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Douri K, Iorio-Morin C, Mercure-Cyr R, Figueiredo G, Touchette CJ, Masson-Côté L, Mathieu D. Response Assessment in Brain Metastases Managed by Stereotactic Radiosurgery: A Reappraisal of the RANO-BM Criteria. Curr Oncol 2023; 30:9382-9391. [PMID: 37999099 PMCID: PMC10670467 DOI: 10.3390/curroncol30110679] [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: 07/23/2023] [Revised: 10/21/2023] [Accepted: 10/23/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Brain metastases (BM) are increasingly being treated using stereotactic radiosurgery (SRS). Standardized response criteria are necessary to improve research and treatment protocols. This study's goal was to validate the RANO-BM criteria thresholds for tumor progression in a cohort of patients with brain metastases managed using SRS. METHODS We performed a retrospective analysis of patients treated at least twice with SRS for brain metastases. Local progression, as defined by RANO-BM criteria, was compared to our multidisciplinary tumor board's treatment recommendation. A ROC curve was generated using varying diameter thresholds to assess the sensitivity and specificity of current RANO-BM criteria. RESULTS 249 metastases in 67 patients were included in the analysis. RANO-BM criteria current progression thresholds yielded a sensitivity of 38%, a specificity of 95%, a positive predictive value of 71%, and a negative predictive value of 84% relative to our tumor board's treatment recommendation. Modified RANO-BM criteria using absolute diameter differences of 2.5 mm yielded a sensitivity of 83%, a specificity of 87%, a positive predictive value of 67% and a negative predictive value of 94%. CONCLUSIONS Current RANO-BM criteria unreliably identifies clinically relevant tumor progression. The use of absolute diameter differences thresholds appears superior in our BM cohort.
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Affiliation(s)
- Keiss Douri
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC J1H 5H3, Canada; (K.D.); (C.I.-M.); (C.J.T.)
| | - Christian Iorio-Morin
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC J1H 5H3, Canada; (K.D.); (C.I.-M.); (C.J.T.)
| | - Rosalie Mercure-Cyr
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC J1H 5H3, Canada; (K.D.); (C.I.-M.); (C.J.T.)
| | - Gabrielle Figueiredo
- Department of Radiology, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC J1H 5H3, Canada;
| | - Charles Jean Touchette
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC J1H 5H3, Canada; (K.D.); (C.I.-M.); (C.J.T.)
| | - Laurence Masson-Côté
- Division of Radiation Oncology, Department of Medicine, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC J1H 5H3, Canada;
| | - David Mathieu
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC J1H 5H3, Canada; (K.D.); (C.I.-M.); (C.J.T.)
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Kumar R, Qi T, Cao Y, Topp B. Incorporating lesion-to-lesion heterogeneity into early oncology decision making. Front Immunol 2023; 14:1173546. [PMID: 37350966 PMCID: PMC10282604 DOI: 10.3389/fimmu.2023.1173546] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/23/2023] [Indexed: 06/24/2023] Open
Abstract
RECISTv1.1 (Response Evaluation Criteria In Solid Tumors) is the most commonly used response grading criteria in early oncology trials. In this perspective, we argue that RECISTv1.1 is ambiguous regarding lesion-to-lesion variation that can introduce bias in decision making. We show theoretical examples of how lesion-to-lesion variability causes bias in RECISTv1.1, leading to misclassification of patient response. Next, we review immune checkpoint inhibitor (ICI) clinical trial data and find that lesion-to-lesion heterogeneity is widespread in ICI-treated patients. We illustrate the implications of ignoring lesion-to-lesion heterogeneity in interpreting biomarker data, selecting treatments for patients with progressive disease, and go/no-go decisions in drug development. Further, we propose that Quantitative Systems Pharmacology (QSP) models can aid in developing better metrics of patient response and treatment efficacy by capturing patient responses robustly by considering lesion-to-lesion heterogeneity. Overall, we believe patient response evaluation with an appreciation of lesion-to-lesion heterogeneity can potentially improve decision-making at the early stage of oncology drug development and benefit patient care.
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Affiliation(s)
| | - Timothy Qi
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Yanguang Cao
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Brian Topp
- Quantitative Pharmacology & Pharmacometrics, Immuno-oncology, Merck & Co., Inc., Rahway, NJ, United States
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3
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Dosimetric and clinical analysis of pseudo-progression versus recurrence after hypo-fractionated radiotherapy for brain metastases. Radiat Oncol 2023; 18:30. [PMID: 36788610 PMCID: PMC9930329 DOI: 10.1186/s13014-023-02214-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 01/28/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND The main challenge in follow-up duration of patients with brain metastases after stereotactic radiotherapy is to distinguish between pseudo-progression and tumor recurrence. The objective of this study is to retrospectively analyze the predictive factors. METHODS The study included 123 patients with enlarged brain metastases after hypo-fractionated radiotherapy in our center from March 2009 to October 2019, and the baseline clinical features, radiotherapy planning parameters, and enhanced magnetic resonance imaging before and after radiation therapy were analyzed. Logistic regression was performed to compare the differences between groups. Independent risk factors with P < 0.05 and associated with recurrence were used to establish a nomogram prediction model and validated by Bootstrap repeated sampling, which was validated in an internal cohort (n = 23) from October 2019 to December 2021. RESULTS The median follow-up time was 68.4 months (range, 8.9-146.2 months). A total of 76 (61.8%) patients were evaluated as pseudo-progression, 47 patients (38.2%) were evaluated as tumor recurrence. The median time to pseudo-progression and tumor recurrence were 18.3 months (quartile range, 9.4-27.8 months) and 12.9 months (quartile range, 8.7-19.6 months) respectively. Variables associated with tumor recurrence included: gross tumor volume ≥ 6 cc, biological effective dose < 60 Gy, target coverage < 96% and no targeted therapy. The area under curve values were 0.730 and 0.967 in the training and validation cohorts, respectively. Thirty-one patients received salvage therapy in the tumor recurrence group. The survival time in pseudo-progression and tumor recurrence groups were 66.3 months (95% CI 56.8-75.9 months) and 39.6 months (95% CI 29.2-50.0 months, respectively; P = 0.001). CONCLUSIONS Clinical and dosimetry features of hypo-fractionated radiation therapy based on enhanced brain magnetic resonance can help distinguish pseudo-progression from tumor recurrence after hypo-fractionated radiotherapy for brain metastases. Gross tumor volume, biological effective dose, target coverage, and having received targeted therapy or not were factors associated with the occurrence of tumor recurrence, and the individual risk could be estimated by the nomogram effectively.
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Koch A, Sponholz S, Trainer S, Stratmann J, Sebastian M, Rauch M, Wolff R, Steinbach JP, Ronellenfitsch MW, Urban H. Pulmonary Resection after Radiosurgery and Neoadjuvant Immunochemotherapy for NSCLC Patients with Synchronous Brain Metastasis—A Case Series of Three Patients. Curr Oncol 2022; 29:2225-2239. [PMID: 35448155 PMCID: PMC9030832 DOI: 10.3390/curroncol29040181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/28/2022] [Accepted: 03/17/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary In this short communication, we present three cases of patients with symptomatic, synchronous brain metastases of otherwise locally limited non-small cell lung cancer. The patients received local ablative treatment of the brain metastases followed by neoadjuvant immunochemotherapy with pemetrexed, cisplatin, and pembrolizumab, and resection of the pulmonary lesion with curative intent. With two of the patients still alive and maintaining a good quality of life with a progression-free survival and overall survival of 28 and 35 months, respectively, this case series illustrates the potential of novel combinatorial treatment approaches. Abstract Brain metastases are a common finding upon initial diagnosis of otherwise locally limited non-small cell lung cancer. We present a retrospective case series describing three cases of patients with symptomatic, synchronous brain metastases and resectable lung tumors. The patients received local ablative treatment of the brain metastases followed by neoadjuvant immunochemotherapy with pemetrexed, cisplatin, and pembrolizumab. Afterwards, resection of the pulmonary lesion with curative intent was performed. One patient showed progressive disease 12 months after initial diagnosis, and passed away 31 months after initial diagnosis. Two of the patients are still alive and maintain a good quality of life with a progression-free survival and overall survival of 28 and 35 months, respectively, illustrating the potential of novel combinatorial treatment approaches.
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Affiliation(s)
- Agnes Koch
- Department of Thoracic Surgery, Agaplesion Markuskrankenhaus, 60431 Frankfurt am Main, Germany; (S.S.); (S.T.)
- Correspondence: (A.K.); (H.U.)
| | - Stefan Sponholz
- Department of Thoracic Surgery, Agaplesion Markuskrankenhaus, 60431 Frankfurt am Main, Germany; (S.S.); (S.T.)
| | - Stephan Trainer
- Department of Thoracic Surgery, Agaplesion Markuskrankenhaus, 60431 Frankfurt am Main, Germany; (S.S.); (S.T.)
| | - Jan Stratmann
- Hematology/Oncology, Department of Medicine, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany; (J.S.); (M.S.)
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany; (M.R.); (J.P.S.); (M.W.R.)
- Frankfurt Cancer Institute (FCI), 60590 Frankfurt am Main, Germany
| | - Martin Sebastian
- Hematology/Oncology, Department of Medicine, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany; (J.S.); (M.S.)
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany; (M.R.); (J.P.S.); (M.W.R.)
- Frankfurt Cancer Institute (FCI), 60590 Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), Partner Site Frankfurt am Main, German Cancer Research Center (DKFZ), Stiftung des Öffentlichen Rechts, 69120 Heidelberg, Germany
| | - Maximilian Rauch
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany; (M.R.); (J.P.S.); (M.W.R.)
- Frankfurt Cancer Institute (FCI), 60590 Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), Partner Site Frankfurt am Main, German Cancer Research Center (DKFZ), Stiftung des Öffentlichen Rechts, 69120 Heidelberg, Germany
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt am Main, Germany
| | - Robert Wolff
- Saphir Radiosurgery Center, 60528 Frankfurt am Main, Germany;
| | - Joachim P. Steinbach
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany; (M.R.); (J.P.S.); (M.W.R.)
- Frankfurt Cancer Institute (FCI), 60590 Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), Partner Site Frankfurt am Main, German Cancer Research Center (DKFZ), Stiftung des Öffentlichen Rechts, 69120 Heidelberg, Germany
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt am Main, Germany
| | - Michael W. Ronellenfitsch
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany; (M.R.); (J.P.S.); (M.W.R.)
- Frankfurt Cancer Institute (FCI), 60590 Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), Partner Site Frankfurt am Main, German Cancer Research Center (DKFZ), Stiftung des Öffentlichen Rechts, 69120 Heidelberg, Germany
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt am Main, Germany
| | - Hans Urban
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany; (M.R.); (J.P.S.); (M.W.R.)
- German Cancer Consortium (DKTK), Partner Site Frankfurt am Main, German Cancer Research Center (DKFZ), Stiftung des Öffentlichen Rechts, 69120 Heidelberg, Germany
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt am Main, Germany
- Correspondence: (A.K.); (H.U.)
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Sadanandan N, Shear A, Brooks B, Saft M, Cabantan DAG, Kingsbury C, Zhang H, Anthony S, Wang ZJ, Salazar FE, Lezama Toledo AR, Rivera Monroy G, Vega Gonzales-Portillo J, Moscatello A, Lee JY, Borlongan CV. Treating Metastatic Brain Cancers With Stem Cells. Front Mol Neurosci 2021; 14:749716. [PMID: 34899179 PMCID: PMC8651876 DOI: 10.3389/fnmol.2021.749716] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/20/2021] [Indexed: 12/12/2022] Open
Abstract
Stem cell therapy may present an effective treatment for metastatic brain cancer and glioblastoma. Here we posit the critical role of a leaky blood-brain barrier (BBB) as a key element for the development of brain metastases, specifically melanoma. By reviewing the immunological and inflammatory responses associated with BBB damage secondary to tumoral activity, we identify the involvement of this pathological process in the growth and formation of metastatic brain cancers. Likewise, we evaluate the hypothesis of regenerating impaired endothelial cells of the BBB and alleviating the damaged neurovascular unit to attenuate brain metastasis, using the endothelial progenitor cell (EPC) phenotype of bone marrow-derived mesenchymal stem cells. Specifically, there is a need to evaluate the efficacy for stem cell therapy to repair disruptions in the BBB and reduce inflammation in the brain, thereby causing attenuation of metastatic brain cancers. To establish the viability of stem cell therapy for the prevention and treatment of metastatic brain tumors, it is crucial to demonstrate BBB repair through augmentation of vasculogenesis and angiogenesis. BBB disruption is strongly linked to metastatic melanoma, worsens neuroinflammation during metastasis, and negatively influences the prognosis of metastatic brain cancer. Using stem cell therapy to interrupt inflammation secondary to this leaky BBB represents a paradigm-shifting approach for brain cancer treatment. In this review article, we critically assess the advantages and disadvantages of using stem cell therapy for brain metastases and glioblastoma.
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Affiliation(s)
| | - Alex Shear
- University of Florida, Gainesville, FL, United States
| | - Beverly Brooks
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, United States
| | - Madeline Saft
- University of Michigan, Ann Arbor, MI, United States
| | | | - Chase Kingsbury
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, United States
| | - Henry Zhang
- University of Florida, Gainesville, FL, United States
| | - Stefan Anthony
- Lake Erie College of Osteopathic Medicine, Bradenton, FL, United States
| | - Zhen-Jie Wang
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, United States
| | - Felipe Esparza Salazar
- Centro de Investigación en Ciencias de la Salud (CICSA), Facultad de Ciencias de la Salud (FCS), Universidad Anáhuac México Campus Norte, Huixquilucan, Mexico
| | - Alma R Lezama Toledo
- Centro de Investigación en Ciencias de la Salud (CICSA), Facultad de Ciencias de la Salud (FCS), Universidad Anáhuac México Campus Norte, Huixquilucan, Mexico
| | - Germán Rivera Monroy
- Centro de Investigación en Ciencias de la Salud (CICSA), Facultad de Ciencias de la Salud (FCS), Universidad Anáhuac México Campus Norte, Huixquilucan, Mexico
| | | | - Alexa Moscatello
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, United States
| | - Jea-Young Lee
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, United States
| | - Cesario V Borlongan
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, United States.,Center of Excellence for Aging and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, United States
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Chen ZY, Huang JQ, Zhu Y, Chen YS, Yu XF. Comprehensive Analysis of the Immune Implication of TEX41 in Skin Cutaneous Melanoma. DISEASE MARKERS 2021; 2021:2409820. [PMID: 34795805 PMCID: PMC8595038 DOI: 10.1155/2021/2409820] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 09/27/2021] [Accepted: 10/01/2021] [Indexed: 02/03/2023]
Abstract
Enhancer RNAs (eRNAs), a subclass of noncoding RNAs from enhancers, have been demonstrated to exhibit important regulatory effects on the expressions of various genes. However, the role of eRNAs in skin cutaneous melanoma (SKCM) remained largely unclear. In this study, we aimed to explore the expression and prognostic value of an enhancer RNA TEX41 in SKCM as well as the associations between TEX41 and tumor-infiltrating immune cells (TICs). We observed that TEX41 expression was distinctly increased in SKCM specimens compared with normal skin specimens using GEPIA. Survival assays based on TGCA datasets revealed that patients with low TEX41 expressions displayed a longer overall survival than those with high TEX41 expression. CIBERSORT datasets revealed that TEX41 was related to 8 types of TICs (macrophages M1, T cells regulatory, plasma cells, mast cells resting, T cells CD8, dendritic cells resting, and T cells follicular helper). Three kinds of TICs were negatively related to TEX41 expressions, including macrophages M2, NK cells resting, and macrophages M0. The expressions of TEX41 were involved in five KEGG pathways, including transcriptional misregulation in cancer, SNARE interactions in vesicular transport, mitophagy-animal, melanoma, melanogenesis, and progesterone-mediated oocyte maturation. Overall, TEX41 can be used as a novel biomarker for the prognosis of SKCM patients and is associated with TICs, indicating it as a therapeutic target for SKCM.
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Affiliation(s)
- Zhi-yong Chen
- Department of Burns and Plastic, The Fuling Center Hospital of Chongqing City, Fuling, Chongqing, China
| | - Jie-qing Huang
- Department of Burns and Plastic, The Fuling Center Hospital of Chongqing City, Fuling, Chongqing, China
| | - Yu Zhu
- Department of Burns and Plastic, The Fuling Center Hospital of Chongqing City, Fuling, Chongqing, China
| | - Yong-song Chen
- Department of Burns and Plastic, The Fuling Center Hospital of Chongqing City, Fuling, Chongqing, China
| | - Xue-feng Yu
- Department of Burns and Plastic, The Fuling Center Hospital of Chongqing City, Fuling, Chongqing, China
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Volumetric Response of Limited Brain Metastatic Disease to Focal Hypofractionated Radiation Therapy. Brain Sci 2021; 11:brainsci11111457. [PMID: 34827456 PMCID: PMC8615909 DOI: 10.3390/brainsci11111457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 11/25/2022] Open
Abstract
Background: This is a retrospective study aimed at assessing the volumetric response, morbidity and failure rates of hypofractionated radiation therapy (HFRT) for definitive focal management of limited brain metastasis. Methods: Patients managed with HFRT for unresected limited metastatic (≤10 lesions) brain disease were entered into an ethics-approved database. Included patients had been deemed unsuitable for surgical resection, and lesions managed with prior radiation therapy were excluded. HFRT was delivered using IMRT or VMAT with 25 Gy or 30 Gy in five fractions. Individual lesions had volumetric assessment performed at three timepoints. The primary endpoint was the change of volume from baseline (GTV0) to one month post-HFRT (GTV1) and to seven months post-HFRT (GTV7). Secondary endpoints were local failure, survival and rates of radiation necrosis. Results: One hundred and twenty-four patients with 233 lesions were managed with HFRT. Median follow-up was 23.5 months with 32 (25.8%) patients alive at censure. Median overall survival was 7.3 months with 36.3% survival at 12 months. Superior survival was predicted by smaller GTV0 (p = 0.003) and increased percentage of volumetric response (p < 0.001). Systemic therapy was delivered to 81.5% of patients. At one month post-HFRT, 206 metastases (88.4%) were available for assessment and at seven months post-HFRT, 118 metastases (50.6%) were available. Median metastasis volume at GTV0 was 1.6 cm3 (range: 0.1–19.1). At GTV1 and GTV7, this reduced to 0.7 cm3 (p < 0.001) and 0.3 cm3 (p < 0.001), respectively, correlating to percentage reductions of 54.9% and 83.3%. No significant predictors of volumetric response following HFRT were identified. Local failure was identified in 4.3% of lesions and radiation necrosis in 3.9%. Conclusion: HFRT is an effective therapy for limited metastatic disease in the brain to maximise initial volumetric response whilst minimising toxicity.
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Abstract
Traditionally, treatment responses to chemotherapy had been based on Response Evaluation Criteria in Solid Tumours (RECIST) criteria evaluating tumor shrinkage, stabilization of disease, growth, or development of new metastatic lesions. Using the same criteria to determine response in patients on immunotherapy has proven difficult, as some patients have initial growth of disease or develop new small metastatic lesions. The phenomenon of pseudoprogression is the initial growth of a primary lesion followed by latent or delayed response. Advanced practitioners need to be aware of the possibility of pseudoprogression in order to educate patients and help them stay on effective treatment.
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Affiliation(s)
| | - Donna Lee Gerber
- The University of Texas MD Anderson Cancer Center, Houston, Texas
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9
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Castello A, Lopci E. The Role of PET/CT in the Era of Immune Checkpoint Inhibitors: State of Art. Curr Radiopharm 2020; 13:24-31. [PMID: 31749440 DOI: 10.2174/1874471012666191015100106] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/09/2019] [Accepted: 07/17/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) have achieved astonishing results and improved overall survival (OS) in several types of malignancies, including advanced melanoma. However, due to a peculiar type of anti-cancer activity provided by these drugs, the response patterns during ICI treatment are completely different from that with "old" chemotherapeutic agents. OBJECTIVE To provide an overview of the available literature and potentials of 18F-FDG PET/CT in advanced melanoma during the course of therapy with ICI in the context of treatment response evaluation. METHOD Morphologic criteria, expressed by Response Evaluation Criteria in Solid Tumors (RECIST), immune-related response criteria (irRC), irRECIST, and, more recently, immune-RECIST (iRECIST), along with response criteria based on the metabolic parameters with 18F-Fluorodeoxyglucose (18FFDG), have been explored. RESULTS To overcome the limits of traditional response criteria, new metabolic response criteria have been introduced on time and are being continuously updated, such as the PET/CT Criteria for the early prediction of Response to Immune checkpoint inhibitor Therapy (PECRIT), the PET Response Evaluation Criteria for Immunotherapy (PERCIMT), and "immunotherapy-modified" PET Response Criteria in Solid Tumors (imPERCIST). The introduction of new PET radiotracers, based on monoclonal antibodies combined with radioactive elements ("immune-PET"), are of great interest. CONCLUSION Although the role of 18F-FDG PET/CT in malignant melanoma has been widely validated for detecting distant metastases and recurrences, evidences in course of ICI are still scarce and larger multicenter clinical trials are needed.
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Affiliation(s)
- Angelo Castello
- Nuclear Medicine, Humanitas Clinical and Research Hospital, Rozzano, Italy
| | - Egesta Lopci
- Nuclear Medicine, Humanitas Clinical and Research Hospital, Rozzano, Italy
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10
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Aquilanti E, Brastianos PK. Immune Checkpoint Inhibitors for Brain Metastases: A Primer for Neurosurgeons. Neurosurgery 2020; 87:E281-E288. [PMID: 32302389 PMCID: PMC7426188 DOI: 10.1093/neuros/nyaa095] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 01/30/2020] [Indexed: 12/26/2022] Open
Abstract
Immune checkpoint inhibitors enhance immune recognition of tumors by interfering with the cytotoxic T-lymphocyte-associated antigen 4 (CTLA4) and programmed death 1 (PD1) pathways. In the past decade, these agents brought significant improvements to the prognostic outlook of patients with metastatic cancers. Recent data from retrospective analyses and a few prospective studies suggest that checkpoint inhibitors have activity against brain metastases from melanoma and nonsmall cell lung cancer, as single agents or in combination with radiotherapy. Some studies reported intracranial response rates that were comparable with systemic ones. In this review, we provide a comprehensive summary of clinical data supporting the use of anti-CTLA4 and anti-PD1 agents in brain metastases. We also touch upon specific considerations on the assessment of intracranial responses in patients and immunotherapy-specific toxicities. We conclude that a subset of patients with brain metastases benefit from the addition of checkpoint inhibitors to standard of care therapeutic modalities, including radiotherapy and surgery.
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Affiliation(s)
- Elisa Aquilanti
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Neuro-Oncology, Department of Neurology, Stephen E. Catherine Pappas Center for Neuro Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Cancer Program, Broad Institute, Boston, Massachusetts
| | - Priscilla K Brastianos
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Neuro-Oncology, Department of Neurology, Stephen E. Catherine Pappas Center for Neuro Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Cancer Program, Broad Institute, Boston, Massachusetts
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11
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Skeie BS, Enger PØ, Knisely J, Pedersen PH, Heggdal JI, Eide GE, Skeie GO. A simple score to estimate the likelihood of pseudoprogression vs. recurrence following stereotactic radiosurgery for brain metastases: The Bergen Criteria. Neurooncol Adv 2020; 2:vdaa026. [PMID: 32642686 PMCID: PMC7212847 DOI: 10.1093/noajnl/vdaa026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background A major challenge in the follow-up of patients treated with stereotactic radiosurgery (SRS) for brain metastases (BM) is to distinguish pseudoprogression (PP) from tumor recurrence (TR). The aim of the study was to develop a clinical risk assessment score. Methods Follow-up images of 87 of 97 consecutive patients treated with SRS for 348 BM were analyzed. Of these, 100 (28.7%) BM in 48 (53.9%) patients responded with either TR (n = 53, 15%) or PP (n = 47, 14%). Differences between the 2 groups were analyzed and used to develop a risk assessment score (the Bergen Criteria). Results Factors associated with a higher incidence of PP vs. TR were as follows: prior radiation with whole brain radiotherapy or SRS (P = .001), target cover ratio ≥98% (P = .048), BM volume ≤2 cm3 (P = .054), and primary lung cancer vs. other cancer types (P = .084). Based on the presence (0) or absence (1) of these 5 characteristics, the Bergen Criteria was established. A total score <2 points was associated with 100% PP, 2 points with 57% PP and 43% TR, 3 points with 57% TR and 43% PP, whereas >3 points were associated with 84% TR and 16% PP, P < .001. Conclusion Based on 5 characteristics at the time of SRS the Bergen Criteria could robustly differentiate between PP vs. TR following SRS. The score is user-friendly and provides a useful tool to guide the decision making whether to retreat or observe at appropriate follow-up intervals.
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Affiliation(s)
| | - Per Øyvind Enger
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
| | - Jonathan Knisely
- Department of Radiation Oncology, Weill Cornell Medical College, New York, NY, USA
| | | | - Jan Ingeman Heggdal
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Geir Egil Eide
- Department of Global Public Health and Primary Care, University of Bergen, Norway.,Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - Geir Olve Skeie
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Systemic Therapies for Melanoma Brain Metastases: A Primer for Radiologists. J Comput Assist Tomogr 2020; 44:346-355. [PMID: 32217896 DOI: 10.1097/rct.0000000000001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this article is to provide a primer for radiologists outlining the modern systemic therapies used in melanoma brain metastases, including tyrosine kinase inhibitors and immune checkpoint inhibitors. The role of radiologic treatment response evaluation will be discussed from the standpoint of both modern systemic therapies and more traditional treatments. CONCLUSION Understanding the role of systemic treatments in melanoma brain metastases is critical for oncologic imaging interpretation in this unique patient population.
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Armocida D, Marzetti F, Pesce A, Caporlingua A, D'Angelo L, Santoro A. Purely Meningeal Intracranial Relapse of Melanoma Brain Metastases After Surgical Resection and Immunotherapy as a Unique Disease Progression Pattern: Our Experience and Review of the Literature. World Neurosurg 2020; 134:150-154. [PMID: 31751613 DOI: 10.1016/j.wneu.2019.10.101] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 10/15/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND We present a case of 72-year-old man with a history of metastatic melanoma diagnosed in 2015 presenting a stable disease in treatment with dabrafenib. CASE DESCRIPTION The patient had been surgically treated for a presumed intracranial parietooccipital metastasis. He presented 1 month later with a meningeal lesion associated with a subdural hematoma. A second surgical treatment confirmed the diagnosis of meningeal recurrence of metastatic melanoma. CONCLUSIONS The most recent literature lacks studies defining the clinical phenomena of an early recurrence of intracranial melanoma with de novo involvement of dural compartment in patients in treatment with a target immunotherapy. The aim of this present study is to report a case of early recurrence of intracranial melanoma metastases with evidence of fast immunohistochemical and macroscopical mutation of pathologic elements, with an analysis of literature that shows the lack of well-described occurrences.
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Affiliation(s)
- Daniele Armocida
- Azienda Ospedaliero-Universitaria "Policlinico Umberto I", Neurosurgery Division, Human Neurosciences Department, Sapienza University, Rome, Italy.
| | - Francesco Marzetti
- Azienda Ospedaliero-Universitaria "Policlinico Umberto I", Neurosurgery Division, Human Neurosciences Department, Sapienza University, Rome, Italy
| | - Alessandro Pesce
- A. O. "Sant'Andrea"-Neurosurgery Division, Sapienza University, Rome NESMOS Department, Rome, Italy
| | - Alessandro Caporlingua
- Azienda Ospedaliero-Universitaria "Policlinico Umberto I", Neurosurgery Division, Human Neurosciences Department, Sapienza University, Rome, Italy
| | - Luca D'Angelo
- Azienda Ospedaliero-Universitaria "Policlinico Umberto I", Neurosurgery Division, Human Neurosciences Department, Sapienza University, Rome, Italy
| | - Antonio Santoro
- Azienda Ospedaliero-Universitaria "Policlinico Umberto I", Neurosurgery Division, Human Neurosciences Department, Sapienza University, Rome, Italy
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