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Balbach ML, Sherry AD, Rexer BN, Abramson VG, Niermann KJ, Johnson CR, Park BH, Mayer IA, Chakravarthy AB. Feasibility and Tolerability of Adjuvant Capecitabine-Based Chemoradiation in Patients With Breast Cancer and Residual Disease After Neoadjuvant Chemotherapy: A Prospective Clinical Trial. Int J Radiat Oncol Biol Phys 2024; 118:1262-1270. [PMID: 37433376 DOI: 10.1016/j.ijrobp.2023.06.076] [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: 03/29/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE Addition of adjuvant capecitabine improves overall survival for patients with breast cancer lacking pathologic complete response to standard-of-care neoadjuvant chemotherapy. Combining radiosensitizing capecitabine concurrent with radiation may further improve disease control, although the feasibility and tolerability of chemoradiation in this setting is unknown. This study aimed to determine the feasibility of this combination. Secondary objectives included the effect of chemoradiation on physician-reported toxicity, patient-reported skin dermatitis, and patient-reported quality of life compared with patients with breast cancer treated with adjuvant radiation. METHODS AND MATERIALS Twenty patients with residual disease following standard neoadjuvant chemotherapy were enrolled in a prospective single-arm trial and treated with adjuvant capecitabine-based chemoradiation. Feasibility was defined as ≥75% of patients completing chemoradiation as planned. Toxicity was assessed using Common Terminology Criteria for Adverse Events version 5.0 and the patient-reported radiation-induced skin reaction scale. Quality of life was measured using the RAND Short-Form 36-Item Health Survey. RESULTS Eighteen patients (90%) completed chemoradiation without interruption or dose reduction. The incidence of grade ≥3 radiation dermatitis was 5% (1 of 20 patients). Patient-reported radiation dermatitis did not show a clinically meaningful difference following chemoradiation (mean increase, 55 points) compared with published reports of patients with breast cancer treated with adjuvant radiation alone (mean increase, 47 points). On the other hand, patient-reported quality of life demonstrated a clinically meaningful decline at the end of chemoradiation (mean, 46; SD, 7) compared with the reference population of patients treated with adjuvant radiation alone (mean, 50; SD, 6). CONCLUSIONS Adjuvant chemoradiation with capecitabine is feasible and tolerable in patients with breast cancer. Although current studies using adjuvant capecitabine for residual disease following neoadjuvant chemotherapy have specified sequential treatment of capecitabine and radiation, these results support the conduct of randomized trials in this setting to investigate the efficacy of concurrent radiation with capecitabine and provide patient-reported toxicity estimates for trial design.
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Affiliation(s)
- Meridith L Balbach
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander D Sherry
- Department of Radiation Oncology, Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brent N Rexer
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vandana G Abramson
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kenneth J Niermann
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Corbin R Johnson
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ben Ho Park
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ingrid A Mayer
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - A Bapsi Chakravarthy
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee.
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2
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Bansal R, Van Swearingen AED, Anders CK. Triple Negative Breast Cancer and Brain Metastases. Clin Breast Cancer 2023; 23:825-831. [PMID: 37586926 DOI: 10.1016/j.clbc.2023.07.008] [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: 03/31/2023] [Revised: 07/11/2023] [Accepted: 07/30/2023] [Indexed: 08/18/2023]
Abstract
The treatment of metastatic breast cancer (MBC) has improved over the past decade, however prognosis continues to be mitigated by the fact that about 1 in 5 patients with MBC will develop brain metastases (BrM) during their metastatic disease course. 1 This number is even higher for patients with triple-negative breast cancer (TNBC), with studies showing as high as 40% of patients developing BrM. 2, 3 Studies have shown that TNBC portends a worse survival after a diagnosis of BrM compared with non-TNBC subtypes. 4 Given the unique location and biologic properties of BrM, treatment options have historically been limited. Challenges to the treatment of TNBC BrM include a lack of targeted therapies and difficulties in delivery of drug to the brain past the blood-brain barrier (BBB). Herein, we will review the advances in local and systemic therapies to most effectively treat patients with TNBC BrM, including therapies on the horizon currently in clinical trials.
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Affiliation(s)
- Rani Bansal
- Division of Medical Oncology, Duke Cancer Institute, Duke University Medical Center, Durham, NC
| | - Amanda E D Van Swearingen
- Division of Medical Oncology, Duke Cancer Institute, Duke University Medical Center, Durham, NC; Division of Medical Oncology, Duke Center for Brain and Spine Metastasis, Duke University Medical Center, Durham, NC
| | - Carey K Anders
- Division of Medical Oncology, Duke Cancer Institute, Duke University Medical Center, Durham, NC; Division of Medical Oncology, Duke Center for Brain and Spine Metastasis, Duke University Medical Center, Durham, NC.
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3
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Gouveia MC, Hidalgo Filho CM, Moreno RA, Alves HCBR, Ayres AS, Testa L, Bonadio RC. Activity of capecitabine for central nervous system metastases from breast cancer. Ecancermedicalscience 2023; 17:1638. [PMID: 38414937 PMCID: PMC10898896 DOI: 10.3332/ecancer.2023.1638] [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: 09/21/2023] [Indexed: 02/29/2024] Open
Abstract
Purpose Central nervous system (CNS) metastases are a significant burden in breast cancer (BC). Capecitabine is a frequent choice in this scenario, but data supporting its single-agent activity are scarce. We aimed to evaluate the intracranial efficacy of capecitabine in CNS metastases from BC. Methods This retrospective cohort included patients with CNS metastases from BC treated with capecitabine at a single centre. Study endpoints were intracranial CNS objective response rate (CNS-ORR), intracranial CNS disease control rate (CNS-DCR), intracranial CNS progression-free survival (CNS-PFS) and overall survival (OS). Results 209 patients were included; 41.6% hormone receptor-positive HER2-negative (HR + HER2-), 33.9% human epidermal growth factor receptor 2 positive (HER2+), and 26.4% triple-negative breast cancer (TNBC). Radiotherapy was performed in 90.4% and CNS surgery in 27.5%. Among patients accessible for intracranial response, 3-month CNS-ORR and CNS-DCR were 41.6% and 81.2%. CNS-ORR was numerically higher among TNBC (61% versus 38% in HR + HER2-BC and 35% in HER2 + BC) (p = 0.194). When considering patients who were not evaluable at 3-month as non-responders, the 3-month CNS-ORR was 19.1% (18.4% in HR + HER2-, 18.3% in HER2+, and 21.6% in TNBC). Nevertheless, TNBC was associated with lower CNS-PFS (p < 0.001) and OS (p < 0.001). Median PFS was 8.3 months in HR + HER2-, 5.0 months in HER2+, and 3.0 months in TNBC. Median OS was 8.7, 9.1 and 4.5 months, respectively. Conclusion Among patients with BC and CNS metastases accessible for intracranial response at 3 months, intracranial activity was observed with capecitabine. These patients have a poor prognosis regardless of the BC subtype, especially in scenarios where newer therapeutic options are unavailable.
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Affiliation(s)
- Mariana Carvalho Gouveia
- Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Av Dr Arnaldo 251, Cerqueira Cesar, São Paulo 01246-000, Brazil
- This author contributed equally to this work
- https://orcid.org/0000-0001-8194-7594
| | - Cassio Murilo Hidalgo Filho
- Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Av Dr Arnaldo 251, Cerqueira Cesar, São Paulo 01246-000, Brazil
- This author contributed equally to this work
- https://orcid.org/0000-0002-7046-0059
| | - Raquel Andrade Moreno
- Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Av Dr Arnaldo 251, Cerqueira Cesar, São Paulo 01246-000, Brazil
- https://orcid.org/0000-0002-7729-7418
| | | | - Aline Sgnolf Ayres
- Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Av Dr Arnaldo 251, Cerqueira Cesar, São Paulo 01246-000, Brazil
- https://orcid.org/0000-0001-5042-4897
| | - Laura Testa
- Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Av Dr Arnaldo 251, Cerqueira Cesar, São Paulo 01246-000, Brazil
- https://orcid.org/0000-0001-6080-7429
| | - Renata Colombo Bonadio
- Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Av Dr Arnaldo 251, Cerqueira Cesar, São Paulo 01246-000, Brazil
- https://orcid.org/0000-0001-5818-922X
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Chi Y, Shang M, Xu L, Gong H, Tao R, Song L, Zhang B, Yin S, Cong B, Li H. Durable Effect of Pyrotinib and Metronomic Vinorelbine in HER2-Positive Breast Cancer With Leptomeningeal Disease: A Case Report and Literature Review. Front Oncol 2022; 12:811919. [PMID: 35251981 PMCID: PMC8888838 DOI: 10.3389/fonc.2022.811919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/25/2022] [Indexed: 12/26/2022] Open
Abstract
Leptomeningeal metastases (LM) are rare and catastrophic for metastatic breast cancer (MBC). The prognosis of HER2-positive breast cancer (BC) with LM is extremely poor. There is no high-quality evidence of treatment regimens in HER2-positive BC with LM yet. Here, we present a case of LM in a 50-year-old woman with HER2-positive BC. Immunohistochemistry revealed invasive ductal carcinoma, estrogen receptor negative, progesterone receptor negative, HER2 3+, P53 positive 80%, and Ki-67 positive 35%. Reported for the first time, the patient was given pyrotinib-targeted therapy (400 mg, oral, every day), metronomic vinorelbine (40 mg, oral, three times a week), and intrathecal methotrexate (10 mg, infrequent and irregular use due to poor compliance) synchronously. The patient received and benefited from the treatment regimen for 16 months. And the quality of life, as self-reported, improved significantly. We also comprehensively summarized all the case reports, observational studies, and clinical trials related to HER2-positive BC with LM in the PubMed database and ClinicalTrials.gov. Intrathecal chemotherapy (methotrexate, cytarabine, thiotepa), intrathecal trastuzumab, whole-brain radiotherapy, and systemic therapy are commonly used treatment options according to a review of the literature and research. Pembrolizumab and trastuzumab deruxtecan (DS-8201) as novel drugs are promising in LM. Furthermore, trastuzumab emtansine (T-DM1) and tyrosine kinase inhibitors (TKIs) such as tucatinib and neratinib have exhibited good efficacy in HER2-positive BC with central nervous system (CNS) metastases and deserve further exploration. In our report, combining pyrotinib-targeted therapy with metronomic chemotherapy is a potential regimen, which has presented satisfactory therapeutic efficacy and also warrants additional investigation in HER2-positive BC with LM.
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Affiliation(s)
- Yajing Chi
- Department of Breast Medical Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
- School of Medicine, Nankai University, Tianjin, China
| | - Mao Shang
- Department of Oncology, Jinan Central Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Liang Xu
- Department of Radiology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Heyi Gong
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Rongjie Tao
- Department of Neurosurgery, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Lihua Song
- Department of Breast Medical Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Baoxuan Zhang
- Department of Breast Medical Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Sha Yin
- Department of Breast Medical Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Binbin Cong
- Department of Breast Surgery, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Huihui Li
- Department of Breast Medical Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
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Intracranial Response Rate in Patients with Breast Cancer Brain Metastases after Systemic Therapy. Cancers (Basel) 2022; 14:cancers14040965. [PMID: 35205723 PMCID: PMC8869862 DOI: 10.3390/cancers14040965] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/06/2022] [Accepted: 02/10/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary For many years, patients with breast cancer and brain metastases were excluded from participation in clinical trials. It was believed that anticancer drugs could not cross the blood–brain barrier. However, recent evidence strongly suggests that some drugs can act against brain metastases, with the greatest intracranial response rate reported in the case of capecitabine, neratinib plus capecitabine, trastuzumab deruxtecan and tucatinib plus trastuzumab and capecitabine. In this article, we discuss the achievements in systemic therapy of breast cancer patients with brain metastases. We stress on the newest clinical trial results which indicate tremendous progress in HER2-positive breast cancer. On the other hand, in patients with triple-negative breast cancer or hormone-receptor-positive brain metastases, much fewer compounds were discovered. Based on the presented results, patients with active brain metastases should be routinely included in clinical trials with novel agents. Abstract Brain metastases are detected in 5% of patients with breast cancer at diagnosis. The rate of brain metastases is higher in HER2-positive and triple-negative breast cancer patients (TNBC). In patients with metastatic breast cancer, the risk of brain metastases is much higher, with up to 50% of the patients having two aggressive biological breast cancer subtypes. The prognosis for such patients is poor. Until recently, little was known about the response to systemic therapy in brain metastases. The number of trials dedicated to breast cancer with brain metastases was scarce. Our review summarizes the current knowledge on this topic including very significant results of clinical trials which have been presented very recently. We focus on the intracranial response rate of modern drugs, including new antibody–drug conjugates, HER2- targeted tyrosine kinase inhibitors and other targeted therapies. We highlight the most effective and promising drugs. On the other hand, we also suggest that further efforts are needed to improve the prognosis, especially patients with TNBC and brain metastases. The information contained in this article can help oncologists make treatment-related decisions.
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Kadamkulam Syriac A, Nandu NS, Leone JP. Central Nervous System Metastases from Triple-Negative Breast Cancer: Current Treatments and Future Prospective. BREAST CANCER (DOVE MEDICAL PRESS) 2022; 14:1-13. [PMID: 35046721 PMCID: PMC8760391 DOI: 10.2147/bctt.s274514] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/24/2021] [Indexed: 12/18/2022]
Abstract
It is estimated that approximately one-third of patients with triple-negative breast cancer (TNBC) will develop brain metastases. The prognosis for patients with breast cancer brain metastasis has improved in the recent past, especially for hormone receptor and human epidermal growth factor receptor 2 (HER) positive subtypes. However, the overall survival rate for patients with triple-negative subtype remains poor. The development of newer treatment options, including antibody-drug conjugates such as Sacituzumab govitecan, is particularly encouraging. This article reviews the clinical outcomes, challenges, and current approach to the treatment of brain metastasis in TNBC. We have also briefly discussed newer treatment options and ongoing clinical trials. The development of brain metastasis significantly decreases the quality of life of patients with TNBC, and newer treatment strategies and therapeutics are the need of the hour for this disease subgroup.
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Affiliation(s)
| | - Nitish Singh Nandu
- Department of Hospice and Palliative Medicine, Montefiore Medical Center/ Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jose Pablo Leone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, 02215, USA
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7
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Sherry AD, Mayer IA, Ayala-Peacock DN, Abramson VG, Rexer BN, Chakravarthy AB. Combining Adjuvant Radiotherapy With Capecitabine in Chemotherapy-resistant Breast Cancer: Feasibility, Safety, and Toxicity. Clin Breast Cancer 2020; 20:344-352.e1. [PMID: 32234364 DOI: 10.1016/j.clbc.2020.02.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/21/2020] [Accepted: 02/28/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND In a randomized trial (CREATE-X), patients with residual disease after standard neoadjuvant chemotherapy had improved survival with the addition of adjuvant capecitabine. For patients who required radiotherapy (RT), capecitabine was given sequentially. Concurrent capecitabine-RT might be more efficacious. We hypothesized that the safety, feasibility, and toxicity of adjuvant capecitabine-RT would not be significantly different compared with adjuvant RT alone. PATIENT AND METHODS We retrospectively studied the data from patients with stage I-III invasive mammary carcinoma. Patients who had received capecitabine-RT were matched 1:3 with control patients who had received RT alone. Logistic regression analysis was used to evaluate the predictors of radiation dermatitis. RESULTS A total of 64 patients were enrolled, including 16 who had received capecitabine-RT and 48 who had received RT alone. The cohorts were balanced regarding the clinicopathologic factors. No treatment in either cohort resulted in hospitalization, short-term disability, or fatality. Most toxicities of capecitabine-RT were related to radiation dermatitis. Radiation dermatitis was not significantly different between the capecitabine-RT and RT cohort at either grade 2 (odds ratio [OR], 1.36; 95% confidence interval [CI], 0.38-4.93; P = .63) or grade 3 (OR, 3.00; 95% CI, 0.85-10.63; P = .09) or after multivariable analysis. However, the capecitabine-RT group was more likely to require modifications in the RT schedule, including treatment breaks or cancelled fractions (44% vs. 17%; OR, 3.89; 95% CI, 1.12-13.52; P = .03). CONCLUSION Capecitabine-RT appears to be safe in the adjuvant treatment of breast cancer with comparable toxicity to RT alone. It might require more treatment adjustments. Prospective studies are needed to evaluate the safety and tolerability of this combination.
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Affiliation(s)
| | - Ingrid A Mayer
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | | | - Vandana G Abramson
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Brent N Rexer
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - A Bapsi Chakravarthy
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN.
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8
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Lee KL, Chen G, Chen TY, Kuo YC, Su YK. Effects of Cancer Stem Cells in Triple-Negative Breast Cancer and Brain Metastasis: Challenges and Solutions. Cancers (Basel) 2020; 12:cancers12082122. [PMID: 32751846 PMCID: PMC7463650 DOI: 10.3390/cancers12082122] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/25/2020] [Accepted: 07/27/2020] [Indexed: 12/14/2022] Open
Abstract
A higher propensity of developing brain metastasis exists in triple-negative breast cancer (TNBC). Upon comparing the metastatic patterns of all breast cancer subtypes, patients with TNBC exhibited increased risks of the brain being the initial metastatic site, early brain metastasis development, and shortest brain metastasis-related survival. Notably, the development of brain metastasis differs from that at other sites owing to the brain-unique microvasculature (blood brain barrier (BBB)) and intracerebral microenvironment. Studies of brain metastases from TNBC have revealed the poorest treatment response, mostly because of the relatively backward strategies to target vast disease heterogeneity and poor brain efficacy. Moreover, TNBC is highly associated with the existence of cancer stem cells (CSCs), which contribute to circulating cancer cell survival before BBB extravasation, evasion from immune surveillance, and plasticity in adaptation to the brain-specific microenvironment. We summarized recent literature regarding molecules and pathways and reviewed the effects of CSC biology during the formation of brain metastasis in TNBC. Along with the concept of individualized cancer therapy, certain strategies, namely the patient-derived xenograft model to overcome the lack of treatment-relevant TNBC classification and techniques in BBB disruption to enhance brain efficacy has been proposed in the hope of achieving treatment success.
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Affiliation(s)
- Kha-Liang Lee
- Division of Neurosurgery, Department of Surgery, Taipei Medical University-Shuang Ho Hospital, New Taipei City 23561, Taiwan; (K.-L.L.); (G.C.); (T.-Y.C.)
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
| | - Gao Chen
- Division of Neurosurgery, Department of Surgery, Taipei Medical University-Shuang Ho Hospital, New Taipei City 23561, Taiwan; (K.-L.L.); (G.C.); (T.-Y.C.)
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
| | - Tai-Yuan Chen
- Division of Neurosurgery, Department of Surgery, Taipei Medical University-Shuang Ho Hospital, New Taipei City 23561, Taiwan; (K.-L.L.); (G.C.); (T.-Y.C.)
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
| | - Yung-Che Kuo
- Taipei Medical University (TMU) Research Center for Cell Therapy and Regeneration Medicine, Taipei Medical University, Taipei 11031, Taiwan;
| | - Yu-Kai Su
- Division of Neurosurgery, Department of Surgery, Taipei Medical University-Shuang Ho Hospital, New Taipei City 23561, Taiwan; (K.-L.L.); (G.C.); (T.-Y.C.)
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Correspondence:
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9
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The necessity of intrathecal chemotherapy for the treatment of breast cancer patients with leptomeningeal metastasis: A systematic review and pooled analysis. Curr Probl Cancer 2017; 41:355-370. [DOI: 10.1016/j.currproblcancer.2017.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 06/23/2017] [Accepted: 07/07/2017] [Indexed: 11/19/2022]
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10
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Dudani S, Mazzarello S, Hilton J, Hutton B, Vandermeer L, Fernandes R, Ibrahim MFK, Smith S, Majeed H, Al-Baimani K, Caudrelier JM, Shorr R, Clemons M. Optimal Management of Leptomeningeal Carcinomatosis in Breast Cancer Patients-A Systematic Review. Clin Breast Cancer 2016; 16:456-470. [PMID: 27553811 DOI: 10.1016/j.clbc.2016.07.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 06/22/2016] [Accepted: 07/20/2016] [Indexed: 11/19/2022]
Abstract
The incidence of leptomeningeal carcinomatosis in breast cancer patients (LC-BC) is increasing. Despite significantly affecting patient quality of life (QoL) and overall survival (OS), little is known about its optimal management. A systematic review of treatment strategies for LC-BC was performed. EMBASE, Ovid Medline, Pubmed, and the Cochrane Central Register of Controlled Trials were searched from 1946 to 2015 for trials reporting on treatments for LC-BC. All treatment modalities and study types were considered. The outcome measures of interest included OS, time to neurologic progression (TTNP), QoL, and treatment toxicity. Of 718 unique citations, 173 studies met the prespecified eligibility criteria. Most were not specific to LC-BC patients. Of 4 identified randomized controlled trials (RCTs), 1 was specific to LC-BC patients and compared systemic therapy and involved-field radiotherapy with or without intrathecal (IT) methotrexate (35 patients), and the remaining 3 had compared different IT chemotherapy regimens (58 of 157 with LC-BC). Of the remaining studies, 19 were nonrandomized interventional studies (225 LC-BC patients), 148 were observational studies (3230 LC-BC patients), and 2 systematic reviews. Minimal prospective data were available on OS, TTNP, QoL, and toxicity. Owing to study heterogeneity, meta-analyses of the endpoint data could not be performed. Limited high-quality evidence exists regarding optimal treatment of LC-BC. The identified studies were heterogeneous and often methodologically poor. The only RCT that specifically assessed the role of IT chemotherapy showed no benefit, and, if anything, harm. Further prospective, tumor-specific trials with improved interstudy methodologic consistency and transparently reported data on OS, TTNP, QoL, and toxicity are urgently needed.
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Affiliation(s)
- Shaan Dudani
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | | | - John Hilton
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada; Division of Medical Oncology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Ricardo Fernandes
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | - Mohammed F K Ibrahim
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | | | - Habeeb Majeed
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | - Khalid Al-Baimani
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | - Jean-Michel Caudrelier
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Radiation Medicine, The Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | | | - Mark Clemons
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada; Division of Medical Oncology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada.
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11
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Abstract
Brain metastases are a common complication of cancer and continue to be associated with a poor prognosis. Management of brain metastases typically requires a multidisciplinary approach which may include whole-brain radiation therapy, stereotactic radiosurgery, surgery, and systemic therapy. Historically, the use of systemic therapy in brain metastases has been challenging because of the resistance to conventional chemotherapies secondary to the blood-brain barrier and an often heavily pre-treated patient population, and the paucity of well-conducted randomized trials in these heterogeneous patient populations. Newer agents, including immunotherapy and targeted therapies, are playing increasingly important roles in the up-front management of brain metastases. In this overview, we review recent advances in systemic therapies for brain metastases and the evidence supporting their use in this patient population.
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Affiliation(s)
- Harry C Brastianos
- Department of Radiation Oncology, Queen's University, Kingston, ON, Canada
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12
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Larsen PB, Kümler I, Nielsen DL. A systematic review of trastuzumab and lapatinib in the treatment of women with brain metastases from HER2-positive breast cancer. Cancer Treat Rev 2013; 39:720-7. [PMID: 23481218 DOI: 10.1016/j.ctrv.2013.01.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 01/05/2013] [Accepted: 01/08/2013] [Indexed: 01/28/2023]
Abstract
Patients with HER2-positive breast cancer are living still longer and increasingly experiencing brain metastases. Current HER2-targeted therapies have limited potential to cross the blood-brain-barrier. We performed a systematic review to investigate data on HER2-targeting therapies in the treatment of brain metastases in breast cancer. We searched PUBMED for all human studies published 1998-2012 using the following search terms: breast neoplasm/cancer, human epidermal growth factor receptor 2/HER2, ErbB2, trastuzumab, lapatinib, brain/cerebral neoplasm/metastases and blood-brain barrier. We identified few and mostly small clinical studies. Study designs were very heterogeneous making comparisons on endpoints difficult. Overall survival for patients treated with trastuzumab varied from 8 to 25 months and 5.5 to 11 months for patients receiving lapatinib. The majority of studies were retrospective thus possibly biasing data. Only three studies were identified comparing trastuzumab to lapatinib. Conclusively, no solid data exist on how to treat patients with HER2-positive disease and brain metastases. Although continuous HER2-blockade is recommended by international consensus guidelines, it is still not evident which HER2-targeting agent should be preferred when brain metastases occur. The choice of chemotherapy to accompany the blockade is not obvious and we do not know if dual is better than single blockade. Further clinical trials are urgently needed.
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Affiliation(s)
- Pia Bükmann Larsen
- Department of Oncology, Herlev Hospital, University of Copenhagen, Denmark.
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13
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Rolski J, Karczmarek-Borowska B, Śmietana A. The possibility of lapatinib treatment for breast cancer patients with central nervous system metastases. Case study and literature review. Contemp Oncol (Pozn) 2013; 16:582-5. [PMID: 23788948 PMCID: PMC3687474 DOI: 10.5114/wo.2012.32494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 12/06/2011] [Accepted: 01/26/2012] [Indexed: 11/22/2022] Open
Abstract
In patients with breast cancer with overexpression of the HER2 receptor, during treatment with trastuzumab, in 30% of cases brain metastases are observed. The use of lapatinib with capecitabine (L + C) seems to be an efficacious method of curing patients in whom the spread of cancer in this location has occurred. In a patient aged 52 treated by the L + C scheme a stabilization of changes in the brain was noted, lingering for 17 months. The tolerance of the treatment was good. Grade 2 hand-foot syndrome on the NCI 2,0 scale, nausea, a first degree increase in transaminase levels and first degree diarrhea were observed. No hematological or cardiac complications were observed. In the third phase test comparing capecitabine with capecitabine and lapatinib in patients with advanced breast cancer, adding lapatinib to capecitabine significantly prolonged the time until progression and contributed to lessening of the amount of progression of the condition into the central nervous system. Recently published studies showed 6% remission of metastases to the central nervous system in patients with advanced breast cancer with brain metastases treated with lapatinib and 20-21% in patients receiving lapatinib with capecitabine. Future studies evaluating the effectiveness of lapatinib in patients with spread into the central nervous system should include the evaluation of lapatinib in association with cytostatics able to break through the blood-brain barrier. Lapatinib should also be tested in association with brain radiation, considering the results of preclinical studies indicating that it may work as a radiation sensitizer.
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Affiliation(s)
- Janusz Rolski
- Department of Clinical Oncology, Subcarpathian Oncology Centre in Rzeszów, Poland
| | | | - Anetta Śmietana
- Daytime Chemotherapy Department, Subcarpathian Oncology Centre in Rzeszów, Poland
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14
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Santa-Maria CA, Cimino-Mathews A, Moseley KF, Wolff AC, Blakeley JO, Connolly RM. Complete radiologic response and long-term survival with use of systemic high-dose methotrexate for breast cancer-associated leptomeningeal disease. Clin Breast Cancer 2012; 12:445-9. [PMID: 23010203 DOI: 10.1016/j.clbc.2012.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Revised: 05/12/2012] [Accepted: 07/09/2012] [Indexed: 11/17/2022]
Affiliation(s)
- Cesar A Santa-Maria
- Department of Medical Oncology, The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
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15
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Clinical outcome of central nervous system metastases from breast cancer: differences in survival depending on systemic treatment. J Neurooncol 2011; 106:303-13. [PMID: 21938531 DOI: 10.1007/s11060-011-0664-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 07/04/2011] [Indexed: 01/17/2023]
Abstract
Central nerve system (CNS) metastases are a feared complication of breast cancer and are associated with poor prognosis. The purpose of this study is to investigate the clinical characteristics of CNS metastases and to clarify the prognostic factors after CNS metastases in breast cancer at a single institution over a long time period. We retrospectively reviewed the medical records of breast cancer patients diagnosed at Seoul National University Hospital from 1981 to 2009 and identified the patients who experienced CNS metastases. We collected the data, including demographics, clinico-pathologic characteristics, dates of diagnosis of original breast cancer and subsequent metastases, and date of death, and correlated the findings with the clinical outcome. A total of 400 patients were identified, of whom 17 (4.3%) were diagnosed with CNS metastases and primary breast cancer concurrently and 383 (95.7%) experienced CNS metastases subsequent to the diagnosis of primary breast cancer. Further, 318 patients (79.5%) had only brain parenchymal metastases, 30 (7.5%) had only leptomeningeal metastases, and 52 (13%) had both. After the diagnosis of CNS metastasis, 170 patients (42.5%) received systemic chemotherapy (CTx) and 143 (35.8%) received CTx after whole brain radiation therapy (WBRT). The patients with good performance status (PS), initial CNS metastasis as recurrence, absence of extracranial metastases, non-visceral extracranial metastases, longer interval from the date of primary breast cancer to the date of CNS metastasis, and CTx after WBRT and gamma-knife surgery (GKS), had better outcomes in univariate analyses. In multivariate analysis, good PS, systemic CTx after WBRT, GKS, and longer interval to CNS metastasis, were independent prognostic factors for overall survival after CNS metastases. Our results suggest that appropriate palliative systemic therapy after WBRT or GKS, and adequate palliative treatment via combined modalities are helpful for breast cancer patients, even after the detection of CNS metastases.
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Zhang X, Zhang W, Cao WD, Cheng G, Liu B, Cheng J. A review of current management of brain metastases. Ann Surg Oncol 2011; 19:1043-50. [PMID: 21861219 DOI: 10.1245/s10434-011-2019-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND The brain metastasis (BM) represents one of the most common and refractory malignancies worldwide with a rising incidence in all countries. It is generally believed that once a BM has developed, this disease cannot be cured and has a poor prognosis. The challenges of managing this tumor include diagnosis and selective treatment options. In addition, patients with BM frequently have greater expectations of the current therapy outcomes, which hope to get long-term survival and good quality of life. METHODS This is a review of current clinical practice based on an exhaustive literature search of PubMed, Embase, and Google Scholar. A series of case studies is presented to provide outcomes of the effective management in BMs that have required treatment for the terminal stage of patients with cancer, and makes recommendations for future practice. RESULTS Current technical advances have been made in the diagnosis and treatment of BM. After surgery, radiotherapy, or stereotactic radiosurgery, and for some cases additional systemic chemotherapy for the primary cancer, most patients experience meaningful symptom relief, improved quality of life and longer survival time. An evidence-based summary of recommendations has been produced to guide neurosurgeons and oncologists in managing this particular group of patients. CONCLUSIONS On the basis of the available data, this treatment approach for well-selected patients is currently not recommended in the treatment of BMs except in experienced medical centers. Clinical judgment is made balancing surgical, radiotherapy, chemotherapy and management principles to advocacy the best therapy outcome.
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Affiliation(s)
- Xiang Zhang
- Department of Neurosurgery, Xijing Institute of Clinical Neuroscience, Xijing Hospital, Fourth Military Medical University, Xi'an, People's Republic of China.
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17
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Bilimagga RS, Nirmala S, Rishi KS, Janaki M, Ponni A, Rajeev A, Kalyan S. Role of palliative radiotherapy in brain metastases. Indian J Palliat Care 2011; 15:71-5. [PMID: 20606860 PMCID: PMC2886217 DOI: 10.4103/0973-1075.53588] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Brain metastases are a common manifestation of systemic cancer and exceed primary brain tumors in number and are a significant cause of neurologic problems. They affect 20-40% of all cancer patients. Aggressive management of brain metastases is effective in both symptom palliation and prolonging the life. Radiotherapy has a major role to play in the management of brain metastases. AIM: The aim of the study was to know the outcome of palliative radiotherapy in symptomatic brain metastases in terms of improvement in their performance status. Materials and Methods: This is a retrospective study of 63 patients diagnosed to have brain metastases and treated with palliative whole brain radiotherapy to a dose of 30 Gy in 10 fractions over two weeks between June 1998 and June 2007. Diagnosis was done in most of the cases with computed tomography scan and in a few with magnetic resonance imaging. Improvement in presenting symptoms has been assessed in terms of improvement in their performance status by using the ECOG scale. Results: Fifty-four patients completed the planned treatment. Eight patients received concurrent Temozolamide; 88% of patients had symptom relief at one month follow-up; 39/54 patients had a follow-up of just one to three months. Hence survival could not be assessed in this study. Conclusion: External beam radiotherapy in the dose of 30 Gy over two weeks achieved good palliation in terms improvement in their performance status in 88% of patients. Addition of concurrent and adjuvant Timozolamide may improve the results.
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Affiliation(s)
- Ramesh S Bilimagga
- Department of Radiotherapy, M. S. Ramaiah Medical College, Bangalore - 560 054, India
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18
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Hirowatari H, Karasawa K, Izawa H, Ito K, Sasai K, Furuya T, Ozawa S, Arakawa A, Orihata G, Saito M. Full-dose capecitabine with local radiotherapy: one of the treatment options for inoperable T4 breast cancer. Jpn J Radiol 2011; 29:222-5. [DOI: 10.1007/s11604-010-0537-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Accepted: 10/26/2010] [Indexed: 11/29/2022]
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Niwińska A, Murawska M, Pogoda K. Breast cancer subtypes and response to systemic treatment after whole-brain radiotherapy in patients with brain metastases. Cancer 2010; 116:4238-47. [PMID: 20549816 DOI: 10.1002/cncr.25391] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The aim of this study was to assess the role of systemic treatment after whole-brain radiotherapy (WBRT) in immunohistochemically defined biological subsets of breast cancer patients with brain metastases. METHODS The group of 420 consecutive breast cancer patients with brain metastases treated at the same institution between the years of 2003 to 2009 was analyzed. Patients were divided into 4 immunohistochemically biological subsets, based on the levels of estrogen, progesterone, and human epidermal growth factor receptor 2 (HER2) receptors, and labeled as luminal A, luminal B, HER2, and triple-negative. Survival from brain metastases with and without systemic treatment after WBRT was calculated in 4 subsets. RESULTS In the entire group, the median survival from brain metastases in patients without and with systemic treatment after WBRT was 3 and 10 months, respectively (P < .0001). In the triple-negative subset, the median survival from brain metastases with and without systemic treatment was 4 and 3 months (P = .16), and in the luminal A subset, it was 12 and 3 months, respectively (P = .003). In the luminal B subset, the median survival without further treatment, after chemotherapy and/or hormonal therapy, and after chemotherapy and/or hormonal therapy with targeted therapy was 2 months, 9 months, and 15 months, respectively (P < .0001). In the HER2 subset, the median survival was 4 months, 6 months, and 13 months, respectively (P < .0001). No significant response to systemic treatment was noted in the triple-negative breast cancer population. CONCLUSIONS Systemic therapy, ordered after WBRT, appears to improve survival in patients with the luminal A, luminal B, and HER2 breast cancer subtypes. Targeted therapy was found to have an additional positive impact on survival. In patients with triple-negative breast cancer, the role of systemic treatment after WBRT appears to be less clear, and therefore this issue requires further investigation.
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Affiliation(s)
- Anna Niwińska
- Department of Breast Cancer and Reconstructive Surgery, The Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland.
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20
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Glück S, Castrellon A. Lapatinib plus capecitabine resolved human epidermal growth factor receptor 2-positive brain metastases. Am J Ther 2010; 16:585-90. [PMID: 19287304 DOI: 10.1097/mjt.0b013e31818bee2b] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Brain metastases affect 25%-30% of women with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer and are associated with a high burden of disease and poor prognosis. A 55-year-old woman presented with HER2-positive, hormone receptor-positive, locally advanced infiltrating ductal carcinoma. She received 4 cycles of neoadjuvant docetaxel (75 mg/m) plus trastuzumab (6 mg/kg) on a 21-day cycle, resulting in complete pathologic response at the time of surgery. Trastuzumab (6 mg/kg every 21 days) plus anastrozole (1 mg/d) was continued for 1 year. Two years later, the patient progressed with pulmonary nodules and a large pleural effusion. Computed tomography and positron emission tomography revealed multiple lesions in the liver and thoracic spine but no evidence of brain metastases. The patient received weekly trastuzumab (2 mg/kg), paclitaxel (80 mg/m), and carboplatin (area under the curve 2) for 6 months; her symptoms resolved and her disease stabilized. Seven months later, she developed diplopia and gait difficulties, and magnetic resonance imaging revealed multiple brain lesions. Whole-brain radiotherapy (30 Gy in 10 fractions) was delivered with excellent clinical results. The patient remained progression free without symptoms for approximately 3 months. When she developed central nervous system symptoms, she was treated with lapatinib (1250 mg/d continuously) plus capecitabine (2000 mg/m given on days 1-14 of a 21-day cycle). Four months later, a brain computed tomography performed shortly before her death from progressive systemic disease revealed near complete resolution of brain metastases. Lapatinib plus capecitabine seems to have clinical activity in HER2-positive brain metastases.
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Affiliation(s)
- Stefan Glück
- Division of Hematology/Oncology, Braman Family Breast Cancer Institute, UM Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, FL 33136, USA.
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21
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Barrett-Lee P, Bidard FC, Pierga JY. Contemporary issues and the potential uses of capecitabine in metastatic breast cancer. Cancer Treat Rev 2009; 35:582-9. [PMID: 19632050 DOI: 10.1016/j.ctrv.2009.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Revised: 06/10/2009] [Accepted: 06/12/2009] [Indexed: 11/26/2022]
Abstract
Since its first regulatory approval more than 10 years ago, oncologists have gained wide experience in using the oral fluoropyrimidine, capecitabine, as monotherapy or in combination with other agents and the body of evidence supporting these approaches continues to grow. Alongside this increasing experience has been the appearance of new challenges in patient management. We now recognise several different biological subtypes of breast cancer, such as HER2-positive disease. The standard of care in these tumours comprises anti-HER2 therapy, and phase III data show that capecitabine can be effectively combined with such agents. Another increasingly prominent and currently unresolved issue resulting from more effective treatment of metastatic disease is the management of patients with brain metastases. The introduction of new, well-tolerated, oral chemotherapies also provides the opportunity for longer duration of therapy. These new clinical scenarios are discussed in the current review.
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Concurrent capecitabine and whole-brain radiotherapy for treatment of brain metastases in breast cancer patients. J Neurooncol 2009; 93:379-84. [PMID: 19169856 DOI: 10.1007/s11060-008-9791-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Accepted: 12/30/2008] [Indexed: 12/31/2022]
Abstract
Preclinical data have demonstrated that ionizing radiation acts synergistically with capecitabine. This report retrospectively assessed the use of capecitabine concurrently with whole-brain radiotherapy (WBRT) in patients with brain metastases from breast cancer. From January 2003 to March 2005, five breast cancer patients with brain metastases were referred for WBRT with concurrent capecitabine. Median age was 44 years (range: 38-53). The median dose of capecitabine was 1,000 mg/m(2) twice daily for 14 days (day1-14). Treatment cycles were repeated every 21 days, concurrently with WBRT (30 Gy, 3 Gy per fraction, 5 days per week). Median survival after starting WBRT plus capecitabine was 6.5 months (range 1-34 months). One patient achieved a complete response. Two patients achieved partial response, including one with local control lasting until most recent follow-up. One patient had stable disease. The remaining patient was not assessable for response because of early death. Most commonly reported adverse events were nausea (n = 2) and headache (n = 2), always grade 1. Other toxicities were grade 3 hand/foot syndrome (n = 1), moderate anemia requiring transfusion and dose reduction of capecitabine (n = 1), and grade 1 mucositis (n = 1). Although promising, these preliminary data warrant further assessment of capecitabine-based chemoradiation in brain metastases from breast cancer and need to be further validated in the setting of a clinical trial.
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Paydas S, Bicakci K, Yavuz S. Dramatic response with capecitabine after cranial radiation to the brain parenchymal and leptomeningeal metastases from lung cancer. Eur J Intern Med 2009; 20:96-9. [PMID: 19237101 DOI: 10.1016/j.ejim.2008.04.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 03/13/2008] [Accepted: 04/27/2008] [Indexed: 10/21/2022]
Abstract
It is known that the prognosis of Non Small Cell Lung Cancer with brain metastasis are very poor with a median survival of only a few months. Although some chemotherapeutic agents penetrate the blood brain barrier generally chemotherapy results are bad but efficiency may be better after radiotherapy. For this reason brain metastatic disease requires some efforts to improve the response rate. Here we reported a case with lung cancer metastatic to the brain and we discussed the good response to capecitabine after cranial radiotherapy (C).
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Affiliation(s)
- Semra Paydas
- Cukurova University, Faculty of Medicine, Department of Oncology, Turkey.
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24
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Shigekawa T, Takeuchi H, Misumi M, Matsuura K, Sano H, Fujiuchi N, Okubo K, Osaki A, Aogi K, Saeki T. Successful treatment of leptomeningeal metastases from breast cancer using the combination of trastuzumab and capecitabine: a case report. Breast Cancer 2008; 16:88-92. [PMID: 18478315 DOI: 10.1007/s12282-008-0056-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Accepted: 03/06/2008] [Indexed: 11/29/2022]
Abstract
We report a case of metastatic breast cancer with leptomeninges and multiple bone metastases that showed an excellent response to the combination of trastuzumab and capecitabine; therapeutic effect was evaluated by MRI at follow-up. A 44-year-old woman underwent modified radical mastectomy in February 1997. In April 2003, a tumor at the right basis cerebri and multiple bone metastases were noted, and in October 2003, she underwent enucleation of the tumor. Histopathologically, the tumor was consistent with a basal skull metastasis from breast cancer. In March 2004, the patient began to experience pain, weakness, and paresthesia of both legs. She was diagnosed, with leptomeningeal metastasis (LM) from breast cancer using MRI. In December 2005, the combination of trastuzumab and capecitabine administered as sixth-line treatment was very effective for LM. Although it is generally very difficult to diagnose LM and assess the therapeutic effect with MRI, in this case, it was possible. To our knowledge, there has been no report in the literature describing the combination of trastuzumab and capecitabine for LM from breast cancer. Although the mechanism underlying the efficacy of this combination is still unknown, the treatment would be worth trying because of its few side effects in extensively treated patients with LM from breast cancer. To confirm the antitumor efficacy of trastuzumab and capecitabine, however, further investigations are required.
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Affiliation(s)
- Takashi Shigekawa
- Department of Breast Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan.
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25
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Abstract
Metastatic brain tumors are the most common intracranial neoplasms in adults. The incidence of brain metastases appears to be rising as a result of superior imaging modalities, earlier detection, and more effective treatment of systemic disease. Therapeutic approaches to brain metastases include surgery, whole brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), and chemotherapy. Treatment decisions must take into account clinical prognostic factors in order to maximize survival and neurologic function whilst avoiding unnecessary treatments. The goal of this article is to review important prognostic factors that may guide treatment selection, discuss the roles of surgery, radiation, and chemotherapy in the treatment of patients with brain metastases, and present new directions in brain metastasis therapy under active investigation. In the future, patients will benefit from a multidisciplinary approach focused on the integration of surgical, radiation, and chemotherapeutic options with the goal of prolonging survival, preserving neurologic and neurocognitive function, and maximizing quality of life.
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Affiliation(s)
- April F Eichler
- Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Boston, MA 02114, USA.
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Ekenel M, Hormigo AM, Peak S, Deangelis LM, Abrey LE. Capecitabine therapy of central nervous system metastases from breast cancer. J Neurooncol 2007; 85:223-7. [PMID: 17611719 DOI: 10.1007/s11060-007-9409-0] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Accepted: 05/02/2007] [Indexed: 12/19/2022]
Abstract
Central nervous system (CNS) metastases from breast cancer carry a poor prognosis. Systemic chemotherapy is often ineffective due to the impermeability of the blood-brain barrier (BBB) and inherent chemoresistance of CNS metastases. There are limited data supporting the use of capecitabine in this setting. Medical records of seven patients with brain metastases from breast cancer who received capecitabine treatment at Memorial Sloan-Kettering Cancer Center from 1994-2006 were reviewed. Treatment outcomes were analyzed retrospectively in those patients. Median time from breast cancer diagnosis to the development of CNS metastasis was 48 (18-165) months. Four patients had brain metastases alone, two patients had both leptomeningeal and brain metastases and one patient had leptomeningeal metastasis alone. Five out of seven patients had failed other treatment modalities before capecitabine. Three patients showed complete response (CR) and three patients had stable disease (SD) after capecitabine. The patient with leptomeningeal disease improved clinically, but refused repeat cerebrospinal fluid (CSF) studies. Median overall and progression-free survival from initiation of capecitabine was 13 and 8 months, respectively, for all patients. Capecitabine may achieve a CR and provide long-term control in patients with both leptomeningeal and parenchymal CNS metastases from breast cancer.
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Affiliation(s)
- Meltem Ekenel
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021, USA.
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Abstract
Brain metastases have traditionally been treated with a surgical or radiotherapeutic approach. Chemotherapy is used occasionally as salvage therapy. The blood-brain barrier excludes most chemotherapeutic agents, rendering many systemic options ineffective within the CNS. Intrathecal chemotherapies do not penetrate into brain tissue or bulky parenchymal tumors, so are ineffective in treatment of brain metastases. However, some patients with brain metastases benefit from chemotherapy, and temozolomide or targeted therapies like gefitinib have demonstrated activity. A better understanding of the biological behavior of brain metastases may lead to development of effective treatments for this common complication of systemic cancer. The review discusses the biology of brain metastases and provides an update on current chemotherapeutic strategies.
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Affiliation(s)
- Scott Peak
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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28
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Abstract
As therapy for systemic cancers improves, an increasing number of patients are developing brain metastases. Although conventional therapy with surgery, radiation therapy and radiosurgery has improved the outcome of a significant number of patients, many develop multiple lesions that are not amenable to standard treatments. In this review, the current role of chemotherapy and targeted molecular agents for brain metastases is summarized and future directions are discussed.
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Affiliation(s)
- Jan Drappatz
- Center for Neuro-oncology Dana-Farber/Brigham and Women's Cancer Center, and Division of Neuro-Oncology, Department of Neurology, Brigham and Women's Hospital, Boston, MA 02115, USA.
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