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Mampre D, Mehkri Y, Rajkumar S, Sriram S, Hernandez J, Lucke-Wold B, Chandra V. Treatment of breast cancer brain metastases: radiotherapy and emerging preclinical approaches. DIAGNOSTICS AND THERAPEUTICS 2022; 1:25-38. [PMID: 35782783 PMCID: PMC9249118 DOI: 10.55976/dt.1202216523-36] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The breast is one of the common primary sites of brain metastases (BM). Radiotherapy for BM from breast cancer may include whole brain radiation therapy (WBRT), stereotactic radiosurgery (SRS), and stereotactic radiotherapy (SRT), but a consensus is difficult to reach because of the wide and varied protocols, indications, and outcomes of these interventions. Overall, dissemination of disease, patient functional status, and tumor size are all important factors in the decision of treatment with WBRT or SRS. Thus far, previous studies indicate that WBRT can improve tumor control compared to SRS, but increase side effects, however no randomized trials have compared the efficacy of these therapies in BM from breast cancer. Therapies targeting long non-coding RNAs and transcription factors, such as MALAT1, HOTAIR, lnc-BM, TGL1, and ATF3, have the potential to both prevent metastatic spread and treat BM with improved radiosensitivity. Given the propensity for HER2+ breast cancer to develop BM, the above-mentioned cell lines may represent an important target for future investigations, and the development of everolimus and pyrotinib are equally important.
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Affiliation(s)
- David Mampre
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | - Yusuf Mehkri
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | | | - Sai Sriram
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | - Jairo Hernandez
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | | | - Vyshak Chandra
- Department of Neurosurgery, University of Florida, Gainesville, FL
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Paul S, Ohri N, Velten C, Brodin P, Mynampati D, Tomé W, Mao SPH, Kabarriti R, Garg M, Fox J. The effect of low-dose radiation spillage during stereotactic radiosurgery for brain metastases on the development of de novo metastases. Clin Transl Radiat Oncol 2021; 28:79-84. [PMID: 33851037 PMCID: PMC8038935 DOI: 10.1016/j.ctro.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/07/2021] [Accepted: 03/13/2021] [Indexed: 11/28/2022] Open
Abstract
165 new brain lesions in 38 patients who had prior SRS for brain metastases. 73% primary lung cancer patients. Lower incidence of new lesions with increasing dose received by the region from prior SRS. Accounting for discrepancies in both volume of the brain and follow-up period, regions that received doses of 4 Gy or more from previous SRS had 3 or fewer new lesions compared to 17 new lesions per 100 cm3 brain per year in regions that received 1 Gy or less.
Purpose/Objective(s) Stereotactic radiosurgery (SRS) for metastatic disease to the brain is associated with higher in-brain failures compared to whole brain radiation therapy (WBRT). Here we investigated the relationship between low-dose fall off during SRS and location of new brain lesions. Materials and Methods One hundred sixty-seven patients treated with single fraction or fractionated SRS for intact or resected brain metastases at our institution from January 2016 to June 2018 were reviewed. Patients with imaging findings of new brain metastases after the initial SRS were included. Patients with WBRT before SRS were excluded. MRI scans for repeat treatments were fused with initial SRS plan. New lesions were outlined on the initial SRS planning CT. The mean dose that the site of new lesions received from initial SRS was tabulated. Results Thirty-eight patients met inclusion criteria. 165 new lesions were evaluated. There was a lower propensity to develop new brain lesions with increasing dose received by the regions from prior SRS, with 66%, 34%, 19%, 13%, 6%, 5%, 2% and 1% of new lesions appearing in regions that received less than 1 Gy, greater than or equal to 1, 2, 3, 4, 5, 6, and 7 Gy, respectively. Higher doses are received by smaller brain volumes during SRS. After accounting for volume, 14, 14, 11, 7, 2, 2, 1 and 1 new lesions appeared per 100 cm3 of brain in regions that received doses of less than 1 Gy, greater than or equal to 1, 2, 3, 4, 5, 6, and 7 Gy, respectively, from prior SRS. Conclusions We identified low dose spillage during SRS to be associated with lower incidence of new brain metastases. Validation in larger dataset or prospective study of the combination of SRS with low dose WBRT would be crucial in order to establish causality of these findings.
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Affiliation(s)
- Shiby Paul
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Nitin Ohri
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Christian Velten
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Patrik Brodin
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Dinesh Mynampati
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Wolfgang Tomé
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Serena P H Mao
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rafi Kabarriti
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Madhur Garg
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jana Fox
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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White PJ, Zhang YZ, Power C, Vykhodtseva N, McDannold N. Observed Effects of Whole-Brain Radiation Therapy on Focused Ultrasound Blood-Brain Barrier Disruption. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:1998-2006. [PMID: 32451192 PMCID: PMC7329597 DOI: 10.1016/j.ultrasmedbio.2020.04.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 03/11/2020] [Accepted: 04/13/2020] [Indexed: 06/11/2023]
Abstract
As focused ultrasound for blood-brain barrier disruption (FUS-BBBD) has progressed to human application, it has become necessary to consider the potential effects of prior irradiation treatments. Using a murine model, we examined the effects of whole-brain irradiation on FUS-BBBD. We first subjected half of the experimental cohort to daily 3-Gy whole-brain irradiation for 10 consecutive days. Then, microbubble-assisted FUS-BBBD was performed unilaterally while the contralateral sides served as unsonicated controls. FUS-BBBD, as evident by measuring the fluorescence yield of extravasated trypan blue dye, was identified at all sites with minimal or no apparent pathology. The peak fluorescence intensity caused by extravasated dye in the sonicated region was 17.5 ± 12.1% higher after radiation and FUS-BBBD than after FUS-BBBD alone, suggesting that prior radiation of the brain may be a sensitizing factor for FUS-BBBD. Radiation alone-without FUS-BBBD-resulted in mild BBB disruption. Hemorrhagic petechiae were observed in 9 of 12 radiated brains, with 77% of them clearly located outside the sonicated area; no petechiae were found in non-irradiated animals. This radiation protocol did not appear to increase the risk for vascular damage associated with FUS-BBBD.
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Affiliation(s)
- Phillip Jason White
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Yong-Zhi Zhang
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Chanikarn Power
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Natalia Vykhodtseva
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nathan McDannold
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Zhuang QY, Li JL, Lin FF, Lin XJ, -lin H, -Wang Y, -Lin Y, Huang YX, Zhang XQ, Tang LR, Wu JX. High Biologically Effective Dose Radiotherapy for Brain Metastases May Improve Survival and Decrease Risk for Local Relapse Among Patients With Small-Cell Lung Cancer: A Propensity-Matching Analysis. Cancer Control 2020; 27:1073274820936287. [PMID: 32614270 PMCID: PMC7333507 DOI: 10.1177/1073274820936287] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/28/2020] [Accepted: 05/29/2020] [Indexed: 11/16/2022] Open
Abstract
To evaluate whether high biologically effective dose (BED) radiotherapy improves local control and survival outcomes for patients with brain metastases (BMs) from small-cell lung cancer (SCLC) and to determine possible prognostic factors. From January 1998 to June 2018, 250 patients with BM from SCLC were retrospectively analyzed. The Cutoff Finder program was used to classify patients by BED. Overall survival (OS) and BM progression-free survival (BM-PFS) were analyzed using the Kaplan-Meier method and log-rank test. A Cox regression model was used to calculate the hazard ratio and 95% CI for prognostic factors for OS among the study population and propensity score (PS)-matched patients. A BED of 47.4 was taken as the optimal cutoff value. Both OS and BM-PFS were significantly improved in the high-BED (>47.4 Gy) than in the low-BED (≤47.4 Gy) group (median OS: 17.5 months vs 9.5 months, P < .001, median BM-PFS: 14.4 months vs 8.3 months, P < .001). Biologically effective dose (P < .001), Eastern Cooperative Oncology Group performance status (P = .047), smoking (P = .005), and pleural effusion (P = .004) were independent prognostic factors for OS. Propensity score matching with a ratio of 1:2 resulted in 57 patients in the high-BED group and 106 patients in the low-BED group. In the PS-matched cohort, OS and BM-PFS were significantly prolonged in the high-BED group compared with the low-BED group (P < .001). Biologically effective dose >47.4 Gy improves survival among patients with BM from SCLC. Eastern Cooperative Oncology Group score, smoking, and pleural effusion independently affect OS of SCLC patients with BM.
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Affiliation(s)
- Qing-yang Zhuang
- Department of Radiation Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Jin-luan Li
- Department of Radiation Oncology, Xiamen Cancer Center, The First Affiliated Hospital, School of Medicine, Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen, People’s Republic of China
| | - Fei-fei Lin
- Department of Radiation Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Xi-jin Lin
- Department of Radiation Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Huaqin -lin
- Department of Radiation Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Youjia -Wang
- Department of Radiation Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Yaobin -Lin
- Department of Radiation Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Yun-xia Huang
- Department of Radiation Oncology, Xiamen Cancer Center, The First Affiliated Hospital, School of Medicine, Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen, People’s Republic of China
| | - Xue-qing Zhang
- Department of Radiation Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Li-rui Tang
- Department of Renal Cancer and Melanoma, The Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing, People’s Republic of China
| | - Jun-xin Wu
- Department of Radiation Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
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Nieder C, Mannsåker B, Yobuta R. Late Brain Oligometastases Diagnosed at Least 36 Months after Cancer Detection are Associated with Favorable Survival Outcome. Cureus 2020; 12:e6553. [PMID: 32042526 PMCID: PMC6996465 DOI: 10.7759/cureus.6553] [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: 11/05/2022] Open
Abstract
Objective The aim of this study was to investigate the impact of a long disease-free interval (at least 36 months from the first diagnosis of cancer) on survival in patients with brain oligometastases (maximum four lesions, no extracranial metastases). Methods This study involves a retrospective analysis in a group of 89 patients treated with different brain-directed approaches. Results We identified seven patients (8%) with an interval from cancer diagnosis to the development of brain metastases of at least 36 months. The median time interval was five months. The one-year survival rates were 80% (interval of at least 36 months) and 43% (shorter interval), respectively (p = 0.049). Correspondingly, a large difference in actuarial median survival was observed (39.9 months [95% confidence interval, 16.8-63.0 months] versus 9.7 months (95% confidence interval, 6.1-13.3 months). However, the two Kaplan-Meier curves were not statistically significantly different, p = 0.13. In addition to treatment-related differences, the two groups also differed with regard to the type of primary tumor (high versus low rates of non-small cell lung cancer) and gender. Conclusion Late dissemination was uncommon. The often applied strategy of effective local treatment for patients with brain-only oligometastases is warranted, especially if the disease-free interval had been at least 36 months. Larger studies are needed to fully understand the impact of confounding factors, such as gender and tumor biology.
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Suteu P, Fekete Z, Todor N, Nagy V. Survival and quality of life after whole brain radiotherapy with 3D conformal boost in the treatment of brain metastases. Med Pharm Rep 2019; 92:43-51. [PMID: 30957086 PMCID: PMC6448499 DOI: 10.15386/cjmed-1040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/05/2018] [Accepted: 06/20/2018] [Indexed: 01/02/2023] Open
Abstract
Background Brain metastases are the most frequent intracranial neoplasms in adults. Although overall survival (OS) is an important endpoint in patients receiving radiotherapy, given their poor life expectancy in general, quality of life is becoming an increasingly useful endpoint. Objectives: to evaluate whole brain radiotherapy (WBRT) with 3D conformal boost in brain metastases patients with regard to OS and quality of life. Methods During April 2015-May 2017, a total of 35 patients with ≤5, previously untreated, inoperable brain metastases were included prospectively. All patients underwent WBRT followed by 3D conformal boost to the metastatic lesions. EORTC quality of life questionnaires QLQ-C30 and QLQ-BN20 were used at baseline and at end of treatment. The mean initial and final scores were compared using Student test. One-year OS with brain metastases was computed with Kaplan Maier method. Results Median survival with brain metastases was 4.43 months (0.73-78.53). The one-year OS for patients with one metastasis was 42% versus 15% for more than one (p<0.04). The presence of extracerebral metastases significantly decreased OS from 39% without extracerebral metastases to 19%. (p<0.05). Quality of life improved significantly in several functional domains: physical (48 vs 60.29), role functioning (28.1 vs 44.7), emotional (47.1 vs 80.2), global health status (40.9 vs 62.3). Symptom scores decreased significantly in most items, corresponding to an improvement in the symptom burden: headache (61.9 vs 0.9), nausea and vomiting (45.7 vs 7.1), visual disorder (26.3 vs 9.2), seizures (30.4 vs 0.9), motor dysfunction (46.6 vs 17.1). Symptom scores for fatigue and drowsiness increased significantly (51.1 vs 74.9, respectively 37.1 vs 70.4), indicating worsening of symptoms. Conclusions WBRT with 3D conformal boost is a feasible technique which improves quality of life in brain metastases patients. Since survival is limited, the assessment of quality of life is a good indicator of the treatment outcome.
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Affiliation(s)
- Patricia Suteu
- Oncology-Radiotherapy Department, Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca, Romania
| | - Zsolt Fekete
- Oncology-Radiotherapy Department, Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca, Romania.,Oncology-Radiotherapy Department, "Prof. Dr. I. Chiricuta" Oncology Institute Cluj-Napoca, Romania
| | - Nicolae Todor
- Oncology-Radiotherapy Department, "Prof. Dr. I. Chiricuta" Oncology Institute Cluj-Napoca, Romania
| | - Viorica Nagy
- Oncology-Radiotherapy Department, Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca, Romania.,Oncology-Radiotherapy Department, "Prof. Dr. I. Chiricuta" Oncology Institute Cluj-Napoca, Romania
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Rades D, Dziggel L, Schild SE. A Specific Survival Score for Patients Receiving Local Therapy for Single Brain Metastasis from a Gynecological Malignancy. In Vivo 2018; 32:825-828. [PMID: 29936465 DOI: 10.21873/invivo.11314] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 03/30/2018] [Accepted: 04/02/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIM Personalization of the treatment of brain metastases considering patient's overall survival (OS) prognosis is gaining importance. This study was conducted to develop an OS score particularly for patients receiving local therapies for single brain metastasis from gynecological malignancies. PATIENTS AND METHODS In 11 patients, the following factors were retrospectively analyzed for associations with OS: Age, Karnofsky performance score (KPS), tumor type, extra-cranial metastatic sites, and time from diagnosis of gynecological malignancy to treatment of brain metastasis. Factors showing at least a strong trend were used for the score. RESULTS A KPS of 80-90% resulted in a significantly better OS than a KPS of 50-70% (p=0.008). Absence of extra-cranial metastases showed a strong trend (p=0.052). For the score, the following points were used: KPS 50-70%=0, KPS 80-90%=1, presence of extra-cranial metastatic sites=0, absence=1. Patients' scores were 0, 1 or 2 points. OS rates at both 6 and 12 months were 0%, 67% and 100%, respectively (p=0.020). CONCLUSION This specific score can be used to estimate OS in patients receiving local therapies for single brain metastasis from gynecological malignancies and personalize their care.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Liesa Dziggel
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, U.S.A
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Kühnöl J, Kühnöl C, Vordermark D. Radiotherapy of brain metastases from breast cancer: Treatment results and prognostic factors. Oncol Lett 2016; 11:3223-3227. [PMID: 27123095 DOI: 10.3892/ol.2016.4349] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 02/25/2016] [Indexed: 11/06/2022] Open
Abstract
Brain metastases (BM) from breast cancer are associated with high morbidity and a poor prognosis. The aim of this study was to analyse the role of radiotherapy in treatment of BM from breast cancer in the context of modern local therapy modalities, current systemic treatment options and prognostic factors. A retrospective analysis of 86 consecutive female patients treated with radiotherapy for BM from breast cancer between 2000 and 2010 was conducted. Patient and treatment characteristics were registered and survival data calculated. All patients received whole-brain radiotherapy (WBRT) with a median dose of 36 Gy, and 19 patients were treated with an additional boost; this included fractionated schemes (median dose, 18 Gy) and radiosurgery (5 and 17 Gy). The median overall survival time from the start of WBRT was 4.1 months in the present cohort. Patients receiving a boost survived 19.7 months in comparison to 3.1 months for patients treated with WBRT alone (P<0.001). Other factors that improved overall survival, based on a univariate analysis, were dose of WBRT and number of BM. There was no statistical evidence for the influence of the human epidermal growth factor receptor 2 status on survival in the current study. The administration of boost treatment following WBRT was also identified as a significant factor influencing survival on multivariate analysis (P=0.030). In conclusion, radiotherapy affects the survival time of patients with BM from breast cancer. In particular, the implementation of boost treatment following WBRT in selected patients seems to extend survival time.
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Affiliation(s)
- Julia Kühnöl
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, D-06120 Halle (Saale), Saxony-Anhalt, Germany
| | - Caspar Kühnöl
- Department of Paediatrics, Martin Luther University Halle-Wittenberg, D-06120 Halle (Saale), Saxony-Anhalt, Germany
| | - Dirk Vordermark
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, D-06120 Halle (Saale), Saxony-Anhalt, Germany
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Bertolini F, Spallanzani A, Fontana A, Depenni R, Luppi G. Brain metastases: an overview. CNS Oncol 2015; 4:37-46. [PMID: 25586424 DOI: 10.2217/cns.14.51] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
So far brain metastases represent a critical stage of a disease course and the frequency is increasing over the years. The treatment of brain metastases should be individualized for each patient: in case of single brain metastasis, surgery or radiosurgery should be considered as first options of treatment; in case of multiple lesions, whole-brain radiotherapy is the standard of care in association with systemic therapy or surgery/radiosurgery. Chemotherapy should be considered when surgery or radiation therapy are not possible. In the last decades, TKIs or monoclonal antibodies have shown increase in overall response rate and overall survival in Phase II-III trials. The aim of this paper is to make an overview of the current approaches in management of patients with brain metastases.
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Affiliation(s)
- F Bertolini
- Department of Oncology, Azienda Ospedaliero-Universitaria Modena, via Del Pozzo, 71, 41124, Modena, Italy
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3D radiation therapy boost improves the outcome of whole brain radiation therapy treated RPA II patients with one or two brain metastases. Int J Mol Sci 2014; 15:7554-62. [PMID: 24798750 PMCID: PMC4057690 DOI: 10.3390/ijms15057554] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 04/07/2014] [Accepted: 04/24/2014] [Indexed: 11/29/2022] Open
Abstract
Purpose to evaluate the role of whole brain radiotherapy (WBRT) and radiation boost (RB) for 208 patients recursive partitioning analysis (RPA) II with 1 or 2 brain metastases (BM) at a single institution. Methods and Materials the dose of WBRT was 30 Gy (10 fractions of 3 Gy). One hundred thirty-two patients (63.5%) benefited from RB of 9 Gy in 3 fractions of 3 Gy at the metastatic site. Patients had 1 or 2 BM in 122 (58.7%) and 86 cases (41.3%), respectively. Results patients with one or two metastases had similar survival (4.6 and 5.1 months, respectively) (p = 0.4). Median overall survival (OS) for patients treated with WBRT and RB, and with WBRT alone was 5.9 and 3.7 months, respectively (p = 0.03). The 6-, 12- and 24-month OS rates after WBRT and RB were 48.5%, 25% and 10.6%, respectively, while WBRT alone resulted in OS rates of 34%, 22.4% and 3.2%, respectively (p = 0.03). After WBRT and RB, the 6-, 12- and 24-month local control rates were 92%, 82% and 67%, respectively, while they were 81.2%, 75% and 37.5%, respectively, after WBRT alone (p = 0.03). The 6-, 12- and 24-month brain control rates after WBRT and RB were 88.7%, 75.8% and 62%, respectively, and after WBRT alone they were 78.5%, 59% and 37.7%, respectively (p = 0.03). Conclusion additional boost delivered with 3D conformal radiotherapy improves local and brain control rates significantly as well as overall survival for RPA II patients with 1 or 2 unresectable BM.
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Abstract
Despite therapeutic advances, the development of breast cancer brain metastases (BCBM) is still the harbinger of a dismal prognosis. Patient outcomes vary depending on factors, including tumor phenotype, extent of disease within and outside the brain, as well as patient performance status. Treatment includes surgery, radiation therapy and systemic therapy determined by patient and tumor characteristics. Despite these approaches, novel treatments are needed and there is growing interest in systemic therapies. However, the efficacy of pharmacologic agents is hampered by poor penetration of drugs across the blood-brain barrier. Therefore, there is a pressing need for a greater understanding of the natural history of BCBM to guide the development of further therapies. This review analyzes prognosis and treatment of BCBM by tumor phenotype and discusses ongoing research into new therapies.
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Affiliation(s)
- Hao-Wen Sim
- Andrew Love Cancer Centre, Geelong Hospital, VIC, Australia
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Rades D, Panzner A, Dziggel L, Haatanen T, Lohynska R, Schild SE. Dose-escalation of whole-brain radiotherapy for brain metastasis in patients with a favorable survival prognosis. Cancer 2011; 118:3852-9. [PMID: 22170514 DOI: 10.1002/cncr.26680] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 09/19/2011] [Accepted: 10/06/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patients with brain metastases who have a favorable survival prognosis may benefit from intensive treatments, including neurosurgery and radiosurgery. However, many patients cannot receive such treatments, and whole-brain radiotherapy (WBRT) alone is their only option. The most common WBRT schedule is 30 grays (Gy) in 10 fractions. In this retrospective study, the authors investigated whether these patients benefit from a dose escalation beyond 30 Gy. METHODS Data from 109 patients who received 30 Gy in 10 fractions were compared with 75 patients who received 40 Gy in 20 fractions. All patients had a favorable survival prognosis. Both groups were compared for local control (LC) and overall survival (OS). Subgroup analyses were performed for patients who had less radiosensitive tumors (N = 27) and for other patients (N = 157). RESULTS The LC rate at 1 year was 28% after 30 Gy and 44% after 40 Gy (P = .064). On multivariate analysis, the 40 Gy dose was associated with improved LC (P = .047). The survival rate at 1 year was 50% after 30 Gy and 61% after 40 Gy (P = .007). On multivariate analysis, the 40 Gy dose was associated with improved OS (P = .008). On subgroup analysis of patients who had less radiosensitive tumors, the 1-year LC rate was 7% after 30 Gy and 38% after 40 Gy (P = .031); and the 1-year OS rate was 40% and 73%, respectively (P = .008). On subgroup analysis of patients who had other tumor types, the 1-year LC rate was 31% after 30 Gy and 45% after 40 Gy (P = .26); and the 1-year OS rate was 52% and 59%, respectively (P = .08). CONCLUSIONS Escalation of the WBRT dose beyond 30 Gy resulted in better outcomes, particularly for patients who had less radiosensitive tumors.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lubeck, Ratzeburger Allee 160, Lubeck, Germany.
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Caroli M, Di Cristofori A, Lucarella F, Raneri FA, Portaluri F, Gaini SM. Surgical brain metastases: management and outcome related to prognostic indexes: a critical review of a ten-year series. ISRN SURGERY 2011; 2011:207103. [PMID: 22084749 PMCID: PMC3195773 DOI: 10.5402/2011/207103] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Accepted: 06/30/2011] [Indexed: 11/23/2022]
Abstract
Brain metastasis are the most common neoplastic lesions of the nervous system. Many cancer patients are diagnosed on the basis of a first clinical presentation of cancer on the basis of a single or multiple brain lesions. Brain metastases are manifestations of primary disease progression and often determine a poor prognosis. Not all patients with a brain metastases undergo surgery: many are submitted to alternative or palliative treatments. Management of patients with brain metastases is still controversial, and many studies have been developed to determine which is the best therapy. Furthermore, management of patients operated for a brain metastasis is often difficult. Chemotherapy, stereotactic radiosurgery, panencephalic radiation therapy, and surgery, in combination or alone, are the means most commonly used. We report our experience in the management of a ten-year series of surgical brain metastasis and discuss our results in the preoperative and postoperative management of this complex condition.
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Affiliation(s)
| | - Andrea Di Cristofori
- Department of Neurosurgery, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy
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Expérience de l’irradiation encéphalique totale avec escalade de dose focalisée pour le traitement des métastases cérébrales uniques d’un carcinome bronchopulmonaire. Cancer Radiother 2011; 15:426-9. [DOI: 10.1016/j.canrad.2011.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Revised: 03/21/2011] [Accepted: 03/23/2011] [Indexed: 11/17/2022]
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Bilimagga RS, Nirmala S, Rishi KS, Janaki M, Ponni A, Rajeev A, Kalyan S. Role of palliative radiotherapy in brain metastases. Indian J Palliat Care 2011; 15:71-5. [PMID: 20606860 PMCID: PMC2886217 DOI: 10.4103/0973-1075.53588] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Brain metastases are a common manifestation of systemic cancer and exceed primary brain tumors in number and are a significant cause of neurologic problems. They affect 20-40% of all cancer patients. Aggressive management of brain metastases is effective in both symptom palliation and prolonging the life. Radiotherapy has a major role to play in the management of brain metastases. AIM: The aim of the study was to know the outcome of palliative radiotherapy in symptomatic brain metastases in terms of improvement in their performance status. Materials and Methods: This is a retrospective study of 63 patients diagnosed to have brain metastases and treated with palliative whole brain radiotherapy to a dose of 30 Gy in 10 fractions over two weeks between June 1998 and June 2007. Diagnosis was done in most of the cases with computed tomography scan and in a few with magnetic resonance imaging. Improvement in presenting symptoms has been assessed in terms of improvement in their performance status by using the ECOG scale. Results: Fifty-four patients completed the planned treatment. Eight patients received concurrent Temozolamide; 88% of patients had symptom relief at one month follow-up; 39/54 patients had a follow-up of just one to three months. Hence survival could not be assessed in this study. Conclusion: External beam radiotherapy in the dose of 30 Gy over two weeks achieved good palliation in terms improvement in their performance status in 88% of patients. Addition of concurrent and adjuvant Timozolamide may improve the results.
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Affiliation(s)
- Ramesh S Bilimagga
- Department of Radiotherapy, M. S. Ramaiah Medical College, Bangalore - 560 054, India
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Assouline A, Levy A, Chargari C, Lamproglou I, Mazeron JJ, Krzisch C. Whole brain radiotherapy: prognostic factors and results of a radiation boost delivered through a conventional linear accelerator. Radiother Oncol 2011; 99:214-7. [PMID: 21620502 DOI: 10.1016/j.radonc.2011.05.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Revised: 04/12/2011] [Accepted: 05/03/2011] [Indexed: 11/25/2022]
Abstract
PURPOSE Assess prognostic factors for overall survival and the potential benefit of a boost in patients treated with whole brain radiation therapy (WBRT). METHODS AND MATERIALS From 2002 to 2006, a retrospective analysis was made from 250 unselected consecutive patients with secondary brain metastases from lung cancer, breast cancer and melanoma. Eighteen patients received surgery and were excluded from analysis. Four potential prognostic factors have been studied: primary tumor type, gender, number of metastases and improvement of neurological symptoms after radiation therapy. A subgroup analysis was performed to determine whether an additional boost could potentially improve outcome in patients who presented with less than three metastases, performance status <2, and no surgical resection of their metastasis. RESULTS Average follow-up was 10.3 months. Median overall survival was 5.6 months and survival rates at 1 and 2 years were 22.7% and 10%, respectively. Age less than 65 (p<0.01), neurological improvement after WBRT (p<0.01), and presence of less than three metastases were significant factors for overall survival in multivariate analysis. When focusing on the selected subgroup (120 assessable patients), median overall survival was 4.0 months in patients with no radiation boost, versus 8.9 months in patients with radiation boost (p=0.0024). CONCLUSIONS Survival and prognostic factors were similar to those found in the literature. Boost delivered after WBRT by a conventional particle accelerator could provide a benefit in selected patients, especially for centers that do not have radiotherapy techniques in stereotactic conditions. This warrants further prospective assessment.
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Affiliation(s)
- Avi Assouline
- Department of Radiation Oncology, Pitie Salpetriere University Hospital, University Paris VI, France.
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18
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Rades D. E18. CNS metastasis: The role of radiotherapy for brain metastasis and metastatic spinal cord compression. EJC Suppl 2010. [DOI: 10.1016/s1359-6349(10)70022-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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19
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Heisterkamp C, Haatanen T, Schild SE, Rades D. Dose Escalation in Patients Receiving Whole-Brain Radiotherapy for Brain Metastases from Colorectal Cancer. Strahlenther Onkol 2010; 186:70-75. [DOI: 10.1007/s00066-010-2067-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 11/09/2009] [Indexed: 11/27/2022]
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20
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Tomasello G, Bedard PL, de Azambuja E, Lossignol D, Devriendt D, Piccart-Gebhart MJ. Brain metastases in HER2-positive breast cancer: the evolving role of lapatinib. Crit Rev Oncol Hematol 2009; 75:110-21. [PMID: 20004109 DOI: 10.1016/j.critrevonc.2009.11.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Revised: 11/09/2009] [Accepted: 11/13/2009] [Indexed: 12/21/2022] Open
Abstract
Due to improvements in diagnosis and systemic therapy, brain metastases are an increasingly common cause of morbidity and mortality for patients with advanced breast cancer. The incidence of symptomatic brain metastases among women with metastatic breast cancer ranges from 10% to 16%. The HER2 receptor, which is overexpressed in approximately 25% of all breast cancers, is an important risk factor for the development of central nervous system metastases. Surgery and radiation therapy are the primary approaches to the treatment of brain metastases but new chemotherapy and biological agents promise to play an important role in the future management of central nervous system disease. This article reviews the epidemiology, current treatment options and recent advances in the field, with a focus on HER2-positive disease and the emerging role of lapatinib for the treatment and prevention of brain metastases.
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Affiliation(s)
- Gianluca Tomasello
- Institut Jules Bordet, Université Libre de Bruxelles, 121 Boulevard de Waterloo, 1000, Brussels, Belgium.
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21
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Gaspar LE, Mehta MP, Patchell RA, Burri SH, Robinson PD, Morris RE, Ammirati M, Andrews DW, Asher AL, Cobbs CS, Kondziolka D, Linskey ME, Loeffler JS, McDermott M, Mikkelsen T, Olson JJ, Paleologos NA, Ryken TC, Kalkanis SN. The role of whole brain radiation therapy in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. J Neurooncol 2009; 96:17-32. [PMID: 19960231 PMCID: PMC2808517 DOI: 10.1007/s11060-009-0060-9] [Citation(s) in RCA: 239] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 11/08/2009] [Indexed: 11/25/2022]
Abstract
Target population This recommendation applies to adults with newly diagnosed single brain metastases amenable to surgical resection; however, the recommendation does not apply to relatively radiosensitive tumors histologies (i.e., small cell lung cancer, leukemia, lymphoma, germ cell tumors and multiple myeloma). Recommendation Surgical resection plus WBRT versus WBRT alone Level 1 Class I evidence supports the use of surgical resection plus post-operative WBRT, as compared to WBRT alone, in patients with good performance status (functionally independent and spending less than 50% of time in bed) and limited extra-cranial disease. There is insufficient evidence to make a recommendation for patients with poor performance scores, advanced systemic disease, or multiple brain metastases. If WBRT is used, is there an optimal dosing/fractionation schedule? Target population This recommendation applies to adults with newly diagnosed brain metastases. Recommendation Level 1 Class I evidence suggests that altered dose/fractionation schedules of WBRT do not result in significant differences in median survival, local control or neurocognitive outcomes when compared with “standard” WBRT dose/fractionation. (i.e., 30 Gy in 10 fractions or a biologically effective dose (BED) of 39 Gy10). If WBRT is used, what impact does tumor histopathology have on treatment outcomes? Target population This recommendation applies to adults with newly diagnosed brain metastases. Recommendation Given the extremely limited data available, there is insufficient evidence to support the choice of any particular dose/fractionation regimen based on histopathology. The following question is fully addressed in the surgery guideline paper within this series by Kalkanis et al. Given that the recommendation resulting from the systematic review of the literature on this topic is also highly relevant to the discussion of the role of WBRT in the management of brain metastases, this recommendation has been included below. Does the addition of WBRT after surgical resection improve outcomes when compared with surgical resection alone? Target population This recommendation applies to adults with newly diagnosed single brain metastases amenable to surgical resection. Recommendation Surgical resection plus WBRT versus surgical resection alone Level 1 Surgical resection followed by WBRT represents a superior treatment modality, in terms of improving tumor control at the original site of the metastasis and in the brain overall, when compared to surgical resection alone.
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Affiliation(s)
- Laurie E. Gaspar
- Department of Radiation Oncology, University of Colorado-Denver, Denver, CO USA
| | - Minesh P. Mehta
- Department of Human Oncology, Universtity of Wisconsin School of Public Health and Medicine, Madison, WI USA
| | - Roy A. Patchell
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ USA
| | - Stuart H. Burri
- Department of Radiation Oncology, Carolinas Medical Center, Charlotte, NC USA
| | - Paula D. Robinson
- McMaster University Evidence-Based Practice Center, Hamilton, ON Canada
| | - Rachel E. Morris
- McMaster University Evidence-Based Practice Center, Hamilton, ON Canada
| | - Mario Ammirati
- Department of Neurosurgery, Ohio State University Medical Center, Columbus, OH USA
| | - David W. Andrews
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA USA
| | - Anthony L. Asher
- Department of Neurosurgery, Carolina Neurosurgery and Spine Associates, Charlotte, NC USA
| | - Charles S. Cobbs
- Department of Neurosciences, California Pacific Medical Center, San Francisco, CA USA
| | - Douglas Kondziolka
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Mark E. Linskey
- Department of Neurosurgery, University of California-Irvine Medical Center, Orange, CA USA
| | - Jay S. Loeffler
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA USA
| | - Michael McDermott
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA USA
| | - Tom Mikkelsen
- Department of Neurology, Henry Ford Health System, Detroit, MI USA
| | - Jeffrey J. Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA USA
| | - Nina A. Paleologos
- Department of Neurology, Northshore University Health System, Evanston, IL USA
| | - Timothy C. Ryken
- Department of Neurosurgery, Iowa Spine and Brain Institute, Iowa City, IA USA
| | - Steven N. Kalkanis
- Department of Neurosurgery, Henry Ford Health System, Hermelin Brain Tumor Center, 2799 West Grand Blvd, K-11, Detroit, MI 48202 USA
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Ranjan T, Abrey LE. Current management of metastatic brain disease. Neurotherapeutics 2009; 6:598-603. [PMID: 19560748 PMCID: PMC5084194 DOI: 10.1016/j.nurt.2009.04.012] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Revised: 04/15/2009] [Accepted: 04/24/2009] [Indexed: 11/15/2022] Open
Abstract
Brain metastases are the most common intracranial tumor in adults. The incidence of metastases is thought to be rising due to better detection and treatment of systemic malignancy. More widespread use and improved quality of MRI may lead to early detection of brain metastases. Available evidence suggests that survival is longer and quality of life improved if brain metastases are treated aggressively. This article reviews current therapeutic management used for brain metastases. To select the appropriate therapy, the physician must consider the extent of the systemic disease, primary histology, and patient age and performance status, as well as the number, size, and location of the brain metastases. Available treatment options include whole-brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), surgery, and chemotherapy. Multidisciplinary approaches such as the combination of WBRT with SRS or surgery have shown superior results in terms of survival time, neurocognitive function, and quality of life. The utility and optimal use of chemotherapy and radiosensitizing agents is less clear. It is hoped that further advances and multidisciplinary approaches currently under study will result in improved patient outcomes.
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Affiliation(s)
- Tulika Ranjan
- grid.51462.340000000121719952Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, 10065 New York, NY
| | - Lauren E. Abrey
- grid.51462.340000000121719952Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, 10065 New York, NY
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23
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Current world literature. Trauma and rehabilitation. Curr Opin Neurol 2008; 21:762-4. [PMID: 18989123 DOI: 10.1097/wco.0b013e32831cbb85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sánchez de Cos J, Sojo González MA, Montero MV, Pérez Calvo MC, Vicente MJM, Valle MH. Non-small cell lung cancer and silent brain metastasis. Survival and prognostic factors. Lung Cancer 2008; 63:140-5. [PMID: 18556086 DOI: 10.1016/j.lungcan.2008.04.013] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Revised: 04/14/2008] [Accepted: 04/20/2008] [Indexed: 11/18/2022]
Abstract
The detection of silent brain metastasis is becoming increasingly common in patients with non-small cell lung cancer (NSCLC). The aim of this study was to evaluate clinical course, prognostic significance, and treatment efficacy in patients with asymptomatic brain metastasis. A retrospective study of patients with cytologically and histologically diagnosed NSCLC and brain metastasis detected by cranial computed tomography or magnetic resonance imaging was performed. We compared 12 neurologically asymptomatic patients to 69 symptomatic patients and analyzed overall survival, clinical course, and prognostic factors (age, sex, performance status, histologic type, TNM stage, number and size of brain metastases, clinical neurologic status, and treatment of primary tumor and brain metastasis). The strongest favorable prognostic factor was active treatment of both the primary tumor (surgery, chemotherapy and/or thoracic radiotherapy) and brain metastasis (neurosurgery and/or whole brain radiotherapy). Neurologically asymptomatic patients had significantly longer survival times than did symptomatic patients (median survival of 7.5 and 4 months, respectively). Control of clinical neurologic status during follow-up was achieved in a greater proportion of asymptomatic patients (80%) than symptomatic patients (40%). We conclude that it is important to detect brain metastasis in patients with NSCLC before neurologic signs or symptoms develop, as early detection improves prognosis and provides patients with the opportunity of receiving timely and more effective treatment.
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Affiliation(s)
- Julio Sánchez de Cos
- Pulmonology Section, Hospital San Pedro de Alcántara, Cáceres, Extremadura, Spain.
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