Prognostic factors in brain metastases: can we determine patients who do not benefit from whole-brain radiotherapy?

Relationship between the combination of platelet count and neutrophil-lymphocyte ratio and prognosis of patients with advanced non-small cell lung cancer treated with immune checkpoint inhibitors plus chemotherapy: A retrospective cohort study

BACKGROUND

The relationship between the combination of platelet count and neutrophil-lymphocyte ratio (COP-NLR) and prognosis in patients with advanced non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitor (ICI) combination therapy with chemotherapy remains unclear. Thus, we investigated prognostic factors, including the COP-NLR, to identify patients who could benefit from the therapeutic efficacy of ICI combination therapy for advanced NSCLC. Furthermore, we evaluated the relationship between the COP-NLR score during ICI combination therapy and treatment response.

METHODS

We conducted a retrospective cohort study of 88 patients with NSCLC who initially received ICI combination therapy. The primary outcome was overall survival (OS). The prognostic factors were extracted using the Cox proportional hazards model. The relationship between COP-NLR score at 3 weeks after starting ICI combination therapy and a good response (complete response [CR] and partial response [PR]) to treatment was analyzed using the chi-square test.

RESULTS

The median OS was 15.7 months. In the multivariable analysis, Eastern Cooperative Oncology Group Performance Status (ECOG PS) 2, distant metastatic sites ≥2, and baseline COP-NLR scores of 1, 2 were extracted as significant poor prognostic factors. The proportion of patients with CR and PR in the 3-week COP-NLR score of 0 group was significantly higher than that in scores of 1, 2 group.

CONCLUSIONS

Baseline COP-NLR, ECOG PS, and number of distant metastatic sites were prognostic factors in patients with NSCLC with ICI combination therapy. A lower 3-week COP-NLR was associated with a good response to treatment.

Prognostic value of cranial radiotherapy and optimal timing stratified by lung-molGPA for NSCLC patients with brain metastases

PURPOSE

The updated Graded Prognostic Assessment for Lung Cancer Using Molecular Markers (lung-molGPA) index provide more accurate survival prediction for patients diagnose with advanced non-small cell lung cancer (NSCLC) with brain metastases (BM). Given that the value of cranial radiotherapy (CRT) is still controversial for NSCLC patients with BM, this retrospective study aimed to evaluate the value of CRT and optimal timing in NSCLC patients with initial BM after stratified with lung-molGPA index.

METHODS

This study screened NSCLC patients with initial BM in our cancer center from February 2012 to July 2018. The prognosis value of CRT and optimal timing was evaluated with Kaplan-Meier survival analysis and the patients were classified into lung-molGPA0-2 and lung-molGPA2.5-4 group. Upfront CRT was defined as received CRT within 3 months after initial diagnosis and without BM progression, other CRT was classified into deferred CRT.

RESULTS

Overall, 288 patients were enrolled in our study, 156 patients received CRT. The median follow-up time was 47 months. In the entire cohort, the median PFS and OS were 9.2 and 17.0 months, respectively. In the lung-molGPA2.5-4 group, CRT can bring significantly overall survival benefit for NSCLC patients with initial BM (HR: 0.48, 95% CI: 0.34-0.68, P < 0.0001), and the upfront CRT can further expand this survival benefits compared with deferred CRT (HR: 0.49, 95% CI: 0.27-0.89, P = 0.0026). But this phenomenon was not observed in lung-molGPA0-2 group patients.

CONCLUSION

Upfront CRT could bring significantly overall survival benefit for these patients with lung-molGPA2.5-4 but not for patients with lung-molGPA0-2.

Analysis of prognostic factors in patients with brain metastases affecting survival

INTRODUCTION

Brain metastases (BM) are associated with dismal prognosis as they cause significant morbidity and affect the quality of life of patients. Management of BM depends on the following factors: age, patient performance, size and the number of lesions, location of the tumor, comorbidities, primary tumor type, and extracranial disease burden. In the present study, the pattern of occurrence, clinical characteristics, treatment outcome of brain metastases, and factors, tumor characteristics, and treatment that may impact BM patients' overall survival were analyzed.

METHODS

Retrospective analysis of medical records of 116 patients with histologically proven primary site solid tumors with brain metastases was done in the present study. Clinicoradiological and pathological parameters were documented. The relationship between variables and outcome was assessed by univariate analysis using the Cox proportional regression model to reach a significance of p < 0.05, to determine independent predictors of overall survival.

RESULTS

One hundred sixteen patients of BM from various solid malignancies were included. Age ranged from 18 to 81 years (median 53.5). One hundred four patients received WBRT with a dose range of 8-40Gy/1-15fr, 7 received SRS with a dose of 18-24Gy depending on the size of the metastatic lesion, and 2 received SRT 27-33Gy/3fr. At the time of final analysis, 47 patients with BM had expired, 60 were lost to follow-up, and 9 were alive. Median survival was 8.25 (0.5-32.5 months) months. Female gender (χ² = 8.423; p = 0.015), RPA I (χ² = 9.353; p = 0.05), and metachronous BM (χ² = 3.793; p = 0.03) were associated with better survival. Patients with age 41-50 years, adenocarcinoma lung histology, and supratentorial location survived more than 2 years but did not show any statistical significance.

CONCLUSION

Brain metastases portend a very dismal prognosis. Certain clinicoradiological and pathologic factors have been identified to affect survival. More prospective multicentric trials, with a larger sample size, need to be conducted to assess the benefit of radiation in patients with limited life expectancy and identify prognostic and predictive factors for survival.

WBRT for brain metastases from non-small cell lung cancer: for whom and when?-Contemporary point of view

The incidence of brain metastases (BM) is estimated between 20% and 40% of patients with solid cancer. The most common cause of this failure is lung cancer, and in locally advanced non-small cell lung cancer (NSCLC) BM represent a common site of relapse in 30-55% cases. The basic criteria of therapeutic decision-making are based on the significant prognostic factors which are components of prognostic scores. The standard approach to treatment of BM from NSCLC include whole brain radiotherapy (WBRT) which is used as adjuvant modality after local therapy (surgery or stereotactic radiosurgery) or as primary treatment and it remains the primary modality of treatment for patients with multiple metastases. WBRT is also used in combination with systemic therapy. The aim of presented review of literature is trying to answer which patients with BM from NSCLC should receive WBRT and when it could be omitted. There were presented the aspects of application of WBRT in relation to (I) choice between WBRT or the best supportive care and (II) employment of WBRT in combination with local treatment modalities [surgical resection or stereotactic radio-surgery (SRS)] and/or with systemic therapy. According to data from literature we concluded that the most important factor that needs to be considered when assessing the suitability of a patient for WBRT is the patient's prognosis based on the Lung-molGPA score. WBRT should be applied in treatment of multiple BM from lung cancer in patients with favourable prognosis and in in patients with presence of EML4-ALK translocation before therapy with crizotinib. Whereas WBRT could be omitted in patients with poor prognosis and after primary SRS.

A new model outperforming RPA and DS-GPA scores for individualized survival prediction of patients following whole brain irradiation for brain metastasis

PURPOSE

Survival after whole brain radiation therapy (WBRT) in patients with multiple brain metastases (BM) is currently predicted by group-based scoring systems with limited usability for decision. We aimed to develop a more relevant individualized predictive model than Radiation Therapy Oncology Group - Recursive Partitioning Analysis (RTOG-RPA) and Diagnosis - Specific Graded Prognostic Assessment (DS-GPA) for patients with limited life-expectancy.

METHODS

Based on a Discovery cohort of patients undergoing WBRT, multivariable piecewise Cox regression models with time cut-offs at 1 and 3 months were developed to predict overall survival (OS). A final parsimonious model was defined, and an external validation cohort was used to assess its discrimination and calibration at one, six, and 12 months.

RESULTS

In the 173-patient Discovery cohort, the majority of patients had primary lung cancer (56%), presence of extracranial disease (ECD) (75%), Eastern Cooperative Oncolgy Group - Performance Status (ECOG-PS) score 1 (41%) and no intracranial hypertension (ICH) (74%). Most patients were classified as the RPA class II (48%). The final piecewise Cox model was based on primary site, age, ECD, ECOG-PS and ICH. An external validation of the model was carried out using a cohort of 79 patients. Individualized survival estimates obtained with this model outperformed the RPA and DS-GPA scores for overall survival prediction at 1-month, 6-months and 12- months in both Discovery and Validation cohorts. A R/Shiny web application was developed to obtain individualized predictions for new patients, providing an easy-to-use tool for clinicians and researchers.

CONCLUSION

Our model provides individualized estimates of survival for poor prognosis patients undergoing WBRT, outperforming actual scoring systems.

Applying the QUARTZ Trial Results in Clinical Practice: Development of a Prognostic Model Predicting Poor Outcomes for Non-small Cell Lung Cancers with Brain Metastases

AIMS

The role of whole brain radiotherapy (WBRT) in patients with brain metastases from non-small cell lung cancers (NSCLC) has been questioned. However, no reliable criteria exist to identify patients who do not benefit from WBRT. The objective of the current study was to develop a prognostic model to identify such patients whose survival matches that of the Quality of Life after Treatment for Brain Metastases (QUARTZ) study.

MATERIALS AND METHODS

Outcome data of patients with NSCLC with brain metastases undergoing WBRT enrolled in a prospective observational study in a tertiary cancer centre were used to develop a prognostic model. Baseline clinico-radiological factors were used for development of the model. The model was internally validated and calibration accuracy was checked for prediction of 70 day mortality. The generated prognostic model was presented as a nomogram.

RESULTS

The median overall survival of 140 patients enrolled in the study was 166 days (95% confidence interval 108-242 days). The prognostic model identified gender, Karnofsky performance status and epidermal growth factor receptor activating mutation status as significant factors influencing overall survival. The model showed a modest discriminative ability with an optimism-corrected C-index of 0.64. However, model calibration error did reveal a moderate degree of calibration error. The high-risk subgroup identified by the model had a median overall survival of 67 days (95% confidence interval 56-101 days), which was similar to that observed in the QUARTZ trial.

CONCLUSION

This prognostic model derived from traditional clinico-radiological features had a modest ability to identify patients with poor prognosis who may not benefit from WBRT. However, the high-risk subgroup identified using this prognostic model had a survival similar to that observed for patients in the QUARTZ trial.

Prognostic factors analysis in EGFR mutation-positive non-small cell lung cancer with brain metastases treated with whole brain-radiotherapy and EGFR-tyrosine kinase inhibitors

The survival time of non-small cell lung cancer (NSCLC) patients with brain metastases has been previously reported to be 6.5-10.0 months, even with systematic treatment. Patients that possess a certain epidermal growth factor receptor (EGFR) mutation alongside NSCLC with brain metastases also have a short survival rate, and a reliable prognostic model for these patients demonstrates a strong correlation between the outcome and treatment recommendations. The Cox proportional hazards regression and classification tree models were used to explore the prognostic factors in EGFR mutation-positive NSCLC patients with brain metastases following whole-brain radiation therapy (WBRT) and EGFR-tyrosine kinase inhibitor (EGFR-TKI) treatment. A total of 66 EGFR mutation-positive NSCLC patients with brain metastases were retrospectively reviewed. Univariate and multivariate analyses by Cox proportional hazards regression were then performed. The classification tree model was applied in order to identify prognostic groups of the patients. In the survival analysis, age, carcinoembryonic antigen (CEA) and status of the primary tumor were prognostic factors for progression free survival (P=0.006, 0.014 and 0.005, respectively) and overall survival (P=0.009, 0.013 and 0.009, respectively). The classification tree model was subsequently applied, which revealed 3 patient groups with significantly different survival times: Group I, age <65 years and CEA ≤10 µg/ml; Group II, age <65 years and CEA >10 µg/ml or age ≥65 years and CEA ≤10 µg/ml; and Group III, age ≥65 years and CEA >10 µg/ml. The major prognostic predictors for EGFR mutation-positive NSCLC patients with brain metastases following WBRT and EGFR-TKI were age and CEA. In addition, primary tumor control may be important for predicting survival.

Early identification of asymptomatic brain metastases from renal cell carcinoma

Current guidelines for metastatic renal cell carcinoma (mRCC) do not recommend routine brain imaging as part of the surveillance protocol unless central nervous system (CNS) symptoms or abnormal laboratory values suggest brain involvement. We hypothesized that strict adherence to these guidelines will delay diagnosis and management of RCC brain metastases. Retrospective review of our IRB-approved kidney cancer database examined a consecutive series of subjects from 1995 to 2012. We identified all mRCC patients with radiographic evidence of renal cell brain metastasis (RCCBM). RCCBM patients were divided into two cohorts: CNS symptoms present at RCCBM diagnosis and those without symptoms present at diagnosis. Fifty-two patients within our database met criteria; CNS symptoms were present at RCCBM diagnosis in 73 % (36) of patients. Median size of RCCBM on presentation was smaller in the asymptomatic verses the symptomatic cohort (0.83 vs. 1.7 cm, p = 0.003). Multivariate analysis demonstrated presence of CNS symptoms and female gender as a survival advantage (p < 0.05) while poor performance status, history of tobacco abuse and coexistence of lung metastasis were poor indicators for survival (p < 0.05). Patients with pulmonary metastases and a history of tobacco abuse are more likely to harbor RCCBM and perhaps in the absence of CNS symptoms these subjects should have routine brain surveillance incorporated into the RCC follow up. Overall, the current urologic guidelines may be missing a subset of metastatic RCC patients who could potentially benefit from early radiation or neurosurgical intervention. This may result in improved overall survival.

Probabilistic modeling of short survivability in patients with brain metastasis from lung cancer

The prediction of substantially short survivability in patients is extremely risky. In this study, we proposed a probabilistic model using Bayesian network (BN) to predict the short survivability of patients with brain metastasis from lung cancer. A nationwide cancer patient database from 1996 to 2010 in Taiwan was used. The cohort consisted of 438 patients with brain metastasis from lung cancer. We utilized synthetic minority over-sampling technique (SMOTE) to solve the imbalanced property embedded in the problem. The proposed BN was compared with three competitive models, namely, naive Bayes (NB), logistic regression (LR), and support vector machine (SVM). Statistical analysis showed that performances of BN, LR, NB, and SVM were statistically the same in terms of all indices with low sensitivity when these models were applied on an imbalanced data set. Results also showed that SMOTE can improve the performance of the four models in terms of sensitivity, while keeping high accuracy and specificity. Further, the proposed BN is more effective as compared with NB, LR, and SVM from two perspectives: the transparency and ability to show the relation of factors affecting brain metastasis from lung cancer; it allows decision makers to find the probability despite incomplete evidence and information; and the sensitivity of the proposed BN is the highest among all standard machine learning methods.

Brain metastases in non-small-cell lung cancer

Up to 50% of patients with advanced non-small-cell lung cancer will develop brain metastases at some point during their illness. These metastases cause a substantial burden in morbidity and mortality, which has motivated research and technological innovation over the past 2 decades. Surgery, radiotherapy, and systemic therapies have each played a role in management, with the greatest changes associated with the popularization of stereotactic radiosurgery. In this review, the evidence behind each modality used in the management of brain metastases for non-small-cell lung cancer patients is examined, and recommendations regarding the current standards of care and areas of future research focus are provided.

Incidence of symptomatic brain metastasis following radical radiotherapy for non-small cell lung cancer: is there a role for prophylactic cranial irradiation?

OBJECTIVE

Brain metastases following radical radiotherapy for non-small cell lung cancer (NSCLC) are a recognised phenomenon; however, the incidence of symptomatic brain metastasis is currently unknown. The aim of the study was to identify the number of patients, staged in accordance with National Institute for Health and Clinical Excellence (NICE) guidance, who developed symptomatic brain metastasis following radical radiotherapy. There are two aims: to evaluate NICE guidance; and to provide vital information on the likely benefit of prophylactic cranial irradiation (PCI) in reducing neurological symptoms from brain metastasis.

METHODS

A retrospective review of 455 patients with NSCLC who had undergone radical radiotherapy in 2009 and 2010 was performed. Computer-based systems were used to identify patient and tumour demographics, the staging procedures performed and whether brain imaging had identified brain metastasis in the follow-up period.

RESULTS

The total number of patients with brain metastasis within 6 months was 3.7%. The proportion of brain metastasis within 6 months in Stage I, II and III NSCLC throughout both years was 2.8%, 1.0% and 5.7%, respectively. Within the follow-up period (median 16 months, range 6-30 months), the total number of patients who developed symptomatic brain metastasis was 7.9%.

CONCLUSION

Patients staged in accordance with NICE guidance, of whom only 7.7% underwent brain staging, have a minimal incidence of brain metastasis following radical radiotherapy. The number of patients developing symptoms from brain metastasis following radical radiotherapy may be less than the morbidity caused by PCI.

ADVANCES IN KNOWLEDGE

This finding supports the NICE guidance and brings into question the potential benefit of PCI.

Short survival after palliative radiotherapy for brain metastases in lung cancer: does the end justify the means?

People with lung cancer (LCa) and symptomatic metastatic disease deserve palliative radiotherapy to promote a better quality of remaining life. On the other hand, in the case being described that of a LCa patient with brain and spinal metastases who died shortly after irradiation-- could management consisting of hospice and/or supportive care have been a better choice? Prognostic factors were analyzed in this retrospective study of the early deaths of 20 LCa patients with brain metastases in order to assist in a more rational decision making regarding treatment.

Local control of newly diagnosed and distally recurrent, low-volume brain metastases with fixed-dose (20 gy) gamma knife radiosurgery

BACKGROUND

Metastases to the brain occur in 20% to 30% of patients with cancer and have been identified on autopsy in as many as 50% of patients.

OBJECTIVE

To analyze the efficacy of 20-Gy Gamma Knife radiosurgery (GKR) as initial treatment in patients with 1 to 3 brain metastases ≤ 2 cm in greatest diameter.

METHODS

A retrospective analysis of 114 consecutive adults with Karnofsky performance status ≥ 60 who received GKR for 1 to 3 brain metastases ≤ 2 cm in size was performed. Five patients lacked detailed follow-up and were excluded, leaving 109 for outcome analysis (34 men and 75 women; median age, 61.2 years). All metastases received 20 Gy to the 50% isodose line.

RESULTS

One hundred nine patients underwent treatment of 164 metastases at initial GKR. Twenty-six patients (23.9%) were alive at last follow-up (median time, 29.9 months; range, 6.6 months to 7.8 years). The median overall survival was 13.8 months (range, 1 day to 7.6 years). Among the 52 patients with distant failure, 33 patients received 20 Gy to 95 new lesions. A total of 259 metastases received 20 Gy, and 4 patients lacked imaging follow-up secondary to death before posttreatment imaging. Local failure occurred in 17 of 255 treated lesions (6.7%), yielding an overall local control rate of 93.3%. Actuarial local control at 6, 12, 24, and 36 months was 96%, 93%, 89%, and 88%, respectively. Permanent neurological complications occurred in 3 patients (2.8%).

CONCLUSION

Among patients with 1 to 3 brain metastases ≤ 2 cm in size who have not received whole-brain radiation therapy, GKR with 20 Gy provides high rates of local control with low morbidity and excellent neurological symptom-free survival.

Patient selection and clinical outcomes in patients operated for brain metastases--is specialty of the referring physicians a prognostic factor?

INTRODUCTION

As median survival in patients with brain metastases is short, but with wide confidence intervals, it is crucial to select the appropriate therapy. Various specialists diagnose brain metastases and refer selected patients to neurosurgical departments. There is, however, no robust and objective instrument for clinical decision making in individual patients with brain metastases. In consecutive patients treated with open surgery, we aimed to explore if clinical outcomes differed between the specialties of the referring physicians.

METHODS

We retrospectively included all adult (≥ 18 years) patients undergoing open surgery for brain metastases from 2004 through 2009 (n = 141). We divided the specialties of referring physicians in three groups; oncologists, pulmonologists and others.

RESULTS

59 patients (42%) were referred from oncologists, 24 (17%) referred from pulmonologists and 58 (41%) referred from other specialties. There was no significant association between the graded prognostic assessment score and clinical specialty (P = 0.366), reflecting similar referral practice. Twenty-four patients (17%) died within 3 months from surgery. There was no association between clinical specialty and 3 months mortality (P = 0.461). The perioperative mortality was 7% (n = 10), and we registered 19% (n = 27) complications. Risk of perioperative mortality (P = 0.448) or surgical complications (P = 0.330) were also not associated with the specialty of the referring clinician.

CONCLUSION

Patient selection and clinical outcomes did not differ between the specialties of referring physicians. We believe patient selection and outcomes were fairly similar between groups as a result of the multidisciplinary work-up between referring physicians and neurosurgeons. However, with 17% 3-month mortality there is still room for improvement in patient selection.

Surgical resection of brain metastases: the prognostic value of the graded prognostic assessment score

There is a need for better predictors for short survival in patients with brain metastases undergoing open surgery. The graded prognostic assessment (GPA) has recently been developed to predict survival in patients with brain metastases. We explored the prognostic capabilities of GPA in a consecutive neurosurgical population of brain metastases. Secondarily, we evaluated if GPA scores can provide information on safety of the operation and postoperative functional outcome. We retrospectively included all adult (≥18 years) patients undergoing open surgery for brain metastases from 2004 through 2009 (n = 141). The population was grouped into GPA 0–1 (n = 22, 16%), GPA 1.5–2.5 (n = 90, 64%), GPA 3 (n = 19, 14%), and GPA 3.5–4 (n = 10, 7%) according to the prognostic indices. Median survival times were 6.3 months (range 0.8–23.7) in GPA 0–1, 7.8 months in GPA 1.5–2.5 (range 0.2–75.0), 14.0 months in GPA 3 (range 0.0–77.4), and 18.4 months in GPA 3.5–4 (range 0.1–63.7). This represents a significant difference between groups (P = 0.010). There were no associations between GPA and 30-day mortality (P = 0.871), 3-month mortality (P = 0.750), complications (P = 0.330) or change in Karnofsky Performance status postoperatively (P = 0.558). GPA scores hold prognostic properties in patients operated for brain metastases. However, GPA did not predict short-term mortality, limiting the clinical usefulness in a neurosurgical population. The prognostic indices cannot be used alone to decide if surgery is warranted on an individual basis, or to evaluate risks and benefits of surgery.

Defining treatment for brain metastases patients: nihilism versus optimism

AIMS

Treatment of brain metastases patients has included whole brain radiotherapy (WBRT) for over 50 years, and there is much data showing this to be associated with short-term gains. The integration of resection and radiosurgery to these patients allows some better prognostic groups to experience long-term local control and improvement in quality of life. The recursive partitioning analysis of the Radiation Therapy Oncology Group (RTOG) has been used as a predictive model for over a decade to identify three classes of patients. Number of lesions has been used to define treatment for a good prognostic subgroup that is eligible for surgery or radiosurgery, but there are few prospective studies of poorer prognosis brain metastases patients to evaluate the influence of number of lesions on the prediction of outcome. We examined patient, treatment and outcome parameters of all brain metastases patients in a 5-year period so that we could measure outcome and evaluate various factors on survival.

METHODS AND RESULTS

This was a population-based study of all brain metastases patients in Southern Alberta between 2000 and 2005. It used an Excel spreadsheet database and STATA 8 software to analyze outcomes. The study included 568 patients representing 4.4% of our radiotherapy population. Median age, performance status and distribution of primary disease sites were comparable with other large series. Overall survival for the whole group was 3.05 months. Independent factors predicting for improved overall survival included younger age, KPS <70, less than four lesions and the use of stereotactic radiosurgery. Presence of extracranial disease or persistence of primary disease did not adversely impact survival outcome.

CONCLUSIONS

This series shows that the number of lesions is a strong predictor of outcome. Integration of this factor into a decision-making model allows for identification of not only good prognosis patients who will benefit from aggressive treatment but it also facilitates decision making for poorer prognosis patients who are less likely to benefit from WBRT. Recursive partitioning RTOG class 2 and 3 patients with more than three lesions did particularly poor and had an overall survival of 3 months with WBRT. We question the value of WBRT in this subgroup and wonder if best supportive care would be more justifiable given the low survival figures achieved.

Prognostic index to identify patients who may not benefit from whole brain radiotherapy for multiple brain metastases from lung cancer

Palliative whole brain radiotherapy (WBRT) is often recommended in the management of multiple brain metastases. Allowing for WBRT waiting time, duration of the WBRT course and time to clinical response, it may take 6 weeks from the point of initial assessment for a benefit from WBRT to manifest. Patients who die within 6 weeks ('early death') may not benefit from WBRT and may instead experience a decline in quality of life. This study aimed to develop a prognostic index (PI) that identifies the subset of patients with lung cancer with multiple brain metastases who may not benefit from WBRT because of 'early death'. The medical records of patients with lung cancer who had WBRT recommended for multiple brain metastases over a 10-year period were retrospectively reviewed. Patients were classified as either having died within 6 weeks or having lived beyond 6 weeks. Potential prognostic indicators were evaluated for correlation with 'early death'. A PI was constructed by modelling the survival classification to determine the contribution of these factors towards shortened survival. Of the 275 patients recommended WBRT, 64 (23.22%) died within 6 weeks. The main prognostic factor predicting early death was Eastern Cooperative Oncology Group (ECOG) status >2. Patients with a high PI score (>13) were at higher risk of 'early death'. Twenty-three per cent of patients died prior to benefit from WBRT. ECOG status was the most predictive for 'early death'. Other factors may also contribute towards a poor outcome. With further refinement and validation, the PI could be a valuable clinical decision tool.

The management of brain metastases in patients with non-small cell lung cancer-is it time to go back to the drawing board?

Unless confirmation of a solitary brain metastasis is made in the context of absent extracranial disease and good performance status, patients with metastatic brain disease from non-small cell lung cancer fare badly. There are no level I recommendations for the management of those with multiple brain metastases. The role of whole brain radiotherapy is not certain in those of poorer performance status. This overview assesses what we know and what we are uncertain of in the context of a changing paradigm for some subsets of patients who may obtain superior palliation with treatments targeted at the histological or molecular level. Once the standard treatment is established (steroids plus or minus whole brain radiotherapy), those who are of better performance status may be considered for comparison of this standard with or without systemic management.

Physician expectations of treatment outcomes for patients with brain metastases referred for whole brain radiotherapy

PURPOSE

Patients with advanced cancer are referred to our Rapid Response Radiotherapy Program for quick access to palliative radiotherapy. The primary objective of this prospective study was to determine the physician expectations of the treatment outcomes for patients with brain metastases referred for whole brain radiotherapy (WBRT). The secondary objectives were to determine the factors influencing the expectations and to examine the accuracy of the physician-estimated patient survival.

METHODS AND MATERIALS

Patients were identified during a 17-month period. The referring physicians were sent a survey by facsimile to be completed and returned before the patient consultation. Information was sought on the patient's disease status, the physician's expectations of WBRT, the estimated patient survival and performance status, and physician demographic data.

RESULTS

A total of 137 surveys were sent out, and the overall response rate was 57.7%. The median patient age was 66 years (range, 35-87), 78.5% had multiple brain metastases, 42.3% had a controlled primary tumor, and 62.3% had extracranial disease. WBRT was thought to stabilize neurologic symptoms, improve quality of life, and allow for a Decadron (dexamethasone) taper by > or =94.9% of the referring physicians; 87.0% thought WBRT would improve performance status; 77.9% thought it would improve neurologic symptoms; and 40.8% thought it would improve survival. The referring physicians estimated patient survival as a median of 6.0 months; however, the actual survival was a median of 2.5 months, for a median individual difference of 1.9 months (p < .0001).

CONCLUSION

Physicians referring patients with brain metastases for consideration of WBRT are often overly optimistic when estimating the clinical benefit of the treatment and overestimate patient survival. These findings highlight the need for education and additional research in this field.

Prediction of short survival in patients with brain metastases based on three different scores: a role for 'triple-negative' status?

AIMS

To evaluate models predicting short survival in patients with brain metastases treated with whole-brain radiotherapy (WBRT).

MATERIALS AND METHODS

This was a retrospective analysis of 312 patients. Each patient was assigned to three different four-tiered prognostic scores: the Basic Score for Brain Metastases (BSBM), the Graded Prognostic Assessment (GPA) and the score developed by Rades et al. In addition, a 'triple-negative' cohort was evaluated (all three scores predicted unfavourable prognosis, n=30).

RESULTS

No statistically significant survival differences were found between the most unfavourable BSBM, GPA, Rades et al. and 'triple-negative' groups. The BSBM best predicted short survival: patients classified in the unfavourable group (Karnofsky performance status <80, uncontrolled primary tumour and presence of extracranial metastases) had a 12.5% survival at 4 months and a 0% 1-year survival. Patients in this group who survived for 4 months or more had simultaneously detected cancer and brain metastases, were treatment naive, and received systemic therapy in addition to WBRT. Excluding this type of patient from the analysis resulted in survival figures that were indistinguishable from those obtained with best supportive care without WBRT in other studies.

CONCLUSIONS

Although continuous research is necessary to identify patients who can be managed safely and palliated without WBRT, we feel that a model of the BSBM unfavourable group (Karnofsky performance status <80, uncontrolled primary tumour and presence of extracranial metastases) and no intent to treat systemically might form a basis for validation in other large databases. The triple-negativity criterion was not superior for predicting poor prognosis.

Prediction of very short survival in patients with brain metastases from breast cancer

AIMS

Current prognostic models are not accurate enough to identify brain metastases patients with very short survival, i.e. <2 months, who are unlikely to derive major benefit from whole brain radiotherapy. Our aim was to develop a more reliable model.

MATERIALS AND METHODS

This was a retrospective analysis of a German database, which was used to develop a score, and an additional database from Norway, which was used for validation purposes.

RESULTS

The groups included 67 and 32 patients, respectively. An analysis of prognostic factors resulted in a risk score based on performance status, extra-cranial metastases, the interval from breast cancer to brain metastases and a need for corticosteroid treatment, which classified 63 of 67 test patients correctly. However, the validation failed and unfortunately the risk score that performed best in the Norwegian patients (31 of 32 correctly predicted) was not applicable to the German patients.

CONCLUSIONS

The prediction of short survival is associated with several caveats and seems to result in an unacceptable risk of withholding radiotherapy in patients who actually survive for longer than 2 months.

Brain metastases

PURPOSE OF REVIEW

Brain metastases occur in 10-30% of cancer patients, and they are associated with a dismal prognosis. Radiation therapy has been the mainstay of treatment for patients without surgically treatable lesions. For patients with good prognostic factors and a single metastasis, surgical resection is recommended. The management of patients with multiple metastases, poor prognostic factors, or unresectable lesions is, however, controversial. Recently published data will be reviewed.

RECENT FINDINGS

Radiation therapy has been shown to substantially reduce the risk of local recurrence after surgical resection of brain metastases, although this does not translate into improved survival. Recently, stereotactic radiosurgery has emerged as an increasingly important alternative to surgery that appears to be associated with less morbidity and similar outcomes. Other potentially promising therapies under investigation include interstitial brachytherapy, new chemotherapeutic agents that cross the blood-brain barrier, and targeted molecular agents.

SUMMARY

Patients with brain metastases are now eligible for a number of treatment options that are increasingly likely to improve outcomes. Randomized, prospective trials are necessary to better define the utility of radiosurgery versus surgery in the management of patients with brain metastases. Future investigations should address quality of life and neurocognitive outcomes, in addition to traditional outcome measures such as recurrence and survival rates. The potentially substantial role for chemotherapeutics that cross the blood-brain barrier and for novel targeted molecular agents is now being elucidated.