Dose-escalation of whole-brain radiotherapy for brain metastasis in patients with a favorable survival prognosis

Factors associated with the local control of brain metastases: a systematic search and machine learning application

BACKGROUND

Enhancing Local Control (LC) of brain metastases is pivotal for improving overall survival, which makes the prediction of local treatment failure a crucial aspect of treatment planning. Understanding the factors that influence LC of brain metastases is imperative for optimizing treatment strategies and subsequently extending overall survival. Machine learning algorithms may help to identify factors that predict outcomes.

METHODS

This paper systematically reviews these factors associated with LC to select candidate predictor features for a practical application of predictive modeling. A systematic literature search was conducted to identify studies in which the LC of brain metastases is assessed for adult patients. EMBASE, PubMed, Web-of-Science, and the Cochrane Database were searched up to December 24, 2020. All studies investigating the LC of brain metastases as one of the endpoints were included, regardless of primary tumor type or treatment type. We first grouped studies based on primary tumor types resulting in lung, breast, and melanoma groups. Studies that did not focus on a specific primary cancer type were grouped based on treatment types resulting in surgery, SRT, and whole-brain radiotherapy groups. For each group, significant factors associated with LC were identified and discussed. As a second project, we assessed the practical importance of selected features in predicting LC after Stereotactic Radiotherapy (SRT) with a Random Forest machine learning model. Accuracy and Area Under the Curve (AUC) of the Random Forest model, trained with the list of factors that were found to be associated with LC for the SRT treatment group, were reported.

RESULTS

The systematic literature search identified 6270 unique records. After screening titles and abstracts, 410 full texts were considered, and ultimately 159 studies were included for review. Most of the studies focused on the LC of the brain metastases for a specific primary tumor type or after a specific treatment type. Higher SRT radiation dose was found to be associated with better LC in lung cancer, breast cancer, and melanoma groups. Also, a higher dose was associated with better LC in the SRT group, while higher tumor volume was associated with worse LC in this group. The Random Forest model predicted the LC of brain metastases with an accuracy of 80% and an AUC of 0.84.

CONCLUSION

This paper thoroughly examines factors associated with LC in brain metastases and highlights the translational value of our findings for selecting variables to predict LC in a sample of patients who underwent SRT. The prediction model holds great promise for clinicians, offering a valuable tool to predict personalized treatment outcomes and foresee the impact of changes in treatment characteristics such as radiation dose.

The First Survival Score for Patients Aged ≥80 Years Irradiated for Brain Metastases

Survival scores facilitate personalized cancer treatment. Due to demographic changes, very elderly patients are more prevalent than in the past. A score was developed in 94 patients aged ≥ 80 years undergoing whole-brain radiotherapy for brain metastases. Dose fractionation, treatment period, age, sex, performance score (ECOG-PS), tumor type, count of lesions, metastases outside the brain, and interval tumor diagnosis to radiotherapy were retrospectively evaluated. Independent predictors of survival were used for the score. Based on individual scoring points obtained from 3-month survival rates, prognostic groups were designed. Additionally, the score was compared to an existing tool developed in patients ≥ 65 years. ECOG-PS, count of lesions, and extra-cranial metastases were independent prognostic factors. Three groups were created (7, 10, and 13−16 points) with 3-month survival of 6%, 25%, and 67% (p < 0.001), respectively. Positive predictive values (PPVs) regarding death ≤ 3 and survival ≥ 3 months were 94% and 67% (new score) vs. 96% and 48% (existing tool), respectively. PPVs for survival ≥1 and ≥2 months were 88% and 79% vs. 63% and 58%, respectively. Both tools were accurate in predicting death ≤2, ≤3, and ≤6 months. The new score was more precise regarding death ≤1 month and survival (all time periods) and appeared preferable. However, it still needs to be validated.

Combination of radiotherapy and targeted therapy for melanoma brain metastases: a systematic review

Radiotherapy is a mainstay of efficient treatment of brain metastases from solid tumors. Immunotherapy has improved the survival of metastatic cancer patients across many tumor types. However, targeted therapy is a feasible alternative for patients unable to continue immunotherapy or with poor outcomes of immunotherapy. The combination of radiotherapy and targeted therapy for the treatment of brain metastases has a strong theoretical underpinning, but data on the efficacy and safety of this combination is still limited. A systematic search of PubMed, Embase, Web of Science and the Cochrane library database was conducted. Eleven studies were included for a total of 316 patients. Median OS was about 6.2-17.8 months from radiotherapy. Weighted survival and local control at 1 and 2 years were correlated (50.1 and 17.8%, 90.7 and 14.7% at 1 and 2 year, respectively). Radiotherapy given before or concurrently to targeted therapy provided the best effect on the outcome. For patients with brain metastases from cutaneous melanoma, the addition of concurrent targeted therapy to brain radiotherapy can increase survival and provide long-term control.

A Simple Implement for Assessing the Survival of Elderly Patients With Melanoma Irradiated for Cerebral Metastases

BACKGROUND/AIM

Secondary brain lesions occur commonly in patients with advanced melanoma. Despite increasing use of local therapies, many elderly patients qualify for whole-brain radiotherapy (WBRT). For these patients, a survival score was created.

PATIENTS AND METHODS

Seven characteristics were retrospectively investigated in 35 elderly (≥65 years) patients with melanoma, namely WBRT regimen, age, gender, Karnofsky performance score (KPS), number of brain lesions, non-cerebral metastases and interval from melanoma diagnosis to WBRT.

RESULTS

Age ≤71 years (p=0.044) and KPS ≥80% (p=0.005) were significantly associated with more favorable survival. Based on these characteristics, patients received 0 (n=13), 1 (n=12) or 2 points (n=10). Two prognostic groups were designed, 0 or 1 point vs. 2 points, with actuarial 6-month survival rates of 12% and 48%, respectively (p=0.002).

CONCLUSION

This simple implement allows quick estimation of the survival of elderly patients receiving WBRT for cerebral metastases from melanoma.

Estimating the Lifespan of Elderly Patients With Cerebral Metastases from Kidney Cancer

BACKGROUND/AIM

Outcomes of elderly patients with cerebral metastases from kidney cancer may be improved by personalized treatment. A scoring instrument for estimating survival in these patients is presented.

PATIENTS AND METHODS

Twenty-four elderly kidney cancer patients receiving whole-brain irradiation (WBI) were retrospectively investigated. WBI-regimen and six pre-treatment factors were evaluated including age, gender, performance score, number of cerebral metastases, extracranial metastases and time from kidney cancer diagnosis to WBI.

RESULTS

Number of cerebral metastases (p=0.194) and time from kidney cancer diagnosis to WBI (p=0.107) correlated with survival and were included in the instrument. Based on these factors, patient scores of 0, 1 and 2 points resulted in 6-month survival rates of 0%, 15% and 60% (p=0.131), respectively. Two groups were designed, 0-1 and 2 points, with 6-month survival rates of 11% and 60% (p=0.108), respectively.

CONCLUSION

This new instrument can assist physicians aiming to estimate a patient's survival prognosis to provide personalized treatment.

Development of a multivariable prediction model to estimate the remaining lifespan of elderly patients with cerebral metastases from small-cell lung cancer

Background

Prognostic tools estimating survival of elderly patients with cerebral metastases from small-cell lung cancer (SCLC) improve treatment personalization. A specific tool for these patients was developed and compared to existing instruments.

Methods

One-hundred-and-forty elderly patients (≥65 years) receiving whole-brain irradiation (WBI) for cerebral metastases from SCLC were retrospectively evaluated. WBI-program, age, gender, Karnofsky performance score, number of cerebral lesions, extracerebral metastases, and interval between SCLC-diagnosis and WBI were investigated. Characteristics significantly associated with survival in the multivariate analysis were used for the tool. Scoring points were calculated by dividing 6-month survival rates (%) by 10 and added for patient scores. The tool was compared to existing diagnosis-specific instruments including updated diagnosis-specific graded prognostic assessment (DS-GPA), Rades-SCLC and WBRT-30-SCLC.

Results

In the multivariate analysis, KPS (P<0.001), number of cerebral lesions (P=0.013) and extracerebral metastases (P=0.049) were significantly associated with survival. Patient scores of 2 (n=37), 5 (n=69), 8 (n=20) and 11 (n=14) points were obtained; 6-month survival rates were 0%, 9%, 50% and 79% (P<0.001). The positive predictive value (PPV) of the worst group (2 points) to identify patients dying ≤6 months was 100%; PPVs of updated DS-GPA, Rades-SCLC and WBRT-30-SCLC were 94%, 100% and 94%. PPV of the best group (11 points) to identify patients surviving ≥6 months was 79%; PPVs of updated DS-GPA, Rades-SCLC and WBRT-30-SCLC were 86%, 79% and 100%.

Conclusions

The most precise instruments were the new tool and Rades-SCLC for identification of patients dying ≤6 months, and the WBRT-30-SCLC to identify patients surviving ≥6 months.

Migration of treatment planning system using existing commissioned planning system

Introduction:

Commissioning of a new planning system involves extensive data acquisition which can be onerous involving significant clinic downtime. This could be circumvented by extracting data from existing treatment planning system (TPS) to speed up the process.

Material and methods:

In this study, commissioning beam data was obtained from a clinically commissioned TPS (Pinnacle™) using Matlab™ generated Pinnacle™ executable scripts to commission an independent 3D dose verification TPS (Eclipse™). Profiles and output factors for commissioning as required by Eclipse™ were computed on a 50 × 50 × 50 cm3 water phantom at a dose grid resolution of 2 mm3. Verification doses were computed and compared to clinical TPS dose profiles based on TG-106 guidelines. Standard patient plans from Pinnacle™ including intensity modulated radiation therapy and volumetric modulated arc therapy were re-computed on Eclipse™ TPS while maintaining the same monitor units. Computed dose was exported back to Pinnacle for comparison with the original plans. This methodology enabled us to alleviate all ambiguities that arise in such studies.

Results:

Profile analysis using in-house software showed that for all field sizes including small multi-leaf collimator-generated fields, >95% of infield and penumbra data points of Eclipse™ match Pinnacle™ generated and measured profiles with 2%/2 mm gamma criteria. Excellent agreement was observed in the penumbra regions, with >95% of the data points passing distance to agreement criteria for complex C-shaped and S-shaped profiles. Dose volume histograms and isodose lines of patient plans agreed well to within a 0·5% for target coverage.

Findings:

Migration of TPS is possible without compromising accuracy or enduring the cumbersome measurement of commissioning data. Economising time for commissioning such a verification system or for migration of TPS can add great QA value and minimise downtime.

An Easy-To-Use Survival Score Compared to Existing Tools for Older Patients with Cerebral Metastases from Colorectal Cancer

An easy-to-use survival score was developed specifically for older patients with cerebral metastases from colorectal cancer, and was compared to existing tools regarding the accuracy of identifying patients who die in ≤6 months and those who survive for ≥6 months. The new score was built from 57 patients receiving whole-brain irradiation. It included three groups identified from 6-month survival rates based on two independent predictors (performance status and absence/presence of non-cerebral metastases), with 6-month survival rates of 0% (0 points), 26% (1 point), and 75% (2 points), respectively. This score was compared to diagnosis-specific scores, namely the diagnosis-specific graded prognostic assessment (DS-GPA), the Dziggel-Score and the WBRT-30-CRC (whole-brain radiotherapy with 30 Gy in 10 fractions for cerebral metastases from colorectal cancer) score and to a non-diagnosis-specific score for older persons (Evers-Score). Positive predictive values were 100% (new score), 87% (DS-GPA), 86% (Dziggel-Score), 91% (WBRT-30-CRC), and 100% (Evers-Score), respectively, for patients dying ≤6 months, and 75%, 33%, 75%, 60%, and 45%, respectively, for survivors ≥6 months. Of the five tools, the new score and the Evers-Score were most precise in identifying patients dying ≤6 months. The new score and the Dziggel-Scores were best at identifying patients surviving ≥6 months. When combining the results, the new score appeared preferable to the existing tools. The score appears not necessary for patients with additional liver metastases, since their 6-month survival rate was 0%.

Are hypothalamic- pituitary (HP) axis deficiencies after whole brain radiotherapy (WBRT) of relevance for adult cancer patients? - a systematic review of the literature

Background

Cranial radiotherapy (cRT) can induce hormonal deficiencies as a consequence of significant doses to the hypothalamic-pituitary (HP) axis. In contrast to profound endocrinological follow-up data from survivors of childhood cancer treated with cRT, little knowledge exists for adult cancer patients.

Methods

A systematic search of the literature was conducted using the PubMed database and the Cochrane library offering the basis for our debate of the relevance of HP axis impairment after cRT in adult cancer patients. Against the background of potential relevance for patients receiving whole brain radiotherapy (WBRT), a particular focus was set on the temporal onset of hypopituitarism and the radiation dose to the HP axis.

Results

Twenty-eight original papers with a total of 1728 patients met the inclusion criteria. Radiation doses to the HP area ranged from 4 to 97 Gray (Gy). Hypopituitarism incidences ranged from 20 to 93% for adult patients with nasopharyngeal cancer or non-pituitary brain tumors. No study focused particularly on hypopituitarism after WBRT. The onset of hypopituitarism occurred as early as within the first year following cRT (range: 3 months to 25.6 years). However, since most studies started follow-up evaluation only several years after cRT, early onset of hypopituitarism might have gone unnoticed.

Conclusion

Hypopituitarism occurs frequently after cRT in adult cancer patients. Despite the general conception that it develops only after several years, onset of endocrine sequelae can occur within the first year after cRT without a clear threshold. This finding is worth debating particularly in respect of treatment options for patients with brain metastases and favorable survival prognoses.

Breast cancer patients with brain metastases or leptomeningeal disease: 10-year results of a national cohort with validation of prognostic indexes

Development of brain metastasis (BM) and leptomeningeal (LM) disease in breast cancer (BC) patients indicates poor prognosis and impairs patients' quality of life. Prognostic survival scores for BM can help predict expected survival in order to choose the most appropriate treatment. The aim of our study was to analyze national data for BC patients treated with radiation therapy for BM/LM disease and validate the applicability of different survival prognostic scores. We retrospectively evaluated medical records of 423 BC patients with BM/LM disease receiving radiation therapy between April 2005 and December 2015. Patients were classified by BC Recursive Partitioning Analysis (B-RPA), Breast Graded Prognostic Assessment (Breast-GPA), Modified Breast Graded Prognostic Assessment (MB-GPA), and Simple Survival score for patients with BM from BC (SS-BM). Overall survival (OS) was calculated from the development of BM/LM disease to death or last follow-up date. After a median follow-up of 7.5 years, the median OS was 6.9 months (95% CI 5.5-7.8, range 0-146.4) and 1- and 2-year survival rates were 35% and 17%, respectively. Survival analysis showed significant differences in median OS regarding biologic subtypes (P < 0.0001), as follows: 3.2 (95% Confidence Interval (CI) 2.5-3.9), 3.9 (95% CI 2.3-5.6), 7.1 (95% CI 4.3-9.8), 12.1 (95% CI 8.3-15.9), and 15.4 (95% CI 8.8-22.1) months for primary triple-negative BC (TNBC), Luminal B HER2-negative, Luminal A, HER2-enriched, and Luminal B HER2-positive tumors, respectively. Good Karnofsky Performance Status (KPS), single metastasis, and absence of LM or extracranial disease all demonstrated better OS in univariate and multivariate analysis. All four employed prognostic indexes provided good prognostic value in predicting survival. SS-BM and MB-GPA showed the best discriminating ability (Concordance indexes C were 0.768 and 0.738, respectively). This study presents one of the largest single-institution series validating prognostic scores for BC patients with BM/LM. SS-BM and MB-GPA proved to be useful tools in the clinical decision-making process.

A new instrument for predicting survival of patients with cerebral metastases from breast cancer developed in a homogeneously treated cohort

Background Previous survival scores for breast cancer patients with cerebral metastases were developed in cohorts receiving heterogeneous treatments, which could have introduced selection biases. A new instrument (WBRT-30-BC) was created from 170 patients receiving whole-brain radiotherapy (WBRT) alone with 30 Gy in 10 fractions. Methods Characteristics showing significant associations (p < 0.05) with overall survival (OS) or a trend (p < 0.08) on multivariate analysis were used for the WBRT-30-BC. For each characteristic, 6-month OS rates were divided by 10. These scoring points were added for each patient (patient scores). The WBRT-30-BC was compared to the diagnosis- specific graded prognostic assessment (DS-GPA) classification and Rades-Score for breast cancer regarding positive predictive values (PPVs) to identify patients dying within 6 months and patients surviving at least 6 months following WBRT. Results On multivariate analysis, Karnofsky performance score (KPS) was significant (risk ratio [RR]: 2.45, p < 0.001). In addition, extra-cerebral metastatic disease (RR: 1.52, p = 0.071) and time between breast cancer diagnosis and WBRT (RR: 1.37, p = 0.070) showed a trend. Based on these three characteristics, four predictive groups were designed: 7-9, 10-12, 13-15 and 16 points. Six-month OS rates were 8%, 41%, 68% and 100% (p < 0.001). PPVs to identify patients dying within 6 months were 92% (WBRT-30-BC), 84% (DS-GPA) and 92% (Rades-Score). PPVs to identify patients surviving for at least 6 months were 100% (WBRT-30-BC), 74% (DS-GPA) and 68% (Rades-Score). Conclusions The WBRT-30-BC appeared very accurate in predicting death ≤ 6 months and survival ≥ 6 months of breast cancer patients receiving WBRT. It was superior to previous instruments in predicting survival ≥ 6 months.

A New Diagnosis-Specific Survival Score for Patients to be Irradiated for Brain Metastases from Non-small Cell Lung Cancer

INTRODUCTION

Personalized treatment helps one achieve optimal outcomes in patients with non-small cell lung cancer (NSCLC). Understanding patients' survival prognoses in a palliative situation like intracerebral metastases is critical. A new survival score, the WBRT-30-NSCLC, was developed for patients with intracerebral metastases from NSCLC.

METHODS

Eight factors were investigated in 157 patients receiving 10 × 3 Gy of whole-brain radiotherapy (WBRT) including age, gender, Karnofsky performance score (KPS), interval from diagnosis of NSCLC to WBRT, pre-WBRT systemic treatment, primary tumor control, number of intracerebral metastases, and metastasis outside the brain. Factors significant (p < 0.05) or showing a trend (p < 0.08) on multivariate analysis were used for the WBRT-30-NSCLC. Patient scores were derived by adding factor scores (6-month survival rates divided by 10). WBRT-30-NSCLC was compared to other scores for intracerebral metastases from NSCLC.

RESULTS

On multivariate analysis, age (p = 0.005), KPS (p < 0.001), systemic treatment (p = 0.018), and metastasis outside the brain (p < 0.001) were significant; number of intracerebral metastases (p = 0.075) showed a trend. Four groups were designed (912, 1317, 1820, and 22 points) with 6-month survival rates of 3, 26, 65, and 100%. Positive predictive value (PPV) to predict death ≤ 6 months after WBRT was 97% (updated DS-GPA classification 86%, Rades-NSCLC 88%), and PPV to predict survival ≥ 6 months was 100% (updated DS-GPA 78%, Rades-NSCLC 74%).

CONCLUSIONS

The WBRT-30-NSCLC appeared very precise in identifying patients with intracerebral metastases from NSCLC dying ≤ 6 months or surviving ≥ 6 months. It appeared more precise than previous scores and can support physicians developing personalized treatment regimens.

Comparison of Diagnosis-Specific Survival Scores for Patients with Small-Cell Lung Cancer Irradiated for Brain Metastases

Diagnosis-specific survival scores including a new score developed in 157 patients with brain metastases from small-cell lung cancer (SCLC) receiving whole-brain radiotherapy (WBRT) with 30 Gy in 10 fractions (WBRT-30-SCLC) were compared. Three prognostic groups were designed based on the 6-month survival probabilities of significant or almost significant factors, (age, performance score, number of brain metastases, extra-cerebral metastasis). Six-month survival rates were 6% (6–11 points), 44% (12–14 points) and 86% (16–19 points). The WBRT-30-SCLC was compared to three disease-specific scores for brain metastasis from SCLC, the original and updated diagnosis-specific graded prognostic assessment DS-GPA classifications and the Rades-SCLC. Positive predictive values (PPVs) used to correctly predict death ≤6 months were 94% (WBRT-30-SCLC), 88% (original DS-GPA), 88% (updated DS-GPA) and 100% (Rades-SCLC). PPVs to predict survival ≥6 months were 86%, 75%, 76% and 100%. For WBRT-30-SCLC and Rades-SCLC, differences between poor and intermediate prognoses groups and between intermediate and favorable prognoses groups were significant. For both DS-GPA classifications, only the difference between poor and intermediate prognoses groups was significant. Of these disease-specific tools, Rades-SCLC appeared to be the most accurate in identifying patients dying ≤6 months and patients surviving ≥6 months after irradiation, followed by the new WBRT-30-SCLC and the DS-GPA classifications.

Predicting Survival After Whole-brain Irradiation for Cerebral Metastases in Patients with Cancer of the Bladder

BACKGROUND/AIM

This study aimed to create a predictive tool for estimating the remaining lifespan of patients after whole-brain irradiation (WBI) for cerebral metastases from bladder cancer.

PATIENTS AND METHODS

In 34 of these patients clinical parameters were analyzed for survival including age at start of WBI, gender, Karnofsky score, number of cerebral metastases and involvement of extra-cranial sites of metastasis.

RESULTS

Involvement of extra-cranial sites (14%) and Karnofsky score (9%) showed the greatest difference regarding 6-month survival and were considered for the tool. Points were assigned based on the following: no involvement of extra-cranial sites=1 point, involvement of extra-cranial sites=0 points, Karnofsky score ≥70=1 point, Karnofsky score ≤60=0 points. Patients' scores were 0, 1 or 2 points with 6-month survival rates of 13%, 27% and 50%, respectively.

CONCLUSION

Based on two clinical parameters, a tool was developed that may help estimate the lifespan of patients irradiated for cerebral metastases from bladder cancer.

BRAF inhibitor and stereotactic radiosurgery is associated with an increased risk of radiation necrosis

We retrospectively compared the outcomes and toxicities of melanoma brain metastases (MBM) patients treated with BRAF inhibitors (BRAFi) and stereotactic radiosurgery (SRS) with SRS alone. We identified 87 patients with 157 MBM treated with SRS alone from 2005 to 2013. Of these, 15 (17.2%) patients with 32 MBM (21.4%) received BRAFi therapy: three (20.0%) before SRS, two (13.3%) concurrent, and 10 (66.7%) after SRS. Overall survival (OS) was compared between cohorts using the product limit method. Intracranial outcomes were compared using cumulative incidence with competing risk for death. Baseline patient characteristics were similar between groups, except for the SRS cohort, which had higher rates of chemotherapy and more recent year of diagnosis. Radiation characteristics, including dose per fraction, total dose, gross tumor volume size, and prescription isodose, were also similar between cohorts. One-year outcomes - OS (64.3 vs. 40.4%, P=0.205), local failure (3.3 vs. 9.6%, P=0.423), and distant intracranial failure (63.9 vs. 65.1%, P=0.450) were not statistically different between the SRS+BRAFi and SRS-alone groups, respectively. The SRS+BRAFi group showed higher rates of radiographic radiation necrosis (RN) (22.2 vs. 11.0% at 1 year, P<0.001) and symptomatic radiation necrosis (SRN) (28.2 vs. 11.1% at 1 year, P<0.001). Multivariable analysis showed that BRAFi predicted an increased risk of both radiographic and SRN. SRS and BRAFi predicted for an increased risk of radiographic and SRN compared with SRS alone. Approaches to mitigate RN for patients receiving SRS and BRAFi should be considered until the clinical trial (http//:www.clinicaltrials.gov: NCT01721603) evaluating this treatment regimen is completed.

Management of intracranial melanomas in the era of precision medicine

Melanoma is the most lethal of skin cancers, in part because of its proclivity for rapid and distant metastasis. It is also potentially the most neurotropic cancer in terms of probability of CNS metastasis from the primary lesion. Despite surgical resection and radiotherapy, prognosis remains guarded for patients with brain metastases. Over the past five years, a new domain of personalized therapy has emerged for advanced melanoma patients with the introduction of BRAF and other MAP kinase pathway inhibitors, immunotherapy, and combinatory therapeutic strategies. By targeting critical cellular signaling pathways and unleashing the adaptive immune response against tumor antigens, a subset of melanoma patients have demonstrated remarkable responses to these treatments. Over time, acquired resistance to these modalities inexorably develops, providing new challenges to overcome. We review the rapidly evolving terrain for intracranial melanoma treatment, address likely and potential mechanisms of resistance, as well as evaluate promising future therapeutic approaches currently under clinical investigation.

A New Prognostic Instrument Specifically Designed for Patients Irradiated for Recurrent Carcinoma of the Bladder

BACKGROUND/AIM

To develop an instrument that could estimate the 1-year survival probabilities of patients irradiated for recurrent carcinoma of the bladder.

PATIENTS AND METHODS

Thirty patients irradiated for locally recurrent bladder carcinoma were included. Six pre-treatment factors [age, gender, Karnofsky score (KPS), pack years, grading and time between cancer diagnosis and radiotherapy] were evaluated for survival. Of those factors showing a trend or significance on multivariate analysis, 1-year survival rates were added.

RESULTS

On multivariate analysis, KPS was significant (hazard ratio(HR)=3.76, p=0.008), age showed a trend (HR=2.04, p=0.13). Patient scores were five, nine, ten or fourteen points with 1-year survival rates of 13%, 25%, 57% and 82% (p=0.003). Three groups were designed, A (5-9 points), B (10 points) and C (14 points) with 1-year survival rates of 17%, 57% and 82% (p=0.001).

CONCLUSION

This score, including three groups with different 1-year survival probabilities, can aid physicians treating patients with recurrent bladder carcinoma.

Clinical Factors Asssociated with Treatment Outcomes following Whole-brain Irradiation in Patients with Prostate Cancer

BACKGROUND/AIM

Patients with prostate cancer represent a small minority of cancer patients presenting with metastases to the brain. This study investigated the role of whole-brain irradiation (WBI) in this rare group.

PATIENTS AND METHODS

Eighteen such patients were included. Clinical factors including fractionation program of WBI, age at WBI, Karnofsky performance score (KPS), number of metastases to the brain, involvement of extracerebral metastatic sites, time from prostate cancer diagnosis to WBI and recursive-partitioning-analysis (RPA) class were investigated regarding local (intracerebral) control and survival.

RESULTS

On multivariate evaluation, longer time from prostate cancer diagnosis to WBI showed a trend towards improved local control (hazard ratio 2.77, p=0.098). Better KPS (hazard ratio 5.64, p=0.021) and longer time from prostate cancer diagnosis to WBI (hazard ratio 5.64, p=0.013) were significantly associated with better survival.

CONCLUSION

Two independent predictors of survival were identified and should be considered when designing for personalized treatment regimens and clinical trials.

Comparative Effectiveness Analysis of Treatment Options for Single Brain Metastasis

BACKGROUND

Brain metastases (BMs) occur in up to 30% of patients with cancer. Treatments include surgery, whole-brain radiotherapy (WBRT), and stereotactic radiosurgery (SRS), alone or in combination. Although guidelines exist, data to inform individualized approaches to therapy remain sparse. We sought to compare semiquantitatively the effectiveness of various modalities in the treatment of single brain metastasis.

METHODS

We performed a comparative effectiveness analysis (CEA) that integrated efficacy, cost, and quality of life (QoL) data for alternate BM treatments. Efficacy data were obtained from a comprehensive review of current literature. Cost estimates were based on publicly available data. QoL data included the Karnofsky Performance Status (KPS) and other questionnaires. Six treatment strategies using combinations of surgery, WBRT, and SRS were compared with decision tree software.

RESULTS

The clinical efficacy, cost, and QoL effects of each strategy were scored semiquantitatively. We constructed a model to integrate individual preferences regarding the relative importance of efficacy, QoL, and cost to provide personalized rankings of the effectiveness of each strategy.

CONCLUSION

The choice of strategy must be individualized for patients with a single BM. Our CEA and decision model combines empirical data with patient priorities to produce a ranking of alternate management strategies.

A new tool to predict survival after radiosurgery alone for newly diagnosed cerebral metastases

Many patients with few cerebral metastases receive radiosurgery alone. The goal of this study was to create a tool to estimate the survival of such patients. To identify characteristics associated with survival, nine variables including radiosurgery dose, age, gender, Eastern cooperative oncology group performance score (ECOG-PS), primary tumor type, number/size of cerebral metastases, location of cerebral metastases, extra-cerebral metastases and time between cancer diagnosis and radiosurgery were analyzed in 214 patients. On multivariate analysis, age (p=0.03), ECOG-PS (p=0.02) and extra-cerebral metastases (p<0.01) had significant impacts on survival. Scoring points for each patient were obtained from 12-month survival rates (in %) related to the significant variables divided by 10. Addition of the scoring points of the three variables resulted in a patient's total predictive score. Two groups were designed, A (10-14 points) and B (16-17 points). Twelve-month survival rates were 33% and 77%, respectively (p<0.001). Median survival times were 8 and 20 months, respectively. Because most patients of group A died from extra-cerebral disease and/or new cerebral lesions, early systemic treatment and additional WBI should be considered. As cause of death in group B was mostly new cerebral metastases, additional WBI appears even more important for this group.

Novel treatments for melanoma brain metastases

BACKGROUND

The development of brain metastases is common in patients with melanoma and is associated with a poor prognosis. Treating patients with melanoma brain metastases (MBMs) is a major therapeutic challenge. Standard approaches with conventional chemotherapy are disappointing, while surgery and radiotherapy have improved outcomes.

METHODS

In this article, we discuss the biology of MBMs, briefly outline current treatment approaches, and emphasize novel and emerging therapies for MBMs.

RESULTS

The mechanisms that underlie the metastases of melanoma to the brain are unknown; therefore, it is necessary to identify pathways to target MBMs. Most patients with MBMs have short survival times. Recent use of immune-based and targeted therapies has changed the natural history of metastatic melanoma and may be effective for the treatment of patients with MBMs.

CONCLUSIONS

Developing a better understanding of the factors responsible for MBMs will lead to improved management of this disease. In addition, determining the optimal treatments for MBMs and how they can be optimized or combined with other therapies, along with appropriate patient selection, are challenges for the management of this disease.

How radiation oncologists evaluate and incorporate life expectancy estimates into the treatment of palliative cancer patients: a survey-based study

PURPOSE

We surveyed how radiation oncologists think about and incorporate a palliative cancer patient's life expectancy (LE) into their treatment recommendations.

METHODS AND MATERIALS

A 41-item survey was e-mailed to 113 radiation oncology attending physicians and residents at radiation oncology centers within the Boston area. Physicians estimated how frequently they assessed the LE of their palliative cancer patients and rated the importance of 18 factors in formulating LE estimates. For 3 common palliative case scenarios, physicians estimated LE and reported whether they had an LE threshold below which they would modify their treatment recommendation. LE estimates were considered accurate when within the 95% confidence interval of median survival estimates from an established prognostic model.

RESULTS

Among 92 respondents (81%), the majority were male (62%), from an academic practice (75%), and an attending physician (70%). Physicians reported assessing LE in 91% of their evaluations and most frequently rated performance status (92%), overall metastatic burden (90%), presence of central nervous system metastases (75%), and primary cancer site (73%) as "very important" in assessing LE. Across the 3 cases, most (88%-97%) had LE thresholds that would alter treatment recommendations. Overall, physicians' LE estimates were 22% accurate with 67% over the range predicted by the prognostic model.

CONCLUSIONS

Physicians often incorporate LE estimates into palliative cancer care and identify important prognostic factors. Most have LE thresholds that guide their treatment recommendations. However, physicians overestimated patient survival times in most cases. Future studies focused on improving LE assessment are needed.

Brain metastasis. Prognostic value of the number of involved extracranial organs

BACKGROUND AND PURPOSE

This study was performed to evaluate the prognostic role for survival of the number and the type of involved extracranial organs in patients with brain metastasis.

MATERIAL AND METHODS

The data of 1146 patients who received whole-brain radiotherapy (WBRT) alone for brain metastasis have been retrospectively analyzed. In addition to the number of involved extra cranial organs, seven potential prognostic factors were investigated including WBRT regimen, age, gender, Karnofsky Performance Score (KPS), primary tumor type, number of brain metastases, and the interval from cancer diagnosis to WBRT. Additionally, subgroup analyses were performed for patients with involvement of one (lung vs. bone vs. liver vs. other metastasis) and two (lung + lymph nodes vs. lung + bone vs. lung + liver vs. liver + bone vs. other combinations) extracranial organs.

RESULTS

The 6-month survival rates for the involvement of 0, 1, 2, 3, and ≥4 extracranial organs were 51, 30, 16, 13, and 10%, respectively (p<0.001). On multivariate analysis, the number of involved extracranial organs maintained significance (risk ratio 1.26; 95% confidence interval 1.18-1.34; p<0.001). According to the multivariate analysis, age (p<0.001), gender (p=0.002), and KPS (p<0.001) were also independent prognostic factors for survival. In the subgroup analyses of patients with involvement of one and two extracranial organs, survival was not significantly different based on the extracranial organ involved.

CONCLUSION

The number of involved extracranial organs proved to be an independent prognostic factor in patients with brain metastasis, regardless of the organs involved. The number of involved extracranial organs should be considered in future trials designed for patients with brain metastasis.

Brain metastasis from non-small cell lung cancer (NSCLC): prognostic importance of the number of involved extracranial organs

BACKGROUND AND PURPOSE

This study investigated the potential prognostic value of the number of involved extracranial organs in patients with brain metastasis from non-small cell lung cancer (NSCLC).

MATERIAL AND METHODS

A total of 472 patients who received whole-brain radiotherapy (WBRT) alone with 5 × 4 Gy or 10 × 3 Gy for brain metastasis from NSCLC were included in this retrospective study. In addition to the number of involved extracranial organs, 6 further potential prognostic factors were investigated including WBRT regimen, age, gender, Karnofsky Performance Score (KPS), number of brain metastases, and the interval from cancer diagnosis to WBRT. Subgroup analyses were performed for patients with metastatic involvement of one (lung vs. bone vs. other metastasis) and two (lung + bone vs. lung+lymph nodes vs. other combinations) extracranial organs.

RESULTS

The survival rates at 6 months of the patients with involvement of 0, 1, 2, 3, and ≥ 4 extracranial organs were 52, 27, 17, 4, and 14%, respectively (p<0.001). On multivariate analysis, the number of involved extracranial organs remained significant (risk ratio 1.32; 95% confidence interval 1.19-1.46; p<0.001). Age <65 years (p=0.004), KPS ≥ 70 (p<0.001), and only 1-3 brain metastases (p=0.022) were also significantly associated with survival in the multivariate analysis. In the separate analyses of patients with involvement of one and two extracranial organs, survival was not significantly different based on the pattern of extracranial organ involvement.

CONCLUSION

The number of involved extracranial organs is an independent prognostic factor of survival in patients with brain metastasis from NSCLC, irrespective of the pattern of extracranial organ involvement.

Predicting life expectancy in patients with metastatic cancer receiving palliative radiotherapy: the TEACHH model

BACKGROUND

Predicting life expectancy (LE) in patients with metastatic cancer who are receiving palliative therapies is a difficult task. The purpose of the current study was to develop a LE prediction model among patients receiving palliative radiotherapy (RT) that identifies those patients with short (< 3 months) and long (> 1 year) LEs.

METHODS

The records of 862 patients with metastatic cancer receiving palliative RT at the Dana-Farber/Brigham and Women's Cancer Center between June 2008 and July 2011 were retrospectively reviewed. Cox proportional hazards models were used to evaluate established and potential clinical predictors of LE to construct a model predicting LE of < 3 months and > 1 year.

RESULTS

The median survival was 5.6 months. On multivariate analysis, factors found to be significantly associated with a shorter LE were cancer type (lung and other vs breast and prostate), older age (> 60 years vs ≤ 60 years), liver metastases, Eastern Cooperative Oncology Group performance status (2-4 vs 0-1), hospitalizations within 3 months before palliative RT (0 vs ≥ 1), and prior palliative chemotherapy courses (≥ 2 vs 0-1). Patients were divided into 3 groups with distinct median survivals: group A (those with 0-1 risk factors), 19.9 months (95% confidence interval [95% CI, 13.9 months-31.1 months]); group B (those with 2-4 risk factors), 5.0 months (95% CI, 4.3 months -5.6 months); and group C (those with 5-6 risk factors), 1.7 months (95% CI, 1.2 months-2.1 months).

CONCLUSIONS

The TEACHH model (type of cancer, Eastern Cooperative Oncology Group performance status, age, prior palliative chemotherapy, prior hospitalizations, and hepatic metastases) divides patients receiving palliative RT into 3 distinct LE groups at clinically informative extremes of the LE spectrum. It holds promise to assist radiation oncologists in tailoring palliative therapies to a patient's LE.

Preservation of neurocognitive function and local control of 1 to 3 brain metastases treated with surgery and carmustine wafers

Background

Neurosurgical resection and whole-brain radiation therapy (WBRT) are accepted treatments for single and oligometastatic cancer to the brain. To avoid the decline in neurocognitive function (NCF) linked to WBRT, the authors conducted a prospective, multicenter, phase 2 study to determine whether surgery and carmustine wafers (CW), while deferring WBRT, could preserve NCF and achieve local control (LC).

Methods

NCF and LC were measured in 59 patients who underwent resection and received CW for a single (83%) or dominant (oligometastatic, 2 to 3 lesions) metastasis and received stereotactic radiosurgery (SRS) for tiny nodules not treated with resection plus CW. Preservation of NCF was defined as an improvement or a decline ≤1 standard deviation from baseline in 3 domains: memory, executive function, and fine motor skills, evaluated at 2-month intervals.

Results

Significant improvements in executive function and memory occurred throughout the 1-year follow-up. Preservation or improvement of NCF occurred in all 3 domains for the majority of patients at each of the 2-month intervals. NCF declined in only 1 patient. The chemowafers were well tolerated, and serious adverse events were reversible. There was local recurrence in 28% of the patients at 1-year follow-up.

Conclusions

Patients with brain metastases had improvements in their cognitive trajectory, especially memory and executive function, after treatment with resection plus CW. The rate of LC (78%) was comparable to historic rates of surgery with WBRT and superior to reports of WBRT alone. For patients who undergo resection for symptomatic or large-volume metastasis or for tissue diagnosis, the addition of CW can be considered as an option.

The number of involved extracranial organs: a new predictor of survival in breast cancer patients with brain metastasis

OBJECTIVE

This study was performed to investigate the potential impact of the number of involved extracranial organs on survival in patients with brain metastasis from breast cancer.

METHODS

The data of 196 patients treated with whole-brain radiotherapy (WBRT) alone for brain metastases from breast cancer were retrospectively analyzed. Six potential prognostic factors were evaluated for associations with survival. These factors included WBRT regimen, age, Karnofsky performance score (KPS), number of brain metastases, interval from breast cancer diagnosis to WBRT, and the number of involved extracranial organs.

RESULTS

The 6-month survival rates of patients with involvement of 0, 1, 2, 3 and ≥4 extracranial organs were 59%, 49%, 26%, 26% and 13%, respectively, and the 12-month survival rates were 45%, 36%, 17%, 17% and 13%, respectively (p<0.001). On multivariate analysis, the number of involved extracranial organs (risk ratio 1.17; 95%-confidence interval 1.02-1.35; p=0.028) maintained significance, as did KPS (p<0.001), but not age (p=0.27).

CONCLUSION

The number of involved extracranial organs is an independent prognostic factor of survival in patients with brain metastasis from breast cancer.

The first survival score for patients with brain metastases from small cell lung cancer (SCLC)

OBJECTIVE

Survival scores can help physicians select appropriate treatment for patients with brain metastasis. Primary tumors have different biological behavior justifying separate scoring systems for different tumors. In this study, a survival score was developed for patients with brain metastasis from SCLC.

METHODS

Data of 172 patients receiving whole-brain radiotherapy alone for brain metastasis from SCLC were included. Patients were assigned to a test (N=86) or a validation group (N=86). In the test group, Karnofsky Performance Score, number of brain metastases, and extracranial metastasis were associated with survival and included in the score. Scores for each factor were obtained from the 6-month survival rate divided by 10. According to the total scores, which represented the sum of the three scores, three prognostic groups were formed.

RESULTS

6-Month survival rates in the test group were 3% for 5-8 points, 40% for 9-12 points, and 89% for 15 points (p<0.001). In the validation group, 6-month survival rates were 3%, 41%, and 89% (p<0.001). The comparisons between the three prognostic groups of the test group and the validation group did not show significant differences.

CONCLUSIONS

This new score appears valid and reproducible. It can be used to personalize the treatment to patients with brain metastasis from SCLC.

A new survival score for patients with brain metastases from non-small cell lung cancer

BACKGROUND AND PURPOSE

Non-small cell lung cancer (NSCLC) is the most common primary tumor in patients developing brain metastasis. This study was performed to develop and validate a survival score particularly for this group of patients.

PATIENTS AND METHODS

In this study, the data of 514 patients treated with whole-brain radiotherapy (WBRT) alone for brain metastasis from NSCLC were retrospectively analyzed. The patients were divided into a test group (n = 257) and a validation group (n = 257). In the multivariate analysis of the test group, gender, performance status, and extracranial metastases were independent predictors of survival and, therefore, included in the scoring system. The score for each of the three factors was obtained from the 6-month survival rate (in %) divided by 10. The total scores that represented the sum of the three scores were 5, 8, 9, 11, 12, or 15 points. Three prognostic groups were formed according to the total scores.

RESULTS

The 6-month survival rates in the test group were 9 % for 5-9 points (group A), 54 % for 11-12 points (group B), and 79 % for 15 points (group C). In the validation group the 6-month survival rates were 14, 56, and 78 %, respectively. The comparisons between the prognostic groups A, B, and C of the test and the validation group did not reveal any significant differences.

CONCLUSION

This new score appears valid and reproducible. It can help predict the survival of patients with brain metastasis from NSCLC.

A simple survival score for patients with brain metastases from breast cancer

BACKGROUND AND PURPOSE

Personalized cancer treatment considers the patient's survival prognosis. Therefore, it is important to be able to estimate the patient's survival time, particularly in a palliative situation such as brain metastasis. This study aimed to create and validate a survival score for patients with brain metastasis from breast cancer, which is the second most common primary tumor in these patients.

PATIENTS AND METHODS

Data of 230 patients treated with whole-brain radiotherapy (WBRT) alone for brain metastasis from breast cancer were retrospectively analyzed. Patients were assigned to a test (n = 115) or a validation group (n = 115). According to the results of the multivariate analysis of the test group, Karnofsky Performance Score and extracranial metastases were included in the scoring system. The score for each factor was obtained from the 6-month survival rate (in %) divided by 10. Total scores represented the sum of these scores and were 4, 7, 9, or 12 points. Three prognostic groups were formed.

RESULTS

The 6-month survival rates in the test group were 10 % for 4-7 points, 55 % for 9 points, and 78 % for 15 points (p < 0.001). In the validation group the corresponding 6-month survival rates were 11, 54, and 75 %, respectively (p < 0.001). The comparisons between the prognostic groups of the test and the validation group did not show significant differences.

CONCLUSION

This simple survival score appears valid and reproducible. It can be used to estimate the survival time of patients with brain metastasis from breast cancer receiving WBRT alone.

Optimal management of brain metastases from breast cancer. Issues and considerations

The incidence of brain metastases (BM) in breast cancer patients has increased over the last decade, presumably due to advances in systemic treatment. Today, breast cancer is the second most common cause of BM among all solid malignancies, second only to lung cancer; furthermore, it is the most common cause of leptomeningeal carcinomatosis. The HER2-positive subtype was consistently shown to have a higher risk for BM as compared with HER2-negative disease. More recently, however, it was shown that a similar incidence exists in triple-negative tumours. Local treatment options, radiotherapy and neurosurgical resection, remain the mainstay of therapy for BM. While some studies have suggested a direct effect of conventional chemotherapy on BM, the main beneficial aspect of systemic treatment is rather due to control of non-CNS systemic disease. Importantly, in patients with HER2-positive breast cancer receiving HER2-targeted therapy after local treatment for BM, superior survival outcomes were reported. Leptomeningeal carcinomatosis has a dismal prognosis. Survival with whole brain radiotherapy alone remains short and the potential additional benefit of intrathecal chemotherapy is still disputed. According to case reports, intrathecal administration of trastuzumab appears to be a promising strategy in patients with HER2-positive leptomeningeal carcinomatosis. In conclusion, while the outcome of breast cancer patients with BM has improved especially in the HER2-positive subtype, the prognosis for the majority of patients remains poor. Therefore, development of novel systemic treatment options offering activity within the brain is urgently warranted. Novel insights into the pathobiology of BM formation may offer the possibility for targeted drug prophylaxis of CNS involvement in high-risk patients.