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Park H, Chung HT, Kim JW, Dho YS, Lee EJ. A 3-month survival model after Gamma Knife surgery in patients with brain metastasis from lung cancer with Karnofsky performance status ≤ 70. Sci Rep 2023; 13:13159. [PMID: 37573417 PMCID: PMC10423256 DOI: 10.1038/s41598-023-40356-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 08/09/2023] [Indexed: 08/14/2023] Open
Abstract
Gamma Knife surgery (GKS) for brain metastasis (BM) has been generally advocated for patients with a Karnofsky performance status (KPS) scale of ≥ 70. However, some patients with a poor KPS scale of < 70 are recoverable after GKS and show durable survival. A purpose of this study is to devise a 3-month survival prediction model to screen patients with BM with a KPS of ≤ 70 in whom GKS is needed. A retrospective analysis of 67 patients with a KPS scale of 60-70 undergoing GKS for BM of non-small cell lung cancer (NSCLC) from 2016 to 2020 in our institute was performed. Univariate and multivariate logistic regression analyses were performed to investigate factors related to survival for more than 3 months after GKS. The probability (P) prediction model was designed by giving a weight corresponding to the odds ratio of the variables. The overall survival was 9.9 ± 12.7 months (range 0.2-53.2), with a 3-month survival rate of 59.7% (n = 40). In multivariate logistic regression analysis, extracranial disease (ECD) control (p = .033), focal neurological deficit (FND) (p = .014), and cumulative tumor volume (∑ TV) (p = .005) were associated with 3-month survival. The prediction model of 3-month survival (Harrell's C index = 0.767) was devised based on associated factors. In conclusion, GKS for BMs is recommended in selected patients, even if the KPS scale is ≤ 70.
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Affiliation(s)
- Hangeul Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyun-Tai Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
- Gamma Knife Radiosurgery Center, Seoul National University Hospital, Seoul, Republic of Korea
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Wook Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
- Gamma Knife Radiosurgery Center, Seoul National University Hospital, Seoul, Republic of Korea
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yun-Sik Dho
- Neuro-Oncology Clinic, National Cancer Center, Goyang, Republic of Korea
| | - Eun Jung Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea.
- Gamma Knife Radiosurgery Center, Seoul National University Hospital, Seoul, Republic of Korea.
- Seoul National University College of Medicine, Seoul, Republic of Korea.
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Ramos A, Giantini-Larsen A, Pannullo SC, Brandmaier A, Knisely J, Magge R, Wilcox JA, Pavlick AC, Ma B, Pisapia D, Ashamalla H, Ramakrishna R. A multidisciplinary management algorithm for brain metastases. Neurooncol Adv 2022; 4:vdac176. [PMID: 36532509 PMCID: PMC9749403 DOI: 10.1093/noajnl/vdac176] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
The incidence of brain metastases continues to present a management issue despite the advent of improved systemic control and overall survival. While the management of oligometastatic disease (ie, 1-4 brain metastases) with surgery and radiation has become fairly straightforward in the era of radiosurgery, the management of patients with multiple metastatic brain lesions can be challenging. Here we review the available evidence and provide a multidisciplinary management algorithm for brain metastases that incorporates the latest advances in surgery, radiation therapy, and systemic therapy while taking into account the latest in precision medicine-guided therapies. In particular, we argue that whole-brain radiation therapy can likely be omitted in most patients as up-front therapy.
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Affiliation(s)
- Alexander Ramos
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Alexandra Giantini-Larsen
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Susan C Pannullo
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Andrew Brandmaier
- Department of Radiation Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Jonathan Knisely
- Department of Radiation Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Rajiv Magge
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Jessica A Wilcox
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anna C Pavlick
- Department of Oncology, Weill Cornell Medicine, New York Presbyterian, New York, New York, USA
| | - Barbara Ma
- Department of Oncology, Weill Cornell Medicine, New York Presbyterian, New York, New York, USA
| | - David Pisapia
- Department of Pathology, Weill Cornell Medicine, New York Presbyterian, New York, New York, USA
| | - Hani Ashamalla
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Rohan Ramakrishna
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
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3
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Booth TC, Thompson G, Bulbeck H, Boele F, Buckley C, Cardoso J, Dos Santos Canas L, Jenkinson D, Ashkan K, Kreindler J, Huskens N, Luis A, McBain C, Mills SJ, Modat M, Morley N, Murphy C, Ourselin S, Pennington M, Powell J, Summers D, Waldman AD, Watts C, Williams M, Grant R, Jenkinson MD. A Position Statement on the Utility of Interval Imaging in Standard of Care Brain Tumour Management: Defining the Evidence Gap and Opportunities for Future Research. Front Oncol 2021; 11:620070. [PMID: 33634034 PMCID: PMC7900557 DOI: 10.3389/fonc.2021.620070] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/06/2021] [Indexed: 12/19/2022] Open
Abstract
OBJECTIV E To summarise current evidence for the utility of interval imaging in monitoring disease in adult brain tumours, and to develop a position for future evidence gathering while incorporating the application of data science and health economics. METHODS Experts in 'interval imaging' (imaging at pre-planned time-points to assess tumour status); data science; health economics, trial management of adult brain tumours, and patient representatives convened in London, UK. The current evidence on the use of interval imaging for monitoring brain tumours was reviewed. To improve the evidence that interval imaging has a role in disease management, we discussed specific themes of data science, health economics, statistical considerations, patient and carer perspectives, and multi-centre study design. Suggestions for future studies aimed at filling knowledge gaps were discussed. RESULTS Meningioma and glioma were identified as priorities for interval imaging utility analysis. The "monitoring biomarkers" most commonly used in adult brain tumour patients were standard structural MRI features. Interval imaging was commonly scheduled to provide reported imaging prior to planned, regular clinic visits. There is limited evidence relating interval imaging in the absence of clinical deterioration to management change that alters morbidity, mortality, quality of life, or resource use. Progression-free survival is confounded as an outcome measure when using structural MRI in glioma. Uncertainty from imaging causes distress for some patients and their caregivers, while for others it provides an important indicator of disease activity. Any study design that changes imaging regimens should consider the potential for influencing current or planned therapeutic trials, ensure that opportunity costs are measured, and capture indirect benefits and added value. CONCLUSION Evidence for the value, and therefore utility, of regular interval imaging is currently lacking. Ongoing collaborative efforts will improve trial design and generate the evidence to optimise monitoring imaging biomarkers in standard of care brain tumour management.
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Affiliation(s)
- Thomas C. Booth
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London, United Kingdom
- Department of Neuroradiology, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Gerard Thompson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Florien Boele
- Leeds Institute of Medical Research at St James’s, St James’s University Hospital, Leeds, United Kingdom
- Faculty of Medicine and Health, Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | | | - Jorge Cardoso
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London, United Kingdom
| | - Liane Dos Santos Canas
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London, United Kingdom
| | | | - Keyoumars Ashkan
- Department of Neurosurgery, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Nicky Huskens
- The Tessa Jowell Brain Cancer Mission, London, United Kingdom
| | - Aysha Luis
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London, United Kingdom
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Catherine McBain
- Department of Oncology, Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
| | - Samantha J. Mills
- Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Marc Modat
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London, United Kingdom
| | - Nick Morley
- Department of Radiology, Wales Research and Diagnostic PET Imaging Centre, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Caroline Murphy
- King’s College Trials Unit, King’s College London, London, United Kingdom
| | - Sebastian Ourselin
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London, United Kingdom
| | - Mark Pennington
- King’s Health Economics, King’s College London, London, United Kingdom
| | - James Powell
- Department of Oncology, Velindre Cancer Centre, Cardiff, United Kingdom
| | - David Summers
- Department of Neuroradiology, Western General Hospital, Edinburgh, United Kingdom
| | - Adam D. Waldman
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Colin Watts
- Birmingham Brain Cancer Program, University of Birmingham, Birmingham, United Kingdom
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Matthew Williams
- Department of Neuro-oncology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Robin Grant
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Michael D. Jenkinson
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
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Benveniste RJ, Yechieli R, Diwanji T. Early Magnetic Resonance Imaging After Gamma Knife Radiosurgery of Brain Metastases. World Neurosurg 2020; 146:e1177-e1181. [PMID: 33253947 DOI: 10.1016/j.wneu.2020.11.119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 11/20/2020] [Accepted: 11/21/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Gamma knife radiosurgery (GKRS) is often performed to treat brain metastases (BrMs). Widely referenced guidelines have suggested post-treatment imaging studies at 3-month intervals. However, clinicians frequently obtain magnetic resonance imaging (MRI) studies at <3 months after GKRS. METHODS We performed a retrospective medical record review study to assess the utility of early (<3 months) MRI after GKRS in patients with BrMs. RESULTS A total of 415 GKRS procedures were performed. For 325 patients, early MRI studies were obtained. A total of 31 patients had new or worsened neurological symptoms. The early MRI studies showed adverse findings in 25 patients (78%), which in 23 (72%) had resulted in a change in treatment. For 294 patients, no new or worsened neurological symptoms were found on early MRI studies. Of these 294 patients, 86 (29%) had ≥1 adverse finding on MRI, and 60 (20%) had a change in management as a result. However, no rapidly growing tumors or other emergent adverse findings were seen. CONCLUSIONS Early MRI (within 3 months) after post GKRS will frequently show adverse findings even in asymptomatic patients, more often in patients aged <65 years and patients with multiple treated BrMs. However, according to the nature of the adverse findings observed in our retrospective study, it is unlikely that the clinical outcomes would have been affected if the post-GKRS MRI studies had been deferred to 3 months after treatment. Our data support deferring post-GKRS MRI to 3 months after treatment in the absence of new neurological signs or symptoms.
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Affiliation(s)
- Ronald J Benveniste
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
| | - Raphael Yechieli
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Tejan Diwanji
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida, USA
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5
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Repeated stereotactic radiosurgery for recurrent brain metastases: An effective strategy to control intracranial oligometastatic disease. Crit Rev Oncol Hematol 2020; 153:103028. [PMID: 32622322 DOI: 10.1016/j.critrevonc.2020.103028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/07/2020] [Accepted: 06/09/2020] [Indexed: 11/21/2022] Open
Abstract
Due to improvements in systemic therapies and longer survivals, cancer patients frequently present with recurrent brain metastases (BM). The optimal therapeutic strategies for limited brain relapse remain undefined. We analyzed tumor control and survival in patients treated with salvage focal radiotherapy in our center. Thirty-three patients with 112 BM received salvage stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT) for local or regional recurrences. Local progression was observed in 11 BM (9.8 %). After 1 year, 72 % of patients were free of distant brain failure, and the 2-year overall survival (OS) was 37.7 %. No increase in toxicity or neurologically related deaths were observed. The 2- and 3-year whole brain radiation therapy free survival (WFS) rates were 92.9 % and 77.4 %, respectively. Hence, focal radiotherapy is a feasible salvage of recurrent BM in selected group of patients with limited brain disease, achieving a maintained intracranial control and less neurological toxicity.
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6
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Hulsbergen AFC, Cho LD, Mammi M, Lamba N, Smith TR, Brastianos PK, Broekman MLD, Lin NU. Systemic therapy following craniotomy in patients with a solitary breast cancer brain metastasis. Breast Cancer Res Treat 2020; 180:147-155. [PMID: 31953697 PMCID: PMC7031200 DOI: 10.1007/s10549-020-05531-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 01/09/2020] [Indexed: 01/11/2023]
Abstract
Purpose To describe practice patterns and patient outcomes with respect to the use of postoperative systemic therapy (ST) after resection of a solitary breast cancer brain metastasis (BCBM). Methods A multi-institutional retrospective review of consecutive patients undergoing resection of a single BCBM without extracranial metastases was performed to describe subtype-specific postoperative outcomes and assess the impact of types of ST on site of recurrence, progression-free survival (PFS), and overall survival (OS). Results Forty-four patients were identified. Stratified estimated survival was 15, 24, and 23 months for patients with triple negative, estrogen receptor positive (ER+), and HER2+ BCBMs, respectively. Patients receiving postoperative ST had a longer median PFS (8 versus 4 months, adjusted p-value 0.01) and OS (32 versus 15 months, adjusted p-value 0.21). Nine patients (20%) had extracranial progression, 23 (52%) had intracranial progression, three (8%) had both, and nine (20%) did not experience progression at last follow-up. Multivariate analysis showed that postoperative hormonal therapy was associated with longer OS (HR 0.26; 95% CI 0.08–0.89; p = 0.03) but not PFS (HR 0.35, 95% CI 0.08–1.47, p = 0.15) in ER+ patients. Postoperative HER2-targeted therapy was not associated with longer OS or PFS in HER2+ patients. Conclusions Disease progression occurred intracranially more often than extracranially following resection of a solitary BCBM. In ER+ patients, postoperative hormonal therapy was associated with longer OS. Postoperative HER2-targeted therapy did not show survival benefit in HER2+ patients. These results should be validated in larger cohorts.
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Affiliation(s)
- Alexander F C Hulsbergen
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Faculty of Medicine, Utrecht University, Universiteitsweg 98, 3584 CG, Utrecht, The Netherlands.,Department of Neurosurgery, Leiden University Medical Center, Zuid-Holland, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.,Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512 VA, The Hague, The Netherlands
| | - Logan D Cho
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Brown University, 69 Brown Street, Providence, RI, 02912, USA
| | - Marco Mammi
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Nayan Lamba
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Timothy R Smith
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Priscilla K Brastianos
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Marike L D Broekman
- Department of Neurosurgery, Leiden University Medical Center, Zuid-Holland, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.,Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512 VA, The Hague, The Netherlands.,Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Nancy U Lin
- Division of Breast Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA.
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McTyre ER, Soike MH, Farris M, Ayala-Peacock DN, Hepel JT, Page BR, Shen C, Kleinberg L, Contessa JN, Corso C, Chiang V, Henson-Masters A, Cramer CK, Ruiz J, Pasche B, Watabe K, D'Agostino R, Su J, Laxton AW, Tatter SB, Fiveash JB, Ahluwalia M, Kotecha R, Chao ST, Braunstein SE, Attia A, Chung C, Chan MD. Multi-institutional validation of brain metastasis velocity, a recently defined predictor of outcomes following stereotactic radiosurgery. Radiother Oncol 2019; 142:168-174. [PMID: 31526671 DOI: 10.1016/j.radonc.2019.08.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Brain metastasis velocity (BMV) is a prognostic metric that describes the recurrence rate of new brain metastases after initial treatment with radiosurgery (SRS). We have previously risk stratified patients into high, intermediate, and low-risk BMV groups, which correlates with overall survival (OS). We sought to externally validate BMV in a multi-institutional setting. METHODS Patients from nine academic centers were treated with upfront SRS; the validation cohort consisted of data from eight institutions not previously used to define BMV. Patients were classified by BMV into low (<4 BMV), intermediate (4-13 BMV), and high-risk groups (>13 BMV). Time-to-event outcomes were estimated using the Kaplan-Meier method. Cox proportional hazards methods were used to estimate the effect of BMV and salvage modality on OS. RESULTS Of 2829 patients, 2092 patients were included in the validation dataset. Of these, 921 (44.0%) experienced distant brain failure (DBF). Median OS from initial SRS was 11.2 mo. Median OS for BMV < 4, BMV 4-13, and BMV > 13 were 12.5 mo, 7.0 mo, and 4.6 mo (p < 0.0001). After multivariate regression modeling, melanoma histology (β: 10.10, SE: 1.89, p < 0.0001) and number of initial brain metastases (β: 1.52, SE: 0.34, p < 0.0001) remained predictive of BMV (adjusted R2 = 0.06). CONCLUSIONS This multi-institutional dataset validates BMV as a predictor of OS following initial SRS. BMV is being utilized in upcoming multi-institutional randomized controlled trials as a stratification variable for salvage whole brain radiation versus salvage SRS after DBF.
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Affiliation(s)
- Emory R McTyre
- Department of Radiation Oncology, Greenville Health System Cancer Institute, USA
| | - Michael H Soike
- Hazelrig-Salter Radiation Oncology Center, University of Alabama at Birmingham, USA.
| | - Michael Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, USA
| | | | - Jaroslaw T Hepel
- Department of Radiation Oncology, Brown University Alpert Medical School, USA
| | - Brandi R Page
- Department of Radiation Oncology, Johns Hopkins School of Medicine, USA
| | - Colette Shen
- Department of Radiation Oncology, University of North Carolina, USA
| | | | | | | | | | | | | | - Jimmy Ruiz
- Department of Medicine, Wake Forest School of Medicine, USA
| | - Boris Pasche
- Department of Medicine, Wake Forest School of Medicine, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, USA
| | - Ralph D'Agostino
- Department of Biostatistical Sciences, Wake Forest School of Medicine, USA
| | - Jing Su
- Department of Biostatistical Sciences, Wake Forest School of Medicine, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, USA
| | | | - John B Fiveash
- Hazelrig-Salter Radiation Oncology Center, University of Alabama at Birmingham, USA
| | - Manmeet Ahluwalia
- Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, USA
| | - Samuel T Chao
- Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, USA
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco, USA
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University School of Medicine, USA
| | - Caroline Chung
- Department of Radiation Oncology, M.D. Anderson Cancer Center, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, USA
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Achrol AS, Rennert RC, Anders C, Soffietti R, Ahluwalia MS, Nayak L, Peters S, Arvold ND, Harsh GR, Steeg PS, Chang SD. Brain metastases. Nat Rev Dis Primers 2019; 5:5. [PMID: 30655533 DOI: 10.1038/s41572-018-0055-y] [Citation(s) in RCA: 529] [Impact Index Per Article: 105.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
An estimated 20% of all patients with cancer will develop brain metastases, with the majority of brain metastases occurring in those with lung, breast and colorectal cancers, melanoma or renal cell carcinoma. Brain metastases are thought to occur via seeding of circulating tumour cells into the brain microvasculature; within this unique microenvironment, tumour growth is promoted and the penetration of systemic medical therapies is limited. Development of brain metastases remains a substantial contributor to overall cancer mortality in patients with advanced-stage cancer because prognosis remains poor despite multimodal treatments and advances in systemic therapies, which include a combination of surgery, radiotherapy, chemotherapy, immunotherapy and targeted therapies. Thus, interest abounds in understanding the mechanisms that drive brain metastases so that they can be targeted with preventive therapeutic strategies and in understanding the molecular characteristics of brain metastases relative to the primary tumour so that they can inform targeted therapy selection. Increased molecular understanding of the disease will also drive continued development of novel immunotherapies and targeted therapies that have higher bioavailability beyond the blood-tumour barrier and drive advances in radiotherapies and minimally invasive surgical techniques. As these discoveries and innovations move from the realm of basic science to preclinical and clinical applications, future outcomes for patients with brain metastases are almost certain to improve.
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Affiliation(s)
- Achal Singh Achrol
- Department of Neurosurgery and Neurosciences, John Wayne Cancer Institute and Pacific Neuroscience Institute, Santa Monica, CA, USA.
| | - Robert C Rennert
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA.
| | - Carey Anders
- Division of Hematology/Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | | | - Manmeet S Ahluwalia
- Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Lakshmi Nayak
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Solange Peters
- Medical Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Nils D Arvold
- Department of Radiation Oncology, St. Luke's Cancer Center, Duluth, MN, USA
| | - Griffith R Harsh
- Department of Neurosurgery, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Patricia S Steeg
- Women's Malignancies Branch, Center for Cancer Research, National Cancer Center, Bethesda, MD, USA
| | - Steven D Chang
- Department of Neurosurgery, University of California-Davis, School of Medicine, Sacramento, CA, USA.
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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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Huang Z, Sun B, Shen G, Cha L, Meng X, Wang J, Zhou Z, Wu S. Brain metastasis reirradiation in patients with advanced breast cancer. JOURNAL OF RADIATION RESEARCH 2017; 58:142-148. [PMID: 27707842 PMCID: PMC5321192 DOI: 10.1093/jrr/rrw087] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 04/05/2016] [Accepted: 07/20/2016] [Indexed: 05/10/2023]
Abstract
The outcome of recurrent brain metastasis is dismal. This study aims to assess the clinical outcomes and toxicity of reirradiation as a salvage treatment for progressive brain metastasis in patients with advanced breast cancer. Between July 2005 and September 2014, the medical records of 56 patients with brain metastasis from breast cancer were retrospectively reviewed. Of these patients, 39 received whole-brain radiotherapy (WBRT) followed by stereotactic radiosurgery (SRS) reirradiation (Group 1), and 17 received SRS followed by WBRT reirradiation (Group 2). Overall survival (OS) and brain progression-free survival rates/times were calculated using the Kaplan-Meier method. Prognostic factors were evaluated using the Cox proportional hazards model. Change in neurologic function was also assessed. The median OS was 10.8 months (range, 1.3-56.8 months). In Group 1, the median PFS time (PFS-1) was 6.5 months and the OS time was 11.4 months. Multivariate analysis revealed that longer OS was significantly associated with a high Karnofsky performance score (KPS) (P = 0.004), controlled extracranial metastasis (P = 0.001) and a good response to reirradiation (P = 0.034). In Group 2, the median PFS time (PFS-2) after reirradiation was 8.5 months and the OS time was 10.8 months. Multivariate analysis revealed that longer OS was significantly associated with a high KPS (P = 0.018). The majority of the patients had improved or stable neurological function. Reirradiation is an effective and a safe treatment for patients with brain metastases from breast cancer. It might delay the progression of intracranial disease and improve neurological function. A suitable patient selection for reirradiation was suggested.
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Affiliation(s)
- Zhou Huang
- Department of Radiotherapy, Affiliated Hospital of Academy of Military Medical Sciences, No. 8 Dongda Street, Fengtai District, Beijing 100071, China
| | - Bing Sun
- Department of Radiotherapy, Affiliated Hospital of Academy of Military Medical Sciences, No. 8 Dongda Street, Fengtai District, Beijing 100071, China
| | - Ge Shen
- Department of Radiotherapy, Affiliated Hospital of Academy of Military Medical Sciences, No. 8 Dongda Street, Fengtai District, Beijing 100071, China
| | - Lei Cha
- Department of Science and Technology, Academy of Military Medical Sciences, Beijing 100850, China
| | - Xiangying Meng
- Department of Radiotherapy, Affiliated Hospital of Academy of Military Medical Sciences, No. 8 Dongda Street, Fengtai District, Beijing 100071, China
| | - Junliang Wang
- Department of Radiotherapy, Affiliated Hospital of Academy of Military Medical Sciences, No. 8 Dongda Street, Fengtai District, Beijing 100071, China
| | - Zhenshan Zhou
- Department of Radiotherapy, Affiliated Hospital of Academy of Military Medical Sciences, No. 8 Dongda Street, Fengtai District, Beijing 100071, China
| | - Shikai Wu
- Department of Radiotherapy, Affiliated Hospital of Academy of Military Medical Sciences, No. 8 Dongda Street, Fengtai District, Beijing 100071, China
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Arvold ND, Lee EQ, Mehta MP, Margolin K, Alexander BM, Lin NU, Anders CK, Soffietti R, Camidge DR, Vogelbaum MA, Dunn IF, Wen PY. Updates in the management of brain metastases. Neuro Oncol 2016; 18:1043-65. [PMID: 27382120 PMCID: PMC4933491 DOI: 10.1093/neuonc/now127] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/09/2016] [Indexed: 12/16/2022] Open
Abstract
The clinical management/understanding of brain metastases (BM) has changed substantially in the last 5 years, with key advances and clinical trials highlighted in this review. Several of these changes stem from improvements in systemic therapy, which have led to better systemic control and longer overall patient survival, associated with increased time at risk for developing BM. Development of systemic therapies capable of preventing BM and controlling both intracranial and extracranial disease once BM are diagnosed is paramount. The increase in use of stereotactic radiosurgery alone for many patients with multiple BM is an outgrowth of the desire to employ treatments focused on local control while minimizing cognitive effects associated with whole brain radiotherapy. Complications from BM and their treatment must be considered in comprehensive patient management, especially with greater awareness that the majority of patients do not die from their BM. Being aware of significant heterogeneity in prognosis and therapeutic options for patients with BM is crucial for appropriate management, with greater attention to developing individual patient treatment plans based on predicted outcomes; in this context, recent prognostic models of survival have been extensively revised to incorporate molecular markers unique to different primary cancers.
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Affiliation(s)
| | | | | | - Kim Margolin
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
| | - Brian M. Alexander
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
| | - Nancy U. Lin
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
| | - Carey K. Anders
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
| | - Riccardo Soffietti
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
| | - D. Ross Camidge
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
| | - Michael A. Vogelbaum
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
| | - Ian F. Dunn
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
| | - Patrick Y. Wen
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
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