The number of involved extracranial organs: a new predictor of survival in breast cancer patients with brain metastasis

Prognostic impacts of extracranial metastasis on non-small cell lung cancer with brain metastasis: A retrospective study based on surveillance, epidemiology, and end results database

This study was designed to investigate the prognostic value of the number and sites of extracranial metastasis (ECM) in NSCLC patients with BM. NSCLC patients with BM from the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015 were enrolled in analysis. Patients from 2010 to 2013 were included in the training set and those from 2014 to 2015 in the validation set. ECM sites among different subtypes of NSCLC were compared by Chi-square tests. Kaplan-Meier methods and Cox regression models were performed to analyze survival data. Competing-risks analysis was used to predict cumulative incidence rates for CSS and non-CSS cause. We included 5974 patients in the training cohort and 3561 patients in the validation cohort. Most (nearly 80%) NSCLC patients with BM showed 0-1 involved extracranial organ, with the most and least common ECM organ being bone and distant lymph nodes (DLNs) among all subtypes of NSCLC, respectively. The number of involved extracranial organs was an independent prognostic factor for patients with BM from NSCLC (p < 0.001). Patients with 0-1 ECM had better survival than those with larger number of involved extracranial organs (p < 0.001). Cumulative incidence rates for CSS were increased with the number of ECM raising (p < 0.001). All involved extracranial organs were associated with worse survival (p < 0.05). In patients with single-organ ECM, we observed a better prognosis in lung and bone metastasis, while liver metastasis showed worst survival. But the difference in survival in these patient groups was relatively small. Patients with liver metastasis had higher cumulative incidence rates for CSS than that in patients with lung and bone metastasis (p < 0.05). More extracranial metastases were associated with poor prognosis in NSCLC patients with BM and ECM sites showed limited effect on survival. Tailored treatments would be reasonable for BM patients from NSCLC with different metastasis patterns.

The Clinicopathological features and survival outcomes of patients with different metastatic sites in stage IV breast cancer

BACKGROUND

The features and survival of stage IV breast cancer patients with different metastatic sites are poorly understood. This study aims to examine the clinicopathological features and survival of stage IV breast cancer patients according to different metastatic sites.

METHODS

Using the Surveillance, Epidemiology, and End Results database, we restricted our study population to stage IV breast cancer patients diagnosed between 2010 to 2015. The clinicopathological features were examined by chi-square tests. Breast cancer-specific survival (BCSS) and overall survival (OS) were compared among patients with different metastatic sites by the Kaplan-Meier method with log-rank test. Univariable and multivariable analyses were also performed using the Cox proportional hazard model to identify statistically significant prognostic factors.

RESULTS

A total of 18,322 patients were identified for survival analysis. Bone-only metastasis accounted for 39.80% of patients, followed by multiple metastasis (33.07%), lung metastasis (10.94%), liver metastasis (7.34%), other metastasis (7.34%), and brain metastasis (1.51%). The Kaplan-Meier plots showed that patients with bone metastasis had the best survival, while patients with brain metastasis had the worst survival in both BCSS and OS (p < 0.001, for both). Multivariable analyses showed that age, race, marital status, grade, tumor subtype, tumor size, surgery of primary cancer, and a history of radiotherapy or chemotherapy were independent prognostic factors.

CONCLUSION

Stage IV breast cancer patients have different clinicopathological characteristics and survival outcomes according to different metastatic sites. Patients with bone metastasis have the best prognosis, and brain metastasis is the most aggressive subgroup.

Prognostic Value of Brain Metastasis-Free Interval in Patients with Breast Cancer Brain Metastases

BACKGROUND

In patients with breast cancer brain metastases (BCBM), time between primary tumor diagnosis and appearance of brain metastases varies widely. Despite being a readily available clinical parameter, it remains unclear whether brain metastasis-free interval (BMFI) carries prognostic value among breast cancer patients. The aim of this study was to compare characteristics and overall survival among patients with varying BMFIs and to assess the prognostic role, if any, for BMFI.

METHODS

We retrospectively reviewed 3 institutional databases of adult female patients who were treated for BCBM between 1996 and 2017. Cox proportional hazards model and Kaplan-Meier survival curves were used to determine prognostic value of BMFI for survival.

RESULTS

A total of 503 patients were included. Median age at first brain metastasis was 52 (interquartile range [IQR]: 45-58) years. Median BMFI was 38 months (IQR: 18-66), and median overall survival was 17 months (IQR: 8-31). In univariate Cox proportional hazards model, younger age at BCBM, estrogen receptor (ER)+/human epidermal growth factor receptor 2 (HER2)+ tumor subtype, and the absence of liver or lung metastases were associated with longer survival. BMFI >3 years was not associated with longer survival (hazard ratio [HR] = 1.13; P = 0.21). In multivariate analysis, only subtype (ER+/HER2+ vs. ER-/HER2-; HR = 0.77; P = 0.02) and liver metastases (HR = 1.36; P = 0.01) were prognostic for survival. There was no significant association between BMFI and overall survival (HR = 0.99; P = 0.91).

CONCLUSIONS

In this large, retrospective cohort of breast cancer patients, BMFI was not prognostic for overall survival.

Population-based Analysis of Treatment and Survival in Women Presenting With Brain Metastasis at Initial Breast Cancer Diagnosis

PURPOSE

Brain metastasis at initial breast cancer diagnosis is rare. This study aims to evaluate the clinical characteristics of these patients and identify prognostic and treatment factors associated with improved survival.

METHODS

Subjects were 35 women referred from 1996 to 2005 with newly diagnosed breast cancer with synchronous brain metastasis. Overall survival (OS) and brain progression-free survival were examined using Kaplan-Meier methods and compared between subgroups with different clinicopathologic and treatment characteristics using log-rank tests.

RESULTS

Median age was 65 years. Whole-brain radiotherapy (WBRT) alone was used in 25 patients, surgical resection and postoperative WBRT in 5 patients, and no or unknown treatment in 5 patients. Patients who underwent cranial resection were more likely to have solitary brain metastasis (P=0.003) and no visceral involvement (P=0.006). Overall, median OS was 6.8 months and median brain progression-free survival was 6.5 months (range, 0.7 to 54 mo). Median OS were 15 months with surgery and postoperative WBRT, 5 months with WBRT alone, and 3 months with no brain treatment. Longer OS was observed with age below 65 years versus 65 years and above (11 vs. 5 mo, P=0.046), 0 to 1 versus ≥2 sites of extracranial metastasis (10 vs. 3 mo, P=0.047), and diagnosis from 2001 to 2005 versus 1996 to 2000 (10 vs. 3 mo, P=0.018). A trend toward improved OS was observed in patients with no visceral involvement (11 vs. 4 mo, P=0.09).

CONCLUSIONS

In this unique cohort presenting with breast cancer and synchronous brain metastasis, longer survival were observed with young age, limited extracranial metastasis, and no visceral disease. These characteristics may be used to select candidates for more aggressive treatment.

Brain metastasis in breast cancer: a comprehensive literature review

This comprehensive review provides information on epidemiology, size, grade, cerebral localization, clinical symptoms, treatments, and factors associated with longer survival in 14,599 patients with brain metastasis from breast cancer; the molecular features of breast cancers most likely to develop brain metastases and the potential use of these predictive molecular alterations for patient management and future therapeutic targets are also addressed. The review covers the data from 106 articles representing this subject in the era of modern neuroimaging (past 35 years). The incidence of brain metastasis from breast cancer (24 % in this review) is increasing due to advances in both imaging technologies leading to earlier detection of the brain metastases and introduction of novel therapies resulting in longer survival from the primary breast cancer. The mean age at the time of breast cancer and brain metastasis diagnoses was 50.3 and 48.8 years respectively. Axillary node metastasis was noted in 32.8 % of the patients who developed brain metastasis. The median time intervals between the diagnosis of breast cancer to identification of brain metastasis and from identification of brain metastasis to death were 34 and 15 months, respectively. The most common symptoms experienced in patients with brain metastasis consisted of headache (35 %), vomiting (26 %), nausea (23 %), hemiparesis (22 %), visual changes (13 %) and seizures (12 %). A majority of the patients had multiple metastases (54.2 %). Cerebellum and frontal lobes were the most common sites of metastasis (33 and 16 %, respectively). Of the primary tumors for which biomarkers were recorded, 37 % were estrogen receptor (ER)+, 41 % ER-, 36 % progesterone receptor (PR)+, 34 % PR-, 35 % human epithelial growth factor receptor 2 (HER2)+, 41 % HER2-, 27 % triple negative and 18 % triple positive (TP). Treatment in most patients consisted of a multimodality approach often with two or more of the following: whole brain radiation therapy (52 %), chemotherapy (51 %), stereotactic radiosurgery (20 %), surgical resection (14 %), trastuzumab (39 %) for HER2 positive tumors, and hormonal therapy (34 %) for ER and/or PR positive tumors. Factors that had an impact on prognosis included grade and size of the tumor, multiple metastases, presence of extra-cranial metastasis, triple negative or HER2+ biomarker status, and high Karnovsky score. Novel therapies such as application of agents to reduce tumor angiogenesis or alter permeability of the blood brain barrier are being explored with preliminary results suggesting a potential to improve survival after brain metastasis. Other potential therapies based on genetic alterations in the tumor and the microenvironment in the brain are being investigated; these are briefly discussed.