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Layer JP, Shiban E, Brehmer S, Diehl CD, de Castro DG, Hamed M, Dejonckheere CS, Cifarelli DT, Friker LL, Herrlinger U, Hölzel M, Vatter H, Schneider M, Combs SE, Schmeel LC, Cifarelli CP, Giordano FA, Sarria GR, Kahl KH. Multicentric Assessment of Safety and Efficacy of Combinatorial Adjuvant Brain Metastasis Treatment by Intraoperative Radiation Therapy and Immunotherapy. Int J Radiat Oncol Biol Phys 2024; 118:1552-1562. [PMID: 38199383 DOI: 10.1016/j.ijrobp.2024.01.009] [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: 08/11/2023] [Revised: 01/01/2024] [Accepted: 01/03/2024] [Indexed: 01/12/2024]
Abstract
PURPOSE After surgical resection of brain metastases (BMs), intraoperative radiation therapy (IORT) provides a promising alternative to adjuvant external beam radiation therapy by enabling superior organ-at-risk preservation, reduction of in-hospital times, and timely admission to subsequent systemic treatments, which increasingly comprise novel targeted immunotherapeutic approaches. We sought to assess the safety and efficacy of IORT in combination with immune checkpoint inhibitors (ICIs) and other targeted therapies (TTs). METHODS AND MATERIALS In a multicentric approach incorporating individual patient data from 6 international IORT centers, all patients with BMs undergoing IORT were retrospectively assessed for combinatorial treatment with ICIs/TTs and evaluated for toxicity and cumulative rates, including wound dehiscence, radiation necrosis, leptomeningeal spread, local control, distant brain progression (DBP), and estimated overall survival. RESULTS In total, 103 lesions with a median diameter of 34 mm receiving IORT combined with immunomodulatory systemic treatment or other TTs were included. The median follow-up was 13.2 (range, 1.2-102.4) months, and the median IORT dose was 25 (range, 18-30) Gy prescribed to the applicator surface. There was 1 grade 3 adverse event related to IORT recorded (2.2%). A 4.9% cumulative radiation necrosis rate was observed. The 1-year local control rate was 98.0%, and the 1-year DBP-free survival rate was 60.0%. Median time to DBP was 5.5 (range, 1.0-18.5) months in the subgroup of patients experiencing DBP, and the cumulative leptomeningeal spread rate was 4.9%. The median estimated overall survival was 26 (range, 1.2 to not reached) months with a 1-year survival rate of 74.0%. Early initiation of immunotherapy/TTs was associated with a nonsignificant trend toward improved DBP rate and overall survival. CONCLUSIONS The combination of ICIs/TTs with IORT for resected BMs does not seem to increase toxicity and yields encouraging local control outcomes in the difficult-to-treat subgroup of larger BMs. Time gaps between surgery and systemic treatment could be shortened or avoided. The definitive role of IORT in local control after BM resection will be defined in a prospective trial.
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Affiliation(s)
- Julian P Layer
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany; Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Hospital Augsburg, Augsburg, Germany
| | - Stefanie Brehmer
- Department of Neurosurgery, University Medical Center Mannheim, Mannheim, Germany
| | - Christian D Diehl
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Cas S Dejonckheere
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Daniel T Cifarelli
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
| | - Lea L Friker
- Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany; Institute of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Ulrich Herrlinger
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Michael Hölzel
- Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Mannheim, Germany; DKFZ-Hector Cancer Institute of the University Medical Center Mannheim, Mannheim, Germany; Mannheim Institute of Intelligent Systems in Medicine (MIISM), Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany.
| | - Klaus-Henning Kahl
- Department of Radiooncology, University Hospital Augsburg, Augsburg, Germany
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Albers EAC, de Ligt KM, van de Poll-Franse LV, Compter A, de Ruiter MB, Schagen SB. Health-related quality of life after stereotactic radiosurgery in patients with brain metastases. Support Care Cancer 2023; 31:720. [PMID: 38008876 DOI: 10.1007/s00520-023-08203-6] [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: 06/14/2023] [Accepted: 11/21/2023] [Indexed: 11/28/2023]
Abstract
PURPOSE This study aimed to assess health-related quality of life (HRQoL) in patients with brain metastases treated with stereotactic radiosurgery (SRS) and to identify factors associated with this. METHODS HRQoL was measured pre-SRS, at 3- and 6-month follow-up. Physical functioning, cognitive functioning, role functioning, and fatigue were analyzed with the EORTC QLQ-C30 questionnaire. Motor dysfunction, future uncertainty, visual disorder, communication deficit, and headaches were analyzed with the EORTC QLQ-BN20. Clinically important symptom or functional impairment was assessed following set thresholds. Factors associated with impairment were identified through multivariable logistic regression analyses. RESULTS At baseline, 178 patients were included; 54% (n=96) completed questionnaires at 3 months and 39% (n=70) at 6 months. Before SRS, 29% of linear accelerator (LINAC) patients reported physical and cognitive impairment, while 25% reported impairment for fatigue. At 6 months, 39%, 43%, and 57% of LINAC patients reported impairment respectively. Forty-five percent of Gamma Knife (GK) patients reported impairment pre-SRS for physical, cognitive functioning, and fatigue. At 6 months, 48%, 43%, and 33% of GK patients reported impairment respectively. Except for role functioning, pre-SRS symptom and functioning scores were associated with impairment at 3 months, whereas scores at 3 months were associated with impairment at 6 months. Age, gender, systemic therapy, and intracranial progression were not associated with clinically important impairment. CONCLUSION As 33-57% of patients with brain metastases reported symptom burden and functional impairments that were of clinical importance, it is recommended to pay attention to the HRQoL outcomes of these patients during clinical encounters.
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Affiliation(s)
- Elaine A C Albers
- Department of Psychosocial Research, Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066, CX, Amsterdam, The Netherlands.
| | - Kelly M de Ligt
- Department of Psychosocial Research, Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066, CX, Amsterdam, The Netherlands
| | - Lonneke V van de Poll-Franse
- Department of Psychosocial Research, Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066, CX, Amsterdam, The Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
- Department of Medical and Clinical Psychology, Center of Research On Psychological and Somatic Disorders (CoRPS), Tilburg University, Tilburg, The Netherlands
| | - Annette Compter
- Department of neuro-oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michiel B de Ruiter
- Department of Psychosocial Research, Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066, CX, Amsterdam, The Netherlands
| | - Sanne B Schagen
- Department of Psychosocial Research, Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066, CX, Amsterdam, The Netherlands
- Deparment of Psychology, University of Amsterdam, Amsterdam, The Netherlands
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3
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Verhaak E, Schimmel WCM, Sitskoorn MM, Hanssens PEJ, Butterbrod E, Gehring K. The long-term course and relationship with survival of multidimensional fatigue in patients with brain metastases after Gamma Knife radiosurgery. J Cancer Res Clin Oncol 2023; 149:9891-9901. [PMID: 37249646 PMCID: PMC10423137 DOI: 10.1007/s00432-023-04857-1] [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: 02/10/2023] [Accepted: 05/13/2023] [Indexed: 05/31/2023]
Abstract
PURPOSE The aims of this study were to evaluate long-term multidimensional fatigue in patients with brain metastases (BM) up to 21 months after Gamma Knife radiosurgery (GKRS) and (change in) fatigue as predictor of survival. METHODS Patients with 1 to 10 BM, expected survival > 3 months, and Karnofsky Performance Status ≥ 70, and Dutch non-cancer controls were included. Fatigue was measured with the Multidimensional Fatigue Inventory. Levels of fatigue between patients and controls were compared using independent-samples t-tests. Linear mixed models were used to evaluate fatigue within the patient group up to 21 months after GKRS. Pre-GKRS fatigue and minimal clinically important (MCI) changes in fatigue in the first three months (defined as a 2-point difference) after GKRS were evaluated as predictors of survival time. RESULTS Prior to GKRS, patients with BM (n = 92) experienced significantly higher fatigue on all subscales than controls (n = 104). Over 21 months, physical fatigue increased, and mental fatigue decreased significantly. More specifically, general, and physical fatigue increased significantly between pre-GKRS and 3 months, followed by stable scores between 3 (n = 67) and 6 (n = 53), 6 and 12 (n = 34) and 12 and 21 (n = 21) months. An MCI increase in general or physical fatigue over the first 3 months after GKRS was a significant predictor of shorter survival time. CONCLUSION Except for mental fatigue, all aspects of fatigue remained elevated or further increased up to 21 months after treatment. Furthermore, an increase in general or physical fatigue within three months after GKRS may be a prognostic indicator for poorer survival. CLINICALTRIALS GOV IDENTIFIER NCT02953756, November 3, 2016.
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Affiliation(s)
- Eline Verhaak
- Department of Neurosurgery-Gamma Knife Center, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands.
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands.
| | - Wietske C M Schimmel
- Department of Neurosurgery-Gamma Knife Center, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
| | - Margriet M Sitskoorn
- Department of Neurosurgery-Gamma Knife Center, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
| | - Patrick E J Hanssens
- Department of Neurosurgery-Gamma Knife Center, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
| | - Elke Butterbrod
- Department of Neurosurgery-Gamma Knife Center, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
- Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Karin Gehring
- Department of Neurosurgery-Gamma Knife Center, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
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Layer JP, Hamed M, Potthoff AL, Dejonckheere CS, Layer K, Sarria GR, Scafa D, Koch D, Köksal M, Kugel F, Grimmer M, Holz JA, Zeyen T, Friker LL, Borger V, Schmeel FC, Weller J, Hölzel M, Schäfer N, Garbe S, Forstbauer H, Giordano FA, Herrlinger U, Vatter H, Schneider M, Schmeel LC. Outcome assessment of intraoperative radiotherapy for brain metastases: results of a prospective observational study with comparative matched-pair analysis. J Neurooncol 2023; 164:107-116. [PMID: 37477822 PMCID: PMC10462513 DOI: 10.1007/s11060-023-04380-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/20/2023] [Indexed: 07/22/2023]
Abstract
PURPOSE Intraoperative radiation therapy (IORT) is an emerging alternative to adjuvant stereotactic external beam radiation therapy (EBRT) following resection of brain metastases (BM). Advantages of IORT include an instant prevention of tumor regrowth, optimized dose-sparing of adjacent healthy brain tissue and immediate completion of BM treatment, allowing an earlier admission to subsequent systemic treatments. However, prospective outcome data are limited. We sought to assess long-term outcome of IORT in comparison to EBRT. METHODS A total of 35 consecutive patients, prospectively recruited within a study registry, who received IORT following BM resection at a single neuro-oncological center were evaluated for radiation necrosis (RN) incidence rates, local control rates (LCR), distant brain progression (DBP) and overall survival (OS) as long-term outcome parameters. The 1 year-estimated OS and survival rates were compared in a balanced comparative matched-pair analysis to those of our institutional database, encompassing 388 consecutive patients who underwent adjuvant EBRT after BM resection. RESULTS The median IORT dose was 30 Gy prescribed to the applicator surface. A 2.9% RN rate was observed. The estimated 1 year-LCR was 97.1% and the 1 year-DBP-free survival 73.5%. Median time to DBP was 6.4 (range 1.7-24) months in the subgroup of patients experiencing intracerebral progression. The median OS was 17.5 (0.5-not reached) months with a 1 year-survival rate of 61.3%, which did not not significantly differ from the comparative cohort (p = 0.55 and p = 0.82, respectively). CONCLUSION IORT is a safe and effective fast-track approach following BM resection, with comparable long-term outcomes as adjuvant EBRT.
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Affiliation(s)
- Julian P Layer
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
- Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany.
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | - Cas S Dejonckheere
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Katharina Layer
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Davide Scafa
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - David Koch
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Mümtaz Köksal
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Fabian Kugel
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Molina Grimmer
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jasmin A Holz
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Thomas Zeyen
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Lea L Friker
- Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany
- Institute of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - F Carsten Schmeel
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Johannes Weller
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Michael Hölzel
- Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany
| | - Niklas Schäfer
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Stephan Garbe
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | | | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Mannheim, Germany
- DKFZ-Hector Cancer Institute of the University Medical Center Mannheim, Mannheim, Germany
- Mannheim Institute of Intelligent Systems in Medicine (MIISM), Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ulrich Herrlinger
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | - L Christopher Schmeel
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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5
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Wu A, Colón GR, Lim M. Quality of Life and Role of Palliative and Supportive Care for Patients With Brain Metastases and Caregivers: A Review. Front Neurol 2022; 13:806344. [PMID: 35250815 PMCID: PMC8893046 DOI: 10.3389/fneur.2022.806344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/07/2022] [Indexed: 12/25/2022] Open
Abstract
Brain metastases (BM) are the most commonly diagnosed secondary brain lesions in adults, influencing these patients' symptoms and treatment courses. With improvements in oncologic treatments, patients with BM are now living longer with their advanced cancers, and issues pertaining to quality of life become more pressing. The American Society of Clinical Oncology has recommended early implementation of palliative care for cancer patients, though incorporation and implementation of palliative and other supportive services in the setting of true multidisciplinary care requires additional attention and research for patients with intracranial metastases. We review the physical, cognitive, and psychosocial challenges patients with BM and their caregivers face during their cancer course as well as the current published research on quality of life metrics relating to this patient population and the diverse roles specialty palliative care, rehabilitation services, and other healthcare providers play in a comprehensive multidisciplinary care model.
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Affiliation(s)
- Adela Wu
- Department of Neurosurgery, Stanford Healthcare, Stanford, CA, United States
- *Correspondence: Adela Wu
| | - Gabriela Ruiz Colón
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Michael Lim
- Department of Neurosurgery, Stanford Healthcare, Stanford, CA, United States
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Verhaak E, Schimmel WCM, Gehring K, Hanssens PEJ, Sitskoorn MM. Cognitive Functioning and Health-Related Quality of Life of Long-Term Survivors With Brain Metastases Up to 21 Months After Gamma Knife Radiosurgery. Neurosurgery 2021; 88:E396-E405. [PMID: 33575811 DOI: 10.1093/neuros/nyaa586] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 11/18/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Survival rates have improved in the past years for patients with brain metastases (BMs). OBJECTIVE To evaluate cognitive functioning and health-related quality of life (HRQoL) after Gamma Knife radiosurgery (GKRS) in a relatively large sample of long-term survivors. METHODS Data from 38 long-term survivors (assessments available ≥ 12 mo post-GKRS) with, at time of enrollment, 1 to 10 newly diagnosed BMs, expected survival > 3 mo, and Karnofsky Performance Status ≥ 70 were analyzed. Cognitive functioning and HRQoL were assessed pre-GKRS (n = 38) and at 3 (n = 38), 6 (n = 37), 9 (n = 37), 12 (n = 34), 15 (n = 28), and 21 (n = 21) mo post-GKRS. The course of cognitive test performance and of HRQoL over time was analyzed using linear mixed models. Individual changes in cognitive performance and HRQoL from pre-GKRS to 21 mo were determined using reliable change indexes (RCIs) and clinical meaningful cutoffs, respectively. RESULTS Cognitive performances and HRQoL of long-term survivors remained stable or improved up to 21 mo after GKRS. Improvements were found for immediate and delayed verbal memory, working memory, information processing speed, and emotional well-being. On the individual level, most patients had stable or improved test performances or HRQoL. For physical well-being only, most patients (47.6%) showed a decline (vs 28.6% improvement or 23.8% no change) from pre-GKRS until 21 mo post-GKRS. CONCLUSION Up to 21 mo after GKRS, cognitive functioning and overall HRQoL improved or remained stable in long-term survivors. In long-term survivors with 1 to 10 BMs, GKRS did not cause (additional) cognitive deteriorations or declines in HRQoL at longer-term follow-up.
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Affiliation(s)
- Eline Verhaak
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.,Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, the Netherlands
| | - Wietske C M Schimmel
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.,Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, the Netherlands
| | - Karin Gehring
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.,Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, the Netherlands
| | - Patrick E J Hanssens
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.,Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Margriet M Sitskoorn
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, the Netherlands
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Chalubinska-Fendler J, Kepka L. Prophylactic cranial irradiation in non-small cell lung cancer: evidence and future development. J Thorac Dis 2021; 13:3279-3288. [PMID: 34164220 PMCID: PMC8182492 DOI: 10.21037/jtd.2019.11.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
In non-small cell lung cancer (NSCLC) brain metastases (BM) will affect up to 50% of patients during whole disease period. BM themselves impact heavily not only on patient’s prognosis but also are a source of symptoms aggravating quality of life. Standard (pemetrexed), and non-standard chemotherapy (temozolomide) in patients with NSCLC failed to prevent them from BM. In terms of systemic treatment there are promising results showed when durvalumab (PACIFIC study), osimertinib (FLAURA trial) or alectinib (JALEX study) was used. However, those substances are effective only in small cohort with ALK or EGFR alterations. Prophylactic cranial irradiation (PCI) as a non-specific treatment has proven to be a powerful tool in preventing BM without affecting overall survival in neither way. That has been proved in nearly all earlier and all recent studies—NVALT11/DLCRG-02, RTOG 0214 update, Li et al. The positive effect of BM incidence reduction may draw fear form PCI usage due to potential cognitive toxicity the PCI may cause. Results of recent trials show that after PCI only mild cognitive disorders (MCD) may arise. Promising results in terms of reducing MCD are shown when memantine is used or/and hippocampal avoidance techniques are implemented. HA in PCI seem to be cost effective but calculations were made on small-cell lung cancer cohorts. Still even recent studies did not clarify finally which patients could benefit from PCI or other forms of preventing BM. It seems that new trials should focus on younger, fit and non-squamous histology patients and use the tests for mild cognitive disorders (MoCA, BHA) rather than screening tests for dementia (MMSE, HVLT, ADL). The main obstacle in performing new trials on PCI in NSCLC cohorts may be, however, patients’ accrual, as a difficulty which occurred during latest trials.
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Affiliation(s)
| | - Lucyna Kepka
- Department of Radiation Oncology, Military Institute of Medicine, Warsaw, Poland
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8
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Verhaak E, Schimmel WCM, Gehring K, Emons WHM, Hanssens PEJ, Sitskoorn MM. Health-related quality of life after Gamma Knife radiosurgery in patients with 1-10 brain metastases. J Cancer Res Clin Oncol 2021; 147:1157-1167. [PMID: 33025282 PMCID: PMC7954744 DOI: 10.1007/s00432-020-03400-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/18/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Increasingly more patients with multiple (> 4) brain metastases (BM) are being treated with stereotactic radiosurgery (SRS). Preserving patients' health-related quality of life (HRQoL) is an important treatment goal. The aim of this study was to assess (individual) changes in HRQoL in patients with 1-10 BM over time. METHODS A total of 92 patients were assessed before (n = 92) and at 3 (n = 66), 6 (n = 53), and 9 (n = 41) months after Gamma Knife radiosurgery (GKRS), using the Functional Assessment of Cancer Therapy-Brain (FACT-Br). The course of HRQoL was analyzed using linear mixed models. Clinical minimally important differences were used to evaluate individual changes. RESULTS At group level, patients' physical well-being worsened, whereas emotional well-being improved over 9 months. Scores on other HRQoL subscales did not change significantly. Number (1-3 versus 4-10) and volume (small, medium, and large) of BM did not influence HRQoL over time, except for the subscale additional concerns; medium intracranial tumor volume was associated with less additional concerns. On the individual level as well, physical well-being declined while emotional well-being improved in most patients over 9 months after GKRS. At patient level, however, most patients had both declines as well as improvements in the different HRQoL aspects. CONCLUSION Our results indicate that even in patients with up to 10 BM, both at group and individual subscale level, aspects of HRQoL remained stable over nine months after GKRS, except for an improvement in emotional well-being and a decline in physical well-being. Nevertheless, HRQoL scores varied considerably at the individual patient level. TRAIL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT02953756, November 3, 2016.
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Affiliation(s)
- Eline Verhaak
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands.
| | - Wietske C M Schimmel
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands
| | - Karin Gehring
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands
| | - Wilco H M Emons
- Department of Methodology and Statistics, Tilburg University, Tilburg, The Netherlands
| | - Patrick E J Hanssens
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Margriet M Sitskoorn
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands
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Group and Individual Change in Cognitive Functioning in Patients With 1 to 10 Brain Metastases Following Gamma Knife Radiosurgery. Clin Oncol (R Coll Radiol) 2021; 33:314-321. [PMID: 33531195 DOI: 10.1016/j.clon.2021.01.003] [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: 08/27/2020] [Revised: 11/16/2020] [Accepted: 01/06/2021] [Indexed: 11/23/2022]
Abstract
AIMS Stereotactic radiosurgery is increasingly used to treat multiple (four or more) brain metastases. Preserving cognitive functions is a highly relevant treatment goal because cognitive deteriorations may negatively affect a patient's quality of life. The aim of this study was to assess cognitive change, at the group and individual level, in patients with 1 to 10 brain metastases up to 9 months after Gamma Knife radiosurgery (GKRS). MATERIALS AND METHODS Ninety-two patients with 1 to 10 newly diagnosed brain metastases, expected survival >3 months and Karnofsky Performance Status (KPS) ≥70 and 104 non-cancer controls were included. A neuropsychological test battery was administered before GKRS (n = 92) and at 3 (n = 66), 6 (n = 52) and 9 (n = 41) months after GKRS. The course of test performances, while taking into account practice effects, was analysed using linear mixed models. Pre-GKRS predictors of cognitive trajectories were analysed. To determine proportions of individuals with cognitive changes, reliable change indices, with correction for practice effects, were calculated. RESULTS At the group level, immediate memory, working memory and information processing speed significantly improved over 9 months after GKRS. There were no cognitive declines. Neither number nor volume of brain metastases influenced cognitive change over time. At the individual level, proportions of patients with stable, improved or declined performances were comparable with controls, except for information processing speed (more individuals with improvements in patients) and motor dexterity (more improvements and declines in patients). CONCLUSIONS Cognitive functioning in patients with 1 to 10 brain metastases was preserved, or improved, up to 9 months after GKRS. Neither number nor volume of brain metastases influenced cognitive performance.
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Marotta D, Tucker Z, Hayward EN, Gerstenecker A, Gammon M, Mason M, Willhelm G, Bae H, Triebel K. Relationship between cognitive functioning, mood, and other patient factors on quality of life in metastatic brain cancer. Psychooncology 2020; 29:1174-1184. [PMID: 32364662 DOI: 10.1002/pon.5401] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 04/14/2020] [Accepted: 04/22/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Neurocognitive functioning (NCF), mood disturbances, physical functioning, and social support all share a relationship with health-related quality of life (HRQOL). However, investigations into these relationships have not been conducted in persons with brain metastases (BM). PATIENTS AND METHODS Ninety-three newly diagnosed persons with BM were administered various cognitive batteries. Data were collected across a wide range of categories (ie, cognitive, demographic, disease/treatment, mood, social support, physical functioning). The Functional Assessment of Cancer Treatment (FACT) scale was used to measure HRQOL. RESULTS Mood and physical function correlated with lower HRQOL in every measured domain. Verbal learning and memory correlated with every FACT subscale except emotional quality of life. Social support also correlated with several HRQOL domains. Stepwise linear regression revealed that mood predicted general well-being and several FACT subscales, including physical, emotional and cognitive well-being. Social support and physical health were predictive of general well-being. Verbal learning and memory predicted cognitive well-being. CONCLUSION HRQOL is a complex construct affected by numerous variables. In particular, mood, physical functioning, and learning and memory were important predictors of HRQOL, and clinicians are encouraged to obtain information in these areas during baseline assessments in persons with BM.
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Affiliation(s)
- Dario Marotta
- Alabama College of Osteopathic Medicine, Dothan, Alabama, USA.,Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Zachary Tucker
- Department of Neurology, Division of Neuro-Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Emily N Hayward
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, Birmingham, Alabama, USA.,School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Adam Gerstenecker
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Meredith Gammon
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Matthew Mason
- Alabama College of Osteopathic Medicine, Dothan, Alabama, USA.,Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gabrielle Willhelm
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, Birmingham, Alabama, USA.,School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Helen Bae
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, Birmingham, Alabama, USA.,School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kristen Triebel
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, Birmingham, Alabama, USA.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Schimmel WCM, Gehring K, Hanssens PEJ, Sitskoorn MM. Cognitive functioning and predictors thereof in patients with 1-10 brain metastases selected for stereotactic radiosurgery. J Neurooncol 2019; 145:265-276. [PMID: 31552588 PMCID: PMC6856035 DOI: 10.1007/s11060-019-03292-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 09/16/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE Information on predictive factors of cognitive functioning in patients with (multiple) brain metastases (BM) selected for radiosurgery may allow for more individual care and may play a role in predicting cognitive outcome after radiosurgery. The aim of this study was to evaluate cognitive performance, and predictors thereof, in patients with 1-10 BM before radiosurgery. METHODS Cognition was measured before radiosurgery using a standardized neuropsychological test battery in patients with 1-10 BM (expected survival > 3 months; KPS ≥ 70; no prior BM treatment). Regression formulae were constructed to calculate sociodemographically corrected z scores. Group and individual cognitive functioning was analyzed. Multivariable regression was used to explore potential predictors. RESULTS Patients (N = 92) performed significantly worse than controls (N = 104) on all 11 test variables (medium-large effect sizes for 8 variables). Percentages of impairment were highest for information processing (55.3%), dexterity (43.2%) and cognitive flexibility (28.7%). 62% and 46% of patients had impairments in at least two, or three test variables, respectively. Models including combinations of clinical and psychological variables were predictive of verbal memory, psychomotor speed, information processing and dexterity. Neither number nor volume of metastases predicted patients' test performance. CONCLUSIONS Already before radiosurgery, almost half of the patients suffered from severe cognitive deficits in at least three test variables. At group and individual level, information processing, cognitive flexibility, and dexterity were most affected. These cognitive impairments may impair daily functioning and patients' ability to make (shared) treatment decisions. Both clinical (symptomatic BM; timing of BM diagnosis) and psychological (mental fatigue) characteristics influenced cognitive performance. CLINICAL TRIAL INFORMATION Cognition and Radiation Study A (CAR-Study A; ClinicalTrials.gov Identifier: NCT02953756; Medical Ethics Committee file number: NL53472.028.15/P1515).
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Affiliation(s)
- Wietske C M Schimmel
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands. .,Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands. .,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands. .,Department of Cognitive Neuropsychology, Tilburg University, Simon Building; Room S221, P.O. Box 90153, 5000 LE, Tilburg, The Netherlands.
| | - Karin Gehring
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
| | - Patrick E J Hanssens
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.,Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Margriet M Sitskoorn
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
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Multidimensional assessment of fatigue in patients with brain metastases before and after Gamma Knife radiosurgery. J Neurooncol 2019; 144:377-384. [PMID: 31350667 PMCID: PMC6700236 DOI: 10.1007/s11060-019-03240-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/13/2019] [Indexed: 01/09/2023]
Abstract
PURPOSE Fatigue is a common and distressing symptom in cancer patients which negatively affects patients' daily functioning and health-related quality of life. The aim of this study was to assess multidimensional fatigue in patients with brain metastases (BM) before, and after Gamma Knife radiosurgery (GKRS). METHODS Patients with BM, an expected survival > 3 months, and a Karnofsky Performance Status ≥ 70 and 104 Dutch non-cancer controls were recruited. The Multidimensional Fatigue Inventory (MFI), measuring general fatigue, physical fatigue, mental fatigue, reduced activity and reduced motivation, was used. Baseline levels of fatigue between patients and controls were compared using independent-samples t-tests. The course of fatigue over time, and clinical and psychological predictors thereof, were analyzed using linear mixed models (within-group analyses). RESULTS Ninety-two, 67 and 53 patients completed the MFI at baseline, and 3 and 6 months after GKRS. Before GKRS, patients with BM experienced significantly higher levels of fatigue on all subscales compared to controls (medium to large effect sizes). Over 6 months, general and physical fatigue increased significantly (p = .009 and p < .001), and levels of mental fatigue decreased significantly (p = .027). No significant predictors of the course of fatigue over time could be identified. CONCLUSIONS Fatigue is a major problem for patients with BM. Different patterns over time were observed for the various aspects of fatigue in patients with BM. Information on the various aspects of fatigue is important because fatigue may negatively affect patients' functional independence, health-related quality of life, and adherence to therapy.
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