative Medicine, World-Class Research Center “Digital Biodesign and Personalized Healthcare”, Sechenov First Moscow State Medical University, Moscow 119991, Russia
| | - Peter Timashev
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University, Moscow 119991, Russia
| | - Maciej S Lesniak
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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36
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Kotecha R, Kim JM, Miller JA, Juloori A, Chao ST, Murphy ES, Peereboom DM, Mohammadi AM, Barnett GH, Vogelbaum MA, Angelov L, Suh JH, Ahluwalia MS. The impact of sequencing PD-1/PD-L1 inhibitors and stereotactic radiosurgery for patients with brain metastasis. Neuro Oncol 2021; 21:1060-1068. [PMID: 30796838 DOI: 10.1093/neuonc/noz046] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The response of brain metastases (BM) treated with stereotactic radiosurgery (SRS) and immune checkpoint inhibitors (ICIs; programmed cell death 1 and its ligand) is of significant interest. METHODS Patients were divided into cohorts based on ICI sequencing around SRS. The primary outcome was best objective response (BOR) that was lesion specific. Secondary outcomes included overall objective response (OOR), response durability, radiation necrosis (RN), and overall survival (OS). RESULTS One hundred fifty patients underwent SRS to 1003 BM and received ICI. Five hundred sixty-four lesions (56%) treated with concurrent ICI (±5 half-lives) demonstrated superior BOR, OOR, and response durability compared with lesions treated with SRS and delayed ICI. Responses were best in those treated with immediate (±1 half-life) ICI (BOR: -100 vs -57%, P < 0.001; complete response: 50 vs 32%; 12-month durable response: 94 vs 71%, P < 0.001). Lesions pre-exposed to ICI and treated with SRS had poorer BOR (-45%) compared with ICI naive lesions (-63%, P < 0.001); best response was observed in ICI naive lesions receiving SRS and immediate ICI (-100%, P < 0.001). The 12-month cumulative incidence of RN with immediate ICI was 3.2% (95% CI: 1.3-5.0%). First radiographic follow-up and best intracranial response were significantly associated with longer OS; steroids were associated with inferior response rates and poorer OS (median 10 vs 25 mo, P = 0.002). CONCLUSIONS Sequencing of ICI around SRS is associated with overall response, best response, and response durability, with the most substantial effect in ICI naive BM undergoing immediate combined modality therapy. First intracranial response for patients treated with immediate ICI and SRS may be prognostic for OS, whereas steroids are detrimental.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Joseph M Kim
- School of Medicine, Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Jacob A Miller
- Department of Radiation Oncology, Stanford University, Palo Alto, California
| | - Aditya Juloori
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samuel T Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Erin S Murphy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - David M Peereboom
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alireza M Mohammadi
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Vogelbaum
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Manmeet S Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
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37
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Borzillo V, Di Franco R, Giannarelli D, Cammarota F, Scipilliti E, D’Ippolito E, Petito A, Serra M, Falivene S, Grimaldi AM, Simeone E, Festino L, Vanella V, Trojaniello C, Vitale MG, Madonna G, Ascierto PA, Muto P. Ipilimumab and Stereotactic Radiosurgery with CyberKnife ® System in Melanoma Brain Metastases: A Retrospective Monoinstitutional Experience. Cancers (Basel) 2021; 13:cancers13081857. [PMID: 33924595 PMCID: PMC8068853 DOI: 10.3390/cancers13081857] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/27/2021] [Accepted: 04/07/2021] [Indexed: 01/22/2023] Open
Abstract
Simple Summary Retrospective studies have shown a survival advantage in combining ipilimumab with radiotherapy in patients with melanoma brain metastases (MBMs). However, these studies did not clarify the correct timing between the two methods. The aims of our study were to demonstrate the efficacy and toxicity of stereotactic radiotherapy/radiosurgery on MBMs in combination with ipilimumab and estimate the correct timing of treatments to improve patients’ outcomes. Abstract The median overall survival (OS) and local control (LC) of patients with melanoma brain metastases (MBMs) are poor even with immune checkpoint inhibitors and/or radiotherapy (RT). The aims of the study were to evaluate the association and timing of stereotactic radiotherapy (SRT)/radiosurgery (SRS) performed with the CyberKnife® System and ipilimumab (IPI). A total of 63 MBMs patients were analyzed: 53 received RT+IPI and 10 RT alone. Therefore, the patients were divided into four groups: RT PRE-PI (>4 weeks before IPI) (18), RT CONC-IPI (4 weeks before/between first and last cycle/within 3 months of last cycle of IPI) (20), RT POST-IPI (>3 months after IPI) (15), and NO-IPI (10). A total of 127 lesions were treated: 75 with SRS (one fraction) and 24 with SRT (three to five fractions). The median follow-up was 10.6 months. The median OS was 10.6 months for all patients, 10.7 months for RT+IPI, and 3.3 months for NO-IPI (p = 0.96). One-year LC was 50% for all patients, 56% for RT+IPI, and 18% for NO-IPI (p = 0.08). The 1-year intracranial control was 45% for all patients, 44% for RT+IPI, and 51% for NO-IPI (p = 0.73). IPI with SRS/SRT in MBMs treatment could improve LC. However, the impact and timing of the two modalities on patients’ outcomes are still unclear.
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Affiliation(s)
- Valentina Borzillo
- Radiation Oncology Unit, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Naples, Italy; (R.D.F.); (F.C.); (E.S.); (E.D.); (A.P.); (M.S.); (P.M.)
- Correspondence: ; Tel.: +39-08159031764; Fax: +39-0815903809
| | - Rossella Di Franco
- Radiation Oncology Unit, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Naples, Italy; (R.D.F.); (F.C.); (E.S.); (E.D.); (A.P.); (M.S.); (P.M.)
| | - Diana Giannarelli
- Statistical Unit, Regina Elena National Cancer Institute-IRCCS, 00144 Rome, Italy;
| | - Fabrizio Cammarota
- Radiation Oncology Unit, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Naples, Italy; (R.D.F.); (F.C.); (E.S.); (E.D.); (A.P.); (M.S.); (P.M.)
| | - Esmeralda Scipilliti
- Radiation Oncology Unit, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Naples, Italy; (R.D.F.); (F.C.); (E.S.); (E.D.); (A.P.); (M.S.); (P.M.)
| | - Emma D’Ippolito
- Radiation Oncology Unit, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Naples, Italy; (R.D.F.); (F.C.); (E.S.); (E.D.); (A.P.); (M.S.); (P.M.)
| | - Angela Petito
- Radiation Oncology Unit, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Naples, Italy; (R.D.F.); (F.C.); (E.S.); (E.D.); (A.P.); (M.S.); (P.M.)
| | - Marcello Serra
- Radiation Oncology Unit, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Naples, Italy; (R.D.F.); (F.C.); (E.S.); (E.D.); (A.P.); (M.S.); (P.M.)
| | - Sara Falivene
- Radiation Oncology Unit, Ospedale del Mare, Asl Napoli 1 Centro, 80147 Naples, Italy;
| | - Antonio M. Grimaldi
- Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Naples, Italy; (A.M.G.); (E.S.); (L.F.); (V.V.); (C.T.); (M.G.V.); (G.M.); (P.A.A.)
| | - Ester Simeone
- Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Naples, Italy; (A.M.G.); (E.S.); (L.F.); (V.V.); (C.T.); (M.G.V.); (G.M.); (P.A.A.)
| | - Lucia Festino
- Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Naples, Italy; (A.M.G.); (E.S.); (L.F.); (V.V.); (C.T.); (M.G.V.); (G.M.); (P.A.A.)
| | - Vito Vanella
- Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Naples, Italy; (A.M.G.); (E.S.); (L.F.); (V.V.); (C.T.); (M.G.V.); (G.M.); (P.A.A.)
| | - Claudia Trojaniello
- Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Naples, Italy; (A.M.G.); (E.S.); (L.F.); (V.V.); (C.T.); (M.G.V.); (G.M.); (P.A.A.)
| | - Maria Grazia Vitale
- Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Naples, Italy; (A.M.G.); (E.S.); (L.F.); (V.V.); (C.T.); (M.G.V.); (G.M.); (P.A.A.)
| | - Gabriele Madonna
- Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Naples, Italy; (A.M.G.); (E.S.); (L.F.); (V.V.); (C.T.); (M.G.V.); (G.M.); (P.A.A.)
| | - Paolo A. Ascierto
- Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Naples, Italy; (A.M.G.); (E.S.); (L.F.); (V.V.); (C.T.); (M.G.V.); (G.M.); (P.A.A.)
| | - Paolo Muto
- Radiation Oncology Unit, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Naples, Italy; (R.D.F.); (F.C.); (E.S.); (E.D.); (A.P.); (M.S.); (P.M.)
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Melanoma Brain Metastases in the Era of Targeted Therapy and Checkpoint Inhibitor Therapy. Cancers (Basel) 2021; 13:cancers13071489. [PMID: 33804910 PMCID: PMC8037963 DOI: 10.3390/cancers13071489] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/11/2021] [Accepted: 03/22/2021] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Brain metastases are common in melanoma and are often associated with significant morbidity and mortality. Although many new treatments for melanoma have been approved in recent years, including immune checkpoint inhibitors and BRAF/MEK inhibitors, limited data are available for survival for patients with brain metastases treated with these novel therapies. The aim of this retrospective study was to evaluate current surgical, radiation, and systemic therapies over the past 10 years in melanoma patients with brain metastases. Our study noted increased overall survival in patients treated with craniotomy and CTLA-4 checkpoint inhibitors, while whole brain radiation was associated with poorer overall survival. Abstract Brain metastases commonly develop in melanoma and are associated with poor overall survival of about five to nine months. Fortunately, new therapies, including immune checkpoint inhibitors and BRAF/MEK inhibitors, have been developed. The aim of this study was to identify outcomes of different treatment strategies in patients with melanoma brain metastases in the era of checkpoint inhibitors. Patients with brain metastases secondary to melanoma were identified at a single institution. Univariate and multivariable analyses were performed to identify baseline and treatment factors, which correlated with progression-free and overall survival. A total of 209 patients with melanoma brain metastases were identified. The median overall survival of the cohort was 5.3 months. On multivariable analysis, the presence of non-cranial metastatic disease, poor performance status (ECOG 2–4), whole-brain radiation therapy, and older age at diagnosis of brain metastasis were associated with poorer overall survival. Craniotomy (HR 0.66, 95% CI 0.45–0.97) and treatment with a CTLA-4 checkpoint inhibitor (HR 0.55, 95% CI 0.32–0.94) were the only interventions associated with improved overall survival. Further studies with novel agents are needed to extend lifespan in patients with brain metastases in melanoma.
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Clinical Significance of PDCD4 in Melanoma by Subcellular Expression and in Tumor-Associated Immune Cells. Cancers (Basel) 2021; 13:cancers13051049. [PMID: 33801444 PMCID: PMC7958624 DOI: 10.3390/cancers13051049] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/16/2021] [Accepted: 02/22/2021] [Indexed: 12/16/2022] Open
Abstract
Simple Summary While targeting programmed cell death (PDCD) 1 is a central treatment against melanoma, little is known about the related protein PDCD4. We defined differences in melanoma PDCD4 subcellular localization (either total cellular or nuclear-only) during oncogenesis, evaluated its presence on tumor-infiltrating immune cells, and determined its impact on survival. High PDCD4 expression resulted in improved survival in patients with primary and intracranial but not extracranial metastatic melanoma. High PDCD4 levels in surrounding tumor tissue were also associated with increased infiltrating immune cells. PDCD4 may be a potentially useful biomarker in melanoma to help guide our understanding of patient prognosis. Methods to increase PDCD4 in those with melanoma brain metastases may also help improve disease response. Abstract Little is known about the subcellular localization and function of programmed cell death 4 (PDCD4) in melanoma. Our past studies suggest PDCD4 interacts with Pleckstrin Homology Domain Containing A5 (PLEKHA5) to influence melanoma brain metastasis outcomes, as high intracranial PDCD4 expression leads to improved survival. We aimed to define the subcellular distribution of PDCD4 in melanoma and in the tumor microenvironment during neoplastic progression and its impact on clinical outcomes. We analyzed multiple tissue microarrays with well-annotated clinicopathological variables using quantitative immunofluorescence and evaluated single-cell RNA-sequencing on a brain metastasis sample to characterize PDCD4+ immune cell subsets. We demonstrate differences in PDCD4 expression during neoplastic progression, with high tumor and stromal PDCD4 levels associated with improved survival in primary melanomas and in intracranial metastases, but not in extracranial metastatic disease. While the expression of PDCD4 is well-documented on CD8+ T cells and natural killer cells, we show that it is also found on B cells and mast cells. PDCD4 expression in the tumor microenvironment is associated with increased immune cell infiltration. Further studies are needed to define the interaction of PDCD4 and PLEKHA5 and to evaluate the utility of this pathway as a therapeutic target in melanoma brain metastasis.
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Makawita S, Tawbi HA. Nonsurgical Management of Melanoma Brain Metastasis: Current Therapeutics, Challenges, and Strategies for Progress. Am Soc Clin Oncol Educ Book 2021; 41:79-90. [PMID: 34010041 DOI: 10.1200/edbk_321137] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
This review aims to provide an overview of nonsurgical treatment strategies for central nervous system metastases in melanoma as well as discuss treatment challenges and future directions. Recent strategies for melanoma brain metastases have involved proving the intracranial activity of approved therapies as well as identifying novel drug targets. BRAF/MEK combination therapy has intracranial activity in those with BRAF V600 mutations, though disease control is shorter for intracranial than extracranial metastases. Immunotherapy and combination immunotherapies have emerged as providing durable responses in melanoma, and newer studies combining immunotherapy with targeted therapies are emerging. Continued challenges include penetration through the blood-brain barrier and development of resistance mechanisms. Novel therapeutic targets and methods to improve central nervous system penetrance are being identified through the application of deep DNA- and RNA-sequencing analyses. Radiation therapy approaches, especially stereotactic radiosurgery in combination or in sequence with systemic therapies, are also being investigated. Both targeted therapies and immunotherapies have revolutionized the field of melanoma treatment. Multimodality approaches with multidisciplinary teams will pave the way for the future of central nervous system disease treatment in melanoma.
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Affiliation(s)
- Shalini Makawita
- Department of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hussein A Tawbi
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Moyers JT, Chong EG, Peng J, Tsai HHC, Sufficool D, Shavlik D, Nagaraj G. Real world outcomes of combination and timing of immunotherapy with radiotherapy for melanoma with brain metastases. Cancer Med 2021; 10:1201-1211. [PMID: 33484100 PMCID: PMC7926022 DOI: 10.1002/cam4.3716] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/19/2020] [Accepted: 12/30/2020] [Indexed: 12/24/2022] Open
Abstract
Introduction Immunotherapy (IT) and radiotherapy (RT) have improved overall survival in patients with melanoma with brain metastasis (MBM). We examined the real‐world survival impact of IT and RT combination and timing strategies. Materials and Methods From the facility‐based National Cancer Database (NCDB) data set, 3008 cases of MBM were identified between 2011 and 2015. Six treatment cohorts were identified: stereotactic radiosurgery (SRS) + IT, SRS alone, whole brain radiotherapy (WBRT) + IT, WBRT alone, IT alone, and none. Concurrent therapy was defined as IT given within 28 days before or after RT; nonconcurrent defined as IT administered within 28–90 days of RT. The co‐primary outcomes were propensity score‐adjusted overall survival by treatment regimen and overall survival by RT and IT timing. Results Median overall survival (mOS) was performed for each treatment category; SRS +IT 15.77 m; (95%CI 12.13–21.29), SRS alone (9.33 m; 95%CI: 8.0–11.3), IT alone (7.29 m; 95%CI: 5.35–12.91), WBRT +IT (4.89 m; 95%CI: 3.65–5.92), No RT or IT (3.29 m; 95%CI: 2.96–3.75), and WBRT alone (3.12 m; 95%CI 2.79–3.52). By propensity score matching, mOS for SRS +IT (15.5 m; 95%CI: 11.5–20.2) was greater than SRS alone (10.1 m; 95%CI: 8.4–11.8) (p = 0.010), and median survival for WBRT +IT (4.6 m; 95%CI: 3.4–5.6) was greater than WBRT alone (2.9 m; 95%CI: 2.5–3.5) (p < 0.001). In the SRS +IT group, 24‐month landmark survival was 47% (95%CI; 42–52) for concurrent versus 37% (95%CI; 30–44) for nonconcurrent (p = 0.40). Conclusion Those who received IT in addition to WBRT and SRS experienced longer survival compared to RT modalities alone, while those receiving concurrent SRS and IT trended toward improved survival versus nonconcurrent therapy.
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Affiliation(s)
- Justin T Moyers
- Division of Hematology and Oncology, Department of Internal Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Esther G Chong
- Department of Internal Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Jiahao Peng
- School of Public Health, Loma Linda University, Loma Linda, CA, USA
| | | | - Daniel Sufficool
- Department of Radiation Medicine, Loma Linda University, Loma Linda, CA, USA
| | - David Shavlik
- School of Public Health, Loma Linda University, Loma Linda, CA, USA
| | - Gayathri Nagaraj
- Division of Hematology and Oncology, Department of Internal Medicine, Loma Linda University, Loma Linda, CA, USA
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Nunno VD, Nuvola G, Mosca M, Maggio I, Gatto L, Tosoni A, Lodi R, Franceschi E, Brandes AA. Clinical efficacy of immune checkpoint inhibitors in patients with brain metastases. Immunotherapy 2021; 13:419-432. [PMID: 33472433 DOI: 10.2217/imt-2020-0208] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Brain metastases (BMs) represent a negative prognostic factor for patients with solid malignancies. BMs are generally approached with loco-regional treatments and the blood-brain barrier limits the efficacy of some systemic drugs. The aim of this review is to summarize current knowledge about the role of immune checkpoint inhibitors for the management of brain metastases in patients with solid malignancies. We performed a review of available literature. Immune checkpoint inhibitors represent the standard treatment for several advanced solid malignancies. However, with the exception of melanoma their clinical role in other solid malignancies is not completely clear due to the exclusion of patients with BM from approval clinical trials. Immune-checkpoint inhibitors may be an effective treatment of brain metastases of melanoma while their clinical role on brain metastases from other solid malignancies is uncertain.
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Affiliation(s)
| | - Giacomo Nuvola
- Department of Specialized, Experimental & Diagnostic Medicine, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna
| | - Mirta Mosca
- Department of Specialized, Experimental & Diagnostic Medicine, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna
| | - Ilaria Maggio
- Department of Medical Oncology, Azienda USL, Bologna, Italy
| | - Lidia Gatto
- Department of Medical Oncology, Azienda USL, Bologna, Italy
| | - Alicia Tosoni
- Department of Medical Oncology, Azienda USL, Bologna, Italy
| | - Raffaele Lodi
- IRCCS Istituto delle Scienze Neurologiche di Bologna
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Lee MH, Cho KR, Choi JW, Kong DS, Seol HJ, Nam DH, Jung HA, Sun JM, Lee SH, Ahn JS, Ahn MJ, Park K, Lee JI. Immune Checkpoint Inhibitors for Non-Small-Cell Lung Cancer with Brain Metastasis : The Role of Gamma Knife Radiosurgery. J Korean Neurosurg Soc 2020; 64:271-281. [PMID: 33267531 PMCID: PMC7969051 DOI: 10.3340/jkns.2020.0135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/07/2020] [Indexed: 12/26/2022] Open
Abstract
Objective Immune checkpoint inhibitors (ICIs) are approved for treating non-small-cell lung cancer (NSCLC); however, the safety and efficacy of combined ICI and Gamma Knife radiosurgery (GKS) treatment remain undefined. In this study, we retrospectively analyzed patients treated with ICIs with or without GKS at our institute to manage patients with brain metastases from NSCLC. Methods We retrospectively reviewed medical records of patients with brain metastases from NSCLC treated with ICIs between January 2015 and December 2017. Of 134 patients, 77 were assessable for brain responses and categorized into three groups as follows : group A, ICI alone (n=26); group B, ICI with concurrent GKS within 14 days (n=24); and group C, ICI with non-concurrent GKS (n=27). Results The median follow-up duration after brain metastasis diagnosis was 19.1 months (range, 1–77). At the last follow-up, 53 patients (68.8%) died, 20 were alive, and four were lost to follow-up. The estimated median overall survival (OS) of all patients from the date of brain metastasis diagnosis was 20.0 months (95% confidence interval, 12.5–27.7) (10.0, 22.5, and 42.1 months in groups A, B, and C, respectively). The OS was shorter in group A than in group C (p=0.001). The intracranial disease progression-free survival (p=0.569), local progression-free survival (p=0.457), and complication rates did not significantly differ among the groups. Twelve patients showed leptomeningeal seeding (LMS) during follow-up. The 1-year LMS-free rate in treated with ICI alone group (69.1%) was significantly lower than that in treated with GKS before ICI treatment or within 14 days group (93.2%) (p=0.004). Conclusion GKS with ICI showed no favorable OS outcome in treating brain metastasis from NSCLC. However, GKS with ICI did not increase the risk of complications. Furthermore, compared with ICI alone, GKS with ICI may be associated with a reduced incidence of LMS. Further understanding of the mechanism, which remains unknown, may help improve the quality of life of patients with brain metastasis.
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Affiliation(s)
- Min Ho Lee
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, Korea.,Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung-Rae Cho
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Won Choi
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Ae Jung
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Mu Sun
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Se-Hoon Lee
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myung-Ju Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keunchil Park
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Kim PH, Suh CH, Kim HS, Kim KW, Kim DY, Lee EQ, Aizer AA, Guenette JP, Huang RY. Immune Checkpoint Inhibitor with or without Radiotherapy in Melanoma Patients with Brain Metastases: A Systematic Review and Meta-Analysis. Korean J Radiol 2020; 22:584-595. [PMID: 33289357 PMCID: PMC8005357 DOI: 10.3348/kjr.2020.0728] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/09/2020] [Accepted: 07/16/2020] [Indexed: 12/29/2022] Open
Abstract
Objective Immune checkpoint inhibitor (ICI) therapy has shown activity against melanoma brain metastases. Recently, promising results have also been reported for ICI combination therapy and ICI combined with radiotherapy. We aimed to evaluate radiologic response and adverse event rates of these therapeutic options by a systematic review and meta-analysis. Materials and Methods A systematic literature search of Ovid-MEDLINE and EMBASE was performed up to October 12, 2019 and included studies evaluating the intracranial objective response rates (ORRs) and/or disease control rates (DCRs) of ICI with or without radiotherapy for treating melanoma brain metastases. We also evaluated safety-associated outcomes. Results Eleven studies with 14 cohorts (3 with ICI combination therapy; 5 with ICI combined with radiotherapy; 6 with ICI monotherapy) were included. ICI combination therapy {pooled ORR, 53% (95% confidence interval [CI], 44–61%); DCR, 57% (95% CI, 49–66%)} and ICI combined with radiotherapy (pooled ORR, 42% [95% CI, 31–54%]; DCR, 85% [95% CI, 63–95%]) showed higher local efficacy compared to ICI monotherapy (pooled ORR, 15% [95% CI, 11–20%]; DCR, 26% [95% CI, 21–32%]). The grade 3 or 4 adverse event rate was significantly higher with ICI combination therapy (60%; 95% CI, 52–67%) compared to ICI monotherapy (11%; 95% CI, 8–17%) and ICI combined with radiotherapy (4%; 95% CI, 1–19%). Grade 3 or 4 central nervous system (CNS)-related adverse event rates were not different (9% in ICI combination therapy; 8% in ICI combined with radiotherapy; 5% in ICI monotherapy). Conclusion ICI combination therapy or ICI combined with radiotherapy showed better local efficacy than ICI monotherapy for treating melanoma brain metastasis. The grade 3 or 4 adverse event rate was highest with ICI combination therapy, and the CNS-related grade 3 or 4 event rate was similar. Prospective trials will be necessary to compare the efficacy of ICI combination therapy and ICI combined with radiotherapy.
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Affiliation(s)
- Pyeong Hwa Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chong Hyun Suh
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Ho Sung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kyung Won Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong Yeong Kim
- Department of Quarantine, Incheon Airport National Quarantine Station, Incheon, Korea
| | - Eudocia Q Lee
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Ayal A Aizer
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Jeffrey P Guenette
- Department of Radiology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Raymond Y Huang
- Department of Radiology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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Kim PH, Suh CH, Kim HS, Kim KW, Kim DY, Aizer AA, Rahman R, Guenette JP, Huang RY. Immune checkpoint inhibitor therapy may increase the incidence of treatment-related necrosis after stereotactic radiosurgery for brain metastases: a systematic review and meta-analysis. Eur Radiol 2020; 31:4114-4129. [PMID: 33241519 DOI: 10.1007/s00330-020-07514-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/28/2020] [Accepted: 11/12/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To compare the incidence of treatment-related necrosis between combination SRS+ICI therapy and SRS therapy alone in patients with brain metastases from melanoma and non-small cell lung cancer (NSCLC). METHODS A systematic literature search of Ovid-MEDLINE and EMBASE was performed up to August 10, 2020. The difference in the pooled incidence of treatment-related necrosis after SRS+ICI or SRS alone was evaluated. The cumulative incidence of treatment-related necrosis at the specific time point after the treatment was calculated and plotted. Subgroup and meta-regression analyses were additionally performed. RESULTS Sixteen studies (14 on melanoma, 2 on NSCLC) were included. In NSCLC brain metastasis, the reported incidences of treatment-related necrosis in SRS+ICI and SRS alone ranged 2.9-3.4% and 0-2.9%, respectively. Meta-analysis was conducted including 14 studies on melanoma brain metastasis. The incidence of treatment-related necrosis was higher in SRS+ICI than SRS alone (16.0% vs. 6.5%; p = 0.065; OR, 2.35). The incidence showed rapid increase until 12 months after the SRS when combined with ICI therapy (14%; 95% CI, 8-22%) and its pace of increase slowed thereafter. Histopathologic diagnosis as the reference standard for treatment-related necrosis and inclusion of only symptomatic cases were the source of heterogeneity in SRS+ICI. CONCLUSIONS Treatment-related necrosis tended to occur 2.4 times more frequently in the setting of combination SRS+ICI therapy compared with SRS alone in melanoma brain metastasis showing high cumulative incidence within the first year. Treatment-related necrosis should be considered when SRS+ICI combination therapy is used for melanoma brain metastasis, especially in the first year. KEY POINTS • Treatment-related necrosis occurred 2.4 times more frequently in the setting of combination SRS+ICI therapy compared with SRS alone in melanoma brain metastasis. • Treatment-related necrosis more frequently occurred in brain metastases from melanoma than NSCLC. • Reference standard for treatment-related necrosis and inclusion of only symptomatic treatment-related necrosis were a significant source of heterogeneity, indicating varying definitions of treatment-related necrosis in the literature need to be unified.
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Affiliation(s)
- Pyeong Hwa Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 33, Seoul, 05505, Republic of Korea
| | - Chong Hyun Suh
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 33, Seoul, 05505, Republic of Korea.
| | - Ho Sung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 33, Seoul, 05505, Republic of Korea
| | - Kyung Won Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 33, Seoul, 05505, Republic of Korea
| | - Dong Yeong Kim
- Department of Quarantine, Incheon Airport National Quarantine Station, Incheon, Republic of Korea
| | - Ayal A Aizer
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, 02115, USA
| | - Rifaquat Rahman
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, 02115, USA
| | - Jeffrey P Guenette
- Division of Neuroradiology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Raymond Y Huang
- Division of Neuroradiology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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Outcomes of Treatment for Melanoma Brain Metastases. J Skin Cancer 2020; 2020:7520924. [PMID: 33282420 PMCID: PMC7685861 DOI: 10.1155/2020/7520924] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 09/13/2020] [Accepted: 10/15/2020] [Indexed: 11/17/2022] Open
Abstract
Background Historically, melanoma with brain metastases has a poor prognosis. In this retrospective medical record review, we report basic clinicopathological parameters and the outcomes of patients with melanoma and brain metastases treated with different treatment modalities before the era of immunotherapy and modern radiotherapy technique. Methods Patients with metastatic melanoma were treated with surgery, radiotherapy, and/or systemic therapy from 1998 to 2017. In our study, they were identified and stratified depending on treatment methods. Overall survival was defined as the time from the date of brain metastases to the death or last follow-up (2019 June 1st). Survival curves were estimated using the Kaplan–Meier method that was employed to calculate the hazard ratio. Results Six (12%) of 50 patients are still alive as of the last follow-up. The median overall survival from the onset of brain metastases was 11 months. The longest survival time was observed in patients treated by surgery followed by radiotherapy, surgery followed by radiotherapy and systemic therapy, and also radiotherapy followed by systemic therapy. The shortest survival was observed in the best supportive care group and patients treated by systemic therapy only. Conclusions Patients with brain metastases achieved better overall survival when treated by combined treatment modalities: surgery followed by radiotherapy (26.6 months overall survival), combining surgery, radiotherapy, and systemic therapy (18.7 months overall survival), and also radiotherapy followed by systemic therapy (13.8 months overall survival).
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Badrigilan S, Choupani J. SRS in Combination With Ipilimumab: A Promising New Dimension for Treating Melanoma Brain Metastases. Technol Cancer Res Treat 2020; 19:1533033820965607. [PMID: 33111619 PMCID: PMC7607808 DOI: 10.1177/1533033820965607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Dear Editor,I am writing to you in order to highlight some miscalculations in an article published in the journal of Technology in Cancer Research & Treatment, entitled; "SRS in Combination with Ipilimumab: A Promising New Dimension for Treating Melanoma Brain Metastases" by Khan, et al.1 These miscalculations changed the derived conclusion about median survival time, and adverse effects in the selected treatment groups. So, amending these miscalculations may help readers in future research decisions.
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Affiliation(s)
- Samireh Badrigilan
- 108931Tabriz University of Medical Sciences, Faculty of Medicine, Tabriz, Iran, Islamic Republic
| | - Jalal Choupani
- 108931Tabriz University of Medical Sciences, Faculty of Medicine, Tabriz, Iran, Islamic Republic
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Liermann J, Winkler JK, Syed M, Neuberger U, Reuss D, Harrabi S, Naumann P, Ristau J, Weykamp F, El Shafie RA, König L, Debus J, Hassel J, Rieken S. Stereotactic Radiosurgery With Concurrent Immunotherapy in Melanoma Brain Metastases Is Feasible and Effective. Front Oncol 2020; 10:592796. [PMID: 33178618 PMCID: PMC7593445 DOI: 10.3389/fonc.2020.592796] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 09/09/2020] [Indexed: 12/25/2022] Open
Abstract
Objective: Stereotactic radiosurgery (SRS) is an established treatment for brain metastases in the management of metastasized melanoma. The increasing use of checkpoint inhibitors in melanoma therapy leads to combined treatment schemes consisting of immunotherapy and SRS that need to be evaluated regarding safety and feasibility. Methods: We retrospectively analyzed 36 patients suffering from cerebral metastasized melanoma. Between November 2011 and May 2016, altogether 66 brain metastases were treated with single-fraction SRS (18-20 Gy prescribed to the 80% isodose) in combination with a checkpoint inhibitor (ipilimumab: 82%, pembrolizumab: 14% or nivolumab: 4%), administered within 3 months before or after SRS. Toxicity was evaluated with focus on the incidence of central nervous system (CNS) radiation necrosis (CRN). Overall survival (OS), freedom from local progression (FFLP), freedom from central nervous system radiation necrosis (FFCRN), and freedom from distant intracranial progression (FFDIP) were analyzed using the Kaplan-Meier method. Results: The median follow-up was 25 months (range: 2-115 months). Two patients (6%) presented with cerebral edema CTCAE °III and another two patients (6%) presented with one-sided muscle weakness CTCAE °III after SRS. One of these four symptomatic cases correlated with an observed CRN, the other three symptomatic cases were related to local tumor progression (n = 2) or related to the performance of additional whole brain radiotherapy (WBRT). No further CTCAE °III or °IV toxicity was seen. During follow-up, seven of the growing contrast-enhanced lesions were resected, revealing two cases of CRN and five cases of local tumor progression. Altogether, the observed CRN rate of the irradiated metastases was 6-17% at the time of analysis, ranging due to the radiologically challenging differentiation between CRN and local tumor progression. The observed ranges of the 1- and 2-years FFLP rates were 82-85% and 73-80%, respectively. The median FFDIP was 6.1 months, the median OS was 22.2 months. Conclusion: In the presented cohort, the combination of SRS and checkpoint inhibitors in the management of cerebral metastasized melanoma was safe and effective. Compared to historic data on SRS only, the observed CRN rate was acceptable. To gain resilient data on the incidence of CRN after combined treatment schemes, prospective trials are needed.
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Affiliation(s)
- Jakob Liermann
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Julia K Winkler
- National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Dermatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Mustafa Syed
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Ulf Neuberger
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - David Reuss
- Heidelberg University Hospital, Institute of Pathology, Heidelberg, Germany
| | - Semi Harrabi
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Patrick Naumann
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Jonas Ristau
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Fabian Weykamp
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Rami A El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jessica Hassel
- National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Dermatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
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Current Multimodality Treatments Against Brain Metastases from Renal Cell Carcinoma. Cancers (Basel) 2020; 12:cancers12102875. [PMID: 33036276 PMCID: PMC7600559 DOI: 10.3390/cancers12102875] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/02/2020] [Accepted: 10/03/2020] [Indexed: 01/05/2023] Open
Abstract
Simple Summary Brain metastasis (BM) is generally one of poor prognostic factors in patients with advanced renal cell carcinoma. However, because of longer control of extra-cranial disease by the recent introduction of molecular target therapy and immune checkpoint inhibitor, the incidence of BM has been recently increasing and to progress the treatment of BM is one of urgent medical unmet needs. Although the pivotal clinical trials usually excluded patients with BM, BM subgroup data from the prospective and retrospective series have been gradually accumulated. To select the appropriate strategy, individual patient and tumor characteristics (e.g., Karnofsky Performance Status (KPS), systemic cancer burden, the number/size/location of BM) are important information. Among the local treatments, the technology of stereotactic radiosurgery (SRT) has been especially advanced and its adaptation has been expanded. The combination of SRT with molecular target therapy and/or immune checkpoint inhibitor would be promising to further enhance the efficacy without increased toxicity. Abstract In patients with renal cell carcinoma, brain metastasis is generally one of the poor prognostic factors. However, the recent introduction of molecular target therapy and immune checkpoint inhibitor has remarkably advanced the systemic treatment of metastatic renal cell carcinoma and prolonged the patients’ survival. The pivotal clinical trials of those agents usually excluded patients with brain metastasis. The incidence of brain metastasis has been increasing in the actual clinical setting because of longer control of extra-cranial disease. Brain metastasis subgroup data from the prospective and retrospective series have been gradually accumulated about the risk classification of brain metastasis and the efficacy and safety of those new agents for brain metastasis. While the local treatment against brain metastasis includes neurosurgery, stereotactic radiosurgery, and conventional whole brain radiation therapy, the technology of stereotactic radiosurgery has been especially advanced, and the combination with systemic therapy such as molecular target therapy and immune checkpoint inhibitor is considered promising. This review summarizes recent progression of multimodality treatment of brain metastasis of renal cell carcinoma from literature data and explores the future direction of the treatment.
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50
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He Q, Zhang C, Tang S, Li J, Ren Q. Intracranial radiotherapy with or without immune checkpoint inhibition for brain metastases: a systematic review and meta-analysis. Transl Cancer Res 2020; 9:5909-5924. [PMID: 35117204 PMCID: PMC8797322 DOI: 10.21037/tcr-20-902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/02/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND With the development of immunotherapy in recent years, the prognosis of patients is expected to improve due to immune checkpoint inhibition (ICI) combined with radiotherapy (RT). However, studies on combination therapy (ICI + intracranial RT) have reported inconsistent results, and it is unclear whether the combination has increased toxicity. By analyzing the latest relevant literature, we performed a meta-analysis to further clarify the effectiveness and safety of intracranial RT combined with ICI in patients with brain metastases (BMs). METHODS We searched PubMed, Embase and the Cochrane Library for published studies that compared the efficacy and safety of intracranial RT combined with ICI versus intracranial RT alone in the treatment of BMs. Overall survival (OS), local brain failure (LBF), distant brain failure (DBF), and radiation necrosis (RN) were pooled with the use of the hazard ratio (HR) or odds ratio (OR). RESULTS A total of 26 retrospective observation cohort studies were included, and over 1,500 patients who received ICI and intracranial RT were evaluated. Compared with intracranial RT alone, RT combined with ICI significantly improved OS in patients with BMs [HR =0.55, 95% confidence interval (CI): 0.48-0.64, P<0.001 when OS was defined from the date of diagnosis of BMs; HR =0.45, 95% CI: 0.39-0.52, P<0.001 when OS was defined from the date of RT], though the risk of RN was similar to that of RT alone (HR =1.27, 95% CI: 0.58-2.79, P=0.55). However, significant improvement in LBF and DBF was not obtained with RT combined with ICI (1-year LBF: OR =1.71, 95% CI: 0.38-7.67, P=0.48; LBF: HR =0.49, 95% CI: 0.28-0.87, P=0.01; 1-year DBF: OR =1.05, 95% CI: 0.47-2.33, P=0.90). CONCLUSIONS ICI combined with intracranial RT confers a significant OS benefit for patients with BMs without significantly increasing treatment-related toxicity, but further research regarding the specific details of combined treatment application is needed to improve the survival and quality of life of patients with BMs.
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Affiliation(s)
- Qian He
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chi Zhang
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Sheng Tang
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiayi Li
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qinglan Ren
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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