1
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Smith DL, Debeb BG, Diagaradjane P, Larson R, Kumar S, Ning J, Lacerda L, Li L, Woodward WA. Prophylactic cranial irradiation reduces the incidence of brain metastasis in a mouse model of metastatic, HER2-positive breast cancer. Genes Cancer 2021; 12:28-38. [PMID: 33884104 PMCID: PMC8045965 DOI: 10.18632/genesandcancer.212] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/21/2021] [Indexed: 12/02/2022] Open
Abstract
Prophylactic cranial irradiation (PCI) can reduce the incidence of brain metastasis and
improve overall survival in some patients with acute lymphoblastic leukemia or small-cell
lung cancer. We examined the potential effects of PCI in a mouse model of breast cancer
brain metastasis. The HER2+ inflammatory breast cancer cell line MDA-IBC3 was labeled with
green fluorescent protein and injected via tail-vein into female SCID/Beige mice. Mice
were then given 0 Gy or 4 Gy of whole-brain irradiation 2 days before tumor-cell injection
or 5 days, 3 weeks, or 6 weeks after tumor-cell injection. Mice were sacrificed 4-weeks or
8-weeks after injection and brain tissues were examined for metastasis by fluorescent
stereomicroscopy. In the unirradiated control group, brain metastases were present in 77%
of mice at 4 weeks and in 90% of mice at 8 weeks; by comparison, rates for the group given
PCI at 5 days after tumor-cell injection were 20% at 4 weeks (p=0.01) and
30% at 8 weeks (p=0.02). The PCI group also had fewer brain metastases
per mouse at 4 weeks (p=0.03) and 8 weeks (p=0.006)
versus the unirradiated control as well as a lower metastatic burden
(p=0.01). Irradiation given either before tumor-cell injection or 3-6
weeks afterward had no significant effect on brain metastases compared to the unirradiated
control. These results underscore the importance of timing for irradiating subclinical
disease. Clinical whole brain strategies to target subclinical brain disease as safely as
possible may warrant further study.
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Affiliation(s)
- Daniel L Smith
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bisrat G Debeb
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Parmeswaran Diagaradjane
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard Larson
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Swaminathan Kumar
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,The University of Texas MD Anderson Cancer Center, UTHealth Graduate School of Biomedical Sciences, Houston, TX, USA
| | - Jing Ning
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lara Lacerda
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Li Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wendy A Woodward
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abstract
PURPOSE OF REVIEW The current article reviews the state of art of prevention strategies for brain metastases from solid tumors and touches both old pivotal studies and new directions of personalized molecular approaches. RECENT FINDINGS Prophylactic cranial irradiation (PCI) has a definite role in the prevention of relapse into the brain for patients with small cell lung cancer (SCLC) responding to chemotherapy and radiotherapy as it prolongs overall survival (OS). However, the risk of late cognitive deficit following whole brain radiotherapy (WBRT) in this patient population is still not well known. Conversely, PCI significantly reduces the incidence of brain metastases and prolongs the disease-free interval in patients with non-SCLC (NSCLC), but does not improve OS thus far. Pharmacologic prevention is a new concept driven by the efficacy of targeted agents on macrometastases from specific molecular subgroups. SUMMARY The future challenges for prevention of brain metastases are represented by the identification of subgroups of patients at higher risk of relapse into the brain coupled with either new WBRT strategies to better preserve cognition or effective molecular agents to target micrometastases.
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Affiliation(s)
- Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
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3
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Challenges in the treatment of breast cancer brain metastases: evidence, unresolved questions, and a practical algorithm. Clin Transl Oncol 2020; 22:1698-1709. [PMID: 32207041 DOI: 10.1007/s12094-020-02333-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/01/2020] [Indexed: 12/24/2022]
Abstract
Breast cancer is the leading cause of brain metastases in women. Large randomized clinical trials that have evaluated local therapies in patients with brain metastases include patients with brain metastases from a variety of cancer types. The incidence of brain metastases in the breast cancer population continues to grow, which is, aside from the rising breast cancer incidence, mainly attributable to improvements in systemic therapies leading to more durable control of extracranial metastatic disease and prolonged survival. The management of breast cancer brain metastases remains challenging, even more so with the continued advancement of local and highly effective systemic therapies. For most patients, a metastases-directed initial approach (i.e., radiation, surgery) represents the most appropriate initial therapy. Treatment should be based on multidisciplinary team discussions and a shared decision with the patients taking into account the risks and benefits of each therapeutic modality with the goal of prolonging survival while maintaining quality of life. In this narrative review, a multidisciplinary group of experts will address challenging questions in the context of current scientific literature and propose a therapeutic algorithm for breast cancer patients with brain metastases.
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4
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Lucke-Wold B, Scott K. A Brief Overview of Neurosurgical Management for Breast Cancer Metastasis. SF JOURNAL OF MEDICAL ONCOLOGY AND CANCER 2020; 1:1001. [PMID: 32613208 PMCID: PMC7328909 DOI: pmid/32613208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Despite advances in chemotherapy and radiation, stage IV breast cancer presents a serious challenge to clinicians in light of the continued poor outcomes for patients. Stage IV breast cancer frequently metastasizes to the brain often necessitating neurosurgical intervention. The goals of the neurosurgeon are to adequately address metastatic disease to the central nervous system, limit morbidity for the patients, while preserving as much neurologic function as possible, and to help guide next steps regarding need for radiation and immunotherapy. In this review, we provide a background overview of the role of neurosurgery in managing stage IV metastatic breast cancer involving the brain, discuss what is known about brain metastasis, and highlight avenues for future study and investigation.
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Affiliation(s)
- Brandon Lucke-Wold
- Correspondence: Brandon Lucke-Wold, Department of Neurosurgery, University of Florida, USA.
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5
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Murrell DH, Zarghami N, Jensen MD, Dickson F, Chambers AF, Wong E, Foster PJ. MRI surveillance of cancer cell fate in a brain metastasis model after early radiotherapy. Magn Reson Med 2016; 78:1506-1512. [PMID: 27851873 DOI: 10.1002/mrm.26541] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 09/21/2016] [Accepted: 10/14/2016] [Indexed: 12/17/2022]
Abstract
PURPOSE Incidence of brain metastasis attributed to breast cancer is increasing and prognosis is poor. It is thought that disseminated dormant cancer cells persist in metastatic organs and may evade treatments, thereby facilitating a mechanism for recurrence. Radiotherapy is used to treat brain metastases clinically, but assessment has been limited to macroscopic tumor volumes detectable by clinical imaging. Here, we use cellular MRI to understand the concurrent responses of metastases and nonproliferative or slowly cycling cancer cells to radiotherapy. METHODS MRI cell tracking was used to investigate the impact of early cranial irradiation on the fate of individual iron-labeled cancer cells and outgrowth of breast cancer brain metastases in the human MDA-MB-231-BR-HER2 cell model. RESULTS Early whole-brain radiotherapy significantly reduced the outgrowth of metastases from individual disseminated cancer cells in treated animals compared to controls. However, the numbers of nonproliferative iron-retaining cancer cells in the brain were not significantly different. CONCLUSIONS Radiotherapy, when given early in cancer progression, is effective in preventing the outgrowth of solitary cancer cells to brain metastases. Future studies of the nonproliferative cancer cells' clonogenic potentials are warranted, given that their persistent presence suggests that they may have evaded treatment. Magn Reson Med 78:1506-1512, 2017. © 2016 International Society for Magnetic Resonance in Medicine.
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Affiliation(s)
- Donna H Murrell
- Imaging Research Laboratories, Robarts Research Institute, London, Ontario, Canada.,Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Niloufar Zarghami
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Michael D Jensen
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Fiona Dickson
- Imaging Research Laboratories, Robarts Research Institute, London, Ontario, Canada
| | - Ann F Chambers
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada
| | - Eugene Wong
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada
| | - Paula J Foster
- Imaging Research Laboratories, Robarts Research Institute, London, Ontario, Canada.,Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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6
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Gandhi AK, Sharma DN, Rath GK. Prophylactic cranial irradiation in breast cancer: A new way forward. Indian J Med Paediatr Oncol 2015; 36:77-8. [PMID: 26157281 PMCID: PMC4477380 DOI: 10.4103/0971-5851.158822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Ajeet Kumar Gandhi
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Daya Nand Sharma
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Goura Kishor Rath
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India ; Department of Radiation Oncology, National Cancer Institute, Second Campus All India Institute of Medical Sciences, Jhajjar, Haryana, India. E-mail:
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7
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Snider JW, Gondi V, Brown PD, Tome W, Mehta MP. Prophylactic cranial irradiation: recent outcomes and innovations. CNS Oncol 2015; 3:219-30. [PMID: 25055130 DOI: 10.2217/cns.14.22] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Brain metastases represent a frequent problem in several malignancies. They can shorten survival while causing significant morbidity and impairment in the patient's quality of life. Prophylactic cranial irradiation (PCI) has become an integral part of the standard of care in small cell lung cancer (SCLC), yet its role in other malignancies remains the subject of significant discussion. Its role has been extensively investigated in non-small cell lung cancer and less so for breast cancer and other malignancies. Improvements in medical care as well as in whole brain radiotherapy (WBRT) techniques may improve the risk-benefit ratio of this therapy so as to expand its role in cancer care. The use of memantine in WBRT patients as well as the use of hippocampal avoidance techniques are of particular interest in this effort. Herein, we review the history of PCI, its current use, and areas of investigation in the application of PCI.
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Affiliation(s)
- James W Snider
- 22 South Greene Street, Department of Radiation Oncology, Baltimore, MD 21201, USA
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8
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Kodack DP, Askoxylakis V, Ferraro GB, Fukumura D, Jain RK. Emerging strategies for treating brain metastases from breast cancer. Cancer Cell 2015; 27:163-75. [PMID: 25670078 PMCID: PMC4325273 DOI: 10.1016/j.ccell.2015.01.001] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 10/25/2014] [Accepted: 01/06/2015] [Indexed: 12/20/2022]
Abstract
Brain metastasis is an end stage in breast cancer progression. Traditional treatment options have minimal efficacy, and overall survival is on the order of months. The incidence of brain metastatic disease is increasing with the improved management of systemic disease and prolongation of survival. Unfortunately, the targeted therapies that control systemic disease have diminished efficacy against brain lesions. There are reasons to be optimistic, however, as emerging therapies have shown promise in preclinical and early clinical settings. This review discusses recent advances in breast cancer brain metastasis therapy and potential approaches for successful treatment.
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Affiliation(s)
- David P Kodack
- Edwin L. Steele Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Vasileios Askoxylakis
- Edwin L. Steele Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Gino B Ferraro
- Edwin L. Steele Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Dai Fukumura
- Edwin L. Steele Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Rakesh K Jain
- Edwin L. Steele Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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9
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Arslan C, Dizdar O, Altundag K. Chemotherapy and biological treatment options in breast cancer patients with brain metastasis: an update. Expert Opin Pharmacother 2014; 15:1643-58. [PMID: 25032884 DOI: 10.1517/14656566.2014.929664] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Breast cancer (BC) is the second most common cause of CNS metastasis. Ten to 20% of all, and 38% of human epidermal growth factor-2(+), metastatic BC patients experience brain metastasis (BM). Prolonged survival with better control of systemic disease and limited penetration of drugs to CNS increased the probability of CNS metastasis as a sanctuary site of relapse. Treatment of CNS disease has become an important component of overall disease control and quality of life. AREAS COVERED Current standard therapy for BM is whole-brain radiotherapy, surgery, stereotactic body radiation therapy for selected cases, corticosteroids and systemic chemotherapy. Little progress has been made in chemotherapy for the treatment of BM in patients with BC. Nevertheless, new treatment choices have emerged. In this review, we aimed to update current and future treatment options in systemic treatment for BM of BC. EXPERT OPINION Cornerstone local treatment options for BM of BC are radiotherapy and surgery in selected cases. Efficacy of cytotoxic chemotherapeutics is limited. Among targeted therapies, lapatinib has activity in systemic treatment of BM particularly when used in combination with capecitabine. Novel agents are currently investigated.
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Affiliation(s)
- Cagatay Arslan
- Izmir University Medical Park Hospital, Department of Medical Oncology , Izmir , Turkey
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10
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Place de l’association radiothérapie encéphalique et thérapies systémiques dans le traitement des métastases cérébrales d’un cancer du sein. Cancer Radiother 2014; 18:235-42; quiz 246, 249. [DOI: 10.1016/j.canrad.2014.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Revised: 02/15/2014] [Accepted: 02/19/2014] [Indexed: 11/20/2022]
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11
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Brain metastases from breast cancer: lessons from experimental magnetic resonance imaging studies and clinical implications. J Mol Med (Berl) 2013; 92:5-12. [PMID: 24306136 DOI: 10.1007/s00109-013-1108-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 11/14/2013] [Accepted: 11/19/2013] [Indexed: 01/24/2023]
Abstract
Breast cancer that has metastasized to the brain presents difficult clinical challenges. This diagnosis comes with high mortality rates, largely due to complexities in early detection and ineffective therapies associated with both dormancy and impermeability of the blood-brain barrier (BBB). Magnetic resonance imaging (MRI) is the current gold standard for diagnosis and assessment of brain tumors. It has been used clinically to investigate metastatic development as well as monitor response to therapy. Here, we describe preclinical imaging strategies that we have used to study the development of brain metastases due to breast cancer. Using this approach, we have identified three subsets of metastatic disease: permeable metastases, nonpermeable metastases, and solitary, dormant cancer cells, which likely have very different biology and responses to therapy. The ability to simultaneously monitor the spatial and temporal distribution of dormant cancer cells, metastatic growth, and associated tumor permeability can provide great insight into factors that contribute to malignant proliferation. Our preclinical findings suggest that standard clinical detection strategies may underestimate the true metastatic burden of breast cancer that has metastasized to the brain. A better understanding of true metastatic burden in brains will be important to assist in the development of more effective chemotherapeutics-particularly those targeted to cross the BBB-as well as detection of small nonpermeable metastases.
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12
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Dawood S, Gonzalez-Angulo AM. Progress in the biological understanding and management of breast cancer-associated central nervous system metastases. Oncologist 2013; 18:675-84. [PMID: 23740934 DOI: 10.1634/theoncologist.2012-0438] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Metastasis to the central nervous system (CNS) is a devastating neurological complication of systemic cancer. Brain metastases from breast cancer have been documented to occur in approximately 10%-16% of cases over the natural course of the disease with leptomeningeal metastases occurring in approximately 2%-5% of cases of breast cancer. CNS metastases among women with breast cancer tend to occur among those who are younger, have larger tumors, and have a more aggressive histological subtype such as the triple negative and HER2-positive subtypes. Treatment of CNS metastases involves various combinations of whole brain radiation therapy, surgery, stereotactic radiosurgery, and chemotherapy. We will discuss the progress made in the treatment and prevention of breast cancer-associated CNS metastases and will delve into the biological underpinnings of CNS metastases including evaluating the role of breast tumor subtype on the incidence, natural history, prognostic outcome, and impact of therapeutic efficacy.
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Affiliation(s)
- Shaheenah Dawood
- Departments of Breast Medical Oncology and Systems Biology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
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13
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Wong JM, Ho AL, Lin N, Zenonos GA, Martel CB, Frerichs K, Du R, Gormley WB. Radiation exposure in patients with subarachnoid hemorrhage: a quality improvement target. J Neurosurg 2013; 119:215-20. [PMID: 23621604 DOI: 10.3171/2013.3.jns12253] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The care of patients with subarachnoid hemorrhage (SAH) has improved dramatically over the last decades. These gains are the result of improved microsurgical, endovascular, and medical management techniques. This intensive management subjects patients to multiple radiographic studies and thus increased radiation exposure. As greater understanding of the risks of radiation exposure develops, physicians must be better equipped to balance the need for optimal SAH management with the minimization of patient exposure to radiation from imaging studies. The goal in the current study was to determine if there is an opportunity for a reduction in radiation dose without a change in the quality of treatment in patients with SAH. METHODS A retrospective chart review of all patients hospitalized for SAH at the Brigham and Women's Hospital in the period from January 1, 2009, to August 31, 2010, was performed. The authors calculated cumulative and imaging study-specific radiation doses, determined the time of day that imaging studies were performed, and surveyed neurosurgeons regarding issues surrounding imaging-related radiation exposure. RESULTS The data for 77 patients were analyzed. The mean cumulative radiation dose during hospitalization was 2.76 Gy per patient (range 0.46-8.32 Gy). The mean radiation exposure from each CT, CT angiography (CTA), and angiography study was 0.08, 0.29, and 0.77 Gy (ranges 0.02-0.40, 0.15-0.99, and 0.11-4.36 Gy, respectively). Subgroup analysis of the top quartile of patients in terms of total radiation dose revealed a mean cumulative radiation dose of 4.78 Gy (range 3.42-8.32 Gy), mean cumulative number of CT and CTA scans of 14, and mean CT or CTA scan per day of 0.5 (maximum 0.8). Seventeen percent of the noncontrast head CT studies were performed just prior to morning rounds, more than double the 8% expected rate at random. Thirty-four percent of the repeat noncontrast head CTs did not show any change between scans, as documented on radiology reports. When surveyed, a majority of neurosurgeons incorrectly estimated the radiation dose typically received from CT, CTA, and angiography studies, and 65% asserted that radiation exposure is "not important" or only "somewhat important" when considering whether to order an imaging study. CONCLUSIONS Study findings suggested that patients with SAH have significant imaging-related exposure to radiation. The authors believe it is possible to continue the current improved outcomes in SAH with a significant reduction in radiation exposure from imaging studies. This analysis highlights the significance of accurate assessment of radiation exposure as a quality improvement target.
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Affiliation(s)
- Judith M Wong
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA 02115, USA.
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14
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Abstract
Prophylactic cranial irradiation (PCI) plays a role in the management of lung cancer patients, especially small cell lung cancer (SCLC) patients. As multimodality treatments are now able to ensure better local control and a lower rate of extracranial metastases, brain relapse has become a major concern in lung cancer. As survival is poor after development of brain metastases (BM) in spite of specific treatment, PCI has been introduced in the 1970's. PCI has been evaluated in randomized trials in both SCLC and non-small cell lung cancer (NSCLC) to reduce the incidence of BM and possibly increase survival. PCI reduces significantly the BM rate in both limited disease (LD) and extensive disease (ED) SCLC and in non-metastatic NSCLC. Considering SCLC, PCI significantly improves overall survival in LD (from 15 to 20% at 3 years) and ED (from 13 to 27% at 1 year) in patients who respond to first-line treatment; it should thus be part of the standard treatment in all responders in ED and in good responders in LD. No dose-effect relationship for PCI was demonstrated in LD SCLC patients so that the recommended dose is 25 Gy in 10 fractions. In NSCLC, even if the risk of brain dissemination is lower than in SCLC, it has become a challenging issue. Studies have identified subgroups at higher risk of brain failure. There are more local treatment possibilities for BM related to NSCLC, but most BM will eventually recur so that PCI should be reconsidered. Few randomized trials have been performed. Most of them could demonstrate a decreased incidence of BM in patients with PCI, but they were not able to show an effect on survival as they were underpowered. New trials are needed. Among long-term survivors, neuro-cognitive toxicity may be observed. Several approaches are being evaluated to reduce this possible toxicity. PCI has no place for other solid tumours at risk such as HER2+ breast cancer patients.
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15
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Chien AJ, Rugo HS. Emerging treatment options for the management of brain metastases in patients with HER2-positive metastatic breast cancer. Breast Cancer Res Treat 2013; 137:1-12. [PMID: 23143215 PMCID: PMC3528960 DOI: 10.1007/s10549-012-2328-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 10/30/2012] [Indexed: 11/10/2022]
Abstract
The widespread use of trastuzumab in the past decade has led to a significant and measureable improvement in the survival of patients with human epidermal growth factor receptor-2 (HER2) overexpressing breast cancer, and in many ways has redefined the natural history of this aggressive breast cancer subtype. Historically, survival in patients with HER2-positive disease was dictated by the systemic disease course, and what appears to be the central nervous system (CNS) tropism associated with HER2-amplified tumors was not clinically evident. With improved systemic control and prolonged survival, the incidence of brain metastases has increased, and CNS disease, often in the setting of well-controlled extracranial disease, is proving to be an increasingly important and clinically challenging cause of morbidity and mortality in patients with HER2-positive advanced breast cancer. This review summarizes the known clinical data for the systemic treatment of HER2-positive CNS metastases and includes information about ongoing clinical trials of novel therapies as well as emerging strategies for early detection and prevention.
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Affiliation(s)
- A. Jo Chien
- University of California San Francisco Helen Diller Family Comprehensive Cancer Center, 1600 Divisidero Street, Box 1710, San Francisco, CA 94143-1710 USA
| | - Hope S. Rugo
- University of California San Francisco Helen Diller Family Comprehensive Cancer Center, 1600 Divisidero Street, Box 1710, San Francisco, CA 94143-1710 USA
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16
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Preclinical evaluation of oncolytic δγ(1)34.5 herpes simplex virus expressing interleukin-12 for therapy of breast cancer brain metastases. Int J Breast Cancer 2012; 2012:628697. [PMID: 23346408 PMCID: PMC3549352 DOI: 10.1155/2012/628697] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Revised: 11/22/2012] [Accepted: 11/22/2012] [Indexed: 12/23/2022] Open
Abstract
The metastasis of breast cancer to the brain and central nervous system (CNS) is a problem of increasing importance. As improving treatments continue to extend patient survival, the incidence of CNS metastases from breast cancer is on the rise. New treatments are needed, as current treatments are limited by deleterious side effects and are generally palliative. We have previously described an oncolytic herpes simplex virus (HSV), designated M002, which lacks both copies of the γ134.5 neurovirulence gene and carries a murine interleukin 12 (IL-12) expression cassette, and have validated its antitumor efficacy in a variety of preclinical models of primary brain tumors. However, M002 has not been yet evaluated for use against metastatic brain tumors. Here, we demonstrate the following: both human breast cancer and murine mammary carcinoma cells support viral replication and IL-12 expression from M002; M002 replicates in and destroys breast cancer cells from a variety of histological subtypes, including “triple-negative” and HER2 overexpressing; M002 improves survival in an immunocompetent model more effectively than does a non-cytokine control virus. Thus, we conclude from this proof-of-principle study that a γ134.5-deleted IL-12 expressing oncolytic HSV may be a potential new therapy for breast cancer brain metastases.
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17
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Affiliation(s)
- Toral R Patel
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06520, USA
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18
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Mehta AI, Brufsky AM, Sampson JH. Therapeutic approaches for HER2-positive brain metastases: circumventing the blood-brain barrier. Cancer Treat Rev 2012; 39:261-9. [PMID: 22727691 DOI: 10.1016/j.ctrv.2012.05.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 05/09/2012] [Accepted: 05/17/2012] [Indexed: 10/28/2022]
Abstract
We aim to summarize data from studies of trastuzumab in patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (MBC) and brain metastasis and to describe novel methods being developed to circumvent the blood-brain barrier (BBB). A literature search was conducted to obtain data on the clinical efficacy of trastuzumab and lapatinib in patients with HER2-positive MBC and brain metastasis, as well as the transport of therapeutic molecules across the BBB. Trastuzumab-based therapy is the standard of care for patients with HER2-positive MBC. Post hoc and retrospective analyses show that trastuzumab significantly prolongs overall survival when given after the diagnosis of central nervous system (CNS) metastasis; this is probably attributable to its control of extracranial disease, although trastuzumab may have a direct effect on CNS disease in patients with local or general perturbation of the BBB. In patients without a compromised BBB, trastuzumab is thought to have limited access to the brain, because of its relatively large molecular size. Several approaches are being developed to enhance the delivery of therapeutic agents to the brain. These include physical or pharmacologic disruption of the BBB, direct intracerebral drug delivery, drug manipulation, and coupling drugs to transport vectors. Available data suggest that trastuzumab extends survival in patients with HER2-positive MBC and brain metastasis. Novel methods for delivery of therapeutic agents into the brain could be used in the future to enhance access to the CNS by trastuzumab, thereby improving its efficacy in this setting.
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Affiliation(s)
- Ankit I Mehta
- Preston Robert Tisch Brain Tumor Center, Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Box #3807, Durham, NC 27710, USA.
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Abstract
Over 150,000 cancer patients will be diagnosed with brain metastases this year alone. Survival for those diagnosed with brain metastases remains poor despite multimodality management with surgery, chemotherapy, and radiation. Preventative strategies to mitigate brain metastases have met with mixed results. In leukemia and small cell lung cancer there are defined roles for preventative radiation to be delivered, which can result in improved local control and survival. There is a less defined role for preventative radiation in locally advanced non-small cell lung cancer and budding interest for radiation prevention in breast cancer. The potential impact preventative cranial irradiation may have on neurocognitive function and quality of life needs to be considered prior to its administration.
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Goetz P, Ebinu JO, Roberge D, Zadeh G. Current standards in the management of cerebral metastases. Int J Surg Oncol 2011; 2012:493426. [PMID: 22312540 PMCID: PMC3263704 DOI: 10.1155/2012/493426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 09/18/2011] [Accepted: 09/28/2011] [Indexed: 12/15/2022] Open
Abstract
The last 30 years have seen major changes in attitude toward patients with cerebral metastases. This paper aims to outline the major landmarks in this transition and the therapeutic strategies currently used. The controversies surrounding control of brain disease are discussed, and two emerging management trends are reviewed: tumor bed radiosurgery and salvage radiation.
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Affiliation(s)
- Pablo Goetz
- Division of Neurosurgery, Toronto Western Hospital, 399 Bathurst, Toronto, ON, Canada M5T 2S8
| | - Julius O. Ebinu
- Division of Neurosurgery, Toronto Western Hospital, 399 Bathurst, Toronto, ON, Canada M5T 2S8
| | - David Roberge
- Département de Radio-Oncologie, Hôpital Notre Dame, Université de Montréal, Montréal, QC, Canada H3C 3J7
| | - Gelareh Zadeh
- Division of Neurosurgery, Toronto Western Hospital, 399 Bathurst, Toronto, ON, Canada M5T 2S8
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Hamalukic M, Huelsenbeck J, Schad A, Wirtz S, Kaina B, Fritz G. Rac1-regulated endothelial radiation response stimulates extravasation and metastasis that can be blocked by HMG-CoA reductase inhibitors. PLoS One 2011; 6:e26413. [PMID: 22039482 PMCID: PMC3198428 DOI: 10.1371/journal.pone.0026413] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 09/26/2011] [Indexed: 11/19/2022] Open
Abstract
Radiotherapy (RT) plays a key role in cancer treatment. Although the benefit of ionizing radiation (IR) is well established, some findings raise the possibility that irradiation of the primary tumor not only triggers a killing response but also increases the metastatic potential of surviving tumor cells. Here we addressed the question of whether irradiation of normal cells outside of the primary tumor augments metastasis by stimulating the extravasation of circulating tumor cells. We show that IR exposure of human endothelial cells (EC), tumor cells (TC) or both increases TC-EC adhesion in vitro. IR-stimulated TC-EC adhesion was blocked by the HMG-CoA reductase inhibitor lovastatin. Glycyrrhizic acid from liquorice root, which acts as a Sialyl-Lewis X mimetic drug, and the Rac1 inhibitor NSC23766 also reduced TC-EC adhesion. To examine the in vivo relevance of these findings, tumorigenic cells were injected into the tail vein of immunodeficient mice followed by total body irradiation (TBI). The data obtained show that TBI dramatically enhances tumor cell extravasation and lung metastasis. This pro-metastatic radiation effect was blocked by pre-treating mice with lovastatin, glycyrrhizic acid or NSC23766. TBI of mice prior to tumor cell transplantation also stimulated metastasis, which was again blocked by lovastatin. The data point to a pro-metastatic trans-effect of RT, which likely rests on the endothelial radiation response promoting the extravasation of circulating tumor cells. Administration of the widely used lipid-lowering drug lovastatin prior to irradiation counteracts this process, likely by suppressing Rac1-regulated E-selectin expression following irradiation. The data support the concern that radiation exposure might increase the extravasation of circulating tumor cells and recommend co-administration of lipid-lowering drugs to avoid this adverse effect of ionizing radiation.
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Affiliation(s)
- Melanie Hamalukic
- Institute of Toxicology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Johannes Huelsenbeck
- Institute of Toxicology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Arno Schad
- Institute of Pathology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Stefan Wirtz
- Institute of Molecular Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Bernd Kaina
- Institute of Toxicology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Gerhard Fritz
- Institute of Toxicology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Institute of Toxicology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- * E-mail:
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Witzel I, Kantelhardt EJ, Milde-Langosch K, Ihnen M, Zeitz J, Harbeck N, Jänicke F, Müller V. Management of patients with brain metastases receiving trastuzumab treatment for metastatic breast cancer. ACTA ACUST UNITED AC 2011; 34:304-8. [PMID: 21625183 DOI: 10.1159/000328679] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND With the more effective control of visceral metastases in patients with metastatic breast cancer (MBC), an increasing number of patients face brain metastases (BM). The aim of this retrospective analysis was to investigate the incidence and factors affecting the prognosis of patients with BM under trastuzumab treatment for MBC. PATIENTS AND METHODS A total of 75 HER2positive patients treated with trastuzumab for MBC were included. RESULTS are discussed in the context of the current literature. RESULTS Patients who developed BM (n = 29) had longer median progression-free survival (PFS) during first-line chemotherapy and longer overall survival (OS) after diagnosis of MBC than 46 patients without BM (PFS: 27 vs. 14 months, p = 0.039; OS: 46 vs. 18 months, p = 0.067). Median survival of patients with continuation of trastuzumab after diagnosis of BM was longer than survival of patients with discontinuation of trastuzumab treatment after BM (18 vs. 3 months, p = 0.006). Survival of patients who were treated with surgery and radiotherapy for BM was better compared with radiotherapy alone (9 vs. 5 months, p = not significant) or best supportive care (9 vs. 2 months, p = 0.049). CONCLUSIONS Continuation of trastuzumab treatment as well as resection of BM seem to give further benefit in the treatment of patients with HER2-overexpressing MBC.
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Affiliation(s)
- Isabell Witzel
- Department of Gynaecology; University Medical Center Hamburg-Eppendorf, Germany
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Kienast Y, Winkler F. Therapy and prophylaxis of brain metastases. Expert Rev Anticancer Ther 2011; 10:1763-77. [PMID: 21080803 DOI: 10.1586/era.10.165] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Metastases of various tumors to the brain account for the majority of brain cancers, and are associated with a poor prognosis. The most common primary sites are lung, breast, skin, kidney and colon; 10-40% of cancer patients develop brain metastases during the course of the disease. The incidence of brain metastasis appears to be rising; reasons may include better therapies for the systemic disease with longer survival of cancer patients but lower efficiency against brain metastases. In this article, we will discuss the conventional treatment with surgery, radiosurgery, radiotherapy and chemotherapy, but also new directions in the management of solid brain metastases. While general therapeutic nihilism should be avoided, it is important to recognize that the number of brain metastases, the extent of the systemic disease and also the tumor type have to be taken into account when choosing individual treatment regimens. Finally, special emphasis will be put on established and future approaches to prevent the disease. We thus aim to provide a framework for treating patients with different presentations of brain metastases, and to highlight important avenues for research.
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Affiliation(s)
- Yvonne Kienast
- Roche Diagnostics GmbH, Pharma Research Penzberg, Nonnenwald 2, 82377 Penzberg, Germany
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Pal T, Stowe C, Cole A, Lee JH, Zhao X, Vadaparampil S. Evaluation of phone-based genetic counselling in African American women using culturally tailored visual aids. Clin Genet 2010; 78:124-31. [PMID: 20662853 DOI: 10.1111/j.1399-0004.2010.01466.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Genetic counselling (GC) services for inherited breast and ovarian cancer (HBOC) are underutilized by African American (AA) women. We sought to evaluate factors associated with knowledge gain in a sample of AA women diagnosed with early-onset breast cancer, in whom GC for HBOC was provided, using a culturally targeted genetic counselling aid (GCA). Through a cancer registry-based study, phone-based GC for HBOC was offered to AA women with breast cancer < or =50. A questionnaire to assess knowledge about HBOC was completed prior to GC. All women were provided a GCA about HBOC developed by the investigative team for use during the GC session. Following GC, a personalized summary letter was mailed to all study participants and the same knowledge questionnaire was completed. A total of 37 study participants completed the pre- and post-GC knowledge questionnaires with significant gains in knowledge following the GC process (p < 0.0001). Statistically significant factors associated with knowledge gain included earlier stage of diagnosis of breast cancer and education level. Our results indicate that phone-based GC supplemented by a culturally targeted visual aid is an effective means of improving knowledge about HBOC in young AA women with invasive breast cancer.
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Affiliation(s)
- T Pal
- Moffitt Cancer Center, Division of Cancer Prevention and Control, Tampa, Florida, USA.
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Eleven years disease-free: role of chemotherapy in metastatic BRCA2-related breast cancer. Nat Rev Clin Oncol 2009; 6:488-92. [PMID: 19644536 DOI: 10.1038/nrclinonc.2009.90] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Infiltrating ductal carcinoma of the breast, staged as pT1N3, was diagnosed in a 41-year-old premenopausal French-Canadian woman. Rapid nodal recurrence progressed to diffuse bone metastases, despite tamoxifen and megestrol. Following enrollment in an in-house study protocol, she received high-dose anthracycline-based induction chemotherapy followed by tandem autologous bone marrow transplantation with high-dose alkylator and platinum-based conditioning regimens. Upon full remission, protocol-mandated locoregional breast and prophylactic cranial radiation was delivered. Complete clinical and radiologic remission has been maintained in the 11 years since study enrolment, which prompted further investigation. INVESTIGATIONS Pedigree construction and BRCA1/2 mutation analysis. DIAGNOSIS A BRCA2 8765delAG mutation was identified, in the context of unusual and sustained complete remission from widely metastatic breast cancer. MANAGEMENT The patient is now followed at a multidisciplinary high-risk prevention clinic because BRCA2 mutations are associated with increased risk of ovarian and breast cancers. This case supports the possibility of differential treatment response in BRCA2-positive breast cancer, although this remains to be conclusively demonstrated.
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Pieńkowski T, Zielinski CC. Trastuzumab treatment in patients with breast cancer and metastatic CNS disease. Ann Oncol 2009; 21:917-24. [PMID: 19717536 DOI: 10.1093/annonc/mdp353] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with metastatic central nervous system (mCNS) disease progression from breast cancer have a poor prognosis and often develop associated neurological complications. Human epidermal growth factor receptor 2 (HER2)-positivity status increases the risk of developing mCNS disease. Trastuzumab is an mAb that targets HER2 and is known to extend survival across all stages of HER2-positive breast cancer. DESIGN This review considers evidence from preclinical and clinical studies examining the value of continuing trastuzumab treatment in patients who develop mCNS disease. A wealth of data from clinical studies showed that trastuzumab prolonged survival in patients with mCNS disease, compared with no trastuzumab treatment, by effectively controlling their non-CNS disease. Trastuzumab has also been shown to penetrate an impaired blood-brain barrier to a limited degree, such as during radiotherapy, and intrathecal delivery of trastuzumab to the central nervous system (CNS) has shown promise. Research efforts are focussing on improving the delivery of trastuzumab to the CNS. CONCLUSION Evidence indicates that patients with mCNS disease from HER2-positive breast cancer should continue to receive trastuzumab to control HER2-positive metastases outside the CNS and receive established therapies to control the mCNS disease.
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Affiliation(s)
- T Pieńkowski
- Department of Breast Cancer and Reconstructive Surgery, Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland.
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