Whole brain radiation therapy followed by intensity-modulated boosting treatment combined with concomitant temozolomide for brain metastases from non-small-cell lung cancer

Treatments for brain metastases from EGFR/ALK-negative/unselected NSCLC: A network meta-analysis

More clinical evidence is needed regarding the relative priority of treatments for brain metastases (BMs) from EGFR/ALK-negative/unselected non-small cell lung cancer (NSCLC). PubMed, EMBASE, Web of Science, Cochrane Library, and ClinicalTrials.gov databases were searched. Overall survival (OS), central nervous system progression-free survival (CNS-PFS), and objective response rate (ORR) were selected for Bayesian network meta-analyses. We included 25 eligible randomized control trials (RCTs) involving 3,054 patients, investigating nine kinds of treatments for newly diagnosed BMs and seven kinds of treatments for previously treated BMs. For newly diagnosed BMs, adding chemotherapy, EGFR-TKIs, and other innovative systemic agents (temozolomide, nitroglycerin, endostar, enzastaurin, and veliparib) to radiotherapy did not significantly prolong OS than radiotherapy alone; whereas radiotherapy + nitroglycerin showed significantly better CNS-PFS and ORR. Surgery could significantly prolong OS (hazard ratios [HR]: 0.52, 95% credible intervals: 0.41-0.67) and CNS-PFS (HR: 0.32, 95% confidence interval: 0.18-0.59) compared with radiotherapy alone. For previously treated BMs, pembrolizumab + chemotherapy, nivolumab + ipilimumab, and cemiplimab significantly prolonged OS than chemotherapy alone. Pembrolizumab + chemotherapy also showed better CNS-PFS and ORR than chemotherapy. In summary, immune checkpoint inhibitor (ICI)-based therapies, especially ICI-combined therapies, showed promising efficacies for previously treated BMs from EGFR/ALK-negative/unselected NSCLC. The value of surgery should also be emphasized. The result should be further confirmed by RCTs.

Intensity-modulated radiation therapy combined with concomitant temozolomide for brain metastases from lung adenocarcinoma

Short-term efficacy, adverse effects and the impact on quality of life (QoL) of a concomitant treatment with intensity-modulated radiation therapy (IMRT) and temozolomide (TMZ) in patients with brain metastases (BMs) from lung adenocarcinoma were evaluated. This study sought to confirm the benefit of adding TMZ to IMRT in patients with BMs from lung adenocarcinoma. Nine patients were enrolled and received a dose of 30 Gy in 10 daily fractions to clinical tumor volume (CTV) according to IMRT, then additional dose of 9 Gy in 3 fractions of IMRT was delivered to gross tumor volume (GTV) only with concomitant TMZ (75 mg/m²/day) orally during RT for 3 weeks. One patient achieved complete response (CR) (11.1%), 6 patients obtained partial response (PR) (66.7%), and there were no patients in progression. Therefore, objective response (OR) reached 77.8%. The main adverse effects included neutropenia, anemia, vomiting, fatigue and dizziness. Grade ≥3 of hematologic toxicities did not occur. However, the other 9 patients who received only intensity-modulated radiation had much worse results. The CR was 0, PR rate was 44.4%, OR rate was 44.4%. The results indicated that the benefit of adding TMZ to IMRT was confirmed in patients with BMs from lung adenocarcinoma. The treatment was active, a significant OR was observed, and achieved an improvement in QoL demonstrated by QoL grade (p<0.05).

Effectiveness of temozolomide combined with whole brain radiotherapy for non-small cell lung cancer brain metastases

BACKGROUND

We performed a retrospective analysis to compare the efficacy of whole brain radiotherapy (WBRT) combined with temozolomide (TMZ) versus WBRT alone as first-line treatment for brain metastases (BM).

METHODS

Seventy-eight non-small cell lung cancer patients with BM were observed, including 45 patients who received WBRT plus TMZ (TMZ + WBRT) and 33 patients who received WBRT alone (WBRT). The primary outcome was overall survival (OS). Secondary outcomes included progression-free survival (PFS), objective response rate (ORR), and adverse events.

RESULTS

The TMZ + WBRT arm achieved significant improvement in ORR (P = 0.0108) compared to the WBRT arm. PFS in the TMZ + WBRT arm was significantly longer than in the RT arm (6.0 vs. 3.5 months; P = 0.038). OS was not significantly different between the two arms. Although increased adverse reactions were experienced in the TMZ + WBRT arm, patients were tolerant of the side effects. Statistically significant differences in neurocognitive function and quality of life were observed between the arms at six months.

CONCLUSION

Concomitant TMZ + WBRT compared to WBRT alone significantly increases ORR and median PFS in patients with BM, but no remarkable difference in median OS was found. Adding TMZ to the treatment strategy could prevent neurocognitive function and quality of life from deteriorating. Although the addition of TMZ increases the incidence of adverse effects, no significant difference was observed. Thus, TMZ is safe and effective.

Astrocytes promote progression of breast cancer metastases to the brain via a KISS1-mediated autophagy

Formation of metastases, also known as cancer dissemination, is an important stage of breast cancer (BrCa) development. KISS1 expression is associated with inhibition of metastases development. Recently we have demonstrated that BrCa metastases to the brain exhibit low levels of KISS1 expression at both mRNA and protein levels. By using multicolor immunofluorescence and coculture techniques here we show that normal adult astrocytes in the brain are capable of promoting metastatic transformation of circulating breast cancer cells localized to the brain through secretion of chemokine CXCL12. The latter was found in this study to downregulate KISS1 expression at the post-transcriptional level via induction of microRNA-345 (MIR345). Furthermore, we demonstrated that ectopic expression of KISS1 downregulates ATG5 and ATG7, 2 key modulators of autophagy, and works concurrently with autophagy inhibitors, thereby implicating autophagy in the mechanism of KISS1-mediated BrCa metastatic transformation. We also found that expression of KISS1 in human breast tumor specimens inversely correlates with that of MMP9 and IL8, implicated in the mechanism of metastatic invasion, thereby supporting the role of KISS1 as a potential regulator of BrCa metastatic invasion in the brain. This conclusion is further supported by the ability of KISS1, ectopically overexpressed from an adenoviral vector in MDA-MB-231Br cells with silenced expression of the endogenous gene, to revert invasive phenotype of those cells. Taken together, our results strongly suggest that human adult astrocytes can promote brain invasion of the brain-localized circulating breast cancer cells by upregulating autophagy signaling pathways via the CXCL12-MIR345- KISS1 axis.

The efficacy and roles of combining temozolomide with whole brain radiotherapy in protection neurocognitive function and improvement quality of life of non-small-cell lung cancer patients with brain metastases

Background

Brain metastasis (BM) is a poor prognostic factor for non-small-cell lung cancer (NSCLC). The efficacy and roles of combining temozolomide (TMZ) with whole brain radiotherapy (WBRT) in protection neurocognitive function (NCF) and improvement quality of life (QOL) were investigated and compared with WBRT alone in the treatment of NSCLC patients with BM.

Methods

A total of 238 NSCLC patients with BM were reviewed and categorized into WBRT plus TMZ (RCT) arm and WBRT alone (RT), respectively. The efficacy was evaluated with Pearson chi-square or Fisher’s exact tests, Log-rank test and Cox proportional hazards model. NCF was assessed by using revised Hopkins Verbal Learning Test (HVLT-R), Controlled Oral Word Association (COWA) test and Trail-making Test (TMT). QOL was assessed by the Functional Assessment of Cancer Treatment-Lung (FACT-L) Chinese version 4.0 questionnaire.

Results

The average intracranial objective response (ORR) and disease control rate (DCR) for all the patients were 26.9 and 95.8%, respectively. The intracranial ORR and DCR for RCT and RT arm were 34.9% vs. 20.2% (p = 0.01) and 98.4% vs. 92.7% (p = 0.03), respectively. The median intracranial progression-free survival (PFS) and overall survival (OS) of NSCLC patients with BM were 5.2 and 7.3 months, respectively. The median PFS of RCT arm was significantly longer than that of RT arm (5.9 vs. 4.9 months, p = 0.002). The median OS of the RCT arm was also slightly longer than that of the RT arm (8.5 vs. 5.9 months), but without statistical significance (p = 0.11). Multivariate analysis indicated that TMZ was a significant factor for PFS. Statistically significant differences on NCF and QOL were observed between CRT and RT arms at 5 months. RCT showed a trend of toxicities increase compared with RT, however, the toxicities were tolerable and manageable.

Conclusions

Adding TMZ to WBRT in the treatment of NSCLC patients with BM could improve the intracranial ORR, DCR, and median PFS compared with WBRT alone. Although no remarkable difference on median OS was found, adding TMZ could prevent NCF and QOL from worsening. The side effects increased by adding TMZ, but the difference was not statistical significance and toxicities were well tolerated.

Intra-arterial administration improves temozolomide delivery and efficacy in a model of intracerebral metastasis, but has unexpected brain toxicity

We tested the hypothesis that intra-arterial (IA) infusion of temozolomide into the internal carotid artery would safely improve drug delivery to brain and enhance chemotherapy efficacy in a chemosensitive rat brain tumor model. Quantitative autoradiography after 25 µCi (14)C-temozolomide was given by oral, intravenous, or IA route of administration, or IA with osmotic blood-brain barrier disruption (BBBD) (n = 5-7 per group) showed that both IA and IA/BBBD administration increased drug delivery in tumor by over threefold compared to normal brain (P < 0.02), and also significantly elevated delivery throughout the infused right hemisphere. Temozolomide (20 mg/kg; ~150 mg/m(2)) increased median survival when given by oral (25.5 days), intravenous (25.5 days), or IA (33 days) route of administration, compared to 17.5 days in untreated controls (n = 8 per group; overall P < 0.0001). Survival time after IA temozolomide was significantly longer than all other groups (P < 0.01 for all comparisons). BBBD temozolomide was toxic in the efficacy study, but there was no evidence of symptomatic neurotoxicity in rats given IA temozolomide. After these promising animal results, a 49 year old male with glioblastoma multiforme who failed all standard therapy received temozolomide 100 mg/m(2) IA. Upon initiation of the second course of IA infusion the patient had increased heart rate, blood pressure, and rash, and the procedure was terminated without sequelae. Follow up IA infusion of temozolomide diluent in normal rats showed damaged cerebrovasculature as determined by dye leakage. These results demonstrate that IA infusion of temozolomide was toxic, with or without BBBD. We conclude that under the current formulation temozolomide is not safe for IA infusion in patients.

Single fraction volumetric modulated arc radiosurgery of brain metastases

PURPOSE

To show the clinical results of the treatment of brain metastases via radiosurgery using Volumetric Modulated Arc Therapy (VMAT).

MATERIALS AND METHODS

52 patients having lung (62 %), breast (17 %), colorectal (8 %) and other cancers (13 %) with one to three brain metastases were treated with 5 non-coplanar VMAT arcs. The treatment dose varied from 12 to 20 Gy, administered in one single session. The volume of metastases ranged from 0.04 to 24.92 cc. Radiosurgery alone was used for 54 % of cases, while 19 % received whole brain radiotherapy due to relapse. Patients were classified according to the Disease-specific graded prognostic assessment (DS-GPA) index and survival was assessed via the Kaplan-Meier model.

RESULTS

The median survival time was 7.2 months from the date of radiosurgery. The Karnofsky and DS-GPA indices were the most significant with regard to survival. Patients with a Karnofsky performance status (KPS) over 70 had a longer survival time of 9.2 months, as opposed to those with a KPS below 70 of 3.5 months. No significant differences were found with regard to the type of cancer or the number of lesions. Local tumour control was achieved for 42 metastases (82 %), of which a complete response was achieved for 7 lesions, a partial response for 21; 15 lesions were stabilized. Local progression was observed in 8 lesions (15 %). The median treatment time per patient was 29 min.

CONCLUSIONS

The VMAT technique proves to be safe and effective for treating brain metastases via radiosurgery.