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Wiegreffe S, Sarria GR, Layer JP, Dejonckheere E, Nour Y, Schmeel FC, Anton Giordano F, Schmeel LC, Popp I, Grosu AL, Gkika E, Stefaan Dejonckheere C. Incidence of hippocampal and perihippocampal brain metastases and impact on hippocampal-avoiding radiotherapy: A systematic review and meta-analysis. Radiother Oncol 2024; 197:110331. [PMID: 38772476 DOI: 10.1016/j.radonc.2024.110331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/25/2024] [Accepted: 05/03/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND AND PURPOSE In patients requiring prophylactic cranial irradiation (PCI) or whole-brain radiotherapy (WBRT) for brain metastases (BMs), hippocampal avoidance (HA) has been shown to preserve neurocognitive function and quality of life. Here, we aim to estimate the incidence of hippocampal and perihippocampal BMs and the subsequent risk of local undertreatment in patients undergoing hippocampal sparing radiotherapy. MATERIALS AND METHODS MEDLINE, Embase, and Scopus were searched with the terms "Hippocampus", "Brain Neoplasms", and related terms. Trials reporting on the incidence of hippocampal and/or perihippocampal BMs or hippocampal failure rate after PCI or WBRT were included. RESULTS Forty records were included, encompassing a total of 5,374 patients with over 32,570 BMs. Most trials employed a 5 mm margin to define the HA zone. In trials reporting on BM incidence, 4.4 % (range 0 - 27 %) and 9.2 % (3 - 41 %) of patients had hippocampal and perihippocampal BMs, respectively. The most common risk factor for hippocampal BMs was the total number of BMs. The reported failure rate within the HA zone after HA-PCI or HA-WBRT was 4.5 % (0 - 13 %), salvageable with radiosurgery in most cases. SCLC histology was not associated with a higher risk of hippocampal failure (OR = 2.49; p = 0.23). In trials comparing with a conventional (non-HA) PCI or WBRT group, HA did not increase the hippocampal failure rate (OR = 1.90; p = 0.17). CONCLUSION The overall incidence of hippocampal and perihippocampal BMs is considerably low, with a subsequent low risk of local undertreatment following HA-PCI or HA-WBRT. In patients without involvement, the hippocampus should be spared to preserve neurocognitive function and quality of life.
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Affiliation(s)
- Shari Wiegreffe
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | | | - Julian Philipp Layer
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; Institute of Experimental Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | - Egon Dejonckheere
- Faculty of Psychology and Educational Sciences, KU Leuven, 3000 Leuven, Belgium; Department of Medical and Clinical Psychology, Tilburg School of Social and Behavioural Sciences, 5037 Tilburg, the Netherlands
| | - Younèss Nour
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | | | - Frank Anton Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, 68167 Mannheim, Germany; DKFZ-Hector Cancer Institute, University Medical Center Mannheim, 68167 Mannheim, Germany
| | | | - Ilinca Popp
- Department of Radiation Oncology, Medical Faculty, University Freiburg, 79106 Freiburg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, Medical Faculty, University Freiburg, 79106 Freiburg, Germany
| | - Eleni Gkika
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany
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Vojtíšek R. What is the current role of prophylactic cranial irradiation in the treatment algorithm for small cell lung cancer? Rep Pract Oncol Radiother 2023; 28:698-706. [PMID: 38179287 PMCID: PMC10764050 DOI: 10.5603/rpor.97432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 09/04/2023] [Indexed: 01/06/2024] Open
Abstract
Prophylactic cranial irradiation (PCI) is considered an important technological advance made in oncology in an effort to reduce the incidence of brain metastases (BM) and improve overall survival (OS) of patients with small cell lung cancer (SCLC). Although it is often reported that PCI improves the therapeutic potential in limited-stage (LS) SCLC, no randomised trial has ever conclusively confirmed this. Nevertheless, PCI has been considered the standard of care for LS-SCLC since the late 1990s. The data supporting the use of PCI in LS-SCLC are based on an analysis of work performed prior to the current approach to staging [brain magnetic resonance imaging (MRI), positron emission tomography (PET)/computed tomography (CT)]. The evidence for the rationale and feasibility of this approach in the modern diagnostic era should be demonstrated. The situation with extensive stage (ES) SCLC is seemingly easier because, unlike LS-SCLC, we have data from two randomised trials. Unfortunately, their results are in direct conflict with each other. Although it is generally assumed that good control of brain disease leads to better quality of life, this has never been prospectively demonstrated. In fact, PCI is associated not only with increased treatment costs and some patient discomfort, but also with non-negligible potential toxicity. For this reason, efforts have been made to preserve cognitive function by sparing the hippocampus. This concept is called hippocampal avoidance. The optimal fractionation regimen is currently less controversial than the optimal integration of PCI into the treatment algorithm. A dose of 25 Gy administered in 10 fractions should remain the standard for the eventual use of PCI in patients with SCLC. In summary, PCI is not a conditio sine qua non in any indication. Neither in patients with LS-SCLC nor in patients with ES-SCLC has a clear improvement in OS been demonstrated at follow-up using current imaging modalities.
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Affiliation(s)
- Radovan Vojtíšek
- Department of Oncology and Radiotherapy, University Hospital in Pilsen, Czech Republic
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Fujiwara M, Tada H. Perihippocampal Meningeal Carcinomatosis Following Hippocampal Avoidance Prophylactic Cranial Irradiation in Small Cell Lung Cancer: A Case Report. Cureus 2023; 15:e46499. [PMID: 37927701 PMCID: PMC10624598 DOI: 10.7759/cureus.46499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 11/07/2023] Open
Abstract
Prophylactic cranial irradiation (PCI) for limited disease small cell lung cancer is the standard of care for curative treatment of this disease. However, neurocognitive dysfunction is one of the late adverse events of PCI and is often problematic. Recently, hippocampal avoidance prophylactic cranial irradiation (HA-PCI) is sometimes performed to prevent neurocognitive dysfunction after PCI. In HA-PCI, the question is whether or not metastases appear around the hippocampus that were not irradiated. We have experienced a case of perihippocampal meningeal carcinomatosis after HA-PCI. We also draw attention to the potential risks of performing HA-PCI based on this experience.
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Affiliation(s)
- Masateru Fujiwara
- Radiation Oncology, Osaka University Graduate School of Medicine, Suita, JPN
- Radiation Oncology, Suita Tokushukai Hospital, Suita, JPN
| | - Hirohito Tada
- Thoracic Surgery, Suita Tokushukai Hospital, Suita, JPN
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Candiff O, Belderbos J, Wolf AL, Damen E, van Haaren P, Crijns W, Hol S, Paelinck L, van Kesteren Z, Jaspers J, de Kerf G, van Elmpt W, Ubbels F, Schagen S, de Ruysscher D, de Ruiter M. Quality assurance and safety of hippocampal avoidance prophylactic cranial irradiation in the multicenter randomized phase III trial (NCT01780675). JOURNAL OF THE NATIONAL CANCER CENTER 2023; 3:135-140. [PMID: 39035727 PMCID: PMC11256712 DOI: 10.1016/j.jncc.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 05/10/2023] [Accepted: 05/17/2023] [Indexed: 07/23/2024] Open
Abstract
Objective NCT01780675, a multicenter randomized phase III trial of prophylactic cranial irradiation (PCI) versus PCI with hippocampal sparing in small cell lung cancer (SCLC) investigated neurocognitive decline and safety. As part of quality assurance, we evaluated if hippocampal avoidance (HA)-PCI was performed according to the NCT01780675 trial protocol instructions, and performed a safety analysis to study the incidence and location of brain metastases for patients treated with HA-PCI. Methods This retrospective analysis evaluated the quality of the irradiation given in the randomized controlled trial (RCT) comparing SCLC patients receiving PCI with or without hippocampal avoidance, using intensity modulated radiotherapy (IMRT) or volumetric modulated arc therapy (VMAT). The dose distribution for each patient receiving HA-PCI was retrieved and analyzed to evaluate if the treatment dose constraints were met. A questionnaire was sent out to all participating sites, and data on radiotherapy technique, pre-treatment dummy runs, phantom measurements and treatment electronic portal imaging device (EPID) dosimetry were collected and analyzed. As part of the safety analysis, the follow-up magnetic resonance imaging (MRI) or computerized tomography (CT) scans on which cranial disease progression was first diagnosed were collected and matched to the radiotherapy planning dose distribution. The matched scans were reviewed to analyze the location of the brain metastases in relation to the prescribed dose. Results A total of 168 patients were randomized in the NCT01780675 trial in 10 centers in the Netherlands and Belgium from April 2013 until March 2018. Eighty two patients receiving HA-PCI without evidence of brain metastases were analyzed. All patients were treated with 25 Gy in 10 fractions. Dummy runs and phantom measurements were performed in all institutions prior to enrolling patients into the study. The radiotherapy (RT) plans showed a median mean bilateral hippocampal dose of 8.0 Gy, range 5.4-11.4 (constraint ≤ 8.5 Gy). In six patients (7.3%) there was a protocol violation of the mean dose in one or both hippocampi. In four of these six patients (4.9%) the mean dose to both hippocampi exceeded the constraint, in 1 patient (1.2%) only the left and in 1 patient (1.2%) only the right hippocampal mean dose was violated (average median dose left and right 8.9 Gy). All patients met the trial dose constraint of V 115% PTV ≤ 1%; however the D max PTV constraint of ≤ 28.75 Gy was violated in 22.0% of the patients. The safety analysis showed that 14 patients (17.1%) developed cranial progression. No solitary brain metastases in the underdosed region were found. Two out of 11 patients with multiple brain metastasis developed metastasis in the underdosed region(s). Conclusions The radiotherapy quality within the HA-PCI trial is performed according to the protocol guidelines. The dose constraints to the hippocampi are met in the vast majority of cases. In all patients, the volume of the brain for which a higher dose was accepted, is according to the trial. However, within this volume there are small areas with higher doses than advised.
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Affiliation(s)
- Oscar Candiff
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - José Belderbos
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Anne Lisa Wolf
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Eugène Damen
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Paul van Haaren
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Wouter Crijns
- Department of Radiation Oncology/Department of Oncology, Laboratory of Experimental Radiotherapy, KU Leuven, Belguim, the Netherlands
| | - Sandra Hol
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, the Netherlands
| | - Leen Paelinck
- Department of Radiation Oncology, Ghent University Hospital and Ghent University, Gent, Belgium
| | - Zdenko van Kesteren
- Department of Radiation Oncology, Amsterdam UMC–Location University of Amsterdam, Amsterdam, the Netherlands
| | - Jaap Jaspers
- Department of Radiation Oncology, Erasmus Mc Cancer Institute–Erasmus Mc University Medical Center, Rotterdam, the Netherlands
| | - Geert de Kerf
- Department of Radiation Oncology, Antwerp University and Antwerp University Hospital/Iridium Netwerk, Antwerp, Belgium
| | - Wouter van Elmpt
- Radiation Oncology (Maastro), School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Fred Ubbels
- Department of Radiation Oncology, University of Groningen–University Medical Center Groningen, Groningen, the Netherlands
| | - Sanne Schagen
- Division of Psychosocial Research and Epidemiology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Dirk de Ruysscher
- Radiation Oncology (Maastro), School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Michiel de Ruiter
- Division of Psychosocial Research and Epidemiology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
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Chu X, Zhu Z. Prophylactic cranial irradiation in small cell lung cancer: an update. Curr Opin Oncol 2023; 35:61-67. [PMID: 36421007 DOI: 10.1097/cco.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The current review presents recent updates in the seminal literature of research on prophylactic cranial irradiation (PCI) in small cell lung cancer (SCLC). RECENT FINDINGS Brain MRI restaging before the administration of PCI reveals a substantial proportion of brain metastasis in baseline brain metastasis free extensive-stage SCLC (ES-SCLC) and limited-stage SCLC (LS-SCLC). Posthoc analyses from the CASPIAN and IMpower133 trials revealed decreases in brain metastasis rates in ES-SCLC treated with chemoimmunotherapy relative to the brain metastasis rates in ES-SCLC treated with chemotherapy alone. A recent meta-analysis of literature published after the landmark 1999 Auperin meta-analysis confirmed the survival benefit of PCI in LS-SCLC patients. A recent study employing PET before and after PCI demonstrated that hippocampal avoidance -PCI (HA-PCI) preserved the metabolic activity of the hippocampi compared with regular PCI. Two phase III trials evaluating neurocognitive functions after HA-PCI versus PCI have yielded conflicting results. Ongoing clinical trials (MAVERICK, PRIMALung, NRG CC003, NCT04535739, NCT04829708 and NCT03514849) regarding PCI versus MRI surveillance and HA-PCI versus PCI were also discussed. SUMMARY Currently, the indications for PCI in SCLC are under question in the modern MRI era. Result from prospective phase III, MRI staged and MRI monitored RCTs are expected to elucidate the role of PCI in LS-SCLC and ES-SCLC. Preliminary results indicated that adding immunotherapy to chemotherapy may reduce brain metastasis rate in SCLC. Further data to this aspect are warranted to determine the role of PCI in the immuno-chemotherapy era. The future direction for PCI should be the comprehensive integration of personalized patient selection, HA-PCI utilization and potential employment of other neurocognitive preservation strategies.
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Affiliation(s)
- Xiao Chu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center
- Department of Oncology, Shanghai Medical College, Fudan University
- Shanghai Clinical Research Center for Radiation Oncology
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Zhengfei Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center
- Department of Oncology, Shanghai Medical College, Fudan University
- Shanghai Clinical Research Center for Radiation Oncology
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
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Shi W, Wang Y, Xia W, Liu B, Ni M, Shen J, Bai Y, Weng G, Liu W, Yuan S, Gao X. Brain metastases from small cell lung cancer and non-small cell lung cancer: comparison of spatial distribution and identification of metastatic risk regions. J Neurooncol 2023; 161:97-105. [PMID: 36520380 DOI: 10.1007/s11060-022-04211-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE This study aims to investigate the spatial distribution difference of brain metastases (BM) between small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC) and to identify the metastatic risk in brain regions. METHODS T1-enhanced MR images of 2997 BM from 728 eligible patients with SCLC and NSCLC were retrospectively reviewed by three independent medical institutions in China. All images were spatially normalised according to the Montreal Neurological Institute space, following BM delineation confirmed by three senior radiologists. The brain regions in the normalised images were identified based on the merged Anatomical Automatic Labeling atlas, and all BM locations were mapped onto these brain regions. Two-tailed proportional hypothesis testing was used to compare the BM observed rate with the expected rate based on the region's volume, and metastatic risk regions were finally identified. RESULTS In SCLC and NSCLC, BM was mainly present in the deep white matter (22.51% and 17.96%, respectively), cerebellar hemisphere (9.84% and 7.46%, respectively) and middle frontal gyrus (6.72% and 7.97%, respectively). The cerebellar hemisphere was a high-risk brain region in the SCLC. The precentral gyrus, middle frontal gyrus, paracentral lobule and cerebellar hemisphere were high-risk BM in the NSCLC. The inferior frontal gyrus and the temporal pole were a low-risk brain region in the SCLC and NSCLC, respectively. CONCLUSION The spatial BM distribution between SCLC and NSCLC is similar. Several critical brain regions had relatively low BM frequency in both SCLC and NSCLC, where a low-dose radiation distribution can be delivered due to adequate preoperative evaluations.
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Affiliation(s)
- Wei Shi
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, No. 88 Keling Road, Suzhou New District, Suzhou, 215163, Jiangsu, China.,Jinan Guoke Medical Engineering and Technology Development Co., Ltd., Pharmaceutical Valley New Drug Creation Platform, No. 3 Building, Jinan New District, Jinan, 250101, Shandong, China
| | - Yong Wang
- Shandong Cancer Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Wei Xia
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, No. 88 Keling Road, Suzhou New District, Suzhou, 215163, Jiangsu, China.,Jinan Guoke Medical Engineering and Technology Development Co., Ltd., Pharmaceutical Valley New Drug Creation Platform, No. 3 Building, Jinan New District, Jinan, 250101, Shandong, China
| | - Baoyan Liu
- Shandong Academy of Occupational Health and Occupational Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Meng Ni
- Shandong Cancer Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Jingyi Shen
- Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yujun Bai
- Shandong Cancer Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | | | - Wenju Liu
- Liaocheng People's Hospital, Liaocheng, Shandong, China
| | - Shuanghu Yuan
- Shandong Cancer Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China. .,Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China.
| | - Xin Gao
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, No. 88 Keling Road, Suzhou New District, Suzhou, 215163, Jiangsu, China. .,Jinan Guoke Medical Engineering and Technology Development Co., Ltd., Pharmaceutical Valley New Drug Creation Platform, No. 3 Building, Jinan New District, Jinan, 250101, Shandong, China.
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Comparison of whole brain radiation therapy for synchronous brain metastases with irradiation protecting the hippocampus versus whole brain radiotherapy for sequential brain metastases to boost irradiation in the treatment of brain metastases from SCLC: study protocol for a randomized controlled trial. Trials 2022; 23:876. [PMID: 36242060 PMCID: PMC9569116 DOI: 10.1186/s13063-022-06826-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 10/05/2022] [Indexed: 12/04/2022] Open
Abstract
Background This study is in regard to the comparison of whole brain radiation therapy for synchronous brain metastases with irradiation protecting the hippocampus versus whole brain radiotherapy for sequential brain metastases to boost irradiation in the treatment of brain metastases from small cell lung cancer (SCLC). Therapeutically, they have notably varying dose distributions. Based on theoretical and model studies, it has long been speculated that these modes may result in different prognostic outcomes. We aim to assess the efficacy of tomotherapy in the treatment of SCLC brain metastases while protecting the key functional area, the hippocampus, and minimizing any neurocognitive impairments incurred by radiation. Methods This is a randomized, controlled, prospective study including 102 SCLC patients with brain metastases randomized (1:1) to the experimental (whole brain radiation therapy for synchronous brain metastases with irradiation to protect the hippocampus) or control (whole brain radiotherapy for sequential brain metastases to boost irradiation) group. The sample size is calculated through a single-sided test; 102 participants will be required for the main results to have statistical and clinical significance. We aim to provide clinical trial data support for better prognostic treatment options in patients with SCLC and brain metastases. The clinical trial data include both the primary and secondary outcomes; the primary outcome is the intracranial progression-free survival time after the new technology application. The secondary study outcomes include the assessment of neurological function, the quality of life, and the overall survival rate. Follow-up consultations will be conducted every 2 months. After the final patient completes follow-up, the Statistical Product and Service Solutions software will be used for scientific and rigorous data analysis. Version 1.0 of the protocol was implemented on January 1, 2021; the recruitment process for this clinical trial commenced on April 1, 2021, and will end on March 31, 2024. Discussion The study will provide high-quality clinical evidence to support the efficacy and safety of whole brain radiation therapy for synchronous brain metastases with dose irradiation protecting the hippocampus versus whole brain radiotherapy for sequential brain metastases with push volume irradiation for the treatment of patients who have lung cancer as well as brain metastases. This has not been previously reported. Trial registration This trial is registered with the Chinese Clinical Trial Registry (ChiCTR1900027539; November 17, 2019) (URL: https://www.chictr.org.cn/hvshowproject.aspx?id=20515).
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Maragkoudakis E, Kouloulias V, Grenzelia M, Kougioumtzopoulou A, Zygogianni A, Ramfidis V, Charpidou A. Impact of Hippocampal Avoidance - Prophylactic Cranial Irradiation in Small Cell Lung Cancer Patients. CANCER DIAGNOSIS & PROGNOSIS 2022; 2:279-284. [PMID: 35530654 PMCID: PMC9066538 DOI: 10.21873/cdp.10105] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 03/14/2022] [Indexed: 06/01/2023]
Abstract
BACKGROUND/AIM Prophylactic cranial irradiation (PCI) is a well-established treatment of small cell lung cancer (SCLC) patients following response to initial chemoradiotherapy. The benefit of PCI does, however, come at the cost of cognitive decline. This has been attributed to radiation-induced toxicity at the hippocampus, a crucial anatomic area for cognition. Modern radiotherapy techniques allow dose reduction at the hippocampal region. In this review, the safety profile, effect on cognition, and changes on brain imaging modalities of hippocampal avoidance-PCI (HA-PCI) will be presented, aiming to identify a potential clinical rationale for SCLC patients. MATERIALS AND METHODS A systematic review of the literature was performed in Pubmed, Cochrane library databases and ClinicalTrials.gov with no past date limitations until 07/01/2022. Principles as outlined in the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement were followed. RESULTS Eight studies published from 2015 to 2021 were included. CONCLUSION HA-PCI is safe, yet its effect on neurocognition and imaging remains unclear, as studies have shown contradictory results.
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Affiliation(s)
- Emmanouil Maragkoudakis
- National and Kapodistrian University of Athens, 2nd Radiology Department, Radiotherapy Unit, Attikon University Hospital, Athens, Greece
| | - Vasileios Kouloulias
- National and Kapodistrian University of Athens, 2nd Radiology Department, Radiotherapy Unit, Attikon University Hospital, Athens, Greece
| | - Maria Grenzelia
- National and Kapodistrian University of Athens, 1st Radiology Department, Radiotherapy Unit, Aretaieion University Hospital, Athens, Greece
| | - Andromachi Kougioumtzopoulou
- National and Kapodistrian University of Athens, 2nd Radiology Department, Radiotherapy Unit, Attikon University Hospital, Athens, Greece
| | - Anna Zygogianni
- National and Kapodistrian University of Athens, 1st Radiology Department, Radiotherapy Unit, Aretaieion University Hospital, Athens, Greece
| | - Vasileios Ramfidis
- School of Medicine, National & Kapodistrian University, 3rd Department of Medicine, Sotiria General Hospital, Athens, Greece
| | - Andrianni Charpidou
- School of Medicine, National & Kapodistrian University, 3rd Department of Medicine, Sotiria General Hospital, Athens, Greece
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Optimization of hippocampus sparing during whole brain radiation therapy with simultaneous integrated boost-tutorial and efficacy of complete directional hippocampal blocking. Strahlenther Onkol 2022; 198:537-546. [PMID: 35357511 PMCID: PMC9165264 DOI: 10.1007/s00066-022-01916-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/20/2022] [Indexed: 11/25/2022]
Abstract
Purpose Hippocampus-avoidance whole brain radiotherapy with simultaneous integrated boost (HA-WBRT+SIB) is a complex treatment option for patients with multiple brain metastases, aiming to prevent neurocognitive decline and simultaneously increase tumor control. Achieving efficient hippocampal dose reduction in this context can be challenging. The aim of the current study is to present and analyze the efficacy of complete directional hippocampal blocking in reducing the hippocampal dose during HA-WBRT+SIB. Methods A total of 30 patients with multiple metastases having undergone HA-WBRT+SIB were identified. The prescribed dose was 30 Gy in 12 fractions to the whole brain, with 98% of the hippocampus receiving ≤ 9 Gy and 2% ≤ 17 Gy and with SIB to metastases/resection cavities of 36–51 Gy in 12 fractions. Alternative treatment plans were calculated using complete directional hippocampal blocking and compared to conventional plans regarding target coverage, homogeneity, conformity, dose to hippocampi and organs at risk. Results All alternative plans reached prescription doses. Hippocampal blocking enabled more successful sparing of the hippocampus, with a mean dose of 8.79 ± 0.99 Gy compared to 10.07 ± 0.96 Gy in 12 fractions with the conventional method (p < 0.0001). The mean dose to the whole brain (excluding metastases and hippocampal avoidance region) was 30.52 ± 0.80 Gy with conventional planning and 30.28 ± 0.11 Gy with hippocampal blocking (p = 0.11). Target coverage, conformity and homogeneity indices for whole brain and metastases, as well as doses to organs at risk were similar between planning methods (p > 0.003). Conclusion Complete directional hippocampal blocking is an efficient method for achieving improved hippocampal sparing during HA-WBRT+SIB.
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Xue S, Zeng H, Yan S, Wang Q, Jia X. Prophylactic Cranial Irradiation for Extensive-Stage Small-Cell Lung Cancer: A Controversial Area. Front Oncol 2022; 12:772282. [PMID: 35198438 PMCID: PMC8858935 DOI: 10.3389/fonc.2022.772282] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/17/2022] [Indexed: 11/13/2022] Open
Abstract
Small-cell lung cancer (SCLC) is a highly aggressive malignant tumor that is prone to lead to the development of brain metastases (BM). The application of prophylactic cranial irradiation (PCI) has been regarded as an important technological advance made in cancer therapy to reduce the occurrence of BM and improve patient survival. The benefits of PCI in the treatment of limited-stage SCLC have been confirmed. However, there has been continuous controversy about the indications and advantages of PCI for extensive-stage SCLC (ES-SCLC) because of the conflicting results from two prospective trials. In this review, we aimed to discuss the relevant controversy and progress made in the clinical application of PCI in ES-SCLC.
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11
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Popp I, Rau A, Kellner E, Reisert M, Fennell JT, Rothe T, Nieder C, Urbach H, Egger K, Grosu AL, Kaller CP. Hippocampus-Avoidance Whole-Brain Radiation Therapy Is Efficient in the Long-Term Preservation of Hippocampal Volume. Front Oncol 2021; 11:714709. [PMID: 34490112 PMCID: PMC8417356 DOI: 10.3389/fonc.2021.714709] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/26/2021] [Indexed: 12/13/2022] Open
Abstract
Background and Purpose With improved life expectancy, preventing neurocognitive decline after cerebral radiotherapy is gaining more importance. Hippocampal damage has been considered the main culprit for cognitive deficits following conventional whole-brain radiation therapy (WBRT). Here, we aimed to determine to which extent hippocampus-avoidance WBRT (HA-WBRT) can prevent hippocampal atrophy compared to conventional WBRT. Methods and Materials Thirty-five HA-WBRT and 48 WBRT patients were retrospectively selected, comprising a total of 544 contrast-enhanced T1-weighted magnetic resonance imaging studies, longitudinally acquired within 24 months before and 48 months after radiotherapy. HA-WBRT patients were treated analogously to the ongoing HIPPORAD-trial (DRKS00004598) protocol with 30 Gy in 12 fractions and dose to 98% of the hippocampus ≤ 9 Gy and to 2% ≤ 17 Gy. WBRT was mainly performed with 35 Gy in 14 fractions or 30 Gy in 10 fractions. Anatomical images were segmented and the hippocampal volume was quantified using the Computational Anatomy Toolbox (CAT), including neuroradiological expert review of the segmentations. Results After statistically controlling for confounding variables such as age, gender, and total intracranial volume, hippocampal atrophy was found after both WBRT and HA-WBRT (p < 10-6). However, hippocampal decline across time following HA-WBRT was approximately three times lower than following conventional WBRT (p < 10-6), with an average atrophy of 3.1% versus 8.5% in the first 2 years after radiation therapy, respectively. Conclusion HA-WBRT is a therapeutic option for patients with multiple brain metastases, which can effectively and durably minimize hippocampal atrophy compared to conventional WBRT.
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Affiliation(s)
- Ilinca Popp
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexander Rau
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Elias Kellner
- Medical Physics, Department of Radiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marco Reisert
- Medical Physics, Department of Radiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jamina Tara Fennell
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Rothe
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karl Egger
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Anca Ligia Grosu
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christoph P Kaller
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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12
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Rodríguez de Dios N, Couñago F, Murcia-Mejía M, Rico-Oses M, Calvo-Crespo P, Samper P, Vallejo C, Luna J, Trueba I, Sotoca A, Cigarral C, Farré N, Manero RM, Durán X, Gispert JD, Sánchez-Benavides G, Rognoni T, Torrente M, Capellades J, Jiménez M, Cabada T, Blanco M, Alonso A, Martínez-San Millán J, Escribano J, González B, López-Guerra JL. Randomized Phase III Trial of Prophylactic Cranial Irradiation With or Without Hippocampal Avoidance for Small-Cell Lung Cancer (PREMER): A GICOR-GOECP-SEOR Study. J Clin Oncol 2021; 39:3118-3127. [PMID: 34379442 DOI: 10.1200/jco.21.00639] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Radiation dose received by the neural stem cells of the hippocampus during whole-brain radiotherapy has been associated with neurocognitive decline. The key concern using hippocampal avoidance-prophylactic cranial irradiation (HA-PCI) in patients with small-cell lung cancer (SCLC) is the incidence of brain metastasis within the hippocampal avoidance zone. METHODS This phase III trial enrolled 150 patients with SCLC (71.3% with limited disease) to standard prophylactic cranial irradiation (PCI; 25 Gy in 10 fractions) or HA-PCI. The primary objective was the delayed free recall (DFR) on the Free and Cued Selective Reminding Test (FCSRT) at 3 months; a decrease of 3 points or greater from baseline was considered a decline. Secondary end points included other FCSRT scores, quality of life (QoL), evaluation of the incidence and location of brain metastases, and overall survival (OS). Data were recorded at baseline, and 3, 6, 12, and 24 months after PCI. RESULTS Participants' baseline characteristics were well balanced between the two groups. The median follow-up time for living patients was 40.4 months. Decline on DFR from baseline to 3 months was lower in the HA-PCI arm (5.8%) compared with the PCI arm (23.5%; odds ratio, 5; 95% CI, 1.57 to 15.86; P = .003). Analysis of all FCSRT scores showed a decline on the total recall (TR; 8.7% v 20.6%) at 3 months; DFR (11.1% v 33.3%), TR (20.3% v 38.9%), and total free recall (14.8% v 31.5%) at 6 months, and TR (14.2% v 47.6%) at 24 months. The incidence of brain metastases, OS, and QoL were not significantly different. CONCLUSION Sparing the hippocampus during PCI better preserves cognitive function in patients with SCLC. No differences were observed with regard to brain failure, OS, and QoL compared with standard PCI.
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Affiliation(s)
- Núria Rodríguez de Dios
- Radiation Oncology, Hospital del Mar, Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Pompeu Fabra University, Barcelona, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud, Madrid, Spain
| | - Mauricio Murcia-Mejía
- Department of Radiation Oncology, Hospital Universitario Sant Joan de Reus, Reus, Tarragona, Spain
| | - Mikel Rico-Oses
- Department of Radiation Oncology, Complejo Hospitalario Navarra, Pamplona, Spain
| | - Patricia Calvo-Crespo
- Department of Radiation Oncology, Hospital Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Pilar Samper
- Department of Radiation Oncology, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
| | - Carmen Vallejo
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Javier Luna
- Department of Radiation Oncology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Itziar Trueba
- Department of Radiation Oncology, Hospital Universitario de Álava-sede Txagorritxu.Vitoria-Gasteiz, Spain
| | - Amalia Sotoca
- Department of Radiation Oncology, Hospital Ruber Internacional, Madrid, Spain
| | - Cristina Cigarral
- Department of Radiation Oncology, Hospital Clínico de Salamanca, Salamanca, Spain
| | - Núria Farré
- Department of Radiation Oncology, Hospital Universitario Santa Creu i Sant Pau, Barcelona, Spain
| | - Rosa M Manero
- Department of Neurology, Hospital del Mar, Barcelona, Spain
| | - Xavier Durán
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Juan Domigo Gispert
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Pompeu Fabra University, Barcelona, Spain.,BarcelonaBeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Madrid, Spain
| | - Gonzalo Sánchez-Benavides
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,BarcelonaBeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, Spain
| | - Teresa Rognoni
- Department of Neurology, Clínica Universidad de Navarrra, Madrid, Spain
| | - Margarita Torrente
- Department of Psychology, School of Educational Sciences and Psychology, Rovira i Virgili University, Tarragona, Spain.,Laboratory of Toxicology and Environmental Health, School of Medicine, IISPV, Rovira i Virgili University, Tarragona, Spain
| | | | - Mar Jiménez
- Department of Radiology, Hospital Universitario Quirónsalud, Madrid, Spain
| | - Teresa Cabada
- Department of Radiology, Complejo Hospitalario Navarra, Pamplona, Spain
| | - Miguel Blanco
- Department of Radiology, Hospital Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Ana Alonso
- Department of Radiology, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
| | | | - José Escribano
- Department of Radiology, Hospital Ruber Internacional, Madrid, Spain
| | - Beatriz González
- Department of Radiation Oncology, Hospital Clínico de Salamanca, Salamanca, Spain
| | - José Luis López-Guerra
- Department of Radiation Oncology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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13
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Li J, Ding C, Yang C, Wang S, Qiao X. Prophylactic cranial irradiation confers favourable prognosis for patients with limited-stage small cell lung cancer in the era of MRI: A propensity score-matched analysis. J Med Imaging Radiat Oncol 2021; 65:778-785. [PMID: 34159731 DOI: 10.1111/1754-9485.13269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 06/01/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Prophylactic cranial irradiation (PCI) is recommended for patients with limited-stage small cell lung cancer (LS-SCLC) who achieve good response after chemoradiotherapy. But PCI is neurotoxic. Magnetic resonance imaging (MRI) is the standard tool for evaluating brain metastasis (BM). This study was to retrospectively analyse the necessity of PCI in the era of MRI in LS-SCLC. METHODS From July 2013 to June 2017, 190 patients with LS-SCLC who were treated with definitive chemoradiotherapy were included and analysed in this study. They were divided into the PCI group and non-PCI group. Propensity score matching (PSM) analysis was used to balance the variable differences. The Kaplan-Meier method was applied to estimate survival with log-rank test to ascertain significance between different groups. RESULTS Seventy-seven patients (40.5%) received PCI after chemoradiotherapy. After adjustment for propensity scores, 69 pairs of patients were matched between two groups. After PSM, the 1-year and 3-year OS rates were 96.9% and 48.5% in PCI group versus 89.9% and 25.0% in non-PCI group (HR: 0.419, 95% CI: 0.251-0.701, P = 0.001). The 1-year and 3-year BMFS in PCI group were 96.8% and 67.5% versus 62.3% and 37.9% in non-PCI group (HR: 0.247, 95% CI: 0.132-0.460, P < 0.001). CONCLUSION For patients showing no BM on MRI after definitive CRT, PCI confers less BM and better OS in LS-SCLC.
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Affiliation(s)
- Jing Li
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Cuimin Ding
- Department of Respiratory Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chen Yang
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Shuoshuo Wang
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xueying Qiao
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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14
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Kepka L, Socha J, Sas-Korczynska B. Radiotherapy for brain metastases from small-cell lung cancer in distinct clinical indications and scenarios. J Thorac Dis 2021; 13:3269-3278. [PMID: 34164219 PMCID: PMC8182529 DOI: 10.21037/jtd.2019.10.51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 10/14/2019] [Indexed: 12/25/2022]
Abstract
Management of brain metastases (BM) from small-cell lung cancer (SCLC) is complex and not supported by a strong evidence from prospective clinical trials. Owing to the different clinical and pathological characteristics of SCLC, patients with this histology were not included in the prospective studies on the value of whole-brain radiotherapy (WBRT) and local surgical or ablative radiation treatment like stereotactic radiosurgery (SRS). Chemotherapy also represents a major part of the armamentarium against BM from SCLC due to the well-recognized chemoresponsiveness of this cancer and the frequent presentation of BM with extracranial progression. WBRT in combination with chemotherapy has long been a standard approach in this setting. However, data on the neurocognitive toxicity and the lack of documented impact on overall survival of WBRT in the management of BM from other solid tumors, as well as the increasing availability of the stereotactic radiotherapy technologies, has led to the increasing use of SRS with omission of WBRT also in SCLC. In the current review the use of different modalities of radiotherapy and ways of combining radiotherapy with chemotherapy for BM from SCLC will be presented for distinct clinical situations: presentation of BM synchronous with primary, metachronous presentation of BM-without previous prophylactic cranial irradiation (PCI) vs. after PCI, and asymptomatic BM found at the staging before PCI.
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Affiliation(s)
- Lucyna Kepka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | - Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | - Beata Sas-Korczynska
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
- Institute of Medical Sciences, Medical College of Rzeszow University, Rzeszow, Poland
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15
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Abraham AG, Roa W. Hippocampal avoidance in prophylactic cranial irradiation for small cell lung cancer: benefits and pitfalls. J Thorac Dis 2021; 13:3235-3245. [PMID: 34164216 PMCID: PMC8182537 DOI: 10.21037/jtd-2019-rbmlc-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 09/03/2020] [Indexed: 11/25/2022]
Abstract
Small cell lung cancers (SCLC) are a group of cancers that are clinically and pathologically different from other lung cancers. They are associated with high recurrence rates and mortality, and many patients present with metastatic disease. Approximately ten percent of SCLC patients have brain metastases at time of diagnosis, and the cumulative incidence of brain metastases increases to more than fifty percent at two years, even with optimal treatment. Hence, in patients without brain metastases at presentation, prophylactic cranial irradiation (PCI) is an important component of treatment along with systemic chemotherapy and radiotherapy. The goal of PCI is to decrease the incidence of subsequent symptomatic brain metastases in patients who show an initial response to the systemic treatment. Various clinical trials have evaluated the utility of PCI and found substantial benefit. Unfortunately, the long-term toxicity associated with PCI, namely the neuro-cognitive impairment that may develop in patients as a result of the radiation toxicity to the hippocampal areas of the brain, has raised concern both for patients and their treating physicians. Various techniques have been tried to ameliorate the neuro-cognitive impairment associated with PCI, including pharmacological agents and highly conformal hippocampal avoidance radiation. All of these have shown promise, but there is a lack of clarity about the optimal way forward. Hippocampal avoidance PCI appears to be an excellent option and a number of groups are currently evaluating this technique. Although there is clear benefit with this specialized radiation treatment, there are also concerns about the risk of disease recurrence in the undertreated hippocampal areas. This review attempts to compile the available data regarding the benefits and pitfalls associated with hippocampal avoidance PCI in the setting of SCLC.
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Affiliation(s)
| | - Wilson Roa
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Canada
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16
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Abstract
Prophylactic cranial irradiation (PCI) has well established place in therapy for patients with limited-disease small cell lung cancer who responded to treatment. The data from randomized trials document that PCI reduces brain metastases rate from approximately 60% to 30%, and increases 3-year overall survival by approximately 5%. Currently, the dose of 25 Gy in 10 fractions is considered as standard. In attempt to reduce neuropsychological sequelae attributable to PCI hippocampal sparing techniques are employed. The existing studies suggest the benefit of hippocampal sparing in limiting memory and higher neurocognitive function losses, but with a risk of failures in the spared region. Ongoing studies will further validate the role of hippocampal sparing, both in terms of toxicity reduction and metastases prevention. PCI for patients who have undergone resection for stage I small cell lung cancer (SCLC) is not recommended, PCI may be, however, associated with a favourable outcome in SCLC patients who have undergone complete surgery in stages II−III. The role of PCI in extensive-disease (ED) SCLC has been evolving. Most recent evidence indicate that PCI is controversial in ED patients with response to initial chemotherapy and absence of brain metastases confirmed by contrast-enhanced MRI. The patients who do not receive PCI, must, however, receive periodic MRI examination during follow-up, i.e., remain under active surveillance with access to radiotherapy at brain relapse. The assessment of safety and effectiveness of hippocampal-sparing PCI, with or without drug neuroprotection in consideration of diverse combinations of radiotherapy, chemotherapy and immunotherapy create a background for future directions of research.
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Affiliation(s)
- Rafal Suwinski
- Radiotherapy and Chemotherapy Clinic and Teaching Hospital, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Poland
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17
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Cho Y, Lee J, Lee IJ, Kim JW, Baek JG, Jung DM, Cho BC, Hong MH, Kim HR, Lee CG, Yoon HI. Intracranial failure after hippocampal-avoidance prophylactic cranial irradiation in limited-stage small-cell lung cancer patients. Sci Rep 2021; 11:7435. [PMID: 33795826 PMCID: PMC8016941 DOI: 10.1038/s41598-021-86851-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 03/22/2021] [Indexed: 11/20/2022] Open
Abstract
We evaluated intracranial failure after hippocampus-avoidance-prophylactic cranial irradiation (HA-PCI) for limited-stage small-cell lung cancer (SCLC). Data of 106 patients who received PCI with 25 Gy were retrospectively reviewed. The patients were divided into two groups based on whether they underwent HA-PCI: the HA-PCI group (n = 48) and the conventional PCI (C-PCI) group (n = 58). Twenty-one patients experienced intracranial failure: 11 and 10 patients in the C-PCI and HA-PCI groups, respectively. Using the log-rank test, the intracranial failure rate was not significantly different between the groups (p = 0.215). No clinical factor was significantly associated with intracranial failure in multivariate Cox regression analysis, but HA-PCI tended to be associated with increased incidence of intracranial failure (HR 2.87, 95% CI 0.86–9.58, p = 0.087). Among patients who received HA-PCI, two developed peri-hippocampal recurrence. A higher thoracic radiotherapy dose (≥ 60 Gy) was significantly associated with DFS (HR 0.52, p = 0.048) and OS (HR 0.35, p = 0.003). However, HA-PCI was associated with neither DFS nor OS. Although HA-PCI may be associated with an increased risk of intracranial failure, HA-PCI did not impair disease control or survival. Future prospective randomized trials are needed to reach a definite conclusion.
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Affiliation(s)
- Yeona Cho
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joongyo Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Geol Baek
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Dong Min Jung
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Byoung Chul Cho
- Department of Internal Medicine, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Hee Hong
- Department of Internal Medicine, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Ryun Kim
- Department of Internal Medicine, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chang Geol Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hong In Yoon
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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18
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MRI-based brain structural changes following radiotherapy of Nasopharyngeal Carcinoma: A systematic review. Cancer Radiother 2021; 25:62-71. [PMID: 33414057 DOI: 10.1016/j.canrad.2020.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 07/29/2020] [Accepted: 07/31/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE Nasopharyngeal carcinoma (NPC) radiotherapy (RT) irradiates parts of the brain which may cause cerebral tissue changes. This study aimed to systematically review the brain microstructure changes using MRI-based measures, diffusion tensor imaging (DTI), diffusion kurtosis imaging (DKI) and voxel-based morphometry (VBM) and the impact of dose and latency following RT. METHODS PubMed and Scopus databases were searched based on PRISMA guideline to determine studies focusing on changes following NPC RT. RESULTS Eleven studies fulfilled the inclusion criteria. Microstructural changes occur most consistently in the temporal region. The changes were correlated with latency in seven studies; fractional anisotropy (FA) and gray matter (GM) volume remained low even after a longer period following RT and areas beyond irradiation site with reduced FA and GM measures. For dosage, only one study showed correlation, thus requiring further investigations. CONCLUSION DTI, DKI and VBM may be used as a surveillance tool in detecting brain microstructural changes of NPC patients which correlates to latency and brain areas following RT.
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19
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Rades D, Nguyen T, Janssen S, Schild SE. Development of a multivariable prediction model to estimate the remaining lifespan of elderly patients with cerebral metastases from small-cell lung cancer. Transl Lung Cancer Res 2020; 9:1433-1440. [PMID: 32953515 PMCID: PMC7481607 DOI: 10.21037/tlcr-20-327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Prognostic tools estimating survival of elderly patients with cerebral metastases from small-cell lung cancer (SCLC) improve treatment personalization. A specific tool for these patients was developed and compared to existing instruments. Methods One-hundred-and-forty elderly patients (≥65 years) receiving whole-brain irradiation (WBI) for cerebral metastases from SCLC were retrospectively evaluated. WBI-program, age, gender, Karnofsky performance score, number of cerebral lesions, extracerebral metastases, and interval between SCLC-diagnosis and WBI were investigated. Characteristics significantly associated with survival in the multivariate analysis were used for the tool. Scoring points were calculated by dividing 6-month survival rates (%) by 10 and added for patient scores. The tool was compared to existing diagnosis-specific instruments including updated diagnosis-specific graded prognostic assessment (DS-GPA), Rades-SCLC and WBRT-30-SCLC. Results In the multivariate analysis, KPS (P<0.001), number of cerebral lesions (P=0.013) and extracerebral metastases (P=0.049) were significantly associated with survival. Patient scores of 2 (n=37), 5 (n=69), 8 (n=20) and 11 (n=14) points were obtained; 6-month survival rates were 0%, 9%, 50% and 79% (P<0.001). The positive predictive value (PPV) of the worst group (2 points) to identify patients dying ≤6 months was 100%; PPVs of updated DS-GPA, Rades-SCLC and WBRT-30-SCLC were 94%, 100% and 94%. PPV of the best group (11 points) to identify patients surviving ≥6 months was 79%; PPVs of updated DS-GPA, Rades-SCLC and WBRT-30-SCLC were 86%, 79% and 100%. Conclusions The most precise instruments were the new tool and Rades-SCLC for identification of patients dying ≤6 months, and the WBRT-30-SCLC to identify patients surviving ≥6 months.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Trang Nguyen
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Stefan Janssen
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, USA
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Tjong MC, Mak DY, Shahi J, Li GJ, Chen H, Louie AV. Current Management and Progress in Radiotherapy for Small Cell Lung Cancer. Front Oncol 2020; 10:1146. [PMID: 32760673 PMCID: PMC7372592 DOI: 10.3389/fonc.2020.01146] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/08/2020] [Indexed: 12/17/2022] Open
Abstract
Radiotherapy (RT) and chemotherapy continue to be widely utilized in small cell lung cancer (SCLC) management. In most limited stage (LS)-SCLC cases, the standard initial therapy remains concurrent chemoradiotherapy (CRT), typically with an etoposide and platinum-based regimen. Hyperfractionated twice daily (BID) RT remains the standard of care, though conventional daily (QD) RT is now a viable alternative supported by randomized evidence. In LS-SCLC patients who experienced good response to CRT, prophylactic cranial irradiation (PCI) remains the standard of care. Brain imaging, ideally with MRI, should be performed prior to PCI to screen for clinically apparent brain metastases that may require a higher dose of cranial irradiation. Platinum doublet chemotherapy alone is the historic standard initial therapy in extensive stage (ES)-SCLC. Addition of immunotherapy such as atezolizumab and durvalumab to chemotherapy is now recommended after their benefits were demonstrated in recent trials. In patients with response to chemotherapy, consolidation thoracic RT and PCI could be considered, though with caveats. Emergence of hippocampal avoidance cranial irradiation and SRS in SCLC patients may supplant whole cranial irradiation as future standards of care. Incorporation of novel systemic therapies such as immunotherapies has changed the treatment paradigm and overall outlook of patients with SCLC. This narrative review summarizes the current state, ongoing trials, and future directions of radiotherapy in management of SCLC.
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Affiliation(s)
- Michael C Tjong
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - David Y Mak
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jeevin Shahi
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - George J Li
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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21
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Impact of Early Prophylactic Cranial Irradiation With Hippocampal Avoidance on Neurocognitive Function in Patients With Limited Disease Small Cell Lung Cancer. A Multicenter Phase 2 Trial (SAKK 15/12). Int J Radiat Oncol Biol Phys 2020; 107:279-287. [DOI: 10.1016/j.ijrobp.2020.02.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/28/2020] [Accepted: 02/02/2020] [Indexed: 01/10/2023]
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22
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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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Prophylactic cranial irradiation in extensive disease small cell lung cancer: An endless debate. Crit Rev Oncol Hematol 2019; 143:95-101. [DOI: 10.1016/j.critrevonc.2019.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 08/28/2019] [Accepted: 08/30/2019] [Indexed: 12/25/2022] Open
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Nielsen M, Kristiansen C, Schytte T, Hansen O. Initial experiences with hippocampus-sparing whole-brain radiotherapy for lung cancer patients. Acta Oncol 2019; 58:1540-1542. [PMID: 31303085 DOI: 10.1080/0284186x.2019.1632479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- M. Nielsen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - C. Kristiansen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - T. Schytte
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - O. Hansen
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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Chu X, Li S, Xia B, Chu L, Yang X, Ni J, Zou L, Li Y, Xie C, Lin J, Zhu Z. Patterns of brain metastasis immediately before prophylactic cranial irradiation (PCI): implications for PCI optimization in limited-stage small cell lung cancer. Radiat Oncol 2019; 14:171. [PMID: 31533763 PMCID: PMC6749639 DOI: 10.1186/s13014-019-1371-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/28/2019] [Indexed: 12/12/2022] Open
Abstract
Background Prophylactic cranial irradiation (PCI) is indicated for limited-stage small cell lung cancer (LS-SCLC) with good response to chemoradiotherapy (CRT). However, brain metastasis (BM) developed in LS-SCLC before PCI is not rare. In this study, we comprehensively investigated the features of pre-PCI BMs, aiming to explore the potential of PCI optimization for LS-SCLC. Methods One-hundred-ten LS-SCLC patients achieving clinical complete remission after definitive CRT with contrast-enhanced cranial magnetic resonance imaging (MRI) at baseline and immediately before PCI were included. The time trend and risk factors for pre-PCI BM were evaluated. Several radiological features, including numbers, sizes, and locations of pre-PCI BMs, were investigated to explore the technical feasibility of stereotactic radiotherapy and hippocampal-avoidance (HA) PCI. Results Twenty-four (21.8%) of the LS-SCLC patients harbored pre-PCI BM, all except one were asymptomatic. CRT duration (CRT-D) was the only independent risk factor for pre-PCI BM. The pre-PCI BM rate gradually increased in line with a growing time interval between treatment initiation and pre-PCI MRI. Pre-PCI BM and prolonged CRT-D were both correlated with worse overall survival. Of 129 pre-PCI intracranial lesions, 2 (1.5%) were in the HA region. Eight of the 24 (33.3%) pre-PCI BM patients were ineligible for stereotactic radiotherapy. Conclusion Our findings suggest that PCI is still of importance in LS-SCLC, and MRI evaluation before PCI is indispensable. Investigations are warranted to explore the possibility of moving PCI up to before CRT completion in LS-SCLC patients with prolonged CRT-D. HA-PCI could be considered to reduce neurotoxicity. Electronic supplementary material The online version of this article (10.1186/s13014-019-1371-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xiao Chu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Fudan University, 270 DongAn Road, XuHui District, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Shuyan Li
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Fudan University, 270 DongAn Road, XuHui District, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Bingqing Xia
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.,Department of Radiology, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200032, China
| | - Li Chu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Fudan University, 270 DongAn Road, XuHui District, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Xi Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Fudan University, 270 DongAn Road, XuHui District, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Jianjiao Ni
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Fudan University, 270 DongAn Road, XuHui District, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Liqing Zou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Fudan University, 270 DongAn Road, XuHui District, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Yida Li
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Fudan University, 270 DongAn Road, XuHui District, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Congying Xie
- Radiotherapy and Chemotherapy Department, the 1st Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Jie Lin
- Department of Medical Oncology, the Second Affiliated Hospital of Kunming Medical University, 374 Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China.
| | - Zhengfei Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Fudan University, 270 DongAn Road, XuHui District, Shanghai, 200032, China. .,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
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26
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Comparison of Diagnosis-Specific Survival Scores for Patients with Small-Cell Lung Cancer Irradiated for Brain Metastases. Cancers (Basel) 2019; 11:cancers11020233. [PMID: 30781513 PMCID: PMC6406817 DOI: 10.3390/cancers11020233] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 02/12/2019] [Accepted: 02/14/2019] [Indexed: 12/20/2022] Open
Abstract
Diagnosis-specific survival scores including a new score developed in 157 patients with brain metastases from small-cell lung cancer (SCLC) receiving whole-brain radiotherapy (WBRT) with 30 Gy in 10 fractions (WBRT-30-SCLC) were compared. Three prognostic groups were designed based on the 6-month survival probabilities of significant or almost significant factors, (age, performance score, number of brain metastases, extra-cerebral metastasis). Six-month survival rates were 6% (6–11 points), 44% (12–14 points) and 86% (16–19 points). The WBRT-30-SCLC was compared to three disease-specific scores for brain metastasis from SCLC, the original and updated diagnosis-specific graded prognostic assessment DS-GPA classifications and the Rades-SCLC. Positive predictive values (PPVs) used to correctly predict death ≤6 months were 94% (WBRT-30-SCLC), 88% (original DS-GPA), 88% (updated DS-GPA) and 100% (Rades-SCLC). PPVs to predict survival ≥6 months were 86%, 75%, 76% and 100%. For WBRT-30-SCLC and Rades-SCLC, differences between poor and intermediate prognoses groups and between intermediate and favorable prognoses groups were significant. For both DS-GPA classifications, only the difference between poor and intermediate prognoses groups was significant. Of these disease-specific tools, Rades-SCLC appeared to be the most accurate in identifying patients dying ≤6 months and patients surviving ≥6 months after irradiation, followed by the new WBRT-30-SCLC and the DS-GPA classifications.
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Bartel F, van Herk M, Vrenken H, Vandaele F, Sunaert S, de Jaeger K, Dollekamp NJ, Carbaat C, Lamers E, Dieleman EMT, Lievens Y, de Ruysscher D, Schagen SB, de Ruiter MB, de Munck JC, Belderbos J. Inter-observer variation of hippocampus delineation in hippocampal avoidance prophylactic cranial irradiation. Clin Transl Oncol 2018; 21:178-186. [PMID: 29876759 DOI: 10.1007/s12094-018-1903-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 05/24/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Hippocampal avoidance prophylactic cranial irradiation (HA-PCI) techniques have been developed to reduce radiation damage to the hippocampus. An inter-observer hippocampus delineation analysis was performed and the influence of the delineation variability on dose to the hippocampus was studied. MATERIALS AND METHODS For five patients, seven observers delineated both hippocampi on brain MRI. The intra-class correlation (ICC) with absolute agreement and the generalized conformity index (CIgen) were computed. Median surfaces over all observers' delineations were created for each patient and regional outlining differences were analysed. HA-PCI dose plans were made from the median surfaces and we investigated whether dose constraints in the hippocampus could be met for all delineations. RESULTS The ICC for the left and right hippocampus was 0.56 and 0.69, respectively, while the CIgen ranged from 0.55 to 0.70. The posterior and anterior-medial hippocampal regions had most variation with SDs ranging from approximately 1 to 2.5 mm. The mean dose (Dmean) constraint was met for all delineations, but for the dose received by 1% of the hippocampal volume (D1%) violations were observed. CONCLUSION The relatively low ICC and CIgen indicate that delineation variability among observers for both left and right hippocampus was large. The posterior and anterior-medial border have the largest delineation inaccuracy. The hippocampus Dmean constraint was not violated.
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Affiliation(s)
- F Bartel
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - M van Herk
- Department of Cancer Sciences, University of Manchester, Manchester, UK
| | - H Vrenken
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - F Vandaele
- Department of Radiotherapy, Iridium Cancer Network, Antwerp, Belgium
| | - S Sunaert
- Department of Radiology, University Hospitals Leuven, Louvain, Belgium
| | - K de Jaeger
- Department of Radiotherapy, Catharina Hospital, Eindhoven, The Netherlands
| | - N J Dollekamp
- Department of Radiotherapy, The University Medical Center Groningen, Groningen, The Netherlands
| | - C Carbaat
- Department of Radiotherapy, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - E Lamers
- Department of Radiotherapy, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - E M T Dieleman
- Department of Radiotherapy, Academic Medical Center, Amsterdam, The Netherlands
| | - Y Lievens
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - D de Ruysscher
- Department of Radiotherapy, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S B Schagen
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - M B de Ruiter
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - J C de Munck
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - J Belderbos
- Department of Radiotherapy, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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Treatment Design and Rationale for a Randomized Trial of Prophylactic Cranial Irradiation With or Without Hippocampal Avoidance for SCLC: PREMER Trial on Behalf of the Oncologic Group for the Study of Lung Cancer/Spanish Radiation Oncology Group-Radiation Oncology Clinical Research Group. Clin Lung Cancer 2018; 19:e693-e697. [PMID: 29891263 DOI: 10.1016/j.cllc.2018.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 12/21/2017] [Accepted: 05/01/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prophylactic cranial irradiation (PCI) is part of the usual treatment in most patients with small-cell lung cancer (SCLC) and response after treatment of the primary tumor. Clinical evidence suggests that radiation dose received by the hippocampus during whole brain radiotherapy might play a role in radiation-induced neurocognitive decline. PATIENTS AND METHODS This study is a multicenter phase III trial (NCT02397733) randomizing SCLC patients after informed consent, to receive standard PCI treatment or PCI with hippocampus avoidance (PCI-HA) by using intensity modulated radiation therapy or volumetric modulated arc therapy. The primary objective is assessment of hippocampus-dependent memory functioning and safety after PCI with or without hippocampus sparing by the Free and Cued Selective Reminding Test. Secondary objectives are assessment of other neurotoxicity/quality of life, radiological brain abnormalities on magnetic resonance images, and evaluation of the incidence and location of brain metastases after PCI-HA compared with standard PCI. The originally planned sample size (n = 150) has been calculated to detect a 50% difference in the 3-month delayed recall score between the 2 treatment arms, with a statistical power of 80% (β = 20%) and a significance level of 5% (α = 5%), with a maximum loss to follow-up of 10%. CONCLUSION This study is an important step in introducing a new therapeutic approach to patients with SCLC candidates for PCI.
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Sio TT, Prayongrat A, Zhang Y, Lin Q, Xu T, Liao Z, Yue J. The Road Less Traveled: Should We Omit Prophylactic Cranial Irradiation for Patients With Small Cell Lung Cancer? Clin Lung Cancer 2018; 19:289-293. [PMID: 29665993 DOI: 10.1016/j.cllc.2018.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/07/2018] [Accepted: 03/10/2018] [Indexed: 01/29/2023]
Abstract
New randomized data from Japan have raised questions regarding the use of prophylactic cranial irradiation for patients with extensive-stage small-cell lung cancer but without detectable brain metastases on magnetic resonance imaging. In the present focused review, we examine the general role of prophylactic cranial irradiation in the management of small-cell lung cancer and present relevant controversies from both sides of the discussion. Future directions for clinical investigation and research are also highlighted. Strategies for neurocognitive protection, including memantine use and hippocampal sparing using modulated radiotherapy techniques, are also presented.
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Affiliation(s)
- Terence T Sio
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ
| | - Anussara Prayongrat
- Department of Radiation Oncology, King Chulalongkorn Memorial Hospital, Chulalongkorn University Bangkok, Bangkok, Thailand
| | - Yun Zhang
- School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong, China; Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Cancer Hospital affiliated to Shandong University, Jinan, Shandong, China
| | - Qin Lin
- Department of Radiation Oncology, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian, China
| | - Ting Xu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jinbo Yue
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Cancer Hospital affiliated to Shandong University, Jinan, Shandong, China.
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30
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Padovani L, Chapon F, André N, Boucekine M, Geoffray A, Bourdeau F, Masliah-Planchon J, Claude L, Huchet A, Laprie A, Supiot S, Coche-Dequéant B, Kerr C, Alapetite C, Leseur J, Nguyen T, Chapet S, Bernier V, Bondiau PY, Noel G, Habrand JL, Bolle S, Doz F, Dufour C, Muracciole X, Carrie C. Hippocampal Sparing During Craniospinal Irradiation: What Did We Learn About the Incidence of Perihippocampus Metastases? Int J Radiat Oncol Biol Phys 2018; 100:980-986. [DOI: 10.1016/j.ijrobp.2017.12.265] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/08/2017] [Accepted: 12/11/2017] [Indexed: 02/03/2023]
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31
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Moreno AC, Lin SH. The optimal treatment approaches for stage I small cell lung cancer. Transl Lung Cancer Res 2018; 8:88-96. [PMID: 30788238 DOI: 10.21037/tlcr.2018.11.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Although small cell lung cancer (SCLC) represents less than one-sixth of all lung cancer cases, it is an aggressive disease with a high metastatic potential to various sites including the brain. Most landmark trials assessing individual therapy benefits for SCLC dichotomized patients as having either limited or extensive disease. Over the last decade, however, there has been a clear shift towards categorizing and analyzing survival patterns using a more thorough staging system that accounts for tumor size and the degree of nodal or metastatic disease burden. For the 5% of patients who present with clinical stage I (cT1-2aN0M0) SCLC, extrapolating treatment recommendations from a rather heterogeneous population that constitutes limited disease SCLC remains controversial and has led to numerous investigations of alternative therapies such as stereotactic body radiation therapy (SBRT) for the management of this highly select group of patients. Given the changing landscape of multimodal therapy, this review will summarize relevant data pertaining to and outline optimal treatment algorithms for stage I SCLC, with a particular focus on SBRT as a primary mode of local therapy.
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Affiliation(s)
- Amy C Moreno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Korkmaz Kirakli E, Oztekin O. Is Hippocampal Avoidance During Whole-Brain Radiotherapy Risky for Patients With Small-Cell Lung Cancer? Hippocampal Metastasis Rate and Associated Risk Factors. Technol Cancer Res Treat 2017; 16:1202-1208. [PMID: 29332467 PMCID: PMC5762091 DOI: 10.1177/1533034617742301] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objectives: Hippocampal avoidance during whole-brain radiotherapy is performed to prevent neural stem cell injury causing neurocognitive dysfunction. Nevertheless, the estimated risk of metastases in hippocampal avoidance area in small-cell lung cancer is unknown. The current study aimed to characterize the metastatic distribution within the brain relative to the hippocampus, estimate the incidence of hippocampal metastasis in patients with small-cell lung cancer, and identify clinical and radiographic variables that may be associated with the risk of hippocampal avoidance area metastasis. Materials and Methods: Patients with small-cell lung cancer treated with therapeutic whole-brain radiotherapy between January 2010 and December 2015 were reviewed. T1-weighted, postcontrast axial magnetic resonance images obtained just before therapeutic cranial irradiation were retrieved and reviewed for each patient. The hippocampal avoidance area was defined as hippocampus and 5-mm ring area adjacent to the hippocampus to account for necessary dose falloff between the hippocampus and the whole-brain planning target volume. Metastatic lesions within hippocampal avoidance area were defined as hippocampal metastasis. Hippocampal metastasis rate and characteristics of patients with hippocampal metastasis were analyzed and compared to patients without hippocampal metastasis. Results: Fifty-four patients evaluated with cranial magnetic resonance imaging were enrolled. Hippocampal metastasis rate was 32% (17 patients). A total of 4.4% of all metastases involved the hippocampal avoidance area. The most common location was frontal lobe. Being younger than 65 years of age was found to be an independent risk factor for HM (odds ratio: 4.8, 95% confidence interval: 1-23.2, P = .049). The number of brain metastases was significantly higher in patients with hippocampal metastasis (P = .027), and hippocampal metastasis rate was also higher in patients having larger hippocampus (P = .026) and larger brain volumes (P = .02). Conclusion: Hippocampal metastasis might be more common in small-cell lung cancer. Reducing the dose to the hippocampus by hippocampal avoiding whole-brain radiotherapy plan in small-cell lung cancer may be risky for the development of HM compared with other malignant solid tumors.
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Affiliation(s)
| | - Ozgur Oztekin
- 2 Tepecik Education and Research Hospital, Izmir, Turkey
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Lukas RV, Gondi V, Kamson DO, Kumthekar P, Salgia R. State-of-the-art considerations in small cell lung cancer brain metastases. Oncotarget 2017; 8:71223-71233. [PMID: 29050358 PMCID: PMC5642633 DOI: 10.18632/oncotarget.19333] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 07/03/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Small cell lung cancer (SCLC) frequently leads to development of brain metastases. These unfortunately continue to be associated with short survival. Substantial advances have been made in our understanding of the underlying biology of disease. This understanding on the background of previously evaluated and currently utilized therapeutic treatments can help guide the next steps in investigations into this disease with the potential to influence future treatments. DESIGN A comprehensive review of the literature covering epidemiology, pathophysiology, imaging characteristics, prognosis, and therapeutic management of SCLC brain metastases was performed. RESULTS SCLC brain metastases continue to have a poor prognosis. Both unique aspects of SCLC brain metastases as well as features seen more universally across other solid tumor brain metastases are discussed. Systemic therapeutic studies and radiotherapeutic approaches are reviewed. CONCLUSIONS A clearer understanding of SCLC brain metastases will help lay the framework for studies which will hopefully translate into meaningful therapeutic options for these patients.
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Affiliation(s)
- Rimas V. Lukas
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center Warrenville, Northwestern Medicine Chicago Proton Center, Northwestern University, Warrenville, IL, USA
| | - David O. Kamson
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Priya Kumthekar
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Ravi Salgia
- Department of Medical Oncology and Therapeutics, City of Hope, Duarte, CA, USA
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Yeo SG. Perihippocampal metastasis following hippocampus-avoiding prophylactic cranial irradiation for small cell lung cancer: a case report. Onco Targets Ther 2017; 10:4017-4021. [PMID: 28860809 PMCID: PMC5565389 DOI: 10.2147/ott.s143719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Prophylactic cranial irradiation (PCI) lowers the risk of brain metastasis (BM) and increases survival in small cell lung cancer (SCLC) patients, but it also entails a risk of neurocognitive dysfunction (NCD). One strategy to mitigate this neurotoxicity is hippocampus-avoiding (HA) whole-brain radiation therapy, as the hippocampus is mainly responsible for radiation-related NCD and hippocampal or perihippocampal metastases are rare. A few prospective clinical trials have demonstrated a reduction in NCD following HA whole-brain radiation therapy. The 59-year-old male patient described in this report had limited-stage SCLC and a complete response to thoracic chemoradiotherapy. Seven months after receiving HA-PCI of 25 Gy in 10 fractions using intensity-modulated radiation therapy, a 36 mm solitary metastasis was detected in the right perihippocampal region. The mass was surgically removed but the patient died 2 months later. The development of a solitary HA region metastasis is uncommon, considering that metastasis in this area usually occurs in patients with high numbers of BMs. Our case demonstrates the need for further validation of HA-PCI for SCLC patients in terms of both neurocognitive protection and the absence of compromise in terms of BM prevention.
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Affiliation(s)
- Seung-Gu Yeo
- Department of Radiation Oncology, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital, Cheonan, Republic of Korea
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35
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Lok BH, Ma J, Foster A, Perez CA, Shi W, Zhang Z, Li BT, Rudin CM, Rimner A, Wu AJ. Factors influencing the utilization of prophylactic cranial irradiation in patients with limited-stage small cell lung cancer. Adv Radiat Oncol 2017; 2:548-554. [PMID: 29204521 PMCID: PMC5707415 DOI: 10.1016/j.adro.2017.08.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 08/01/2017] [Indexed: 11/17/2022] Open
Abstract
Purpose Brain metastases are common in patients with limited-stage small cell lung cancer (LS-SCLC) due to the inability of most chemotherapeutics to penetrate the blood–brain barrier. Prophylactic cranial irradiation (PCI) is therefore recommended for use in patients with a good response to concurrent chemoradiotherapy. However, PCI is not always delivered; therefore, we investigated the reasons for PCI omission in patients who underwent therapy with curative intent. Methods and materials We retrospectively reviewed all patients with LS-SCLC who were treated with curative intent at our institution. Overall survival and cumulative incidence of brain metastasis were estimated by the Kaplan-Meier method. The Pearson χ2 test and Mann-Whitney U test were used to examine factors associated with PCI use, and prognostic factors were analyzed with Cox proportional hazards modeling. Results We examined 208 patients who were treated for LS-SCLC at our institution. A total of 115 patients (55%) received PCI. The most common documented reason for PCI omission was patient refusal due to neurotoxicity concerns (38%). Physician assessment of being medically unfit (33%) and of advanced age (8%) were the second and third most common reasons, respectively. Karnofsky performance status and clinical American Joint Committee on Cancer stage but not PCI were significantly associated with overall survival. Only clinical stage remained an independent factor on multivariate analysis. Conclusions Approximately half of patients with LS-SCLC ultimately receive PCI, generally for guideline-recommended reasons. The most common reason for PCI omission was patient concerns regarding neurotoxicity. Efforts to decrease PCI neurotoxicity, including hippocampal-sparing radiation and memantine use, may increase the use of this survival-improving intervention in eligible patients with LS-SCLC.
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Affiliation(s)
- Benjamin H Lok
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jennifer Ma
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amanda Foster
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Carmen A Perez
- Department of Radiation Oncology, New York University Langone Medical Center, New York, New York
| | - Weiji Shi
- Department of Epidemiology-Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Epidemiology-Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bob T Li
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles M Rudin
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Zhao L, Shen Y, Guo JD, Gu HL, Yu W, Wang JM, Lv CX, Liu J, Cai XW, Fu XL. Analyses of distribution and dosimetry of brain metastases in small cell lung cancer with relation to the neural stem cell regions: feasibility of sparing the hippocampus in prophylactic cranial irradiation. Radiat Oncol 2017; 12:118. [PMID: 28709456 PMCID: PMC5512955 DOI: 10.1186/s13014-017-0855-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 07/06/2017] [Indexed: 02/04/2023] Open
Abstract
Background This work aims to assess the feasibility of selectively sparing the hippocampus during prophylactic cranial irradiation (PCI) for small cell lung cancer (SCLC). Methods SCLC patients with brain metastases (BMs) diagnosed with MRI were enrolled. Lesions localized to the neural stem cell (NSC) compartments [subventricular zone (SVZ) or hippocampus] were analyzed. Patients were categorized by the total number of intracranial metastases, the therapy processes and the symptoms. Hippocampi and enhanced lesions within 15 mm from the hippocampus were contoured. IMRT treatment plans were generated for hippocampal avoidance (HA)-PCI (25Gy in 10 fractions). Results From Jan 2011 to Oct 2014, 1511 metastases were identified in 238 patients. The overall ratio of metastatic lesions located in NSC regions was 2.0% in the 1511 total metastases and 9.7% in the 238 overall patients. Among the NSC region metastases, 15 (1.0%) lesions involved the HA region of 14 (5.9%) patients and another 15 (1.0%) involved the SVZ of 15 (6.3%) patients. The involvement of HA region or SVZ was significantly different between patients with oligometastatic and non-oligometastatic BMs (P < 0.05). Based on the dosimetric analysis, 26 (10.9%) patients with 41 (2.7%) metastases within 15 mm from the hippocampus had inadequate dosage in case that HA-PCI was applied. Conclusions Our retrospective review of 1511 metastases in 238 patients (among whom 89.5% were male) suggests that the metastatic involvement of the NSC regions (especially hippocampus) is unusual and limited primarily to patients with non-oligometastatic disease in SCLC. Also, dosimetric analysis shows that about 10% of patients may have adequate dosage due to HA-PCI treatment. But we believe that this is still an acceptable clinical treatment strategy for SCLC.
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Affiliation(s)
- Lei Zhao
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai, 200030, China
| | - Yan Shen
- Department of Radiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jin-Dong Guo
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai, 200030, China
| | - Heng-Le Gu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai, 200030, China
| | - Wen Yu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai, 200030, China
| | - Jia-Ming Wang
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai, 200030, China
| | - Chang-Xing Lv
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai, 200030, China
| | - Jun Liu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai, 200030, China
| | - Xu-Wei Cai
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai, 200030, China
| | - Xiao-Long Fu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai, 200030, China.
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Chung SY, Chang JH, Kim HR, Cho BC, Lee CG, Suh CO. Optimal dose and volume for postoperative radiotherapy in brain oligometastases from lung cancer: a retrospective study. Radiat Oncol J 2017; 35:153-162. [PMID: 28712276 PMCID: PMC5518455 DOI: 10.3857/roj.2017.00094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 03/20/2017] [Accepted: 03/24/2017] [Indexed: 01/12/2023] Open
Abstract
PURPOSE To evaluate intracranial control after surgical resection according to the adjuvant treatment received in order to assess the optimal radiotherapy (RT) dose and volume. MATERIALS AND METHODS Between 2003 and 2015, a total of 53 patients with brain oligometastases from non-small cell lung cancer (NSCLC) underwent metastasectomy. The patients were divided into three groups according to the adjuvant treatment received: whole brain radiotherapy (WBRT) ± boost (WBRT ± boost group, n = 26), local RT/Gamma Knife surgery (local RT group, n = 14), and the observation group (n = 13). The most commonly used dose schedule was WBRT (25 Gy in 10 fractions, equivalent dose in 2 Gy fractions [EQD2] 26.04 Gy) with tumor bed boost (15 Gy in 5 fractions, EQD2 16.25 Gy). RESULTS The WBRT ± boost group showed the lowest 1-year intracranial recurrence rate of 30.4%, followed by the local RT and observation groups, at 66.7%, and 76.9%, respectively (p = 0.006). In the WBRT ± boost group, there was no significant increase in the 1-year new site recurrence rate of patients receiving a lower dose of WBRT (EQD2) <27 Gy compared to that in patients receiving a higher WBRT dose (p = 0.553). The 1-year initial tumor site recurrence rate was lower in patients receiving tumor bed dose (EQD2) of ≥42.3 Gy compared to those receiving <42.3 Gy, although the difference was not significant (p = 0.347). CONCLUSIONS Adding WBRT after resection of brain oligometastases from NSCLC seems to enhance intracranial control. Furthermore, combining lower-dose WBRT with a tumor bed boost may be an attractive option.
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Affiliation(s)
- Seung Yeun Chung
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Ryun Kim
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Byoung Chul Cho
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Geol Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
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Péchoux CL, Sun A, Slotman BJ, De Ruysscher D, Belderbos J, Gore EM. Prophylactic cranial irradiation for patients with lung cancer. Lancet Oncol 2017; 17:e277-e293. [PMID: 27396646 DOI: 10.1016/s1470-2045(16)30065-1] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 03/20/2016] [Accepted: 04/05/2016] [Indexed: 01/20/2023]
Abstract
The incidence of brain metastases in patients with lung cancer has increased as a result of improved local and systemic control and better diagnosis from advances in brain imaging. Because brain metastases are responsible for life-threatening symptoms and serious impairment of quality of life, resulting in shortened survival, prophylactic cranial irradiation has been proposed in both small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC) to try to improve incidence of brain metastasis, survival, and eventually quality of life. Findings from randomised controlled trials and a meta-analysis have shown that prophylactic cranial irradiation not only reduces the incidence of brain metastases in patients with SCLC and with non-metastatic NSCLC, but also improves overall survival in patients with SCLC who respond to first-line treatment. Although prophylactic cranial irradiation is potentially associated with neurocognitive decline, this risk needs to be balanced against the potential benefit in terms of brain metastases incidence and survival. Several strategies to reduce neurotoxicity are being investigated.
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Affiliation(s)
- Cécile Le Péchoux
- Department of Radiation Oncology, Gustave Roussy University Hospital, Villejuif, France.
| | - Alexander Sun
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Ben J Slotman
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, Netherlands
| | - Dirk De Ruysscher
- Department of Radiation Oncology (Maastro Clinic), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, Netherlands; Department of Oncology, Experimental Radiation Oncology, KU Leuven, Leuven, Belgium
| | - José Belderbos
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Elizabeth M Gore
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
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Paradigm shift of therapeutic management of brain metastases in EGFR-mutant non-small cell lung cancer in the era of targeted therapy. Med Oncol 2017; 34:121. [PMID: 28555261 DOI: 10.1007/s12032-017-0978-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 05/09/2017] [Indexed: 12/25/2022]
Abstract
Non-small cell lung cancer (NSCLC) patients with epidermal growth factor receptor (EGFR) mutations commonly present brain metastases (BM) at the time of NSCLC diagnosis or during the clinical course. Conventionally, the prognosis of BM has been extremely poor, but the advent of EGFR-tyrosine kinase inhibitors (TKIs) has drastically improved the prognosis in these patients. Despite the presence of the blood-brain barrier, EGFR-TKIs have dramatic therapeutic effects on both BM and extracranial disease. In addition, recent systemic chemotherapies reportedly play a role in controlling BM. These treatment modalities can potentially replace whole brain radiotherapy (WBRT) to prevent or delay neurocognitive decline. Therefore, how to utilize these treatments is one issue. The other issue is what kind of treatment is best for recurrence after TKI therapy. Recent reports have shown a positive effect of a combination therapy of EGFR-TKI and radiotherapy on BM. Although neurocognitive decline is underscored when WBRT is considered, a survival benefit from WBRT has been proven especially in the potential long survivors with good prognostic index, especially disease-specific graded prognostic index (DS-GPA). In this review, treatment strategy including chemotherapeutic agents and radiotherapy is discussed in terms of risk-benefit balance in conjunction with DS-GPA.
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Recent developments in radiotherapy for small-cell lung cancer: a review by the Oncologic Group for the Study of Lung Cancer (Spanish Radiation Oncology Society). Clin Transl Oncol 2017; 19:1183-1192. [PMID: 28447257 DOI: 10.1007/s12094-017-1667-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 04/19/2017] [Indexed: 12/15/2022]
Abstract
Small-cell lung cancer (SCLC) accounts for 13% of all lung tumours. The standard treatment in patients with limited-stage disease is radiotherapy combined with chemotherapy. In extensive SCLC, the importance of consolidation thoracic radiotherapy in patients with a good treatment response has become increasingly recognized. In both limited and extensive disease, prophylactic cranial irradiation is recommended in patients who respond to treatment. New therapeutic approaches such as immunotherapy are being increasingly incorporated into the treatment of SCLC, although more slowly than in non-small cell lung cancer (NSCLC). Diverse radiation dose and fractionation schemes, administered in varying combinations with these new drugs, are being investigated. In the present study we review and update the role of radiotherapy in the treatment of SCLC. We also discuss the main clinical trials currently underway in order to identify future trends.
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Redmond KJ, Hales RK, Anderson-Keightly H, Zhou XC, Kummerlowe M, Sair HI, Duhon M, Kleinberg L, Rosner GL, Vannorsdall T. Prospective Study of Hippocampal-Sparing Prophylactic Cranial Irradiation in Limited-Stage Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2017; 98:603-611. [PMID: 28581401 DOI: 10.1016/j.ijrobp.2017.03.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/21/2017] [Accepted: 03/07/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE To prospectively evaluate cognitive function and intracranial failure patterns after hippocampal-sparing prophylactic cranial irradiation (PCI) for limited-stage small cell lung cancer (SCLC). METHODS AND MATERIALS Adults with limited-stage SCLC, achieving a complete response to chemoradiotherapy and no brain metastases, were eligible. Patients received PCI 25 Gy/10 fractions, with a mean hippocampal dose limited to <8 Gy and ≥90% of the brain receiving 90% of the prescription. A diverse battery of neuropsychological testing was performed at baseline and 6 and 12 months after PCI. Brain MRI scans were performed at baseline and 6, 12, 18, and 24 months. The primary endpoint was memory measured by the Hopkins Verbal Learning Test-Revised Delayed Recall at 6 months after PCI. The 25-Gy arm of Radiation Therapy Oncology Group protocol 0212 was used as a reference of potential efficacy. Development of intracranial metastases was recorded. Overall survival and progression-free survival were estimated using the Kaplan-Meier method. RESULTS Eight men and 12 women with a median age of 61 years enrolled. Two-year overall survival was 88% (95% confidence interval 68%-100%). There was no significant decline in performance between baseline and 6 or 12 months for any of the tests. The association between baseline intelligence quotient and change in performance on testing was not significant. Magnetic resonance imaging revealed asymptomatic brain metastases at a cumulative rate of 20%, with no concurrent extracranial progression. Two patients developed a metastasis in the under-dosed region. Neither involved the dentate gyrus, but 1 involved the avoidance region. Both patients concurrently developed additional metastasis in fully treated brain regions. There were 2 neurologic deaths. CONCLUSIONS This prospective study suggests a potential benefit of hippocampal sparing in limiting the neuropsychological sequelae of brain radiation, but with a risk of failures in the spared region. These data strongly support continued enrollment on ongoing cooperative group randomized trials. Clinical Trials registration number: NCT01797159.
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Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, Maryland.
| | - Russell K Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, Maryland
| | - Heather Anderson-Keightly
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, Maryland
| | - Xian C Zhou
- Division of Biostatistics and Bioinformatics, Department of Oncology, The Johns Hopkins University, Baltimore, Maryland
| | - Megan Kummerlowe
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, Maryland
| | - Haris I Sair
- Department of Radiology, The Johns Hopkins University, Baltimore, Maryland
| | - Mario Duhon
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, Maryland
| | - Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, Maryland
| | - Gary L Rosner
- Division of Biostatistics and Bioinformatics, Department of Oncology, The Johns Hopkins University, Baltimore, Maryland
| | - Tracy Vannorsdall
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University, Baltimore, Maryland; Department of Neurology, The Johns Hopkins University, Baltimore, Maryland
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Prevention of radiotherapy-induced neurocognitive dysfunction in survivors of paediatric brain tumours: the potential role of modern imaging and radiotherapy techniques. Lancet Oncol 2017; 18:e91-e100. [DOI: 10.1016/s1470-2045(17)30030-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/24/2016] [Accepted: 10/26/2016] [Indexed: 02/06/2023]
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Farooqi AS, Holliday EB, Allen PK, Wei X, Cox JD, Komaki R. Prophylactic cranial irradiation after definitive chemoradiotherapy for limited-stage small cell lung cancer: Do all patients benefit? Radiother Oncol 2017; 122:307-312. [PMID: 28073578 DOI: 10.1016/j.radonc.2016.11.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 10/31/2016] [Accepted: 11/12/2016] [Indexed: 12/12/2022]
Abstract
PURPOSE Prophylactic cranial irradiation (PCI) can improve overall survival (OS) and suppress brain metastases (BM) in patients with limited-stage small cell lung cancer (LS-SCLC) after complete response to primary therapy. However, PCI can be toxic. We sought to identify characteristics of patients who may not benefit from PCI. METHODS We identified 658 patients who received chemoradiotherapy at MD Anderson in 1986-2012; 364 received PCI and 294 did not. Median follow-up time was 21.2months (range 1.2-240.8months). Cox proportional hazards regression, competing-risk regression, and Kaplan-Meier analyses were used to identify factors influencing OS and BM. RESULTS PCI reduced risks of death [HR 0.73, 95% CI 0.61-0.88, P=0.001] and BM [HR 0.54, 95% CI 0.39-0.76, P<0.001]. Having tumors ⩾5cm increased the risk of BM [HR 1.77, 95% CI 1.22-2.55, P=0.002] but not death [HR 1.16, 95% CI 0.96-1.40, P=0.114]. Among patients ⩾70years with ⩾5-cm tumors, PCI did not improve OS [2-year rates 39.4% vs 40.9%, P=0.739]. CONCLUSIONS PCI remains standard therapy after complete response to chemoradiotherapy for LS-SCLC. However, older patients may be at risk from comorbidity or extracranial disease. Further work is warranted to identify patients who may not benefit from PCI.
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Affiliation(s)
- Ahsan S Farooqi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Emma B Holliday
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Pamela K Allen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Xiong Wei
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - James D Cox
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Ritsuko Komaki
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States.
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Wu SG, Sun JY, Tong Q, Li FY, He ZY. Clinical features of brain metastases in breast cancer: an implication for hippocampal-sparing whole-brain radiation therapy. Ther Clin Risk Manag 2016; 12:1849-1853. [PMID: 28008263 PMCID: PMC5167295 DOI: 10.2147/tcrm.s124212] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective The objectives of this study were to describe the distribution of brain metastases (BM) in breast cancer patients and investigate the risk factors for perihippocampal metastases (PHM). Patients and methods Retrospective analysis of the clinicopathological characteristics and patterns of BM was performed. Associations between clinicopathological characteristics and PHM (the hippocampus plus 5 mm margin) were evaluated using logistic regression analyses. Results A total of 1,356 brain metastatic lesions were identified in 192 patients. Patients with 1–3 BM, 4–9 BM, and ≥10 BM accounted for 63.0%, 18.8%, and 18.2%, respectively. There were only 7 (3.6%) patients with hippocampal metastases (HM) and 14 (7.3%) patients with PHM. On logistic regression, the number of BM was an independent risk factor for PHM. Patients with ≥10 BM had a significantly higher risk of PHM compared with those with <10 BM. Breast cancer subtype (BCS) was not associated with PHM. The number of BM was significantly correlated with various BCSs. Patients with hormone receptor (HR)+/human epidermal growth factor receptor 2 (HER2)+, HR−/HER2+, and HR−/HER2− subtypes had a higher probability of ≥10 BM, relative to patients with an HR+/HER2− subtype. Conclusion Our study suggests that a low incidence of PHM may be acceptable to perform hippocampal-sparing whole-brain radiation therapy for breast cancer patients. Patients with extensive diffuse metastases (≥10 BM) were associated with higher odds of PHM.
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Affiliation(s)
- San-Gang Wu
- Department of Radiation Oncology, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen
| | - Jia-Yuan Sun
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou
| | - Qin Tong
- Department of Radiation Oncology, The First Affiliated Hospital of University of South China, Hengyang, People's Republic of China
| | - Feng-Yan Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou
| | - Zhen-Yu He
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou
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Clinical Features of Brain Metastases in Small Cell Lung Cancer: an Implication for Hippocampal Sparing Whole Brain Radiation Therapy. Transl Oncol 2016; 10:54-58. [PMID: 27940373 PMCID: PMC5154961 DOI: 10.1016/j.tranon.2016.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 11/02/2016] [Accepted: 11/04/2016] [Indexed: 12/25/2022] Open
Abstract
PURPOSE: To assess the clinical features and distribution of brain metastases (BMs) of small cell lung cancer (SCLC) in the hippocampal and perihippocampal region, with the purpose of exploring the viability of hippocampal-sparing whole-brain radiation therapy (HS-WBRT) on reducing neurocognitive deficits. METHODS: This was a retrospective analysis of the clinical characteristics and patterns of BMs in patients with SCLC. Associations between the clinical characteristics and hippocampal metastases (HMs)/perihippocampal metastases (PHMs) were evaluated in univariate and multivariate regression analyses. RESULTS: A total of 1594 brain metastatic lesions were identified in 180 patients. Thirty-two (17.8%) patients were diagnosed with BMs at the time of primary SCLC diagnosis. The median interval between diagnosis of primary SCLC and BMs was 9.3 months. There were 9 (5.0%) and 22 (12.2%) patients with HMs and PHMs (patients with BMs located in or within 5 mm around the hippocampus), respectively. In the univariate and multivariate analysis, the number of BMs was the risk factor for HMs and PHMs. Patients with BMs ≥ 5 had significantly higher risk of HMs (odds ratio [OR] 7.892, 95% confidence interval [CI] 1.469-42.404, P = .016), and patients with BMs ≥ 7 had significantly higher risk of PHMs (OR 5.162, 95% CI 2.017-13.213, P = .001). Patients with extracranial metastases are also associated with HMs. CONCLUSIONS: Our results indicate that patients with nonoligometastatic disease are significantly associated with HMs and PHMs. The incidence of PHMs may be acceptably low enough to perform HS-WBRT for SCLC. Our findings provide valuable clinical data to assess the benefit of HS-WBRT in SCLC patients with BMs.
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Wu SG, Rao MY, Zhou J, Lin Q, Wang ZJ, Chen YX, He ZY. Distribution of metastatic disease in the brain in relation to the hippocampus: a retrospective single-center analysis of 6064 metastases in 632 patients. Oncotarget 2016; 6:44030-6. [PMID: 26536661 PMCID: PMC4791284 DOI: 10.18632/oncotarget.5828] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/09/2015] [Indexed: 11/25/2022] Open
Abstract
This study aimed to investigate the patterns of brain metastasis and to explore the risk factors affecting hippocampus metastasis (HM). We retrospectively analyzed the clinical information of patients with metastatic disease in the brain. The associations between clinicopathologic variables with HM and peri-hippocampal metastasis (PHM) were evaluated in univariate and multivariate regression analyses. A total of 632 patients with 6064 metastatic lesions were recruited into the present study. Of these, 4.1% (26/632) of patients developed HM, and 5.5% (35/632) of patients developed PHM. Only 0.5% (31/6064) of metastatic lesions were located in the hippocampus and 0.6% (37/6064) were in the PHM. Age ≤60 years was an independent risk factor for HM (odds ratio [OR]: 2.602, 95% confidence interval [CI]: 1.115–6.076, P = 0.027) and PHM (OR: 2.555, 95%CI: 1.229–5.310, P = 0.012) in univariate and multivariate analyses. The hippocampus is a rare site of brain metastasis. Younger patients (age ≤60 years) had increased risk of developing HM and PHM. The current study provides the opportunity to investigate the clinical feasibility of hippocampal sparing whole brain radiation therapy, especially in older patients.
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Affiliation(s)
- San-Gang Wu
- Department of Radiation Oncology, Xiamen Cancer Center, the First Affiliated Hospital of Xiamen University, Xiamen, People's Republic of China
| | - Ming-Yue Rao
- Department of Radiology, the First Affiliated Hospital of Xiamen University, Xiamen, People's Republic of China
| | - Juan Zhou
- Department of Obstetrics and Gynecology, Xiamen Cancer Center, the First Affiliated Hospital of Xiamen University, Xiamen, People's Republic of China
| | - Qin Lin
- Department of Radiation Oncology, Xiamen Cancer Center, the First Affiliated Hospital of Xiamen University, Xiamen, People's Republic of China
| | - Zi-Jing Wang
- Department of Radiation Oncology, Xiamen Cancer Center, the First Affiliated Hospital of Xiamen University, Xiamen, People's Republic of China
| | - Yong-Xiong Chen
- Eye Institute of Xiamen University, Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Medical College of Xiamen University, Xiamen, People's Republic of China
| | - Zhen-Yu He
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, People's Republic of China
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Zhao R, Kong W, Shang J, Zhe H, Wang YY. Hippocampal-Sparing Whole-Brain Radiotherapy for Lung Cancer. Clin Lung Cancer 2016; 18:127-131. [PMID: 28340924 DOI: 10.1016/j.cllc.2016.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/31/2016] [Accepted: 09/06/2016] [Indexed: 11/29/2022]
Abstract
Brain metastases occur in 20% to 40% of lung cancer patients. Whole-brain radiotherapy (WBRT) has long been considered the treatment of choice for many patients with lung cancer, because of its wide availability, ease of delivery, and effectiveness in prolonging survival. However, WBRT is also associated with several side effects, such as decline in memory and other cognitive functions. There exists significant preclinical and clinical evidence that radiation-induced injury to the hippocampus correlates with neurocognitive decline of patients who receive WBRT. Technological advances in treatment planning and delivery facilitate the use of hippocampal-sparing (HS) WBRT as prophylactic cranial irradiation or the primary treatment modality for lung cancer patients with brain metastases. In this review, we provide a detailed and comprehensive discussion of the safety profile, techniques for hippocampus-sparing, and the clinical evidence of HS-WBRT for lung cancer patients.
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Affiliation(s)
- Ren Zhao
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, and Cancer Institute, Ningxia Medical University, Yinchuan, Ningxia, China
| | - Wei Kong
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, and Cancer Institute, Ningxia Medical University, Yinchuan, Ningxia, China
| | - Jun Shang
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, and Cancer Institute, Ningxia Medical University, Yinchuan, Ningxia, China
| | - Hong Zhe
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, and Cancer Institute, Ningxia Medical University, Yinchuan, Ningxia, China
| | - Yan-Yang Wang
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, and Cancer Institute, Ningxia Medical University, Yinchuan, Ningxia, China.
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Maingon P. Argumentaire clinique pour la radiothérapie guidée par imagerie par résonance magnétique. Cancer Radiother 2016; 20:558-63. [DOI: 10.1016/j.canrad.2016.07.070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 07/12/2016] [Accepted: 07/13/2016] [Indexed: 11/24/2022]
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Shahi J, Wright JR, Gabos Z, Swaminath A. Management of small-cell lung cancer with radiotherapy-a pan-Canadian survey of radiation oncologists. ACTA ACUST UNITED AC 2016; 23:184-95. [PMID: 27330347 DOI: 10.3747/co.23.3023] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The management of small-cell lung cancer (sclc) with radiotherapy (rt) varies, with many treatment regimens having been described in the literature. We created a survey to assess patterns of practice and clinical decision-making in the management of sclc by Canadian radiation oncologists (ros). METHODS A 35-item survey was sent by e-mail to Canadian ros. The questions investigated the role of rt, the dose and timing of rt, target delineation, and use of prophylactic cranial irradiation (pci) in limited-stage (ls) and extensive-stage (es) sclc. RESULTS Responses were received from 52 eligible ros. For ls-sclc, staging (98%) and simulation or dosimetric (96%) computed tomography imaging were key determinants of rt suitability. The most common dose and fractionation schedule was 40-45 Gy in 15 once-daily fractions (40%), with elective nodal irradiation performed by 31% of ros. Preferred management of clinical T1/2aN0 sclc favoured primary chemoradiotherapy (64%). For es-sclc, consolidative thoracic rt was frequently offered (88%), with a preferred dose and fractionation schedule of 30 Gy in 10 once-daily fractions (70%). Extrathoracic consolidative rt would not be offered by 23 ros (44%). Prophylactic cranial irradiation was generally offered in ls-sclc (100%) and es-sclc (98%) after response to initial treatment. Performance status, baseline cognition, and pre-pci brain imaging were important patient factors assessed before an offer of pci. CONCLUSIONS Canadian ros show practice variation in sclc management. Future clinical trials and national treatment guidelines might reduce variability in the treatment of early-stage disease, optimization of dose and targeting in ls-sclc, and definition of suitability for pci or consolidative rt.
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Affiliation(s)
- J Shahi
- Department of Oncology, McMaster University, Hamilton, ON
| | - J R Wright
- Department of Oncology, McMaster University, Hamilton, ON;; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON
| | - Z Gabos
- Department of Oncology, University of Edmonton, Edmonton, AB.; Cross Cancer Institute at Alberta Health Services, Edmonton, AB
| | - A Swaminath
- Department of Oncology, McMaster University, Hamilton, ON;; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON
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