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Avila J, Leone J, Vallejo CT, Lin NU, Leone JP. Survival analysis of patients with brain metastases at initial breast cancer diagnosis over the last decade. Breast Cancer Res Treat 2024; 205:579-587. [PMID: 38453783 DOI: 10.1007/s10549-024-07290-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/08/2024] [Indexed: 03/09/2024]
Abstract
PURPOSE There have been significant advances in the treatment of metastatic breast cancer (BC) over the past years, and long-term outcomes after a diagnosis of brain metastases are lacking. We aimed to identify predictors of brain metastases at initial breast cancer diagnosis, describe overall survival (OS) in the past decade, and identify factors associated with OS after brain metastases diagnosis. METHODS We evaluated patients with de novo stage IV BC using the Surveillance, Epidemiology and End Results database from 2010 to 2019. Multivariate logistic regression was conducted to assess predictors of brain metastases at initial breast cancer diagnosis. OS was estimated using the Kaplan-Meier method and log rank test was used to compare differences between groups. Cox regression was used to assess associations between several variables and OS. RESULTS 1,939 patients with brain metastases at initial breast cancer diagnosis were included. Factors associated with this presentation were grade III/IV tumors, ductal histology, hormone receptor (HR)-negative/human epidermal growth factor receptor 2 (HER2)-positive subtype, and extracranial metastases. Patients with HR-positive/HER2-positive disease had the longest OS (median 18 months) and 12.2% were alive at 8 years. Factors associated with shorter OS included older age, lower income, triple-negative subtype, higher grade, and visceral metastases. CONCLUSION Over the last decade, the median OS of patients with brain metastases at initial breast cancer diagnosis remained poor; however, a substantial minority survive 5 or more years, with rates higher in patients with HER2-positive tumors. In addition to tumor subtype, OS varied according to age, extracranial metastases, and sociodemographic factors.
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Affiliation(s)
- Jorge Avila
- Department of Medicine, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
| | - Julieta Leone
- Grupo Oncológico Cooperativo Del Sur (GOCS), Neuquén, Argentina
| | | | - Nancy U Lin
- Medical Oncology, Susan F. Smith Center for Women's Cancer, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - José P Leone
- Medical Oncology, Susan F. Smith Center for Women's Cancer, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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Sim JH, Kim YH, Lee S, Park HS, Koh WU, Jang DM, Choi WJ. Association between Sarcopenia and Survival in Patients Undergoing Gamma Knife Surgery for Brain Metastasis from Breast Cancer: A Retrospective Single-centre Cohort Study. Clin Oncol (R Coll Radiol) 2024; 36:e87-e96. [PMID: 38114358 DOI: 10.1016/j.clon.2023.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 08/27/2023] [Accepted: 11/09/2023] [Indexed: 12/21/2023]
Abstract
AIMS Many recent studies related to cancer surgery have reported that sarcopenia influences mortality in surgical patients. However, few comprehensive studies have examined the associations between sarcopenia and short- and long-term surgical outcomes of metastatic cancer, especially breast cancer with brain metastasis. In the present study, we investigated the association between sarcopenia and mortality in patients who underwent gamma knife radiosurgery (GKRS) for brain metastasis with breast cancer. MATERIALS AND METHODS This retrospective study analysed 157 patients who underwent GKRS for brain metastasis with breast cancer between January 2014 and December 2018. A Cox regression analysis was carried out to evaluate the association between sarcopenia and mortality at 90 days, 180 days, 1 year, 3 years and the overall period. RESULTS In the Cox regression analysis, sarcopenia was significantly associated with high 90-day mortality (adjusted hazard ratio 3.46, 95% confidence interval 1.24-9.67, P = 0.018), 180-day mortality (adjusted hazard ratio 2.67, 95% confidence interval 1.37-5.22, P = 0.004), 1-year mortality (adjusted hazard ratio 2.39, 95% confidence interval 1.42-4.02, P = 0.001), 3-year mortality (adjusted hazard ratio 2.39, 95% confidence interval 1.53-3.74, P < 0.001) and overall mortality (adjusted hazard ratio 2.11, 95% confidence interval 1.37-3.26, P < 0.001). CONCLUSION Sarcopenia could be a risk factor for short- and long-term mortality in patients undergoing GKRS for brain metastasis from breast cancer.
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Affiliation(s)
- J-H Sim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Y-H Kim
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S Lee
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - H-S Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - W U Koh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - D-M Jang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - W-J Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Mashiach E, Alzate JD, De Nigris Vasconcellos F, Bernstein K, Donahue BR, Schnurman Z, Gurewitz J, Rotman LE, Adams S, Meyers M, Oratz R, Novik Y, Kwa MJ, Silverman JS, Sulman EP, Golfinos JG, Kondziolka D. Long-term Survival From Breast Cancer Brain Metastases in the Era of Modern Systemic Therapies. Neurosurgery 2024; 94:154-164. [PMID: 37581437 DOI: 10.1227/neu.0000000000002640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/14/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Median survival for all patients with breast cancer with brain metastases (BCBMs) has increased in the era of targeted therapy (TT) and with improved local control of intracranial tumors using stereotactic radiosurgery (SRS) and surgical resection. However, detailed characterization of the patients with long-term survival in the past 5 years remains sparse. The aim of this article is to characterize patients with BCBM who achieved long-term survival and identify factors associated with the uniquely better outcomes and to find predictors of mortality for patients with BCBM. METHODS We reviewed 190 patients with breast cancer with 931 brain tumors receiving SRS who were followed at our institution with prospective data collection between 2012 and 2022. We analyzed clinical, molecular, and imaging data to assess relationship to outcomes and tumor control. RESULTS The median overall survival from initial SRS and from breast cancer diagnosis was 25 months (95% CI 19-31 months) and 130 months (95% CI 100-160 months), respectively. Sixteen patients (17%) achieved long-term survival (survival ≥5 years from SRS), 9 of whom are still alive. Predictors of long-term survival included HER2+ status ( P = .041) and treatment with TT ( P = .046). A limited number of patients (11%) died of central nervous system (CNS) causes. A predictor of CNS-related death was the development of leptomeningeal disease after SRS ( P = .025), whereas predictors of non-CNS death included extracranial metastases at first SRS ( P = .017), triple-negative breast cancer ( P = .002), a Karnofsky Performance Status of <80 at first SRS ( P = .002), and active systemic disease at last follow-up ( P = .001). Only 13% of patients eventually needed whole brain radiotherapy. Among the long-term survivors, none died of CNS progression. CONCLUSION Patients with BCBM can achieve long-term survival. The use of TT and HER2+ disease are associated with long-term survival. The primary cause of death was extracranial disease progression, and none of the patients living ≥5 years died of CNS-related disease.
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Affiliation(s)
- Elad Mashiach
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | - Juan Diego Alzate
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | | | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Bernadine R Donahue
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Zane Schnurman
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | - Jason Gurewitz
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Lauren E Rotman
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | - Sylvia Adams
- Department of Medical Oncology, Perlmutter Cancer Center, NYU Langone Health, New York University, New York , New York , USA
- Department of Medicine, NYU Langone Health, New York University, New York , New York , USA
| | - Marleen Meyers
- Department of Medical Oncology, Perlmutter Cancer Center, NYU Langone Health, New York University, New York , New York , USA
- Department of Medicine, NYU Langone Health, New York University, New York , New York , USA
| | - Ruth Oratz
- Department of Medical Oncology, Perlmutter Cancer Center, NYU Langone Health, New York University, New York , New York , USA
- Department of Medicine, NYU Langone Health, New York University, New York , New York , USA
| | - Yelena Novik
- Department of Medical Oncology, Perlmutter Cancer Center, NYU Langone Health, New York University, New York , New York , USA
- Department of Medicine, NYU Langone Health, New York University, New York , New York , USA
| | - Maryann J Kwa
- Department of Medical Oncology, Perlmutter Cancer Center, NYU Langone Health, New York University, New York , New York , USA
- Department of Medicine, NYU Langone Health, New York University, New York , New York , USA
| | - Joshua S Silverman
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Erik P Sulman
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - John G Golfinos
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | - Douglas Kondziolka
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
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Hamester F, Stürken C, Legler K, Eylmann K, Möller K, Roßberg M, Gorzelanny C, Bauer AT, Windhorst S, Schmalfeldt B, Laakmann E, Müller V, Witzel I, Oliveira-Ferrer L. Key Role of Hyaluronan Metabolism for the Development of Brain Metastases in Triple-Negative Breast Cancer. Cells 2022; 11:3275. [PMID: 36291142 PMCID: PMC9600690 DOI: 10.3390/cells11203275] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 10/08/2022] [Accepted: 10/12/2022] [Indexed: 09/21/2023] Open
Abstract
Breast cancer (BC) is the second-most common cause of brain metastases (BM) and BCBM patients have a reduced quality of life and a poor prognosis. Hyaluronan (HA), and in particular the hyaluronidase Hyal-1, has been already linked to the development of BCBM, and therefore presents an interesting opportunity to develop new effective therapeutic options. HA metabolism was further discovered by the CRISPR/Cas9-mediated knockout of HYAL1 and the shRNA-mediated down-regulation of HA-receptor CD44 in the brain-seeking triple-negative breast cancer (TNBC) cell line MDA-MB-231-BR. Therefore, the impact of Hyal-1 on adhesion, disruption, and invasion through the brain endothelium, both in vitro and in vivo, was studied. Our analysis points out a key role of Hyal-1 and low-molecular-weight HA (LMW-HA) in the formation of a pericellular HA-coat in BC cells, which in turn promotes tumor cell adhesion, disruption, and migration through the brain endothelium in vitro as well as the extent of BM in vivo. CD44 knockdown in MDA-MB-231-BR significantly reduced the pericellular HA-coat on these cells, and, consequently, tumor cell adhesion and invasion through the brain endothelium. Thus, the interaction between Hyal-1-generated LMW-HA fragments and the HA-receptor CD44 might represent a potential target for future therapeutic options in BC patients with a high risk of cerebral metastases formation.
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Affiliation(s)
- Fabienne Hamester
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Christine Stürken
- Department of Anatomy and Experimental Morphology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- MSH Medical School Hamburg, Faculty of Medicine, Medical University, 20251 Hamburg, Germany
| | - Karen Legler
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Kathrin Eylmann
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Katrin Möller
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Maila Roßberg
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Christian Gorzelanny
- Department of Dermatology and Venerology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Alexander T. Bauer
- Department of Dermatology and Venerology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Sabine Windhorst
- Department of Biochemistry and Signal Transduction, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Barbara Schmalfeldt
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Elena Laakmann
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Volkmar Müller
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Isabell Witzel
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Leticia Oliveira-Ferrer
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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Sim JH, Park YS, Ha S, Kim SH, Kim JU. Association between red blood cell distribution width and mortality in patients with metastatic brain tumors: A retrospective single-center cohort study. Front Oncol 2022; 12:985263. [PMID: 36276127 PMCID: PMC9586452 DOI: 10.3389/fonc.2022.985263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 09/16/2022] [Indexed: 12/04/2022] Open
Abstract
Metastatic brain tumor has been associated with high mortality and poor prognosis. However, information on indicators predicting surgical prognosis in patients with brain metastases is limited. This study aimed to investigate the association between preoperative red blood cell distribution width (RDW) and mortality in patients who underwent surgery for metastatic brain tumors. This study analyzed 282 patients who underwent metastatic brain tumor surgery between August 1999 and March 2020. Patients were divided into two groups based on preoperative RDW cut-off values (<13.2 and ≥13.2). The surgical outcomes were compared between the two groups. Additionally, we performed Cox regression analysis to assess the association between preoperative RDW and 1-year and overall mortality. There were significant differences in 180-day mortality (6.2% vs. 28.7%, P<0.001), 1-year mortality (23.8% vs. 46.7%, P<0.001), and overall mortality (75.0% vs. 87.7%, P=0.012) between the two groups. In the Cox regression analysis, RDW ≥ 13.2 was significantly associated with higher 1-year mortality (adjusted hazard ratio [HR], 2.14; 95% confidence interval [CI], 1.38–3.30; P<0.001) and overall mortality (HR, 1.44; 95% CI, 1.09–1.90; P=0.010). Preoperative RDW is strongly associated with high mortality in metastatic brain tumor surgery.
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Freeman M, Ennis M, Jerzak KJ. Karnofsky Performance Status (KPS) ≤60 Is Strongly Associated With Shorter Brain-Specific Progression-Free Survival Among Patients With Metastatic Breast Cancer With Brain Metastases. Front Oncol 2022; 12:867462. [PMID: 35965535 PMCID: PMC9364681 DOI: 10.3389/fonc.2022.867462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 06/14/2022] [Indexed: 11/22/2022] Open
Abstract
Objective To examine the association between Karnofsky Performance Status (“KPS”) and brain-specific progression-free survival (“bsPFS”) among patients with breast cancer brain metastases (“BCBrM”). Methods Using a previously compiled retrospective cohort of 683 patients who were treated for BCBrM with surgery and/or radiotherapy at the Sunnybrook Odette Cancer Centre from 2008-2018, electronic records were reviewed to impute KPS scores at the time of BCBrM diagnosis. Patients were then grouped into KPS ≤60 and KPS >60 cohorts. The dataset was analyzed to identify variables that were prognostic for bsPFS and/or overall survival (“OS”) using univariable and multivariable Cox proportional hazards models. Results The mean age of patients was 57 (range 24-93). Most patients (n=622, 91%) had extracranial metastatic disease and 174 (25%) had leptomeningeal disease. 247 patients (36%) had hormone receptor (“HR”)-positive/human endothelial growth factor receptor 2 (“HER2”)-negative tumours, 189 (28%) had HER2-positive disease, and 153 (22%) had triple-negative breast cancer. Of the 331 patients (48%) who could be assigned a KPS cohort, 102 (31%) had KPS ≤60. Most patients were treated with whole brain radiotherapy (n=498, 73%) and/or stereotactic radiosurgery (“SRS”) (n=128, 19%). Median bsPFS was 9 months (95% CI 8-10 months) and median OS was not reached. In univariable analyses, KPS ≤60, presence of leptomeningeal disease, neurological symptoms, ≥2 brain metastases, and not undergoing SRS were factors associated with shorter bsPFS. In a multivariable analysis, KPS ≤60 was the only statistically significant determinant of bsPFS (HR 1.86, 95% CI 1.20-2.88). Although survival data was limited, KPS ≤60 was associated with shorter OS in both univariable (HR 3.12, 95% CI 1.85-5.26) and multivariable (HR 2.95, 95% CI 1.55-5.58) analyses. Conclusion Patients with BCBrM who have a KPS ≤60 have significantly shorter bsPFS and OS than those with KPS >60. KPS should be documented routinely at the time of diagnosis of brain metastases to improve prognostication.
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Affiliation(s)
- Mark Freeman
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Katarzyna J. Jerzak
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Science Centre, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute (SRI), Toronto, ON, Canada
- *Correspondence: Katarzyna J. Jerzak,
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7
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Michel A, Dinger TF, Santos AN, Pierscianek D, Darkwah Oppong M, Ahmadipour Y, Dammann P, Wrede KH, Hense J, Pöttgen C, Iannaccone A, Kimmig R, Sure U, Jabbarli R. Time interval between the diagnosis of breast cancer and brain metastases impacts prognosis after metastasis surgery. J Neurooncol 2022; 159:53-63. [PMID: 35672530 PMCID: PMC9325855 DOI: 10.1007/s11060-022-04043-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 05/21/2022] [Indexed: 11/29/2022]
Abstract
Abstract
Purpose
Breast cancer (BC) is the most frequently diagnosed tumor entity in women. Occurring at different time intervals (TI) after BC diagnosis, brain metastases (BM) are associated with poor prognosis. We aimed to identify the risk factors related to and the clinical impact of timing on overall survival (OS) after BM surgery.
Methods
We included 93 female patients who underwent BC BM surgery in our institution (2008–2019). Various clinical, radiographic, and histopathologic markers were analyzed with respect to TI and OS.
Results
The median TI was 45.0 months (range: 9–334.0 months). Fifteen individuals (16.1%) showed late occurrence of BM (TI ≥ 10 years), which was independently related to invasive lobular BC [adjusted odds ratio (aOR) 9.49, 95% confidence interval (CI) 1.47–61.39, p = 0.018] and adjuvant breast radiation (aOR 0.12, 95% CI 0.02–0.67, p = 0.016). Shorter TI (< 5 years, aOR 4.28, 95% CI 1.46–12.53, p = 0.008) was independently associated with postoperative survival and independently associated with the Union for International Cancer Control stage (UICC) III–IV of BC (aOR 4.82, 95% CI 1.10–21.17, p = 0.037), midline brain shift in preoperative imaging (aOR10.35, 95% CI 1.09–98.33, p = 0.042) and identic estrogen receptor status in BM (aOR 4.56, 95% CI 1.35–15.40, p = 0.015).
Conclusions
Several factors seem to influence the period between BC and BM. Occurrence of BM within five years is independently associated with poorer prognosis after BM surgery. Patients with invasive lobular BC and without adjuvant breast radiation are more likely to develop BM after a long progression-free survival necessitating more prolonged cancer aftercare of these individuals.
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Affiliation(s)
- Anna Michel
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany.
- German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, 45147, Essen, Germany.
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Germany.
| | - Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
- German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, 45147, Essen, Germany
| | - Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
- German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, 45147, Essen, Germany
| | - Daniela Pierscianek
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
- German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, 45147, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
- German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, 45147, Essen, Germany
| | - Yahya Ahmadipour
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
- German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, 45147, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
- German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, 45147, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
- German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, 45147, Essen, Germany
| | - Jörg Hense
- Department of Medical Oncology, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, 45147, Essen, Germany
| | - Christoph Pöttgen
- Department of Radiotherapy, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, 45147, Essen, Germany
| | - Antonella Iannaccone
- Department of Obstetrics and Gynecology, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, 45147, Essen, Germany
| | - Rainer Kimmig
- Department of Obstetrics and Gynecology, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, 45147, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
- German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, 45147, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
- German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, 45147, Essen, Germany
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Menendez JA, Lupu R. Fatty acid synthase: A druggable driver of breast cancer brain metastasis. Expert Opin Ther Targets 2022; 26:427-444. [PMID: 35545806 DOI: 10.1080/14728222.2022.2077189] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Brain metastasis (BrM) is a key contributor to morbidity and mortality in breast cancer patients, especially among high-risk epidermal growth factor receptor 2-positive (HER2+) and triple-negative/basal-like molecular subtypes. Optimal management of BrM is focused on characterizing a "BrM dependency map" to prioritize targetable therapeutic vulnerabilities. AREAS COVERED We review recent studies addressing the targeting of BrM in the lipid-deprived brain environment, which selects for brain-tropic breast cancer cells capable of cell-autonomously generating fatty acids by upregulating de novo lipogenesis via fatty acid synthase (FASN). Disruption of FASN activity impairs breast cancer growth in the brain, but not extracranially, and mapping of the molecular causes of organ-specific patterns of metastasis has uncovered an enrichment of lipid metabolism signatures in brain metastasizing cells. Targeting SREBP1-the master regulator of lipogenic gene transcription-curtails the ability of breast cancer cells to survive in the brain microenvironment. EXPERT OPINION Targeting FASN represents a new therapeutic opportunity for patients with breast cancer and BrM. Delivery of brain-permeable FASN inhibitors and identifying strategies to target metabolic plasticity that might compensate for impaired brain FASN activity are two potential roadblocks that may hinder FASN-centered strategies against BrM.
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Affiliation(s)
- Javier A Menendez
- Metabolism and Cancer Group, Program Against Cancer Therapeutic Resistance (ProCURE), Catalan Institute of Oncology, 17007 Girona, Spain.,Girona Biomedical Research Institute (IDIBGI), 17190 Girona, Spain
| | - Ruth Lupu
- Department of Laboratory Medicine and Pathology, Division of Experimental Pathology, Mayo Clinic, Rochester, MN 55905, USA.,Department of Biochemistry and Molecular Biology Laboratory, Mayo Clinic Minnesota, Rochester, MN 55905, USA.,Mayo Clinic Cancer Center, Rochester, MN 55905, USA
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9
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Michel A, Darkwah Oppong M, Rauschenbach L, Dinger TF, Barthel L, Pierscianek D, Wrede KH, Hense J, Pöttgen C, Junker A, Schmidt T, Iannaccone A, Kimmig R, Sure U, Jabbarli R. Prediction of Short and Long Survival after Surgery for Breast Cancer Brain Metastases. Cancers (Basel) 2022; 14:cancers14061437. [PMID: 35326590 PMCID: PMC8946189 DOI: 10.3390/cancers14061437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/02/2022] [Indexed: 12/09/2022] Open
Abstract
Background: Brain metastases requiring surgical treatment determine the prognosis of patients with breast cancer. We aimed to develop the scores for the prediction of short (<6 months) and long (≥3 years) survival after BCBM surgery. Methods: Female patients with BCBM surgery between 2008 and 2019 were included. The new scores were constructed upon independent predictors for short and long postoperative survival. Results: In the final cohort (n = 95), 18 (18.9%) and 22 (23.2%) patients experienced short and long postoperative survival, respectively. Breast-preserving surgery, presence of multiple brain metastases and age ≥ 65 years at breast cancer diagnosis were identified as independent predictors of short postoperative survival. In turn, positive HER2 receptor status in brain metastases, time interval ≥ 3 years between breast cancer and brain metastases diagnosis and KPS ≥ 90% independently predicted long survival. The appropriate short and long survival scores showed higher diagnostic accuracy for the prediction of short (AUC = 0.773) and long (AUC = 0.775) survival than the breast Graded Prognostic Assessment score (AUC = 0.498/0.615). A cumulative survival score (total score) showed significant association with overall survival (p = 0.001). Conclusion: We identified predictors independently impacting the prognosis after BCBM surgery. After external validation, the presented scores might become useful tools for the selection of proper candidates for BCBM surgery.
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Affiliation(s)
- Anna Michel
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, 45147 Essen, Germany; (M.D.O.); (L.R.); (T.F.D.); (L.B.); (D.P.); (K.H.W.); (U.S.); (R.J.)
- Correspondence: ; Tel.: +49-201-723-1230; Fax: +49-201-723-1220
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, 45147 Essen, Germany; (M.D.O.); (L.R.); (T.F.D.); (L.B.); (D.P.); (K.H.W.); (U.S.); (R.J.)
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, 45147 Essen, Germany; (M.D.O.); (L.R.); (T.F.D.); (L.B.); (D.P.); (K.H.W.); (U.S.); (R.J.)
| | - Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, 45147 Essen, Germany; (M.D.O.); (L.R.); (T.F.D.); (L.B.); (D.P.); (K.H.W.); (U.S.); (R.J.)
| | - Lennart Barthel
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, 45147 Essen, Germany; (M.D.O.); (L.R.); (T.F.D.); (L.B.); (D.P.); (K.H.W.); (U.S.); (R.J.)
| | - Daniela Pierscianek
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, 45147 Essen, Germany; (M.D.O.); (L.R.); (T.F.D.); (L.B.); (D.P.); (K.H.W.); (U.S.); (R.J.)
| | - Karsten H. Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, 45147 Essen, Germany; (M.D.O.); (L.R.); (T.F.D.); (L.B.); (D.P.); (K.H.W.); (U.S.); (R.J.)
| | - Jörg Hense
- Department of Medical Oncology, University Hospital Essen, 45147 Essen, Germany;
| | - Christoph Pöttgen
- Department of Radiotherapy, University Hospital Essen, 45147 Essen, Germany;
| | - Andreas Junker
- Department of Neuropathology, University Hospital Essen, 45147 Essen, Germany;
| | - Teresa Schmidt
- Department of Neurooncology, University Hospital Essen, 45147 Essen, Germany;
| | - Antonella Iannaccone
- Department of Obstetrics and Gynecology, University Hospital Essen, 45147 Essen, Germany; (A.I.); (R.K.)
| | - Rainer Kimmig
- Department of Obstetrics and Gynecology, University Hospital Essen, 45147 Essen, Germany; (A.I.); (R.K.)
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, 45147 Essen, Germany; (M.D.O.); (L.R.); (T.F.D.); (L.B.); (D.P.); (K.H.W.); (U.S.); (R.J.)
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, 45147 Essen, Germany; (M.D.O.); (L.R.); (T.F.D.); (L.B.); (D.P.); (K.H.W.); (U.S.); (R.J.)
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10
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Insights into the Steps of Breast Cancer-Brain Metastases Development: Tumor Cell Interactions with the Blood-Brain Barrier. Int J Mol Sci 2022; 23:ijms23031900. [PMID: 35163822 PMCID: PMC8836543 DOI: 10.3390/ijms23031900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/01/2022] [Accepted: 02/05/2022] [Indexed: 02/07/2023] Open
Abstract
Brain metastases (BM) represent a growing problem for breast cancer (BC) patients. Recent studies have demonstrated a strong impact of the BC molecular subtype on the incidence of BM development. This study explores the interaction between BC cells of different molecular subtypes and the blood–brain barrier (BBB). We compared the ability of BC cells of different molecular subtypes to overcome several steps (adhesion to the brain endothelium, disruption of the BBB, and invasion through the endothelial layer) during cerebral metastases formation, in vitro as well as in vivo. Further, the impact of these cells on the BBB was deciphered at the molecular level by transcriptome analysis of the triple-negative (TNBC) cells themselves as well as of hBMECs after cocultivation with BC cell secretomes. Compared to luminal BC cells, TNBC cells have a greater ability to influence the BBB in vitro and consequently develop BM in vivo. The brain-seeking subline and parental TNBC cells behaved similarly in terms of adhesion, whereas the first showed a stronger impact on the brain endothelium integrity and increased invasive ability. The comparative transcriptome revealed potential brain-metastatic-specific key regulators involved in the aforementioned processes, e.g., the angiogenesis-related factors TNXIP and CXCL1. In addition, the transcriptomes of the two TNBC cell lines strongly differed in certain angiogenesis-associated factors and in several genes related to cell migration and invasion. Based on the present study, we hypothesize that the tumor cell’s ability to disrupt the BBB via angiogenesis activation, together with increased cellular motility, is required for BC cells to overcome the BBB and develop brain metastases.
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11
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Radiographic markers of breast cancer brain metastases: relation to clinical characteristics and postoperative outcome. Acta Neurochir (Wien) 2022; 164:439-449. [PMID: 34677686 PMCID: PMC8854251 DOI: 10.1007/s00701-021-05026-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/09/2021] [Indexed: 12/24/2022]
Abstract
Objective Occurrence of brain metastases BM is associated with poor prognosis in patients with breast cancer (BC). Magnetic resonance imaging (MRI) is the standard of care in the diagnosis of BM and determines further treatment strategy. The aim of the present study was to evaluate the association between the radiographic markers of BCBM on MRI with other patients’ characteristics and overall survival (OS). Methods We included 88 female patients who underwent BCBM surgery in our institution from 2008 to 2019. Data on demographic, clinical, and histopathological characteristics of the patients and postoperative survival were collected from the electronic health records. Radiographic features of BM were assessed upon the preoperative MRI. Univariable and multivariable analyses were performed. Results The median OS was 17 months. Of all evaluated radiographic markers of BCBM, only the presence of necrosis was independently associated with OS (14.5 vs 22.5 months, p = 0.027). In turn, intra-tumoral necrosis was more often in individuals with shorter time interval between BC and BM diagnosis (< 3 years, p = 0.035) and preoperative leukocytosis (p = 0.022). Moreover, dural affection of BM was more common in individuals with positive human epidermal growth factor receptor 2 status (p = 0.015) and supratentorial BM location (p = 0.024). Conclusion Intra-tumoral necrosis demonstrated significant association with OS after BM surgery in patients with BC. The radiographic pattern of BM on the preoperative MRI depends on certain tumor and clinical characteristics of patients. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-021-05026-4.
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12
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Kadamkulam Syriac A, Nandu NS, Leone JP. Central Nervous System Metastases from Triple-Negative Breast Cancer: Current Treatments and Future Prospective. BREAST CANCER (DOVE MEDICAL PRESS) 2022; 14:1-13. [PMID: 35046721 PMCID: PMC8760391 DOI: 10.2147/bctt.s274514] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/24/2021] [Indexed: 12/18/2022]
Abstract
It is estimated that approximately one-third of patients with triple-negative breast cancer (TNBC) will develop brain metastases. The prognosis for patients with breast cancer brain metastasis has improved in the recent past, especially for hormone receptor and human epidermal growth factor receptor 2 (HER) positive subtypes. However, the overall survival rate for patients with triple-negative subtype remains poor. The development of newer treatment options, including antibody-drug conjugates such as Sacituzumab govitecan, is particularly encouraging. This article reviews the clinical outcomes, challenges, and current approach to the treatment of brain metastasis in TNBC. We have also briefly discussed newer treatment options and ongoing clinical trials. The development of brain metastasis significantly decreases the quality of life of patients with TNBC, and newer treatment strategies and therapeutics are the need of the hour for this disease subgroup.
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Affiliation(s)
| | - Nitish Singh Nandu
- Department of Hospice and Palliative Medicine, Montefiore Medical Center/ Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jose Pablo Leone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, 02215, USA
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13
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Ferini G, Viola A, Valenti V, Tripoli A, Molino L, Marchese VA, Illari SI, Rita Borzì G, Prestifilippo A, Umana GE, Martorana E, Mortellaro G, Ferrera G, Cacciola A, Lillo S, Pontoriero A, Pergolizzi S, Parisi S. Whole Brain Irradiation or Stereotactic RadioSurgery for five or more brain metastases (WHOBI-STER): A prospective comparative study of neurocognitive outcomes, level of autonomy in daily activities and quality of life. Clin Transl Radiat Oncol 2021; 32:52-58. [PMID: 34926839 PMCID: PMC8649107 DOI: 10.1016/j.ctro.2021.11.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 11/18/2021] [Accepted: 11/21/2021] [Indexed: 02/07/2023] Open
Abstract
The main aim of MBM treatment is to palliate neurological symptoms and to maintain an adequate QoL. SRT could be the “new standard” over WBI in the management of MBM patients. Neurocognitive functions could deteriorate more after WBI than after SRT.
Aims To evaluate neurocognitive performance, daily activity and quality of life (QoL), other than usual oncologic outcomes, among patients with brain metastasis ≥5 (MBM) from solid tumors treated with Stereotactic Brain Irradiation (SBI) or Whole Brain Irradiation (WBI). Methods This multicentric randomized controlled trial will involve the enrollment of 100 patients (50 for each arm) with MBM ≥ 5, age ≥ 18 years, Karnofsky Performance Status (KPS) ≥ 70, life expectancy > 3 months, known primary tumor, with controlled or controllable extracranial disease, baseline Montreal Cognitive Assessment (MoCA) score ≥ 20/30, Barthel Activities of Daily Living score ≥ 90/100, to be submitted to SBI by LINAC with monoisocentric technique and non-coplanar arcs (experimental arm) or to WBI (control arm). The primary endpoints are neurocognitive performance, QoL and autonomy in daily-life activities variations, the first one assessed by MoCa Score and Hopkins Verbal Learning Test-Revised, the second one through the EORTC QLQ-C15-PAL and QLQ-BN-20 questionnaires, the third one through the Barthel Index, respectively. The secondary endpoints are time to intracranial failure, overall survival, retreatment rate, acute and late toxicities, changing of KPS. It will be considered significant a statistical difference of at least 30% between the two arms (statistical power of 80% with a significance level of 95%). Discussion Several studies debate what is the decisive factor accountable for the development of neurocognitive decay among patients undergoing brain irradiation for MBM: radiation effect on clinically healthy brain tissue or intracranial tumor burden? The answer to this question may come from the recent technological advancement that allows, in a context of a significant time saving, improved patient comfort and minimizing radiation dose to off-target brain, a selective treatment of MBM simultaneously, otherwise attackable only by WBI. The achievement of a local control rate comparable to that obtained with WBI remains the fundamental prerequisite. Trial registration NCT number: NCT04891471.
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Key Words
- 3D-CRT, 3Dimensional-ConformalRadioTherapy
- Autonomy in daily activities
- BSC, Best Supportive Care
- Brain metastases
- CRF, Case Report Form
- CT, Computerized Tomography
- CTV, Clinical Target Volume
- EORTC QLQ-C15-PAL, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 for Palliative Care
- FSRT, Fractionated Stereotactic Radiation Therapy
- GTV, Gross Tumor Volume
- KPS, Karnofsky Performance Status
- LINAC, Linear Accelerator
- MBM, Multiple Brain Metastastes
- MRI, Magnetic Resonance Imaging
- MoCA, Montreal Cognitive Assessment
- NCCN, National Comprehensive Cancer Network
- Neurocognitive decay
- Neurocognitive performance
- Neurocognitive tests
- OAR, Organ At Risk
- OS, Overall Survival
- PTV, Planning Target Volume
- Palliative care
- QLQ-BN20, Quality of Life Questionnaire - Brain Neoplasm 20
- QoL, Quality of Life
- Quality of life
- RT, Radiation Therapy
- RTOG, Radiation Therapy Oncology Group
- Radiotherapy for multiple brain metastases
- SBI, Stereotactic Brain Irradiation
- SRS, Stereotactic RadioSurgery
- SRT, Stereotactic Radiation Therapy
- Stereotactic Brain RadioSurgery
- Stereotactic Brain Radiotherapy
- Supportive care in cancer patients
- VEGF, Vascular Endothelial Growth Factor
- Whole Brain Radiotherapy
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Affiliation(s)
| | - Anna Viola
- Fondazione IOM, Viagrande, I-95029 Catania, Italy
| | - Vito Valenti
- REM Radioterapia srl, Viagrande, I-95029 Catania, Italy
| | | | - Laura Molino
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
| | | | | | | | - Angela Prestifilippo
- Medical Oncology Unit, Mediterranean Institute of Oncology, Viagrande, I-95029 Catania, Italy
| | - Giuseppe Emmanuele Umana
- Trauma Center, Gamma Knife Center, Department of Neurosurgery, Cannizzaro Hospital, I-95125 Catania, Italy
| | | | - Gianluca Mortellaro
- Department of Radiation Oncology, ARNAS Ospedale Civico, I-90127 Palermo, Italy
| | - Giuseppe Ferrera
- Department of Radiation Oncology, ARNAS Ospedale Civico, I-90127 Palermo, Italy
| | - Alberto Cacciola
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
| | - Sara Lillo
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
| | - Antonio Pontoriero
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
| | - Stefano Pergolizzi
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
| | - Silvana Parisi
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
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14
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Gao YK, Kuksis M, Id Said B, Chehade R, Kiss A, Tran W, Sickandar F, Sahgal A, Warner E, Soliman H, Jerzak KJ. Treatment Patterns and Outcomes of Women with Symptomatic and Asymptomatic Breast Cancer Brain Metastases: A Single-Center Retrospective Study. Oncologist 2021; 26:e1951-e1961. [PMID: 34506676 DOI: 10.1002/onco.13965] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 08/31/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Breast cancer is the most common cancer among women worldwide and the second leading cause of brain metastases (BrM). We assessed the treatment patterns and outcomes of women treated for breast cancer BrM at our institution in the modern era of stereotactic radiosurgery (SRS). MATERIALS AND METHODS We conducted a retrospective analysis of women (≥18 years of age) with metastatic breast cancer who were treated with surgery, whole brain radiotherapy (WBRT), or SRS to the brain at the Sunnybrook Odette Cancer Centre, Toronto, Canada, between 2008 and 2018. Patients with a history of other malignancies and those with an uncertain date of diagnosis of BrM were excluded. Descriptive statistics were generated and survival analyses were performed with subgroup analyses by breast cancer subtype. RESULTS Among 683 eligible patients, 153 (22.4%) had triple-negative breast cancer, 188 (27.5%) had HER2+, 246 (36.0%) had hormone receptor (HR)+/HER2-, and 61 (13.3%) had breast cancer of an unknown subtype. The majority of patients received first-line WBRT (n = 459, 67.2%) or SRS (n = 126, 18.4%). The median brain-specific progression-free survival and median overall survival (OS) were 4.1 months (interquartile range [IQR] 1.0-9.6 months) and 5.1 months (IQR 2.0-11.7 months) in the overall patent population, respectively. Age >60 years, presence of neurological symptoms at BrM diagnosis, first-line WBRT, and HER2- subtype were independently prognostic for shorter OS. CONCLUSION Despite the use of SRS, outcomes among patients with breast cancer BrM remain poor. Strategies for early detection of BrM and central nervous system-active systemic therapies warrant further investigation. IMPLICATIONS FOR PRACTICE Although triple-negative breast cancer and HER2+ breast cancer have a predilection for metastasis to the central nervous system (CNS), patients with hormone receptor-positive/HER2- breast cancer represent a high proportion of patients with breast cancer brain metastases (BrM). Hence, clinical trials should include patients with BrM and evaluate CNS-specific activity of novel systemic therapies when feasible, irrespective of breast cancer subtype. In addition, given that symptomatic BrM are associated with shorter survival, this study suggests that screening programs for the early detection and treatment of breast cancer BrM warrant further investigation in an era of minimally toxic stereotactic radiosurgery.
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Affiliation(s)
- Yizhuo Kelly Gao
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Markus Kuksis
- School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Badr Id Said
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Rania Chehade
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Alex Kiss
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - William Tran
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Faisal Sickandar
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Ellen Warner
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Katarzyna J Jerzak
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
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15
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Rohatgi N, Munshi A, Bajpai P, Singh M, Sahai S, Ahmad M, Singh K, Singh H, Parikh PM, Aggarwal S. Practical consensus recommendations on Her2 +ve breast cancer with solitary brain mets. South Asian J Cancer 2020; 7:118-122. [PMID: 29721477 PMCID: PMC5909288 DOI: 10.4103/sajc.sajc_116_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Breast cancer is a common cause of brain metastases, with metastases occurring in at least 10-16% of patients. Longer survival of patients with metastatic breast cancer and the use of better imaging techniques are associated with an increased incidence of brain metastases. Current therapies include surgery, whole-brain radiation therapy, stereotactic radiosurgery, chemotherapy and targeted therapies. However, the timing and appropriate use of these therapies is controversial and careful patient selection by using available prognostic tools is extremely important. Expert oncologist discussed on the mode of treatment to extend the OS and improve the quality of life ofHER2-positivebreast cancer patients with Solitary brain metastases. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.
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Affiliation(s)
- Nitesh Rohatgi
- Department of Medical Oncology, Max Hospital, New Delhi, India
| | - A Munshi
- Department of Radiation Oncology, Fortis Hospital, Gurugram, Haryana, India
| | - P Bajpai
- Department of Medical Oncology, Manipal Super Specialty Hospital, New Delhi, India
| | - M Singh
- Department of Medical Oncology, Mahavir Cancer Sansthan, Patna, Bihar, India
| | - S Sahai
- Department of Radiation Oncology, Fortis Hospital, Gurugram, Haryana, India
| | - M Ahmad
- Department of Radiation Oncology, Jolly Grant Himalayan Institute, Dehradoon, Uttarakhand, India
| | - K Singh
- Department of Radiation Oncology, MAMS, New Delhi, India
| | - H Singh
- Department of Radiaton Oncology, Action Balajee Cancer Center, New Delhi, India
| | - Purvish M Parikh
- Department of Oncology, Shalby Cancer and Research Institute, Mumbai, Maharashtra, India
| | - S Aggarwal
- Department of Medical Oncology, Sir Ganga Ram Hospital, New Delhi, India
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16
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Wang K, Hackney JR, Siegal GP, Wei S. RANKLed by the Complexity of Signaling in Breast Cancer Metastasis to the Brain. Clin Breast Cancer 2020; 20:e569-e575. [PMID: 32381383 DOI: 10.1016/j.clbc.2020.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/17/2020] [Accepted: 04/01/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Receptor activator of nuclear factor κB (RANK) and its ligand, RANKL, are essential for mammary gland development and play a vital role in breast carcinogenesis. RANKL-RANK signaling also drives thermoregulation and modulates inflammatory activation in the brain. The expression of RANKL in primary breast cancer (BC) has been negatively associated with brain metastases, while significantly higher levels of RANK are seen in BC with brain metastases. We examined the expression of RANK and RANKL in BC metastasis to the brain. PATIENTS AND METHODS We examined the expression of RANK and RANKL in 40 cases of BC metastasis to the brain. RESULTS RANK was variably expressed in BC cells but minimally expressed in the adjacent brain parenchyma. In contrast, the expression of RANKL was minimal in metastatic BC but highly variable in tumoral stroma. RANKL expression in normal brain stroma obtained during autopsy was negligible. Histologic grade and BC subtypes were not significantly associated with RANK expression in metastatic BC. A significant negative correlation between RANK in metastatic BC and RANKL in tumoral stroma was identified (P < .001). CONCLUSION RANK expressed by primary BC and RANKL detected in the tumor microenvironment together participate in cancer development, while the same principle may operate at distant sites. Further investigation is necessary to provide additional insight into the role of the RANKL-RANK pathway in BC progression and to investigate the potential efficacy of therapeutic strategies targeting these molecules in BC metastasis to the brain.
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Affiliation(s)
- Kai Wang
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL
| | - James R Hackney
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL
| | - Gene P Siegal
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL
| | - Shi Wei
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL.
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17
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Treatment Patterns and Survival of Elderly Patients With Breast Cancer Brain Metastases. Am J Clin Oncol 2019; 42:60-66. [PMID: 29965807 DOI: 10.1097/coc.0000000000000477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The main objective of this study was to analyze treatment patterns of elderly patients with breast cancer brain metastases (BCBM), evaluate characteristics associated with treatment selection, and to analyze trends in overall survival (OS) over time. MATERIALS AND METHODS We included women with BCBM reported to the Surveillance, Epidemiology, and End Results Medicare Program from 1992 to 2012. Treatments were recorded from Medicare claims from the date of brain metastases diagnosis until 60 days after. Treatments included resection, radiation, and chemotherapy. Cochran-Armitage tests were used for analysis of treatment patterns. Multinomial logistic regression was applied to determine factors associated with treatment selection. Cox regression modelled OS trends within each treatment modality across time. RESULTS Among 5969 patients included, treatment rates increased from 50% in 1992 to 64.1% in 2012 (P<0.01). Therapy combining radiation, resection, and/or chemotherapy also increased from 8.8% to 18% over the same period (P<0.01). Combined therapy was significantly more likely among patients with extracranial metastases, those with estrogen-negative tumors, younger age at diagnosis, no comorbidities and more recently diagnosed brain metastases. OS improved over time for patients who received a combination of ≥2 treatments (hazard ratio, 0.89 per every 5 more recent diagnosis years; P<0.05). Older patients, those with extracranial metastases, or estrogen/progesterone-negative tumors showed significantly shorter OS. CONCLUSIONS We observed substantial changes in treatment patterns and OS over time in patients with BCBM. We identified several factors associated with specific treatment use. Patients who underwent a combination of ≥2 treatments experienced a significant improvement in OS over time.
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18
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Zahid KF, Kumar S, Al-Bimani K, Ahmed T, Al-Ajmi A, Burney IA, Al-Moundhri M. Outcome of Omani Women with Breast Cancer-associated Brain Metastases Experience from a University Hospital. Oman Med J 2019; 34:412-419. [PMID: 31555417 PMCID: PMC6745425 DOI: 10.5001/omj.2019.76] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Objectives Breast cancer (BC) is the leading cancer among women. Almost 20% of patients develop brain metastases (BM) and die shortly afterward. There is a dearth of data on the survival outcome of BC patients with BM from the Arab world. Methods Consecutive women diagnosed with BC who developed radiologically-confirmed BM during their illness were identified through the hospital’s electronic patient’s records. Clinicopathological features and treatment outcomes were recorded. Survival was calculated using the Kaplan-Meier method, and factors affecting survival were studied using log-rank analysis. Results Between January 2003 and June 2015, a total of 692 patients were treated for BC at our institute. Forty-eight (6.9%) developed BM. The median age at the diagnosis of BM was 45.2 years. More than half of cohort (54.2%) had HER2 positive disease, while 27.1% had the triple-negative disease. The median time interval between the diagnosis of BC and the development of BM was 21 months, and median survival after development of brain disease was seven months. On univariate analysis, pathological grade, previous systemic treatment, brain as the first site of metastases, brain as the only site of metastases, treatment of BM, systemic treatment after BM, and diagnosis-specific graded prognostic assessment (DS-GPA) score significantly affected survival. On multivariate Cox regression analysis, the brain as the first site of metastases, treatment for brain disease, treatment type, and DS-GPA score significantly affected survival post-BM. Conclusions Our data indicate that Omani women are diagnosed with BC at a younger age, develop BM earlier, and carry a poor outcome.
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Affiliation(s)
- Khawaja F Zahid
- Oncology Department, Castle Hill Hospital, Cottingham, East Riding of Yorkshire, UK
| | - Shiyam Kumar
- Unit of Medical Oncology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Khalid Al-Bimani
- Unit of Medical Oncology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Tanweer Ahmed
- Unit of Medical Oncology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Adil Al-Ajmi
- Department of Surgery, Sultan Qaboos University Hospital, Muscat, Oman
| | - Ikram A Burney
- Unit of Medical Oncology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Mansour Al-Moundhri
- College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
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Liu Y, Chongsathidkiet P, Crawford BM, Odion R, Dechant CA, Kemeny HR, Cui X, Maccarini PF, Lascola CD, Fecci PE, Vo-Dinh T. Plasmonic gold nanostar-mediated photothermal immunotherapy for brain tumor ablation and immunologic memory. Immunotherapy 2019; 11:1293-1302. [PMID: 31530200 DOI: 10.2217/imt-2019-0023] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Brain tumors present unique therapeutic challenges and they include glioblastoma (GBM) and metastases from cancers of other organs. Current treatment options are limited and include surgical resection, radiation therapy, laser interstitial thermal therapy and chemotherapy. Although much research has been done on the development of immune-based treatment platforms, only limited success has been demonstrated. Herein, we demonstrate a novel treatment of GBM through the use of plasmonic gold nanostars (GNS) as photothermal inducers for synergistic immuno photothermal nanotherapy (SYMPHONY), which combines treatments using gold nanostar and laser-induced photothermal therapy with checkpoint blockade immunotherapy. In the treatment of a murine flank tumor model with the CT-2A glioma cell line, SYMPHONY demonstrated the capability of producing long-term survivors that rejects rechallenge with cancer cells, heralding the successful emergence of immunologic memory. This study is the first to investigate the use of this novel therapy for the treatment of GBM in a murine model.
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Affiliation(s)
- Yang Liu
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA.,Department of Chemistry, Duke University, Durham, NC 27708, USA.,Fitzpatrick Institute of Photonics, Duke University, Durham, NC 27708, USA
| | - Pakawat Chongsathidkiet
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA.,Department of Pathology, Duke University Medical Center, Durham, NC 27710, USA
| | - Bridget M Crawford
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA.,Fitzpatrick Institute of Photonics, Duke University, Durham, NC 27708, USA
| | - Ren Odion
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA.,Fitzpatrick Institute of Photonics, Duke University, Durham, NC 27708, USA
| | - Cosette A Dechant
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Hanna R Kemeny
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Xiuyu Cui
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Paolo F Maccarini
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA.,Fitzpatrick Institute of Photonics, Duke University, Durham, NC 27708, USA
| | - Christopher D Lascola
- Department of Radiology, Duke University Medical Center, Durham, NC 27710, USA.,Department of Neurobiology, Duke University Medical Center, Durham, NC 27710, USA
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA.,Department of Pathology, Duke University Medical Center, Durham, NC 27710, USA.,Duke Cancer Institute, Duke University Medical Center, Durham, NC 27710, USA
| | - Tuan Vo-Dinh
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA.,Department of Chemistry, Duke University, Durham, NC 27708, USA.,Fitzpatrick Institute of Photonics, Duke University, Durham, NC 27708, USA.,Duke Cancer Institute, Duke University Medical Center, Durham, NC 27710, USA
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20
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Znidaric T, Gugic J, Marinko T, Gojkovic Horvat A, Paulin Kosir MS, Golo D, Ivanetic Pantar M, Ratosa I. Breast cancer patients with brain metastases or leptomeningeal disease: 10-year results of a national cohort with validation of prognostic indexes. Breast J 2019; 25:1117-1125. [PMID: 31286623 DOI: 10.1111/tbj.13433] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Tanja Znidaric
- Division of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia.,Department of Oncology, University Medical Centre Maribor, Maribor, Slovenia
| | - Jasenka Gugic
- Division of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Tanja Marinko
- Division of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | | | | | - Danijela Golo
- Division of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | | | - Ivica Ratosa
- Division of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
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21
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Xiong Y, Cao H, Zhang Y, Pan Z, Dong S, Wang G, Wang F, Li X. Nomogram-Predicted Survival of Breast Cancer Brain Metastasis: a SEER-Based Population Study. World Neurosurg 2019; 128:e823-e834. [PMID: 31096027 DOI: 10.1016/j.wneu.2019.04.262] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/29/2019] [Accepted: 04/30/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The prognosis of patients with breast cancer brain metastasis (BCBM) was dismal and the prognoses varied according to different prognostic factors. In this study, we used the SEER (Surveillance Epidemiology and End Results) database to identify prognostic factors with the BCBMs. METHODS We identified and built a robust prognostic model and developed reliable nomograms to estimate the individualized overall survival (OS) and breast cancer-specific survival (BCSS) of patients with BCBM. A total of 789 patients with newly diagnosed BCBM were identified from the SEER database and randomly divided into training (n = 554) and testing (n = 235) cohorts. The log-rank tests and the Cox proportional hazards model were applied to evaluate the prognostic effects of multiple clinicopathologic variables on the survival of training cohorts. Significant prognostic factors were combined to build the nomograms that were evaluated using the concordance index and calibration plots for internal and external validations. RESULTS Two nomograms shared the common prognostic indicators including age, tumor subtype, chemotherapy, surgery, number of metastatic sites except the brain, and median household income. In the training cohort, the Harrell concordance index for the constructed nomogram to predict OS and BCSS was 0.668 and 0.676, respectively. The calibration plots were consistent between nomogram-predicted survival probability and actual survival probability. These results were reproducible when nomograms were applied to the testing cohort for external validation. CONCLUSIONS Nomograms that predicted 6-month, 1-year, and 2-year OS and BCSS for patients with newly diagnosed BCBM with satisfactory performance were constructed to help physicians in evaluating the high risk of mortality in patients.
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Affiliation(s)
- Yi Xiong
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Hang Cao
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Yueqi Zhang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Zou Pan
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Siyuan Dong
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Gousiyi Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Feiyifan Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Xuejun Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.
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23
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Nahed BV, Alvarez-Breckenridge C, Brastianos PK, Shih H, Sloan A, Ammirati M, Kuo JS, Ryken TC, Kalkanis SN, Olson JJ. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Role of Surgery in the Management of Adults With Metastatic Brain Tumors. Neurosurgery 2019; 84:E152-E155. [PMID: 30629227 DOI: 10.1093/neuros/nyy542] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/18/2018] [Indexed: 11/13/2022] Open
Abstract
Please see the full-text version of this guideline https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_2) for the target population of each recommendation listed below. SURGERY FOR METASTATIC BRAIN TUMORS AT NEW DIAGNOSIS QUESTION: Should patients with newly diagnosed metastatic brain tumors undergo surgery, stereotactic radiosurgery (SRS), or whole brain radiotherapy (WBRT)? RECOMMENDATIONS Level 1: Surgery + WBRT is recommended as first-line treatment in patients with single brain metastases with favorable performance status and limited extracranial disease to extend overall survival, median survival, and local control. Level 3: Surgery plus SRS is recommended to provide survival benefit in patients with metastatic brain tumors Level 3: Multimodal treatments including either surgery + WBRT + SRS boost or surgery + WBRT are recommended as alternatives to WBRT + SRS in terms of providing overall survival and local control benefits. SURGERY AND RADIATION FOR METASTATIC BRAIN TUMORS QUESTION: Should patients with newly diagnosed metastatic brain tumors undergo surgical resection followed by WBRT, SRS, or another combination of these modalities? RECOMMENDATIONS Level 1: Surgery + WBRT is recommended as superior treatment to WBRT alone in patients with single brain metastases. Level 3: Surgery + SRS is recommended as an alternative to treatment with SRS alone to benefit overall survival. Level 3: It is recommended that SRS alone be considered equivalent to surgery + WBRT. SURGERY FOR RECURRENT METASTATIC BRAIN TUMORS QUESTION: Should patients with recurrent metastatic brain tumors undergo surgical resection? RECOMMENDATIONS Level 3: Craniotomy is recommended as a treatment for intracranial recurrence after initial surgery or SRS. SURGICAL TECHNIQUE AND RECURRENCE QUESTION A: Does the surgical technique (en bloc resection or piecemeal resection) affect recurrence? RECOMMENDATION Level 3: En bloc tumor resection, as opposed to piecemeal resection, is recommended to decrease the risk of postoperative leptomeningeal disease when resecting single brain metastases. QUESTION B Does the extent of surgical resection (gross total resection or subtotal resection) affect recurrence? RECOMMENDATION Level 3: Gross total resection is recommended over subtotal resection in recursive partitioning analysis class I patients to improve overall survival and prolong time to recurrence. The full guideline can be found at https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_2.
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Affiliation(s)
- Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | - Helen Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew Sloan
- Department of Neurosurgery, Case Western Reserve University, Cleveland, Ohio
| | - Mario Ammirati
- Department of Neurosurgery, St. Rita Medical Center, Lima, Ohio.,Department of Biology, College of Science and Technology and Sbarro Health Research Organization, Temple University, Philadelphia, Pennsylvania
| | - John S Kuo
- Department of Neurosurgery and Mulva Clinic for the Neurosciences, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Timothy C Ryken
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Steven N Kalkanis
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
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24
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Abstract
Brain metastases are the most common malignant adult intracranial tumors, occurring in approximately 10-30% of cancer patients, and generally lead to a poor prognosis. The incidence has been steadily rising, likely due to longer survival from newer systemic therapies and increased utilization of magnetic resonance imaging. Historically, whole-brain radiotherapy has been a standard of care for the management of patients with brain metastases. However, better understanding of both the acute and long-term toxicities associated with whole-brain radiotherapy has led to a more selective use of whole-brain radiotherapy. Herein we discuss the background and prognostication of brain metastases as well as the role of palliative whole-brain radiotherapy, as monotherapy and adjuvant use after resection or stereotactic radiosurgery. We also review refined whole-brain radiation techniques, potential neuroprotective drugs, and ongoing trials.
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25
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Qiu Y, Li Z, Copland JA, Mehrling T, Tun HW. Combined alkylation and histone deacetylase inhibition with EDO-S101 has significant therapeutic activity against brain tumors in preclinical models. Oncotarget 2018; 9:28155-28164. [PMID: 29963268 PMCID: PMC6021334 DOI: 10.18632/oncotarget.25588] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 05/24/2018] [Indexed: 12/22/2022] Open
Abstract
There is a clear unmet need for novel therapeutic agents for management of primary and secondary brain tumors. Novel therapeutic agents with excellent central nervous system (CNS) penetration and therapeutic activity are urgently needed. EDO-S101 is a novel alkylating and histone deacetylase inhibiting agent created by covalent fusion of bendamustine and vorinostat. We used murine models to perform CNS pharmacokinetic analysis and preclinical therapeutic evaluation of EDO-S101 for CNS lymphoma, metastatic triple-negative breast cancer of the brain, and glioblastoma multiforme. EDO-S101 has excellent CNS penetration of 13.8% and 16.5% by intravenous infusion and bolus administration respectively. It shows promising therapeutic activity against CNS lymphoma, metastatic triple-negative breast cancer of the brain, and glioblastoma multiforme with significant prolongation of survival compared to no-treatment controls. Therapeutic activity was higher with IV infusion compared to IV bolus. It should be evaluated further for therapeutic use in brain tumors.
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Affiliation(s)
- Yushi Qiu
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Zhimin Li
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - John A Copland
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL 32224, USA
| | | | - Han W Tun
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL 32224, USA.,Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
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26
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Mohar-Betancourt A, Alvarado-Miranda A, Torres-Domínguez JA, Cabrera P, Lara Medina F, Villarreal-Gómez YS, Reynoso-Noverón N. Factores pronósticos en pacientes con cáncer de mama y metástasis cerebral como primer sitio de recurrencia. ACTA ACUST UNITED AC 2018; 60:141-150. [DOI: 10.21149/9082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 01/11/2018] [Indexed: 01/08/2023]
Abstract
Objetivo. Evaluar los factores pronósticos (características clínico-patológicas y tratamientos) en las pacientes con cáncer de mama y metástasis al sistema nervioso central (SNC) como primer sitio de afección. Material y métodos. Cohorte retrospectiva, formada por 125 pacientes con cáncer de mama atendidas en el Instituto Nacional de Cancerología durante 2007-2015, quienes presentaron afección en el SNC como primer sitio de metástasis. A través del método Kaplan-Meier y tablas de vida se estimó la supervivencia global. El modelo de riesgos proporcionales de Cox fue utilizado para determinar los factores pronósticos. Resultados. La mediana de supervivencia global fue de 14.2 meses (IC95% 11.8-26.9). Pacientes clasificadas por inmunohistoquímica como triple negativo (TN) presentaron tiempos de supervivencia más cortos (p<0.004) y con dos veces más riesgo de fallecer, en comparación con los otros inmunofenotipos (HR= 2.77; IC95% 1.10-6.99); asimismo, se identificó que un grado intermedio en la escala Scarff-Bloom-Richardson incrementa el riesgo de morir en pacientes con metástasis (HR=2.76; IC95% 1.17- 6.51). Conclusiones. La metástasis al SNC continúa siendo un factor de mal pronóstico que reduce la supervivencia y afecta la calidad de vida. Se recomienda vigilar puntualmente la presencia de manifestaciones clínicas neurológicas durante el seguimiento, para una rápida intervención. Las pacientes TN tienen peor pronóstico, y las HER2+ (es decir, con resultado positivo para el receptor 2 del factor de crecimiento humano epidérmico), mejor control a mediano plazo.
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27
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Turner TH, Alzubi MA, Sohal SS, Olex AL, Dozmorov MG, Harrell JC. Characterizing the efficacy of cancer therapeutics in patient-derived xenograft models of metastatic breast cancer. Breast Cancer Res Treat 2018. [PMID: 29532339 DOI: 10.1007/s10549-018-4748-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE Basal-like breast cancers are aggressive and often metastasize to vital organs. Treatment is largely limited to chemotherapy. This study aims to characterize the efficacy of cancer therapeutics in vitro and in vivo within the primary tumor and metastatic setting, using patient-derived xenograft (PDX) models. METHODS We employed two basal-like, triple-negative PDX models, WHIM2 and WHIM30. PDX cells, obtained from mammary tumors grown in mice, were treated with twelve cancer therapeutics to evaluate their cytotoxicity in vitro. Four of the effective drugs-carboplatin, cyclophosphamide, bortezomib, and dacarbazine-were tested in vivo for their efficacy in treating mammary tumors, and metastases generated by intracardiac injection of tumor cells. RESULTS RNA sequencing showed that global gene expression of PDX cells grown in the mammary gland was similar to those tested in culture. In vitro, carboplatin was cytotoxic to WHIM30 but not WHIM2, whereas bortezomib, dacarbazine, and cyclophosphamide were cytotoxic to both lines. Yet, these drugs were ineffective in treating both primary and metastatic WHIM2 tumors in vivo. Carboplatin and cyclophosphamide were effective in treating WHIM30 mammary tumors and reducing metastatic burden in the brain, liver, and lungs. WHIM2 and WHIM30 metastases showed distinct patterns of cytokeratin and vimentin expression, regardless of treatment, suggesting that different tumor cell subpopulations may preferentially seed in different organs. CONCLUSIONS This study highlights the utility of PDX models for studying the efficacy of therapeutics in reducing metastatic burden in specific organs. The differential treatment responses between two PDX models of the same intrinsic subtype, in both the primary and metastatic setting, recapitulates the challenges faced in treating cancer patients and highlights the need for combination therapies and predictive biomarkers.
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Affiliation(s)
- Tia H Turner
- Department of Pathology, Virginia Commonwealth University, Richmond, VA, 23298, USA.,Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Mohammad A Alzubi
- Department of Pathology, Virginia Commonwealth University, Richmond, VA, 23298, USA.,Integrative Life Sciences Doctoral Program, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Sahib S Sohal
- Department of Pathology, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Amy L Olex
- Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Mikhail G Dozmorov
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - J Chuck Harrell
- Department of Pathology, Virginia Commonwealth University, Richmond, VA, 23298, USA. .,Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond, VA, 23298, USA. .,Integrative Life Sciences Doctoral Program, Virginia Commonwealth University, Richmond, VA, 23298, USA. .,Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, 23298, USA.
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28
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Abstract
Central nervous system metastases cause grave morbidity in patients with advanced malignancies. Lung cancer, breast cancer, and melanoma are the three most common causes of brain metastases. Although the exact incidence of brain metastases is unclear, there appears to be an increasing incidence which has been attributed to longer survival, better control of systemic disease, and better imaging modalities. Until recently surgical resection of solitary or symptomatic brain metastases, and radiation therapy (either whole-brain radiation therapy or stereotactic radiation) were the mainstay of treatment for patients with brain metastases. The majority of traditional chemotherapies have shown limited activity in the central nervous system, which has been attributed to the blood-brain barrier and the molecular structure of the used agents. The discovery of driver mutations and drugs targeting these mutations has changed the treatment landscape. Several of these targeted small-molecule tyrosine kinase inhibitors do cross the blood-brain barrier and/or have shown activity in the central nervous system. Another major advance in the care of brain metastases has been the advent of new immunotherapeutic agents, for which initial studies have shown intracranial activity. In this chapter, we will review the unique challenges in the treatment of brain metastases. The pertinent clinical studies of chemotherapy in brain metastases will be discussed. The currently reported clinical trials and evidence for use of targeted therapies and immunotherapeutic agents will be emphasized.
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29
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Mejri N, Benna M, El Benna H, Soumaya L, Afrit M, Zouari B, Boussen H. First site of recurrence after breast cancer adjuvant treatment in the era of multimodality therapy: which imaging for which patient during follow-up? Breast Dis 2017; 37:123-132. [PMID: 29171964 DOI: 10.3233/bd-170290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE We evaluated the relation between first site of recurrence of early breast cancer and disease profile at presentation and reported survival results, suggesting a personalized diagnostic imaging guidance during follow up. METHODS Among 1400 early breast cancer treated from 2000 to 2010, 324 relapses were divided into 4 groups according to first site: A-locoregional, B-bone, C-Brain and D-visceral. We analyzed redictive factors of each group compared to a control group of 100 non relapsing patients and the remaining groups matched. RESULTS In group A, patients were more likely to have histological tumor size above >2 cm, grade 1-2, HR positive and 0-3 involved lymph nodes. In group B, patients had more commonly grade 2-3, 1-3 positive lymph nodes and HR positive tumors. In group C, patients were more frequently young, with large tumor size, grade3, positive lymph nodes and HER2 positive tumors. In group D, patients were more likely to have tumors>2 cm in size, with nodal involvement, grade 3, HR negative and HER2 positive tumors. Annual recurrence rate in group A, was stable ranging between 15%-18%, within the first 3 years and peaked at 19.4% in the interval [1-2]year in group B. Median survival was 46 months in group A, 43 months in group B, with no significant difference. CONCLUSION Outcome of loco-regional and bone relapses was good, suggesting that both systematic mammography and bone-scan/CT scan for high risk patients (N+, gradeIII) during the first 2-3 years may represent a tailored relevant follow-up protocol for breast cancer patients.
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Affiliation(s)
- Nesrine Mejri
- University Tunis EI Manar Tunis, Faculty of Medicine, Medical Oncology Department, AbderrahmenMami Hospital, Ariana, Tunisia
| | - Mehdi Benna
- University Tunis EI Manar Tunis, Faculty of Medicine, Medical Oncology Department, AbderrahmenMami Hospital, Ariana, Tunisia
| | - Houda El Benna
- University Tunis EI Manar Tunis, Faculty of Medicine, Medical Oncology Department, AbderrahmenMami Hospital, Ariana, Tunisia
| | - Labidi Soumaya
- University Tunis EI Manar Tunis, Faculty of Medicine, Medical Oncology Department, AbderrahmenMami Hospital, Ariana, Tunisia
| | - Mehdi Afrit
- University Tunis EI Manar Tunis, Faculty of Medicine, Medical Oncology Department, AbderrahmenMami Hospital, Ariana, Tunisia
| | - Bechir Zouari
- University Tunis EI Manar Tunis, Faculty of Medicine, Department of Epidemiology and Statistics, Tunis, Tunisia
| | - Hamouda Boussen
- University Tunis EI Manar Tunis, Faculty of Medicine, Medical Oncology Department, AbderrahmenMami Hospital, Ariana, Tunisia.,"Clinique Taoufik" hospital, Tunis, Tunisia
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30
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Frisk G, Tinge B, Ekberg S, Eloranta S, Bäcklund LM, Lidbrink E, Smedby KE. Survival and level of care among breast cancer patients with brain metastases treated with whole brain radiotherapy. Breast Cancer Res Treat 2017; 166:887-896. [PMID: 28831636 PMCID: PMC5680371 DOI: 10.1007/s10549-017-4466-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 08/14/2017] [Indexed: 11/08/2022]
Abstract
Purpose The benefit of whole brain radiotherapy (WBRT) for late stage breast cancer patients with brain metastases has been questioned. In this study we evaluated survival and level of care (hospital or home) following WBRT in a population-based cohort by personal and tumor characteristics. Methods We identified 241 consecutive patients with breast cancer and brain metastases receiving WBRT in Stockholm, Sweden, 1999–2012. Through review of medical records, we collected data on prognostic determinants including level of care before and after WBRT. Survival was estimated using Cox regression, and odds ratios (OR) of not coming home using logistic regression. Results Median age at WBRT was 58 years (range 30--–88 years). Most patients (n = 212, 88%) were treated with 4 Gray × 5. Median survival following WBRT was 2.9 months (interquartile range 1.1–6.6 months), and 57 patients (24%) were never discharged from hospital. Poor performance status and triple-negative tumors were associated with short survival (WHO 3–4 median survival 0.9 months, HR = 5.96 (3.88–9.17) versus WHO 0–1; triple-negative tumors median survival 2.0 months, HR = 1.87 (1.23–2.84) versus Luminal A). Poor performance status and being hospitalized before WBRT were associated with increased ORs of not coming home whereas cohabitation with children at home was protective. Conclusion Survival was short following WBRT, and one in four breast cancer patients with brain metastases could never be discharged from hospital. When deciding about WBRT, WHO score, level of care before WBRT, and the patient’s choice of level of care in the end-of-life period should be considered. Electronic supplementary material The online version of this article (doi:10.1007/s10549-017-4466-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gabriella Frisk
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institute Solna, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Beatrice Tinge
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institute Solna, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Sara Ekberg
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institute Solna, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Sandra Eloranta
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institute Solna, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - L Magnus Bäcklund
- Department of Medicine Solna, Unit for Experimental Cardiovascular Research, Karolinska Institute Solna, 171 76, Stockholm, Sweden
| | - Elisabet Lidbrink
- Department of Oncology-Pathology, Karolinska Institute, Karolinska University Hospital Solna, 171 76, Stockholm, Sweden
| | - Karin E Smedby
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institute Solna, Karolinska University Hospital, 171 76, Stockholm, Sweden
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31
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Mutations targeting the coagulation pathway are enriched in brain metastases. Sci Rep 2017; 7:6573. [PMID: 28747664 PMCID: PMC5529435 DOI: 10.1038/s41598-017-06811-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 06/19/2017] [Indexed: 12/29/2022] Open
Abstract
Brain metastases (BMs) are the most common malignancy of the central nervous system. Recently it has been demonstrated that plasminogen activator inhibitor serpins promote brain metastatic colonization, suggesting that mutations in serpins or other members of the coagulation cascade can provide critical advantages during BM formation. We performed whole-exome sequencing on matched samples of breast cancer and BMs and found mutations in the coagulation pathway genes in 5 out of 10 BM samples. We then investigated the mutational status of 33 genes belonging to the coagulation cascade in a panel of 29 BMs and we identified 56 Single Nucleotide Variants (SNVs). The frequency of gene mutations of the pathway was significantly higher in BMs than in primary tumours, and SERPINI1 was the most frequently mutated gene in BMs. These findings provide direction in the development of new strategies for the treatment of BMs.
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32
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Yamada SM, Tomita Y, Shibui S, Kurokawa T, Baba Y. A Case of Breast Cancer Brain Metastasis with a 16-Year Time Interval without Evidence of Cancer Recurrence. J Breast Cancer 2017; 20:212-216. [PMID: 28690660 PMCID: PMC5500407 DOI: 10.4048/jbc.2017.20.2.212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 01/06/2017] [Indexed: 11/30/2022] Open
Abstract
The median time of brain metastasis from the diagnosis of breast cancer is approximately 3 years. In this case report, a 69-year-old woman demonstrated cerebellar ataxia. Brain magnetic resonance imaging revealed enhanced lesions in bilateral cerebellar hemispheres. She had undergone surgery, radiation, and chemotherapy for uterine and breast cancer 24 years prior and 16 years prior, respectively. Although she had not received any anticancer treatment for 10 years, no recurrences were identified using whole body scans. A partial tumor resection was performed and the histological diagnosis was an adenocarcinoma from breast cancer. As no extracranial lesions were found, gamma-knife irradiation was performed, without additional systemic chemotherapy. One month posttreatment, the tumors dramatically reduced in size and the patient completely recovered from cerebellar ataxia. Systemic chemotherapy is not always required for brain metastasis from breast cancer with a long interval period, as long as no evidence of extracranial recurrence is detected.
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Affiliation(s)
- Shoko Merrit Yamada
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Yusuke Tomita
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Soichiro Shibui
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Takashi Kurokawa
- Department of Neurology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Yasuhisa Baba
- Department of Neurology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
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Li R, Zhang K, Siegal GP, Wei S. Clinicopathological factors associated with survival in patients with breast cancer brain metastasis. Hum Pathol 2017; 64:53-60. [PMID: 28428107 DOI: 10.1016/j.humpath.2017.03.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/17/2017] [Accepted: 03/30/2017] [Indexed: 11/29/2022]
Abstract
Brain metastasis from breast cancer generally represents a catastrophic event yet demonstrates substantial biological heterogeneity. There have been limited studies solely focusing on the prognosis of patients with such metastasis. In this study, we carried out a comprehensive analysis in 108 consecutive patients with breast cancer brain metastases between 1997 and 2012 to further define clinicopathological factors associated with early onset of brain metastasis and survival outcomes after development of them. We found that lobular carcinoma, higher clinical stages at diagnosis, and lack of coexisting bone metastasis were significantly associated with a worse brain relapse-free survival when compared with brain-only metastasis. High histologic grade, triple-negative breast cancer, and absence of visceral involvement were unfavorable prognostic factors after brain metastasis. Furthermore, high histologic grade, advanced tumor stages, and lack of coexisting bone involvement indicated a worse overall survival. Thus, the previously established prognostic factors in early stage or advanced breast cancers may not entirely apply to patients with brain metastases. Furthermore, the prognostic significance of the clinicopathological factors differed before and after a patient develops brain metastasis. This knowledge might help in establishing an algorithm to further stratify patients with breast cancer into prognostically significant categories for optimal prevention, screening, and treatment of their brain metastasis.
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Affiliation(s)
- Rong Li
- Department of Pathology, the University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Kui Zhang
- Department of Mathematical Sciences, Michigan Technological University, Houghton, MI 49931, USA
| | - Gene P Siegal
- Department of Pathology, the University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Shi Wei
- Department of Pathology, the University of Alabama at Birmingham, Birmingham, AL 35249, USA.
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34
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Crozier JA, Cornell LF, Rawal B, Perez EA. Breast cancer brain metastases: Molecular subtype, treatment and survival. Breast Dis 2017; 36:133-141. [PMID: 27802190 DOI: 10.3233/bd-160237] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND No clear guidelines exist for management of breast cancer brain metastases (BCBM). OBJECTIVE We assessed the relationship between patient and tumor characteristics, treatment, and overall survival (OS). METHODS We conducted a retrospective review of 196 patients who received brain radiation for BCBM between 2009-2013 at Mayo Clinic. Primary tumor characteristics were collected, including simplified molecular subtype. Other characteristics included patient's ECOG, number of brain lesions at BCBM diagnosis, and treatment received, including neurosurgery, whole-brain radiation therapy (WBRT), and stereotactic radiosurgery (SRS). The primary endpoint was OS from time of BCBM diagnosis. RESULTS Single-variable analysis revealed patients with HER2+ breast cancer had improved OS (HR = 0.6, p = 0.008). Compared to patients with 1-3 brain lesions, the risk of death in patients with leptomeningeal disease was 2.5-fold higher (p = 0.003). Worsening ECOG status was associated with worsening OS. Patients who received SRS and WBRT had improved OS (HR = 0.37, p < 0.001) compared to patients receiving WBRT alone. CONCLUSIONS Patients with the best OS had an ECOG of 0, HER2+ disease, and 1-3 brain lesions. The best OS was associated with the combination of neurosurgery and radiation therapy. A comprehensive treatment plan including neurosurgical evaluation and radiation therapy should be considered for patients with BCBM.
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Affiliation(s)
| | - Lauren F Cornell
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Bhupendra Rawal
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA.,Department of Biostatistics and Computational Biology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Edith A Perez
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL, USA.,Genentech, Inc., San Francisco, CA, USA
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35
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Leone JP, Leone J, Zwenger AO, Iturbe J, Leone BA, Vallejo CT. Prognostic factors and survival according to tumour subtype in women presenting with breast cancer brain metastases at initial diagnosis. Eur J Cancer 2017; 74:17-25. [PMID: 28335884 DOI: 10.1016/j.ejca.2016.12.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/29/2016] [Accepted: 12/16/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The presence of brain metastases at the time of initial breast cancer diagnosis (BMIBCD) is uncommon. Hence, the prognostic assessment and management of these patients is very challenging. The aim of this study was to analyse the influence of tumour subtype compared with other prognostic factors in the survival of patients with BMIBCD. METHODS We evaluated women with BMIBCD, reported to Surveillance, Epidemiology and End Results program from 2010 to 2013. Patients with other primary malignancy were excluded. Univariate and multivariate analyses were performed to determine the effects of each variable on overall survival (OS). RESULTS We included 740 patients. Median OS for the whole population was 10 months, and 20.7% of patients were alive at 36 months. Tumour subtype distribution was: 46.6% hormone receptor (HR)+/HER2-, 17% HR+/HER2+, 14.1% HR-/HER2+ and 22.3% triple-negative. Univariate analysis showed that the presence of liver metastases, lung metastases and triple-negative patients (median OS 6 months) had worse prognosis. The HR+/HER2+ subtype had the longest OS with a median of 22 months. In multivariate analysis, older age (hazard ratio 1.8), lobular histology (hazard ratio 2.08), triple-negative subtype (hazard ratio 2.25), liver metastases (hazard ratio 1.6) and unmarried patients (hazard ratio 1.39) had significantly shorter OS. CONCLUSIONS Although the prognosis of patients with BMIBCD is generally poor, 20.7% were still alive 3 years after the diagnosis. There were substantial differences in OS according to tumour subtype. In addition to tumour subtype, other independent predictors of OS are age at diagnosis, marital status, histology and liver metastases.
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Affiliation(s)
- José Pablo Leone
- University of Iowa Holden Comprehensive Cancer Center, Iowa City, IA, USA.
| | - Julieta Leone
- Grupo Oncológico Cooperativo del Sur (GOCS), Argentina
| | - Ariel Osvaldo Zwenger
- Grupo Oncológico Cooperativo del Sur (GOCS), Argentina; Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Argentina
| | - Julián Iturbe
- Grupo Oncológico Cooperativo del Sur (GOCS), Argentina
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36
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Genre L, Roché H, Varela L, Kanoun D, Ouali M, Filleron T, Dalenc F. External validation of a published nomogram for prediction of brain metastasis in patients with extra-cerebral metastatic breast cancer and risk regression analysis. Eur J Cancer 2016; 72:200-209. [PMID: 28042991 DOI: 10.1016/j.ejca.2016.10.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 10/04/2016] [Accepted: 10/21/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Survival of patients with metastatic breast cancer (MBC) suffering from brain metastasis (BM) is limited and this event is usually fatal. In 2010, the Graesslin's nomogram was published in order to predict subsequent BM in patients with breast cancer (BC) with extra-cerebral metastatic disease. This model aims to select a patient population at high risk for BM and thus will facilitate the design of prevention strategies and/or the impact of early treatment of BM in prospective clinical studies. PATIENTS AND METHODS Nomogram external validation was retrospectively applied to patients with BC and later BM between January 2005 and December 2012, treated in our institution. Moreover, risk factors of BM appearance were studied by Fine and Gray's competing risk analysis. RESULTS Among 492 patients with MBC, 116 developed subsequent BM. Seventy of them were included for the nomogram validation. The discrimination is good (area under curve = 0.695 [95% confidence interval, 0.61-0.77]). Risk factors of BM appearance are: human epidermal growth factor receptor 2 (HER2) overexpression/amplification, triple-negative BC and number of extra-cerebral metastatic sites (>1). With a competing risk model, we highlight the nomogram interest for HER2+ tumour subgroup exclusively. CONCLUSION Graesslin's nomogram external validation demonstrates exportability and reproducibility. Importantly, the competing risk model analysis provides additional information for the design of prospective trials concerning the early diagnosis of BM and/or preventive treatment on high risk patients with extra-cerebral metastatic BC.
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Affiliation(s)
- Ludivine Genre
- Department of Gynecologic Surgery, IUCT-O, Toulouse, France
| | - Henri Roché
- Department of Medical Oncology, Institut Claudius Regaud, IUCT-O, Toulouse, France
| | - Léonel Varela
- Department of Radiotherapy, Institut Claudius Regaud, IUCT-O, Toulouse, France
| | - Dorra Kanoun
- Department of Medical Oncology, Institut Claudius Regaud, IUCT-O, Toulouse, France
| | - Monia Ouali
- Department of Biostatistics, Institut Claudius Regaud, IUCT-O, Toulouse, France
| | - Thomas Filleron
- Department of Biostatistics, Institut Claudius Regaud, IUCT-O, Toulouse, France
| | - Florence Dalenc
- Department of Medical Oncology, Institut Claudius Regaud, IUCT-O, Toulouse, France.
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37
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Gene Expression Profiling of Breast Cancer Brain Metastasis. Sci Rep 2016; 6:28623. [PMID: 27340107 PMCID: PMC4919653 DOI: 10.1038/srep28623] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 06/06/2016] [Indexed: 12/11/2022] Open
Abstract
The biology of breast cancer brain metastasis (BCBM) is poorly understood. We aimed to explore genes that are implicated in the process of brain metastasis of primary breast cancer (BC). NanoString nCounter Analysis covering 252 target genes was used for comparison of gene expression levels between 20 primary BCs that relapsed to brain and 41 BCBM samples. PAM50-based intrinsic subtypes such as HER2-enriched and basal-like were clearly over-represented in BCBM. A panel of 22 genes was found to be significantly differentially expressed between primary BC and BCBM. Five of these genes, CXCL12, MMP2, MMP11, VCAM1, and MME, which have previously been associated with tumor progression, angiogenesis, and metastasis, clearly discriminated between primary BC and BCBM. Notably, the five genes were significantly upregulated in primary BC compared to BCBM. Conversely, SOX2 and OLIG2 genes were upregulated in BCBM. These genes may participate in metastatic colonization but not in primary tumor development. Among patient-matched paired samples (n = 17), a PAM50 molecular subtype conversion was observed in eight cases (47.1%), with a trend toward unfavorable subtypes in patients with the distinct gene expression. Our findings, although not conclusive, reveal differentially expressed genes that might mediate the brain metastasis process.
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38
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Jacot W, Pons E, Frenel JS, Guiu S, Levy C, Heudel PE, Bachelot T, D’Hondt V, Darlix A, Firmin N, Romieu G, Thezenas S, Dalenc F. Efficacy and safety of trastuzumab emtansine (T-DM1) in patients with HER2-positive breast cancer with brain metastases. Breast Cancer Res Treat 2016; 157:307-318. [DOI: 10.1007/s10549-016-3828-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 05/05/2016] [Indexed: 10/21/2022]
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39
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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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40
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Rostami R, Mittal S, Rostami P, Tavassoli F, Jabbari B. Brain metastasis in breast cancer: a comprehensive literature review. J Neurooncol 2016; 127:407-14. [PMID: 26909695 DOI: 10.1007/s11060-016-2075-3] [Citation(s) in RCA: 174] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 02/10/2016] [Indexed: 11/24/2022]
Abstract
This comprehensive review provides information on epidemiology, size, grade, cerebral localization, clinical symptoms, treatments, and factors associated with longer survival in 14,599 patients with brain metastasis from breast cancer; the molecular features of breast cancers most likely to develop brain metastases and the potential use of these predictive molecular alterations for patient management and future therapeutic targets are also addressed. The review covers the data from 106 articles representing this subject in the era of modern neuroimaging (past 35 years). The incidence of brain metastasis from breast cancer (24 % in this review) is increasing due to advances in both imaging technologies leading to earlier detection of the brain metastases and introduction of novel therapies resulting in longer survival from the primary breast cancer. The mean age at the time of breast cancer and brain metastasis diagnoses was 50.3 and 48.8 years respectively. Axillary node metastasis was noted in 32.8 % of the patients who developed brain metastasis. The median time intervals between the diagnosis of breast cancer to identification of brain metastasis and from identification of brain metastasis to death were 34 and 15 months, respectively. The most common symptoms experienced in patients with brain metastasis consisted of headache (35 %), vomiting (26 %), nausea (23 %), hemiparesis (22 %), visual changes (13 %) and seizures (12 %). A majority of the patients had multiple metastases (54.2 %). Cerebellum and frontal lobes were the most common sites of metastasis (33 and 16 %, respectively). Of the primary tumors for which biomarkers were recorded, 37 % were estrogen receptor (ER)+, 41 % ER-, 36 % progesterone receptor (PR)+, 34 % PR-, 35 % human epithelial growth factor receptor 2 (HER2)+, 41 % HER2-, 27 % triple negative and 18 % triple positive (TP). Treatment in most patients consisted of a multimodality approach often with two or more of the following: whole brain radiation therapy (52 %), chemotherapy (51 %), stereotactic radiosurgery (20 %), surgical resection (14 %), trastuzumab (39 %) for HER2 positive tumors, and hormonal therapy (34 %) for ER and/or PR positive tumors. Factors that had an impact on prognosis included grade and size of the tumor, multiple metastases, presence of extra-cranial metastasis, triple negative or HER2+ biomarker status, and high Karnovsky score. Novel therapies such as application of agents to reduce tumor angiogenesis or alter permeability of the blood brain barrier are being explored with preliminary results suggesting a potential to improve survival after brain metastasis. Other potential therapies based on genetic alterations in the tumor and the microenvironment in the brain are being investigated; these are briefly discussed.
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Affiliation(s)
- Rezvan Rostami
- Department of Neurology, Yale University School of Medicine, 15 York Street, LCI Building, New Haven, CT, 06520, USA.
| | - Shivam Mittal
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, 44106-5040, USA
| | - Pooya Rostami
- School of Medicine, St. George University, St. George's, Grenada, West Indies
| | - Fattaneh Tavassoli
- Department of Pathology, Yale University School of Medicine, 20 York Street, Ste East Pavilion Suite 2608, New Haven, CT, 06510, USA
| | - Bahman Jabbari
- Department of Neurology, Yale University School of Medicine, 15 York Street, LCI Building, New Haven, CT, 06520, USA
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Tayyeb B, Parvin M. Pathogenesis of Breast Cancer Metastasis to Brain: a Comprehensive Approach to the Signaling Network. Mol Neurobiol 2016; 53:446-454. [PMID: 25465242 DOI: 10.1007/s12035-014-9023-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 11/20/2014] [Indexed: 02/05/2023]
Abstract
There is a general consensus that breast cancer is a rising trend disease in the world. It is one of the most common cancer types and is the leading cause of death among women's cancers. There are several reasons for this high rate of mortality including metastasis which is responsible for about 90 % of cancer-related mortality. Therefore, recognition and understanding of metastatic process is important, and by considering the key role of pathophysiological route in metastasis as a multistep cascade of "invasion-metastasis," it might modify and improve our insight toward this complex phenomenon. Moreover, it can provide novel approaches for designing advanced targeted therapies. The present work aimed to review the published papers regarding molecular basis of metastatic process of breast cancer to brain metastasis, especially related genes and signaling network. Furthermore, the use of molecular aspects of metastatic breast cancer to brain was discussed in horizon of future treatment of breast cancer.
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Affiliation(s)
- Bahrami Tayyeb
- Department of Medical Genetics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdipour Parvin
- Department of Medical Genetics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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42
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Leone JP, Leone BA. Breast cancer brain metastases: the last frontier. Exp Hematol Oncol 2015; 4:33. [PMID: 26605131 PMCID: PMC4657380 DOI: 10.1186/s40164-015-0028-8] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 11/09/2015] [Indexed: 01/16/2023] Open
Abstract
Breast cancer is a common cause of brain metastases, with metastases occurring in at least 10–16 % of patients. Longer survival of patients with metastatic breast cancer and the use of better imaging techniques are associated with an increased incidence of brain metastases. Unfortunately, patients who develop brain metastases tend to have poor prognosis with short overall survival. In addition, brain metastases are a major cause of morbidity, associated with progressive neurologic deficits that result in a reduced quality of life. Tumor subtypes play a key role in prognosis and treatment selection. Current therapies include surgery, whole-brain radiation therapy, stereotactic radiosurgery, chemotherapy and targeted therapies. However, the timing and appropriate use of these therapies is controversial and careful patient selection by using available prognostic tools is extremely important. This review will focus on current treatment options, novel therapies, future approaches and ongoing clinical trials for patients with breast cancer brain metastases.
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Affiliation(s)
- José Pablo Leone
- University of Iowa Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, C32 GH, 200 Hawkins Drive, Iowa City, IA 52242 USA
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43
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Shen Q, Sahin AA, Hess KR, Suki D, Aldape KD, Sawaya R, Ibrahim NK. Breast cancer with brain metastases: clinicopathologic features, survival, and paired biomarker analysis. Oncologist 2015; 20:466-73. [PMID: 25802405 DOI: 10.1634/theoncologist.2014-0107] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 01/12/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The aim of this study was to describe clinicopathologic features of patients with breast cancer brain metastasis (BCBM); to evaluate survival after diagnosis of BCBM; and to compare estrogen receptor (ER), progesterone receptor (PR), and HER2 expression in the paired primary and brain tumors. MATERIALS AND METHODS We identified 140 consecutive patients who underwent craniotomy for BCBM (either for diagnostic purpose or with therapeutic intent) at the University of Texas MD Anderson Cancer Center between 2002 and 2009. RESULTS Most patients had invasive ductal histology (91%), grade 3 tumors (67%), and positive axillary lymph node (64%). Of the tumors, 56% were ER-negative, 62% were PR-negative, 44% were HER2-positive, and 28% were triple negative (TN). Brain metastasis (BM) was solitary in 51% of patients. Median interval from breast cancer diagnosis to BM was 46 months; median survival after BM was 14.1 months. In the univariate analysis, younger age, solitary brain metastasis, and ER or PR positivity in the breast tumors were associated with longer survival. There was a statistical trend toward increased survival in HER2-positive patients compared with HER2-negative patients (18 vs. 11 months). In the multivariate analysis, predictors for longer survival included younger age, solitary brain lesion, and HER2 positivity in the breast cancer. Biomarkers were evaluated in paired primary and brain tumors in 35 patients for ER status, 34 for PR status, and 36 for HER2 status. Discordant rates were 28% for ER, 20% for PR, and 3% for HER2. CONCLUSION Compared with unselected breast cancer patients at the same institution, patients with breast cancer who had brain metastases had a higher proportion of hormone receptor-negative, HER2-positive, and TN tumors. Younger age, solitary brain lesion, and HER2 expression were independent predictors of better survival in patients with BCBM. HER2 status was highly concordant between the paired primary and brain tumors, whereas changes of ER and PR status occurred in a substantial proportion of the patients. These findings are important for making effective treatment decisions for patients with BCBM.
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Affiliation(s)
- Qi Shen
- Departments of Pathology, Biostatistics, Neurosurgery, and Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Aysegul A Sahin
- Departments of Pathology, Biostatistics, Neurosurgery, and Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kenneth R Hess
- Departments of Pathology, Biostatistics, Neurosurgery, and Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Dima Suki
- Departments of Pathology, Biostatistics, Neurosurgery, and Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kenneth D Aldape
- Departments of Pathology, Biostatistics, Neurosurgery, and Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Raymond Sawaya
- Departments of Pathology, Biostatistics, Neurosurgery, and Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nuhad K Ibrahim
- Departments of Pathology, Biostatistics, Neurosurgery, and Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Leone JP, Lee AV, Brufsky AM. Prognostic factors and survival of patients with brain metastasis from breast cancer who underwent craniotomy. Cancer Med 2015; 4:989-94. [PMID: 25756607 PMCID: PMC4529337 DOI: 10.1002/cam4.439] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 01/29/2015] [Accepted: 02/02/2015] [Indexed: 01/28/2023] Open
Abstract
Brain metastasis (BM) in patients with breast cancer is a catastrophic event that results in poor prognosis. Identification of prognostic factors associated with breast cancer brain metastases (BCBM) could help to identify patients at risk. The aim of this study was to assess clinical characteristics, prognostic factors, and survival of patients with BCBM who had craniotomy and resection in a series of patients treated with modern multimodality therapy. We analyzed 42 patients with BCBM who underwent resection. Patients were diagnosed with breast cancer between April 1994 and May 2010. Cox proportional hazards regression was selected to describe factors associated with time to BM, survival from the date of first recurrence, and overall survival (OS). Median age was 51 years (range 24–74). Median follow-up was 4.2 years (range 0.6–18.5). The proportion of the biological subtypes of breast cancer was ER+/HER2− 25%, ER+/HER2+ 15%, ER-/HER2+ 30%, and ER-/HER2− 30%. Median OS from the date of primary diagnosis was 5.74 years. Median survival after diagnosis of BM was 1.33 years. In multivariate Cox regression analyses, stage was the only factor associated with shorter time to the development of BM (P = 0.033), whereas age was the only factor associated with survival from the date of recurrence (P = 0.027) and with OS (P = 0.037). Stage at primary diagnosis correlated with shorter time to the development of BM, while age at diagnosis was associated with shorter survival in BCBM. None of the other clinical factors had influence on survival.
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Affiliation(s)
- José Pablo Leone
- Division of Hematology and Oncology, University of Pittsburgh Cancer Institute, 5150 Centre Avenue, Pittsburgh, Pennsylvania, 15232
| | - Adrian V Lee
- Division of Hematology and Oncology, University of Pittsburgh Cancer Institute, 5150 Centre Avenue, Pittsburgh, Pennsylvania, 15232
| | - Adam M Brufsky
- Division of Hematology and Oncology, University of Pittsburgh Cancer Institute, 5150 Centre Avenue, Pittsburgh, Pennsylvania, 15232
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Abstract
Brain metastases are less common than bone or visceral metastases in patients with breast cancer. The overall prognosis of breast cancer patients with brain metastases remains poor, and these metastases are less responsive to systemic therapies. Brain metastasis is associated with a reduced quality of life due to progressive neurologic impairments. Recently, a trend of increased incidence of brain metastases in breast cancer has been noted. Reasons for this increased incidence include the more frequent use of sensitive detection methods such as contrast-enhanced magnetic resonance imaging and increased awareness of brain metastasis among patients and clinicians. Adjuvant and systemic therapy with drugs that have a low blood-brain barrier penetrance can lead to an increased risk of brain metastases in breast cancer patients. Molecular subtype is a predictive factor for overall survival after developing brain metastases. Patients who do not have a poor prognosis based on previously identified prognostic factors should be treated with radiation therapy to control symptoms. Whole-brain radiation therapy, stereotactic irradiation and surgery are tools for the local treatment of brain metastases. Novel molecular target therapy, including HER2-targeted therapy, has demonstrated an antitumor effect on brain metastases. In this review, we provide a practical algorithm for the treatment of breast cancer brain metastases. This review provides an overview of the incidence, risk factors, diagnosis, prognostic factors and current and potential future management strategies of breast cancer brain metastases.
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Affiliation(s)
- Naoki Niikura
- Department of Target Therapy Oncology, Kyoto University Graduate School of Medicine, Kyoto Departments of Breast and Endocrine Surgery, Tokai University School of Medicine, Kanagawa
| | - Shigehira Saji
- Department of Target Therapy Oncology, Kyoto University Graduate School of Medicine, Kyoto Department of Medical Oncology, Fukushima Medical University, Fukushima
| | - Yutaka Tokuda
- Departments of Breast and Endocrine Surgery, Tokai University School of Medicine, Kanagawa
| | - Hiroji Iwata
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Japan
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46
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Abstract
Over 150,000 cancer patients will be diagnosed with brain metastases this year alone. Survival for those diagnosed with brain metastases remains poor despite multimodality management with surgery, chemotherapy, and radiation. Preventative strategies to mitigate brain metastases have met with mixed results. In leukemia and small cell lung cancer there are defined roles for preventative radiation to be delivered, which can result in improved local control and survival. There is a less defined role for preventative radiation in locally advanced non-small cell lung cancer and budding interest for radiation prevention in breast cancer. The potential impact preventative cranial irradiation may have on neurocognitive function and quality of life needs to be considered prior to its administration.
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47
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Brogi E, Murphy C, Johnson M, Conlin A, Hsu M, Patil S, Akram M, Nehhozina T, Jhaveri K, Hudis C, Seidman A. Breast carcinoma with brain metastases: clinical analysis and immunoprofile on tissue microarrays. Ann Oncol 2011; 22:2597-2603. [DOI: 10.1093/annonc/mdr022] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Witzel I, Kantelhardt EJ, Milde-Langosch K, Ihnen M, Zeitz J, Harbeck N, Jänicke F, Müller V. Management of patients with brain metastases receiving trastuzumab treatment for metastatic breast cancer. ACTA ACUST UNITED AC 2011; 34:304-8. [PMID: 21625183 DOI: 10.1159/000328679] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND With the more effective control of visceral metastases in patients with metastatic breast cancer (MBC), an increasing number of patients face brain metastases (BM). The aim of this retrospective analysis was to investigate the incidence and factors affecting the prognosis of patients with BM under trastuzumab treatment for MBC. PATIENTS AND METHODS A total of 75 HER2positive patients treated with trastuzumab for MBC were included. RESULTS are discussed in the context of the current literature. RESULTS Patients who developed BM (n = 29) had longer median progression-free survival (PFS) during first-line chemotherapy and longer overall survival (OS) after diagnosis of MBC than 46 patients without BM (PFS: 27 vs. 14 months, p = 0.039; OS: 46 vs. 18 months, p = 0.067). Median survival of patients with continuation of trastuzumab after diagnosis of BM was longer than survival of patients with discontinuation of trastuzumab treatment after BM (18 vs. 3 months, p = 0.006). Survival of patients who were treated with surgery and radiotherapy for BM was better compared with radiotherapy alone (9 vs. 5 months, p = not significant) or best supportive care (9 vs. 2 months, p = 0.049). CONCLUSIONS Continuation of trastuzumab treatment as well as resection of BM seem to give further benefit in the treatment of patients with HER2-overexpressing MBC.
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Affiliation(s)
- Isabell Witzel
- Department of Gynaecology; University Medical Center Hamburg-Eppendorf, Germany
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49
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Effect of tumor subtype on survival and the graded prognostic assessment for patients with breast cancer and brain metastases. Int J Radiat Oncol Biol Phys 2011; 82:2111-7. [PMID: 21497451 DOI: 10.1016/j.ijrobp.2011.02.027] [Citation(s) in RCA: 249] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 02/08/2011] [Accepted: 02/11/2011] [Indexed: 01/09/2023]
Abstract
PURPOSE The diagnosis-specific Graded Prognostic Assessment (GPA) was published to clarify prognosis for patients with brain metastases. This study refines the existing Breast-GPA by analyzing a larger cohort and tumor subtype. METHODS AND MATERIALS A multi-institutional retrospective database of 400 breast cancer patients treated for newly diagnosed brain metastases was generated. Prognostic factors significant for survival were analyzed by multivariate Cox regression and recursive partitioning analysis (RPA). Factors were weighted by the magnitude of their regression coefficients to define the GPA index. RESULTS Significant prognostic factors by multivariate Cox regression and RPA were Karnofsky performance status (KPS), HER2, ER/PR status, and the interaction between ER/PR and HER2. RPA showed age was significant for patients with KPS 60 to 80. The median survival time (MST) overall was 13.8 months, and for GPA scores of 0 to 1.0, 1.5 to 2.0, 2.5 to 3.0, and 3.5 to 4.0 were 3.4 (n = 23), 7.7 (n = 104), 15.1 (n = 140), and 25.3 (n = 133) months, respectively (p < 0.0001). Among HER2-negative patients, being ER/PR positive improved MST from 6.4 to 9.7 months, whereas in HER2-positive patients, being ER/PR positive improved MST from 17.9 to 20.7 months. The log-rank statistic (predictive power) was 110 for the Breast-GPA vs. 55 for tumor subtype. CONCLUSIONS The Breast-GPA documents wide variation in prognosis and shows clear separation between subgroups of patients with breast cancer and brain metastases. This tool will aid clinical decision making and stratification in clinical trials. These data confirm the effect of tumor subtype on survival and show the Breast-GPA offers significantly more predictive power than the tumor subtype alone.
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50
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Jacot W, Gerlotto-Borne MC, Thezenas S, Pouderoux S, Poujol S, About M, Romieu G. Carmustine and methotrexate in combination after whole brain radiation therapy in breast cancer patients presenting with brain metastases: a retrospective study. BMC Cancer 2010; 10:257. [PMID: 20525352 PMCID: PMC2887781 DOI: 10.1186/1471-2407-10-257] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Accepted: 06/04/2010] [Indexed: 11/21/2022] Open
Abstract
Background Since 1999, patients presenting with brain metastases (BM) from breast cancer (BC) are treated in our institution with a carmustine (BCNU) - methotrexate (MTX) combination. We report here our clinical experience regarding this combination. Patients and Methods Patients were treated by a combination of BCNU 100 mg/m² on day 1 and MTX 600 mg/m² on day 1 and 15 of a 28 day cycle. Treatment was continued until progression or unacceptable toxicity. Results 50 patients were treated between 1999 and 2007. 94% of the patients presented with concomitant extra-cerebral disease. Median number of previous metastatic setting chemotherapy regimens was 2 (0-5). Median number of cycles was 3 (1-20). There were 11 objective responses (23% [95%CI 12-37]) among 48 evaluable patients. Median progression-free survival and overall survival (OS) were 4.2 (95%CI: 2.8-5.3) and 6.9 (4.2-10.7) months respectively, with a one-year OS rate of 32% (20-46). Median Relative Dose Intensity for BCNU and MTX were 0.98 (0.31-1.1) and 0.96 (0.57-1.66) respectively. There were 2 presumed treatment-related deaths. One patient developed febrile neutropenia. Performance status, BS-BM score and presence of liver metastases were associated with OS in univariate analysis. Conclusions This combination appears to be effective and well tolerated in good performance status BC patients presenting with BM.
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Affiliation(s)
- William Jacot
- Department of Medical Oncology, CRLC Val d'Aurelle, Montpellier, France.
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