1
|
Smith DE, Hamby T, Heym K, Mohamed A, Vallance KL, Ray A. Intracranial Relapse in Pediatric Sarcoma. J Pediatr Hematol Oncol 2023; 45:e810-e816. [PMID: 37526369 DOI: 10.1097/mph.0000000000002713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 05/08/2023] [Indexed: 08/02/2023]
Abstract
Advances in local control techniques, chemotherapy regimens, and imaging modalities have led to improvements in both morbidity and mortality in pediatric sarcoma patients. However, approximately one-third of patients develop disease relapse and intracranial metastasis was considered rare. The incidence of sarcoma brain metastasis is thought to have increased and is associated with grim outcomes. This was a retrospective study of 3 deidentified patient charts illustrating the possibility of the central nervous system as a potential site for pediatric sarcoma relapse and investigate the patterns of such relapses. We note this is the first report of infantile fibrosarcoma brain metastasis and a rare report of sarcoma lymph node metastasis. In addition, each patient was treated with targeted therapies, including entrectinib, Ruxolitnib, and pazopanib. Caregivers in cases 2 and 3 reported new-onset neurological manifestations before identification of new brain metastasis, indicating a lag in detection of new intracranial relapse in asymptomatic sarcoma patients. We suggest implementing a brief review of systems screening tool focused on concerning neurological manifestations to screen for new brain metastasis.
Collapse
Affiliation(s)
- Danielle E Smith
- University of North Texas Health Science Center, Texas College of Osteopathic Medicine
| | - Tyler Hamby
- University of North Texas Health Science Center, Texas College of Osteopathic Medicine
- Departments of Research Operations
| | - Kenneth Heym
- Pediatric Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX
| | - Ashraf Mohamed
- Pediatric Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX
| | - Kelly L Vallance
- Pediatric Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX
| | - Anish Ray
- Pediatric Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX
| |
Collapse
|
2
|
Alzate JD, Mullen R, Mashiach E, Bernstein K, De Nigris Vasconcellos F, Rotmann L, Berger A, Qu T, Silverman JS, Golfinos JG, Donahue BR, Kondziolka D. EGFR-mutated non-small lung cancer brain metastases and radiosurgery outcomes with a focus on leptomeningeal disease. J Neurooncol 2023; 164:387-396. [PMID: 37691032 DOI: 10.1007/s11060-023-04442-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/30/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE Patients with EGFR-mutated NSCLC represent a unique subset of lung cancer patients with distinct clinical and molecular characteristics. Previous studies have shown a higher incidence of brain metastases (BM) in this subgroup of patients, and neurologic death has been reported to be as high as 40% and correlates with leptomeningeal disease (LMD). METHODS Between 2012 and 2021, a retrospective review of our prospective registry identified 606 patients with BM from NSCLC, with 170 patients having an EGFR mutation. Demographic, clinical, radiographic, and treatment characteristics were correlated to the incidence of LMD and survival. RESULTS LMD was identified in 22.3% of patients (n = 38) at a median follow-up of 19 (2-98) months from initial SRS. Multivariate regression analysis showed targeted therapy and a cumulative number of metastases as significant predictors of LMD (p = 0.034, HR = 0.44), (p = .04, HR = 1.02). The median survival time after SRS of the 170 patients was 24 months (CI 95% 19.1-28.1). In a multivariate Cox regression analysis, RPA, exon 19 deletion, and osimertinib treatment were significant predictors of overall survival. The cumulative incidence of neurological death at 2 and 4 years post initial stereotactic radiosurgery (SRS) was 8% and 11%, respectively, and correlated with LMD. CONCLUSION The study shows that current-generation targeted therapy for EGFR-mutated NSCLC patients may prevent the development and progression of LMD, leading to improved survival outcomes. Nevertheless, LMD is associated with poor outcomes and neurologic death, making innovative strategies to treat LMD essential.
Collapse
Affiliation(s)
- Juan Diego Alzate
- Department of Neurological Surgery, NYU Langone Health, New York University, New York, USA.
| | - Reed Mullen
- Department of Neurological Surgery, NYU Langone Health, New York University, New York, USA
| | - Elad Mashiach
- Department of Neurological Surgery, NYU Langone Health, New York University, New York, USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Health, New York University, New York, USA
| | | | - Lauren Rotmann
- Department of Neurological Surgery, NYU Langone Health, New York University, New York, USA
| | - Assaf Berger
- Department of Neurological Surgery, NYU Langone Health, New York University, New York, USA
| | - Tanxia Qu
- Department of Radiation Oncology, NYU Langone Health, New York University, New York, USA
| | - Joshua S Silverman
- Department of Radiation Oncology, NYU Langone Health, New York University, New York, USA
| | - John G Golfinos
- Department of Neurological Surgery, NYU Langone Health, New York University, New York, USA
| | - Bernadine R Donahue
- Department of Radiation Oncology, NYU Langone Health, New York University, New York, USA
| | - Douglas Kondziolka
- Department of Neurological Surgery, NYU Langone Health, New York University, New York, USA
| |
Collapse
|
3
|
Damante MA, Wang JL, Elder JB. Surgical Management of Recurrent Brain Metastasis: A Systematic Review of Laser Interstitial Thermal Therapy. Cancers (Basel) 2022; 14:cancers14184367. [PMID: 36139527 PMCID: PMC9496803 DOI: 10.3390/cancers14184367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 11/16/2022] Open
Abstract
The incidence of recurrent metastatic brain tumors is increasing due to advances in local therapy, including surgical and radiosurgical management, as well as improved systemic disease control. The management of recurrent brain metastases was previously limited to open resection and/or irradiation. In recent years, laser interstitial thermal therapy (LITT) has become a promising treatment modality. As systemic and intracranial disease burden increases in a patient, patients may no longer be candidates for surgical resection. LITT offers a relatively minimally invasive option for patients that cannot tolerate or do not want open surgery, as well as an option for accessing deep-seated tumors that may be difficult to access via craniotomy. This manuscript aims to critically review the available data regarding the use of LITT for recurrent intracranial brain metastasis. Ten of seventy-two studies met the criteria for review. Generally, the available literature suggests that LITT is a safe and feasible option for the treatment of recurrent brain metastases involving supratentorial and cortical brain, as well as posterior fossa and deep-seated locations. Among all studies, only one directly compared craniotomy to LITT in the setting of recurrent brain metastasis. Prospective studies are needed to better elucidate the role of LITT in the management of recurrent brain metastases.
Collapse
|
4
|
Tunthanathip T, Sangkhathat S, Kanjanapradit K. Risk Factors Associated with Malignant Transformation of Astrocytoma: Competing Risk Regression Analysis. Asian J Neurosurg 2022; 17:3-10. [PMID: 35873847 PMCID: PMC9298577 DOI: 10.1055/s-0042-1748789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background
Malignant transformation (MT) of low-grade astrocytoma (LGA) triggers a poor prognosis in benign tumors. Currently, factors associated with MT of LGA have been inconclusive. The present study aims to explore the risk factors predicting LGA progressively differentiated to malignant astrocytoma.
Methods
The study design was a retrospective cohort study of medical record reviews of patients with LGA. Using the Fire and Gray method, the competing risk regression analysis was performed to identify factors associated with MT, using both univariate and multivariable analyses. Hence, the survival curves of the cumulative incidence of MT of each covariate were constructed following the final model.
Results
Ninety patients with LGA were included in the analysis, and MT was observed in 14.4% of cases in the present study. For MT, 53.8% of patients with MT transformed to glioblastoma, while 46.2% differentiated to anaplastic astrocytoma. Factors associated with MT included supratentorial tumor (subdistribution hazard ratio [SHR] 4.54, 95% confidence interval [CI] 1.08–19.10), midline shift > 1 cm (SHR 8.25, 95% CI 2.18–31.21), and nontotal resection as follows: subtotal resection (SHR 5.35, 95% CI 1.07–26.82), partial resection (SHR 10.90, 95% CI 3.13–37.90), and biopsy (SHR 11.10, 95% CI 2.88–42.52).
Conclusion
MT in patients with LGA significantly changed the natural history of the disease to an unfavorable prognosis. Analysis of patients' clinical characteristics from the present study identified supratentorial LGA, a midline shift more than 1 cm, and extent of resection as risk factors associated with MT. The more extent of resection would significantly help to decrease tumor burden and MT. In addition, future molecular research efforts are warranted to explain the pathogenesis of MT.
Collapse
Affiliation(s)
- Thara Tunthanathip
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Surasak Sangkhathat
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
- Department of Biomedical Sciences, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Kanet Kanjanapradit
- Department of Pathology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| |
Collapse
|
5
|
Lin SY, Tsan DL, Chuang CC, Yang CC, Pai PC, Wang CL, Wu YM, Lee CC, Lin CH, Wei KC, Chou WC. Oncological Outcomes After Hippocampus-Sparing Whole-Brain Radiotherapy in Cancer Patients With Newly Diagnosed Brain Oligometastases: A Single-Arm Prospective Observational Cohort Study in Taiwan. Front Oncol 2022; 11:784635. [PMID: 35096584 PMCID: PMC8790705 DOI: 10.3389/fonc.2021.784635] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/13/2021] [Indexed: 12/03/2022] Open
Abstract
Background Promisingly, the technique of hippocampus sparing during WBRT (HS-WBRT) might preserve NCFs. In this research, we examined oncological outcomes, with emphasis on neurologic/non-neurologic causes of death, CNS progression, and leptomeningeal disease (LMD) recurrence in cancer patients who underwent HS-WBRT. Methods One hundred and fourteen cancer patients with newly diagnosed brain oligometastases underwent HS-WBRT were consecutively enrolled. The cumulative incidence of cancer-specific deaths (neurologic or non-neurologic), LMD recurrence, and the composite endpoint of CNS progression (CNS-CE) as the first event were computed with a competing-risks approach to characterize the oncological outcomes after HS-WBRT. Results Patients with intact brain metastases had a significantly increased likelihood of dying from non-neurologic causes of death associated with early manifestation of progressive systemic disease (hazard ratio for non-neurologic death, 1.78; 95% CI, 1.08–2.95; p = 0.025; competing-risks Fine–Gray regression), which reciprocally rendered them unlikely to encounter LMD recurrence or any pattern of CNS progression (HR for CNS-CE as the first event, 0.13; 95% CI, 0.02–0.97; p = 0.047; competing-risks Fine–Gray regression). By contrast, patients with resection cavities post-craniotomy had reciprocally increased likelihood of CNS progression which might be associated with neurologic death eventually. Conclusions Patterns of oncological endpoints including neurologic/non-neurologic death and cumulative incidence of CNS progression manifesting as LMD recurrence are clearly clarified and contrasted between patients with intact BMs and those with resection cavities, indicating they are clinically distinct subgroups. Trial Registration ClinicalTrials.gov, Identifier: NCT02504788, NCT03223675.
Collapse
Affiliation(s)
- Shinn-Yn Lin
- Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Department of Medical Imaging and Radiological Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Din-Li Tsan
- Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Chi-Cheng Chuang
- Department of Neurosurgery, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Cheng Yang
- Department of Psychology, National Chengchi University, Taipei, Taiwan
| | - Ping-Ching Pai
- Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Department of Medical Imaging and Radiological Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Liang Wang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yi-Ming Wu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Chi Lee
- Department of Neurosurgery, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Hsin Lin
- Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Kuo-Chen Wei
- Department of Neurosurgery, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Chi Chou
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Deparment of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| |
Collapse
|
6
|
Eggen AC, Wind TT, Bosma I, Kramer MCA, van Laar PJ, van der Weide HL, Hospers GAP, Jalving M. Value of screening and follow-up brain MRI scans in patients with metastatic melanoma. Cancer Med 2021; 10:8395-8404. [PMID: 34741440 PMCID: PMC8633235 DOI: 10.1002/cam4.4342] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/09/2021] [Accepted: 09/26/2021] [Indexed: 11/19/2022] Open
Abstract
Background Novel treatments make long‐term survival possible for subsets of patients with melanoma brain metastases. Brain magnetic resonance imaging (MRI) may aid in early detection of brain metastases and inform treatment decisions. This study aimed to determine the impact of screening MRI scans in patients with metastatic melanoma and follow‐up MRI scans in patients with melanoma brain metastases. Methods This retrospective cohort study included patients diagnosed with metastatic melanoma or melanoma brain metastases between June 2015 and January 2018. The impact of screening MRI scans was evaluated in the first 2 years after metastatic melanoma diagnosis. The impact of follow‐up MRI scans was examined in the first year after brain metastases diagnosis. The number of MRI scans, scan indications, scan outcomes, and changes in treatment strategy were analyzed. Results In total, 116 patients had no brain metastases at the time of the metastatic melanoma diagnosis. Twenty‐eight of these patients (24%) were subsequently diagnosed with brain metastases. Screening MRI scans detected the brain metastases in 11/28 patients (39%), of which 8 were asymptomatic at diagnosis. In the 96 patients with melanoma brain metastases, treatment strategy changed after 75/168 follow‐up MRI scans (45%). In patients treated with immune checkpoint inhibitors, the number of treatment changes after follow‐up MRI scans was lower when patients had been treated longer. Conclusion(s) Screening MRI scans aid in early detection of melanoma brain metastases, and follow‐up MRI scans inform treatment strategy. In patients with brain metastases responding to immune checkpoint inhibitors, treatment changes were less frequently observed after follow‐up MRI scans. These results can inform the development of brain imaging protocols for patients with immune checkpoint inhibitor sensitive tumors.
Collapse
Affiliation(s)
- Annemarie C Eggen
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thijs T Wind
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ingeborg Bosma
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Miranda C A Kramer
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter Jan van Laar
- Department of Radiology, Ziekenhuisgroep Twente, Almelo, and Hengelo, Almelo, The Netherlands.,Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hiska L van der Weide
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Geke A P Hospers
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mathilde Jalving
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
7
|
Cummins DD, Morshed RA, Chavez MM, Avalos LN, Sudhakar V, Chung JE, Gallagher A, Saggi S, Daras M, Braunstein S, Theodosopoulos PV, McDermott MW, Aghi MK. Salvage Surgery for Local Control of Brain Metastases After Previous Stereotactic Radiosurgery: A Single-Center Series. World Neurosurg 2021; 158:e323-e333. [PMID: 34740830 DOI: 10.1016/j.wneu.2021.10.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although overall survival (OS) has improved in patients with brain metastases (BMs), control of recurrent BMs remains a therapeutic challenge. Salvage surgery may achieve acceptable control rates in the setting of progression after previous stereotactic radiosurgery (SRS), yet it remains a question how additional adjuvant therapies may affect outcomes and how patient selection for salvage surgery may be optimized. METHODS Patients receiving salvage surgery for BM progression after previous SRS were retrospectively reviewed from a single center. Outcomes of interest included local tumor progression, leptomeningeal dissemination, and OS. Cox proportional hazard models and nominal logistic regression were applied to determine factors associated with outcomes of interest. RESULTS A total of 43 patients with 50 BMs were included. After salvage surgery, local progression was observed for 17 BMs (34%), leptomeningeal dissemination was observed in 17 patients (39.5%), and censored median OS was 17.9 months. On multivariate analysis, use of brachytherapy was associated with improved local control (hazard ratio [HR], 0.15; 95% confidence interval [CI], 0.04-0.6; P = 0.008). For patients treated with SRS ≥4.5 months before salvage surgery, both brachytherapy (HR, 0.07; 95% CI, 0.01-0.39; P = 0.002) and postoperative adjuvant SRS (HR, 0.14; 95% CI, 0.02-1.00; P = 0.05) were associated with improved local control compared with no adjuvant radiation therapy. Presence of extracranial malignancy (HR, 6.70; 95% CI, 2.58-17.42; P < 0.0001) was associated with shorter survival. Graded prognostic assessment underestimated survival in 79.1% of patients, with a mean difference of 18.9 months between graded prognostic assessment-estimated and actual OS. CONCLUSIONS In properly selected patients, salvage surgery may be an appropriate therapy for BM progression after previous SRS. Adjuvant brachytherapy and repeat SRS can offer significant benefit for local control with salvage resection.
Collapse
Affiliation(s)
- Daniel D Cummins
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA; School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ramin A Morshed
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
| | - Miguel M Chavez
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Lauro N Avalos
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Vivek Sudhakar
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason E Chung
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Aaron Gallagher
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Satvir Saggi
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Mariza Daras
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Steve Braunstein
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California, USA
| | - Philip V Theodosopoulos
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | | | - Manish K Aghi
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
8
|
Gallo J, Garimall S, Shanker M, Castelli J, Watkins T, Olson S, Huo M, Foote MC, Pinkham MB. Outcomes Following Hypofractionated Stereotactic Radiotherapy to the Cavity After Surgery for Melanoma Brain Metastases. Clin Oncol (R Coll Radiol) 2021; 34:179-186. [PMID: 34642065 DOI: 10.1016/j.clon.2021.09.015] [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: 07/03/2021] [Revised: 09/05/2021] [Accepted: 09/21/2021] [Indexed: 11/18/2022]
Abstract
AIMS Hypofractionated stereotactic radiotherapy (HSRT) to the cavity after surgical resection of brain metastases improves local control. Most reported cohorts include few patients with melanoma, a population known to have high rates of recurrence and neurological death. We aimed to assess outcomes in patients with melanoma brain metastases who received HSRT after surgery at two Australian institutions. MATERIALS AND METHODS A retrospective analysis was carried out including patients treated between January 2012 and May 2020. HSRT was recommended for patients with melanoma brain metastases at high risk of local recurrence after surgery. Treatment was delivered using appropriately commissioned linear accelerators. Routine follow-up included surveillance magnetic resonance imaging brain every 3 months for at least 2 years. Primary outcomes were overall survival, local control, incidence of radiological radionecrosis and symptomatic radionecrosis. RESULTS There were 63 cavities identified in 57 patients. The most common HSRT dose prescriptions were 24 Gy in three fractions and 27.5 Gy in five fractions. The median follow-up was 32 months in survivors. Local control was 90% at 1 year, 83% at 2 years and 76% at 3 years. Subtotal brain metastases resection (hazard ratio 12.5; 95% confidence interval 1.4-111; P = 0.0238) was associated with more local recurrence. Overall survival was 64% at 1 year, 45% at 2 years and 40% at 3 years. There were 10 radiological radionecrosis events (16% of cavities) during the study period, with 5% at 1 year and 8% at 2 years after HSRT. The median time to onset of radiological radionecrosis was 21 months (range 6-56). Of these events, three became symptomatic (5%) during the study period at a median time to onset of 26 months (range 21-32). CONCLUSION Cavity HSRT is associated with high rates of local control in patients with melanoma brain metastases. Subtotal resection strongly predicts for local recurrence after HSRT. Symptomatic radionecrosis occurred in 5% of cavities but increased to 8% of longer-term survivors.
Collapse
Affiliation(s)
- J Gallo
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
| | - S Garimall
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - M Shanker
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Princess Alexandra Hospital Research Foundation, Woolloongabba, Queensland, Australia
| | - J Castelli
- Icon Cancer Centre, Greenslopes Private Hospital, Greenslopes, Queensland, Australia
| | - T Watkins
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - S Olson
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - M Huo
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - M C Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Icon Cancer Centre, Greenslopes Private Hospital, Greenslopes, Queensland, Australia
| | - M B Pinkham
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Icon Cancer Centre, Greenslopes Private Hospital, Greenslopes, Queensland, Australia
| |
Collapse
|
9
|
Lamba N, Kearney RB, Catalano PJ, Hassett MJ, Wen PY, Haas-Kogan DA, Aizer AA. Population-based estimates of survival among elderly patients with brain metastases. Neuro Oncol 2021; 23:661-676. [PMID: 33068418 DOI: 10.1093/neuonc/noaa233] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Prognostic estimates for patients with brain metastases (BM) stem from younger, healthier patients enrolled in clinical trials or databases from academic centers. We characterized population-level prognosis in elderly patients with BM. METHODS Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified 9882 patients ≥65 years old with BM secondary to lung, breast, skin, kidney, esophageal, colorectal, and ovarian primaries between 2014 and 2016. Survival was assessed by primary site and evaluated with Cox regression. RESULTS In total, 2765 versus 7117 patients were diagnosed with BM at primary cancer diagnosis (synchronous BM, median survival = 2.9 mo) versus thereafter (metachronous BM, median survival = 3.4 mo), respectively. Median survival for all primary sites was ≤4 months, except ovarian cancer (7.5 mo). Patients with non-small-cell lung cancer (NSCLC) receiving epidermal growth factor receptor (EGFR)- or anaplastic lymphoma kinase (ALK)-based therapy for synchronous BM displayed notably better median survival at 12.5 and 20.1 months, respectively, versus 2.8 months exhibited by other patients with NSCLC; survival estimates in melanoma patients based on receipt of BRAF/MEK therapy versus not were 6.7 and 2.8 months, respectively. On multivariable regression, older age, greater comorbidity, and type of managing hospital were associated with poorer survival; female sex, higher median household income, and use of brain-directed stereotactic radiation, neurosurgical resection, or systemic therapy (versus brain-directed non-stereotactic radiation) were associated with improved survival (all P < 0.05). CONCLUSIONS Elderly patients with BM have a poorer prognosis than suggested by prior algorithms. If prognosis is driven by systemic and not intracranial disease, brain-directed therapy with potential for significant toxicity should be utilized cautiously.
Collapse
Affiliation(s)
- Nayan Lamba
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rachel Brigell Kearney
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, Massachusetts
| | - Paul J Catalano
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, and Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Michael J Hassett
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ayal A Aizer
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
10
|
Sadetsky N, Hernandez A, Wallick CJ, McKenna EF, Surinach A, Colburn DE. Survival outcomes in an older US population with advanced melanoma and central nervous system metastases: SEER-Medicare analysis. Cancer Med 2020; 9:6216-6224. [PMID: 32667719 PMCID: PMC7476818 DOI: 10.1002/cam4.3256] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 05/28/2020] [Accepted: 06/10/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Central nervous system (CNS) metastasis is common in advanced melanoma patients. New treatment options have improved overall prognosis, but information is lacking for patients with CNS metastases. We investigated treatment patterns and survival outcomes in older melanoma patients with and without CNS metastases. METHODS A retrospective analysis of SEER-Medicare, a population-based linked database, was undertaken in patients aged > 65 years with advanced melanoma diagnosed from 2004 to 2011 and followed until 2013. RESULTS A total of 2522 patients were included. CNS metastases were present in 24.8% of patients at initial metastatic diagnosis; 16.5% developed CNS metastases during follow-up. Chemotherapy was the most common treatment regardless of CNS metastases. Overall survival (OS) was better for patients without CNS metastases (median, 9.5 months; 95% confidence interval [CI], 8.8-10.2) vs patients with CNS metastases (3.63 months; 95% CI, 3.4-3.9). Among patients with CNS metastases, median OS for targeted therapy, immunotherapy, and chemotherapy was 6 (95% CI, 2.5-9.6), 5.5 (95% CI, 3.8-7.5), and 4.5 (95% CI, 3.8-5.4) months, respectively, vs 2.4 (95% CI, 2.1-2.7) and 2.1 (95% CI, 1.8-2.7) months for local radiotherapy and no treatment, respectively. Stereotactic radiosurgery demonstrated higher OS vs whole-brain radiation therapy (median, 4.98 [95% CI, 3.5-7.5] vs 2.4 [95% CI, 2.1-2.7] months). CONCLUSION Patients with CNS metastases from melanoma remain a population with high unmet medical need despite recent advances in treatment. Systemic treatments (eg, BRAF-targeted therapy and immunotherapy) and stereotactic radiosurgery demonstrated meaningful but modest improvements in OS. Further explorations of combinations of radiotherapy, BRAF-targeted therapies, and immunotherapies are needed.
Collapse
Affiliation(s)
- Natalia Sadetsky
- Real World Data Science - Product Development, Genentech, Inc, South San Francisco, CA, USA
| | - Alexandra Hernandez
- Real World Data Science - Product Development, Genentech, Inc, South San Francisco, CA, USA
| | - Chris J Wallick
- US Medical Affairs, Genentech, Inc, South San Francisco, CA, USA
| | - Edward F McKenna
- US Medical Affairs, Genentech, Inc, South San Francisco, CA, USA
| | | | - Dawn E Colburn
- Product Development - Oncology, Genentech, Inc, South San Francisco, CA, USA
| |
Collapse
|
11
|
Jiang X. Identification of Patients with Brain Metastases with Favorable Prognosis After Local and Distant Recurrence Following Stereotactic Radiosurgery. Cancer Manag Res 2020; 12:4139-4149. [PMID: 32581585 PMCID: PMC7276324 DOI: 10.2147/cmar.s251285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/13/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose This retrospective study aimed to determine the prognostic factors associated with overall survival after intracranial local and distant recurrence in patients undergoing stereotactic radiosurgery (SRS) for brain metastases. Patients and Methods Clinical characteristics and therapeutic parameters of 251 patients, who were treated with initial stereotactic radiosurgery for brain metastases and later experienced intracranial recurrence, were analyzed to identify prognostic factors of post-recurrence overall survival (PROS). A Cox proportional hazard model was applied for univariate and multivariate analyses. Results Among the 251 patients, the median post-recurrence overall survival was 8 months, and the six-month PROS rate was 60.2%. The interval from initial radiosurgery treatment to intracranial recurrence (hazard ratio [HR]:0.970), the number of brain recurrent tumors (HR:1.245), the number of extracranial metastatic organs (HR:1.183), recursive partition analysis (RPA) (HR:1.778), and Eastern Cooperative Oncology Group Performance Status (ECOG PS) (HR:2.442) were identified as independent prognostic factors. The patients who received local treatment for solitary brain recurrence achieved better survival (the median survival time after recurrence was 22 months). In patients without extracranial metastasis, the median post-recurrence overall survival of the local treatment group was longer than that in the whole brain radiation therapy (WBRT) group (P<0.001) and the systemic therapy group (P<0.001). Conclusion A shorter interval from initial stereotactic radiosurgery to recurrence, an increasing number of brain recurrences and extracranial metastatic organs, and poor RPA and ECOG PS values are associated with poor post-recurrence prognosis. When the number of brain recurrent tumors and extracranial metastatic organs was limited, local treatment including stereotactic radiosurgery, surgery or intensity-modulated radiation therapy (IMRT) improved the post-recurrence overall survival.
Collapse
Affiliation(s)
- Xuechao Jiang
- Department of Radiation Oncology, Binzhou Center Hospital Affiliated to Binzhou Medical College, Binzhou, Shandong, People's Republic of China
| |
Collapse
|
12
|
Kaye J, Patel NV, Danish SF. Laser interstitial thermal therapy for in-field recurrence of brain metastasis after stereotactic radiosurgery: does treatment with LITT prevent a neurologic death? Clin Exp Metastasis 2020; 37:435-444. [PMID: 32377943 DOI: 10.1007/s10585-020-10035-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/29/2020] [Indexed: 10/24/2022]
Abstract
Brain metastasis (BM) affects up to one-third of adults with cancer and carries a historically bleak prognosis. Despite advances in stereotactic radiosurgery (SRS), rates of in-field recurrence (IFR) after SRS range from 10 to 25%. High rates of neurologic death have been reported after SRS failure, particularly for recurrences deep in the brain and surgically inaccessible. Laser interstitial thermal therapy (LITT) is an emerging option in this setting, but its ability to prevent a neurologic death is unknown. In this study, we investigate the causes of death among patients with BM who undergo LITT for IFR after SRS. We conducted a single institution retrospective case series of patients with BM who underwent LITT for IFR after SRS. Clinical and demographic data were collected via chart review. The primary endpoint was cause of death. Between 2010 and 2018, 70 patients with BM underwent LITT for IFR after SRS. Median follow-up after LITT was 12.0 months. At analysis, 49 patients died; a cause was determined in 44. Death was neurologic in 20 patients and non-neurologic in 24. The 24-month cumulative incidence of neurologic and non-neurologic death was 35.1% and 38.6%, respectively. Etiologies of neurologic death included local recurrence (n = 7), recovery failure (n = 7), distant progression (n = 5), and other (n = 1). Among our patient population, LITT provided the ability to stabilize neurologic disease in up to 2/3 of patients. For IFR after SRS, LITT may represent a reasonable treatment strategy for select patients. Additional work is necessary to determine the extent to which LITT can prevent neurologic death after recurrence of BM.
Collapse
Affiliation(s)
- Joel Kaye
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Nitesh V Patel
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Shabbar F Danish
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| |
Collapse
|
13
|
Iorio-Morin C, Mercure-Cyr R, Figueiredo G, Touchette CJ, Masson-Côté L, Mathieu D. Repeat stereotactic radiosurgery for the management of locally recurrent brain metastases. J Neurooncol 2019; 145:551-559. [DOI: 10.1007/s11060-019-03323-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 10/25/2019] [Indexed: 01/23/2023]
|
14
|
CD138 plasma cells may predict brain metastasis recurrence following resection and stereotactic radiosurgery. Sci Rep 2019; 9:14385. [PMID: 31591443 PMCID: PMC6779906 DOI: 10.1038/s41598-019-50298-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 08/14/2019] [Indexed: 12/24/2022] Open
Abstract
We sought to identify candidate biomarkers for early brain metastasis (BM) recurrence in patients who underwent craniotomy followed by adjuvant stereotactic radiosurgery. RNA sequencing was performed on eight resected brain metastasis tissue samples and revealed B-cell related genes to be highly expressed in patients who did not experience a distant brain failure and had prolonged overall survival. To translate the findings from RNA sequencing data, we performed immunohistochemistry to stain for B and T cell markers from formalin-fixed parffin-embedded tissue blocks on 13 patients. CD138 expressing plasma cells were identified and quantitatively assessed for each tumor sample. Patients’ tumor tissues that expressed high levels of CD138 plasma cells (N = 4) had a statistically significant improvement in OS compared to low levels of CD138 (N = 9) (p = 0.01). Although these findings are preliminary, the significance of CD138 expressing plasma cells within BM specimens should be investigated in a larger cohort. Immunologic markers based on resection cavity analysis could be predictive for determining patient outcomes following cavity-directed SRS.
Collapse
|
15
|
Șuteu P, Todor N, Ignat RM, Nagy V. Clinical prognostic factors associated with survival and a survival score for patients with brain metastases. Future Oncol 2019; 15:2619-2634. [PMID: 31290342 DOI: 10.2217/fon-2019-0119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To identify prognostic factors of survival in patients with brain metastases (BM) and to devise a prognostic score. Patients & methods: In this single-institution retrospective study, we analyzed potential clinical prognostic factors in 1363 patients with BM. Based on the Cox proportional hazard model, we devised a BM score with three classes (score <5, 5-6 and >6). Results: The 1-year overall survival (OS) was 26%. Independent prognostic factors of OS were: age, gender, Karnofski performance status, number of BM, control of primary, presence of extracerebral metastases and type of primary tumor. The 1-year OS was 56% for score <5; 21% for score 5-6 and 4% for score >6 (p < 0.01). Conclusion: The BM score we propose is effective in grouping patients according to their prognosis and can help decision making regarding treatment adjustments.
Collapse
Affiliation(s)
- Patricia Șuteu
- Department of Radiation Oncology, "Iuliu Hațieganu" University of Medicine & Pharmacy, Cluj-Napoca, Romania.,"Prof.Dr. I. Chiricuță" Oncology Institute, Cluj-Napoca, Romania
| | - Nicolae Todor
- "Prof.Dr. I. Chiricuță" Oncology Institute, Cluj-Napoca, Romania
| | - Radu-Mihai Ignat
- Department of Anatomy & Embriology, "Iuliu Hațieganu" University of Medicine & Pharmacy, Cluj-Napoca, Romania
| | - Viorica Nagy
- Department of Radiation Oncology, "Iuliu Hațieganu" University of Medicine & Pharmacy, Cluj-Napoca, Romania.,"Prof.Dr. I. Chiricuță" Oncology Institute, Cluj-Napoca, Romania
| |
Collapse
|
16
|
McTyre E, Ayala-Peacock D, Contessa J, Corso C, Chiang V, Chung C, Fiveash J, Ahluwalia M, Kotecha R, Chao S, Attia A, Henson A, Hepel J, Braunstein S, Chan M. Multi-institutional competing risks analysis of distant brain failure and salvage patterns after upfront radiosurgery without whole brain radiotherapy for brain metastasis. Ann Oncol 2019; 29:497-503. [PMID: 29161348 DOI: 10.1093/annonc/mdx740] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background In this study, we use a competing risks analysis to assess factors predictive of early-salvage whole brain radiotherapy (WBRT) and early death after upfront stereotactic radiosurgery (SRS) alone for brain metastases in an attempt to identify populations that benefit less from upfront SRS. Patients and methods Patients from eight academic centers were treated with SRS for brain metastasis. Competing risks analysis was carried out for distant brain failure (DBF) versus death prior to DBF as well as for salvage SRS versus salvage WBRT versus death prior to salvage. Linear regression was used to determine predictors of the number of brain metastases at initial DBF (nDBF). Results A total of 2657 patients were treated with upfront SRS alone. Multivariate analysis (MVA) identified an increased hazard of DBF associated with increasing number of brain metastases (P < 0.001), lowest SRS dose received (P < 0.001), and melanoma histology (P < 0.001), while there was a decreased hazard of DBF associated with increasing age (P < 0.001), KPS < 70 (P < 0.001), and progressive systemic disease (P = 0.004). MVA for first salvage SRS versus WBRT versus death prior to salvage revealed an increased hazard of first salvage WBRT seen with increasing number of brain metastases (P < 0.001) and a decreased hazard with widespread systemic disease (P = 0.002) and increasing age (P < 0.001). Variables associated with nDBF included age (P = 0.02), systemic disease status (P = 0.03), melanoma histology (P = 0.05), and initial number of brain metastases (P < 0.001). Conclusions Patients with a higher initial number of brain metastases were more likely to experience DBF, have a higher nDBF, and receive early-salvage WBRT, while patients who were older, had lower KPS, or had more systemic disease were more likely to experience death prior to DBF or salvage WBRT.
Collapse
Affiliation(s)
- E McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA.
| | - D Ayala-Peacock
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA; Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, USA
| | - J Contessa
- Department of Therapeutic Radiology/Southeast Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, USA
| | - C Corso
- Department of Therapeutic Radiology/Southeast Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, USA
| | - V Chiang
- Department of Therapeutic Radiology/Southeast Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, USA; Department of Neurosurgery, Yale University School of Medicine, New Haven, USA
| | - C Chung
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, USA; Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada, USA
| | - J Fiveash
- Department of Radiation Oncology, University of Alabama-Birmingham, Birmingham, USA
| | - M Ahluwalia
- Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, USA
| | - R Kotecha
- Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, USA
| | - S Chao
- Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, USA
| | - A Attia
- Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, USA
| | - A Henson
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| | - J Hepel
- Department of Radiation Oncology, Brown University Alpert Medical School, Providence, USA
| | - S Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, USA
| | - M Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| |
Collapse
|
17
|
Lanier CM, Hughes R, Ahmed T, LeCompte M, Masters AH, Petty WJ, Ruiz J, Triozzi P, Su J, O'Neill S, Watabe K, Cramer CK, Laxton AW, Tatter SB, Wang G, Whitlow C, Chan MD. Immunotherapy is associated with improved survival and decreased neurologic death after SRS for brain metastases from lung and melanoma primaries. Neurooncol Pract 2019; 6:402-409. [PMID: 31555455 DOI: 10.1093/nop/npz004] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background The effect of immunotherapy on brain metastasis patients remains incompletely understood. Our goal was to evaluate its effect on survival, neurologic death, and patterns of failure after stereotactic radiosurgery (SRS) without prior whole-brain radiation therapy (WBRT) in patients with lung and melanoma primaries metastatic to the brain. Methods We performed a retrospective analysis of 271 consecutive lung or melanoma patients treated with upfront SRS for brain metastases between 2013 and 2018. Of these patients, 101 (37%) received immunotherapy and 170 (63%) did not. Forty-three percent were treated with nivolumab. Thirty-seven percent were treated with pembrolizumab. Fifteen percent were treated with ipilimumab. One percent were treated with a combination of nivolumab and ipilimumab. One percent were treated with atezolizumab. Three percent were treated with another immunotherapy regimen. Survival was estimated by the Kaplan-Meier method and cumulative incidences of neurologic death, and local and distant brain failure were estimated using death as a competing risk. Results The median overall survival (OS) of patients treated with immunotherapy vs without was 15.9 (95% CI: 13.3 to 24.8) vs 6.1 (95% CI: 5.1 to 8.8) months (P < .01). The 1-year cumulative incidence of neurologic death was 9% in patients treated with immunotherapy vs 23% in those treated without (P = .01), while nonneurologic death was not significantly different (29% vs 41%, P = .51). Median brain metastasis velocity (BMV) did not differ between groups, and rates of salvage SRS and WBRT were similar. Conclusions The use of immunotherapy in patients with lung cancer or melanoma metastatic to the brain treated with SRS is associated with improved OS and decreased incidence of neurologic death.
Collapse
Affiliation(s)
- Claire M Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Ryan Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Tamjeed Ahmed
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC
| | - Michael LeCompte
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Adrianna H Masters
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - William J Petty
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC.,W.G. (Bill) Hefner Veteran Administration Medical Center, Cancer Center, Salisbury, NC
| | - Pierre Triozzi
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC
| | - Jing Su
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Stacy O'Neill
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Kuonosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Ge Wang
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY
| | | | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| |
Collapse
|
18
|
Perez JL, Ozpinar A, Kano H, Phan B, Niranjan A, Lunsford LD. Salvage Stereotactic Radiosurgery in Breast Cancer Patients with Multiple Brain Metastases. World Neurosurg 2019; 125:e479-e486. [PMID: 30710716 DOI: 10.1016/j.wneu.2019.01.108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 01/14/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND The overall survival rates for breast cancer are increasing due to controlled brain disease and improved systemic treatments. This study examined neurologic outcomes, tumor control, and survival data in breast cancer patients with multiple brain metastases and who required salvage stereotactic radiosurgery (SRS) for recurrent breast cancer brain metastases. METHODS The study included 231 patients with a primary diagnosis of breast cancer who underwent SRS for more than 1 brain metastases from May 1993 and July 2007. Survival analyses via univariate and multivariate Cox regression demonstrated interactions between survival and predictor values including Karnofsky Performance Scale, Recursive Partitioning Analysis Class, number of brain metastases, whole-brain radiotherapy (WBRT), immunotherapy, and chemotherapy. RESULTS Of the 231 patients, the survival rate was 53% at 1 year and 26% at 5 years from initial SRS. Controlled systemic disease, adjuvant chemotherapy, and Recursive Partitioning Analysis class II were significant predictors of increased survival, while WBRT was a significant predictor of decreased survival. The median survival in patients who received WBRT after SRS was 11 months versus 23 months in those who did not. The local tumor control rate at initial follow-up was 95%. Of these, 40% of patients underwent additional brain SRS. Following salvage SRS, 8% of patients developed symptomatic adverse radiation events; however, the development of symptomatic adverse radiation events had no effect on patient survival. CONCLUSIONS This report indicated that both initial and salvage SRS procedures in breast cancer patients with multiple brain metastases are effective for local control of intracranial disease while minimizing adverse radiation effects.
Collapse
Affiliation(s)
- Jennifer L Perez
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
| | - Alp Ozpinar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - BaDoi Phan
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
19
|
Romagna A, Alexander R, Schwartz C, Ladisich B, Hitzl W, Heidorn SC, Winkler PA, Muacevic A. CyberKnife Radiosurgery in Recurrent Brain Metastases: Do the Benefits Outweigh the Risks? Cureus 2018; 10:e3741. [PMID: 30800551 PMCID: PMC6384047 DOI: 10.7759/cureus.3741] [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: 11/17/2022] Open
Abstract
Introduction Local treatment concepts are in high demand in the salvage treatment of recurrent brain metastases. Still, their risks and benefits are scarcely characterized. In this study, we analyzed the outcome and risk-/benefit-ratio of salvage CyberKnife (Accuray Incorporated, Sunnyvale, California, US) radiosurgery in the treatment of recurrent brain metastases after whole brain radiotherapy (WBRT). Materials and methods Seventy-six patients with 166 recurrent brain metastases and a multimodal pretreatment were retrospectively investigated. All patients underwent salvage CyberKnife radiosurgery (single fraction, reference dose: 17-22 Gy). Study endpoints were post-recurrence survival (PRS) after salvage treatment as well as local and distant tumor control rates. Central nervous system (CNS) toxicity was assessed according to the toxicity criteria of the Radiation Therapy Oncology Group and the European Organization for Research and Treatment of Cancer (RTOG/EORTC)). Results The population was homogenous regarding its demographic parameters. All patients had a history of WBRT prior to salvage CyberKnife radiosurgery. PRS was 13.3 months (10.4 - 16.2 months), one-year local and distant tumor control rates were 87% (95% CI: 75-99) and 38% (95% CI: 23-52), respectively. Eighteen patients suffered from RTOG/EORTC grade I/II toxicity. No toxicity-related risk factors were identified. Discussion This study found indicative survival and tumor control rates as well as a favorable risk/benefit ratio regarding radiotoxicity in salvage CyberKnife radiosurgery. These results point to a proactive therapeutic strategy based on appropriate patient selection instead of therapeutic nihilism.
Collapse
Affiliation(s)
| | - Romagna Alexander
- Neurosurgery, Christian-Doppler-Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | - Christoph Schwartz
- Neurosurgery, Christian-Doppler-Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | - Barbara Ladisich
- Neurosurgery, Christian-Doppler-Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | - Wolfgang Hitzl
- Biostatistics, Christian-Doppler-Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | | | - Peter A Winkler
- Neurosurgery, Christian-Doppler-Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | | |
Collapse
|
20
|
Dohm AE, Hughes R, Wheless W, Lecompte M, Lanier C, Ruiz J, Watabe K, Xing F, Su J, Cramer C, Laxton A, Tatter S, Chan MD. Surgical resection and postoperative radiosurgery versus staged radiosurgery for large brain metastases. J Neurooncol 2018; 140:749-756. [PMID: 30367382 DOI: 10.1007/s11060-018-03008-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/20/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The purpose of this study was to retrospectively evaluate the new treatment paradigm of staged stereotactic radiosurgery (SRS) for the treatment of large brain metastases (BM) compared to the standard of surgical resection followed by SRS. METHODS We evaluated 78 patients with large BM treated 2012-2017 with surgical resection and postoperative SRS (surgery + SRS) or staged SRS separated by 1 month. Overall survival (OS) was estimated using the Kaplan Meier method and compared across groups using the log-rank test. Cumulative incidence of neurologic death and local and distant brain failure (LF, DBF) were estimated using competing risk methodology. RESULTS Forty patients were treated with surgery + SRS and 38 patients were treated with staged SRS. Median follow-up was 23.2 months (95% CI 20.5-39.3). Median OS was 13.2 months for staged SRS compared to surgery + SRS 9.7 months (p = 0.53). Cumulative incidence of neurologic death at 1 year was 23% after surgery + SRS, 27% after staged SRS (p = 0.69); cumulative incidence of LF at 1 year was 6% and 8% (p = 0.65) and 1-year DBF was 59% and 21% (p ≤ 0.01). Overall rates of leptomeningeal failure and radiation necrosis were similar between the groups (p = 0.63 and p = 1.0). CONCLUSIONS Though surgery and postoperative SRS is the standard, staged SRS represents an attractive treatment paradigm for treating large BM without sacrificing LC or survival, and potentially decreases DBF. Prospective studies are needed to validate these findings.
Collapse
Affiliation(s)
- Ammoren E Dohm
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Ryan Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - William Wheless
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Michael Lecompte
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Claire Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Fei Xing
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jing Su
- Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Christina Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Adrian Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Stephen Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| |
Collapse
|
21
|
He C, Zhang Y, Cai Z, Duan F, Lin X, Li S. Nomogram to Predict Cancer-Specific Survival in Patients with Pancreatic Acinar Cell Carcinoma: A Competing Risk Analysis. J Cancer 2018; 9:4117-4127. [PMID: 30519311 PMCID: PMC6277614 DOI: 10.7150/jca.26936] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 07/22/2018] [Indexed: 02/07/2023] Open
Abstract
Background: The objective of this study was to evaluate the probability of cancer-specific death of patients with acinar cell carcinoma (ACC) and build nomograms to predict overall survival (OS) and cancer-specific survival (CSS) of these patients. Methods: Data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Patients diagnosed with ACC between 2004 and 2014 were retrospectively collected. Cancer-specific mortality and competing risk mortality were evaluated. Nomograms for estimating 1-, 2- and 3-year OS and CSS were established based on Cox regression model and Fine and Grey's model. The precision of the 1-, 2- and 3-year survival of the nomograms was evaluated and compared using the area under receiver operating characteristic (ROC) curve (AUC). Results: The study cohort included 227 patients with ACC. The established nomograms were well calibrated, and had good discriminative ability, with a concordance index (C-index) of 0.742 for OS prediction and 0.766 for CSS prediction. The nomograms displayed better discrimination power than 7th or 8th edition Tumor-Node-Metastasis (TNM) stage systems in training set and validation set for predicting both OS and CSS. The AUC values of the nomogram predicting 1-, 2-, and 3-year OS rates were 0.784, 0.797 and 0.805, respectively, which were higher than those of 7th or 8th edition TNM stage systems. Regard to the prediction of CSS rates, the AUC values of the nomogram were also higher than those of 7th or 8th edition TNM stage systems. Conclusion: We evaluated the 1-, 2- and 3-year OS and CSS in patients with ACC for the first time. Our nomograms showed relatively good performance and could be considered as convenient individualized predictive tools for prognosis.
Collapse
Affiliation(s)
- Chaobin He
- Department of Hepatobiliary and Pancreatic Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Yu Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, Guangdong, 510060, P.R. China
| | - Zhiyuan Cai
- Department of Hepatobiliary and Pancreatic Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Fangting Duan
- Department of Hepatobiliary and Pancreatic Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Xiaojun Lin
- Department of Hepatobiliary and Pancreatic Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Shengping Li
- Department of Hepatobiliary and Pancreatic Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| |
Collapse
|
22
|
Kim IY, Jung S, Jung TY, Moon KS, Jang WY, Park JY, Song TW, Lim SH. Repeat Stereotactic Radiosurgery for Recurred Metastatic Brain Tumors. J Korean Neurosurg Soc 2018; 61:633-639. [PMID: 30064202 PMCID: PMC6129758 DOI: 10.3340/jkns.2017.0238] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 11/24/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE We investigated the outcomes of repeat stereotactic radiosurgery (SRS) for metastatic brain tumors that locally recurred despite previous SRS, focusing on the tumor control. METHODS A total of 114 patients with 176 locally recurring metastatic brain tumors underwent repeat SRS after previous SRS. The mean age was 59.4 years (range, 33 to 85), and there were 68 male and 46 female patients. The primary cancer types were non-small cell lung cancer (n=67), small cell lung cancer (n=12), gastrointestinal tract cancer (n=15), breast cancer (n=10), and others (n=10). The number of patients with a single recurring metastasis was 95 (79.8%), and another 19 had multiple recurrences. At the time of the repeat SRS, the mean volume of the locally recurring tumors was 5.94 mL (range, 0.42 to 29.94). We prescribed a mean margin dose of 17.04 Gy (range, 12 to 24) to the isodose line at the tumor border primarily using a 50% isodose line. RESULTS After the repeat SRS, we obtained clinical and magnetic resonance imaging follow-up data for 84 patients (73.7%) with a total of 108 tumors. The tumor control rate was 53.5% (58 of the 108), and the median and mean progression-free survival (PFS) periods were 246 and 383 days, respectively. The prognostic factors that were significantly related to better tumor control were prescription radiation dose of 16 Gy (p=0.000) and tumor volume less than both 4 mL (p=0.001) and 10 mL at the repeat SRS (p=0.008). The overall survival (OS) periods for all 114 patients after repeat SRS varied from 1 to 56 months, and median and mean OS periods were 229 and 404 days after the repeat SRS, respectively. The main cause of death was systemic problems including pulmonary dysfunction (n=58, 51%), and the identified direct or suspected brain-related death rate was around 20%. CONCLUSION The tumor control following repeat SRS for locally recurring metastatic brain tumors after a previous SRS is relatively lower than that for primary SRS. However, both low tumor volume and high prescription radiation dose were significantly related to the tumor control following repeat SRS for these tumors after previous SRS, which is a general understanding of primary SRS for metastatic brain tumors.
Collapse
Affiliation(s)
- In-Young Kim
- Department of Neurosurgery, Brain Tumor Clinic & Gamma Knife Center, Chonnam National University Hwasun Hospital, Chonnam National University College of Medecine, Hwasun, Korea.,Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Shin Jung
- Department of Neurosurgery, Brain Tumor Clinic & Gamma Knife Center, Chonnam National University Hwasun Hospital, Chonnam National University College of Medecine, Hwasun, Korea.,Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Tae-Young Jung
- Department of Neurosurgery, Brain Tumor Clinic & Gamma Knife Center, Chonnam National University Hwasun Hospital, Chonnam National University College of Medecine, Hwasun, Korea.,Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Kyung-Sub Moon
- Department of Neurosurgery, Brain Tumor Clinic & Gamma Knife Center, Chonnam National University Hwasun Hospital, Chonnam National University College of Medecine, Hwasun, Korea.,Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Woo-Youl Jang
- Department of Neurosurgery, Brain Tumor Clinic & Gamma Knife Center, Chonnam National University Hwasun Hospital, Chonnam National University College of Medecine, Hwasun, Korea
| | - Jae-Young Park
- Department of Neurosurgery, Brain Tumor Clinic & Gamma Knife Center, Chonnam National University Hwasun Hospital, Chonnam National University College of Medecine, Hwasun, Korea
| | - Tae-Wook Song
- Department of Neurosurgery, Brain Tumor Clinic & Gamma Knife Center, Chonnam National University Hwasun Hospital, Chonnam National University College of Medecine, Hwasun, Korea
| | - Sa-Hoe Lim
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| |
Collapse
|
23
|
Hatiboglu MA, Akdur K, Sawaya R. Neurosurgical management of patients with brain metastasis. Neurosurg Rev 2018; 43:483-495. [DOI: 10.1007/s10143-018-1013-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 06/19/2018] [Accepted: 07/15/2018] [Indexed: 12/18/2022]
|
24
|
Dohm A, McTyre ER, Okoukoni C, Henson A, Cramer CK, LeCompte MC, Ruiz J, Munley MT, Qasem S, Lo HW, Xing F, Watabe K, Laxton AW, Tatter SB, Chan MD. Staged Stereotactic Radiosurgery for Large Brain Metastases: Local Control and Clinical Outcomes of a One-Two Punch Technique. Neurosurgery 2018; 83:114-121. [PMID: 28973432 DOI: 10.1093/neuros/nyx355] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 06/11/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Treatment options are limited for large, unresectable brain metastases. OBJECTIVE To report a single institution series of staged stereotactic radiosurgery (SRS) that allows for tumor response between treatments in order to optimize the therapeutic ratio. METHODS Patients were treated with staged SRS separated by 1 mo with a median dose at first SRS of 15 Gy (range 10-21 Gy) and a median dose at second SRS of 14 Gy (range 10-18 Gy). Overall survival was evaluated using the Kaplan-Meier method. Cumulative incidences were estimated for neurological death, radiation necrosis, local failure (marginal or central), and distant brain failure. Absolute cumulative dose-volume histogram was created for each treated lesion. Logistic regression and competing risks regression were performed for each discrete dose received by a certain volume. RESULTS Thirty-three patients with 39 lesions were treated with staged radiosurgery. Overall survival at 6 and 12 mo was 65.0% and 60.0%, respectively. Cumulative incidence of local failure at 6 and 12 mo was 3.2% and 13.3%, respectively. Of the patients who received staged therapy, 4 of 33 experienced local failure. Radiation necrosis was seen in 4 of 39 lesions. Two of 33 patients experienced a Radiation Therapy Oncology Group toxicity grade > 2 (2 patients had grade 4 toxicities). Dosimetric analysis revealed that dose (Gy) received by volume of brain (ie, VDose(Gy)) was associated with radiation necrosis, including the range V44.5Gy to V87.8Gy. CONCLUSION Staged radiosurgery is a safe and effective option for large, unresectable brain metastases. Prospective studies are required to validate the findings in this study.
Collapse
Affiliation(s)
- Ammoren Dohm
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Emory R McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Catherine Okoukoni
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Adrianna Henson
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael C LeCompte
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jimmy Ruiz
- Department of Medicine (Hematology and Oncology), Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael T Munley
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Shadi Qasem
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Hui-Wen Lo
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Fei Xing
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael D Chan
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
25
|
Franchino F, Rudà R, Soffietti R. Mechanisms and Therapy for Cancer Metastasis to the Brain. Front Oncol 2018; 8:161. [PMID: 29881714 PMCID: PMC5976742 DOI: 10.3389/fonc.2018.00161] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/30/2018] [Indexed: 12/12/2022] Open
Abstract
Advances in chemotherapy and targeted therapies have improved survival in cancer patients with an increase of the incidence of newly diagnosed brain metastases (BMs). Intracranial metastases are symptomatic in 60–70% of patients. Magnetic resonance imaging (MRI) with gadolinium is more sensitive than computed tomography and advanced neuroimaging techniques have been increasingly used in the detection, treatment planning, and follow-up of BM. Apart from the morphological analysis, the most effective tool for characterizing BM is immunohistochemistry. Molecular alterations not always reflect those of the primary tumor. More sophisticated methods of tumor analysis detecting circulating biomarkers in fluids (liquid biopsy), including circulating DNA, circulating tumor cells, and extracellular vesicles, containing tumor DNA and macromolecules (microRNA), have shown promise regarding tumor treatment response and progression. The choice of therapeutic approaches is guided by prognostic scores (Recursive Partitioning Analysis and diagnostic-specific Graded Prognostic Assessment-DS-GPA). The survival benefit of surgical resection seems limited to the subgroup of patients with controlled systemic disease and good performance status. Leptomeningeal disease (LMD) can be a complication, especially in posterior fossa metastases undergoing a “piecemeal” resection. Radiosurgery of the resection cavity may offer comparable survival and local control as postoperative whole-brain radiotherapy (WBRT). WBRT alone is now the treatment of choice only for patients with single or multiple BMs not amenable to surgery or radiosurgery, or with poor prognostic factors. To reduce the neurocognitive sequelae of WBRT intensity modulated radiotherapy with hippocampal sparing, and pharmacological approaches (memantine and donepezil) have been investigated. In the last decade, a multitude of molecular abnormalities have been discovered. Approximately 33% of patients with non-small cell lung cancer (NSCLC) tumors and epidermal growth factor receptor mutations develop BMs, which are targetable with different generations of tyrosine kinase inhibitors (TKIs: gefitinib, erlotinib, afatinib, icotinib, and osimertinib). Other “druggable” alterations seen in up to 5% of NSCLC patients are the rearrangements of the “anaplastic lymphoma kinase” gene TKI (crizotinib, ceritinib, alectinib, brigatinib, and lorlatinib). In human epidermal growth factor receptor 2-positive, breast cancer targeted therapies have been widely used (trastuzumab, trastuzumab-emtansine, lapatinib-capecitabine, and neratinib). Novel targeted and immunotherapeutic agents have also revolutionized the systemic management of melanoma (ipilimumab, nivolumab, pembrolizumab, and BRAF inhibitors dabrafenib and vemurafenib).
Collapse
Affiliation(s)
- Federica Franchino
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| |
Collapse
|
26
|
Soike MH, McTyre ER, Hughes RT, Farris M, Cramer CK, LeCompte MC, Lanier CM, Ruiz J, Su J, Watabe K, Bourland JD, Munley MT, O'Neill S, Laxton AW, Tatter SB, Chan MD. Initial brain metastasis velocity: does the rate at which cancers first seed the brain affect outcomes? J Neurooncol 2018; 139:461-467. [PMID: 29740743 DOI: 10.1007/s11060-018-2888-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/12/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE/OBJECTIVE(S) Brain metastasis velocity (BMV) is a metric that describes the rate of development of new brain metastases (BM) after initial stereotactic radiosurgery (SRS). A limitation in the application of BMV is it cannot be applied until time of first BM failure after SRS. We developed initial BM velocity (iBMV), a new metric that accounts for the number of BM at first SRS and the time since initial cancer diagnosis. MATERIALS/METHODS We reviewed patients with BM treated at our institution with upfront SRS without WBRT. iBMV was calculated as the number of BM at initial SRS divided by time (years) from initial cancer diagnosis to first SRS. We performed a linear regression to correlate BMV as a continuous variable and with low, intermediate, and high BMV risk groups. Kaplan-Meier estimation of OS was calculated from time of first SRS to death. iBMV was not calculated for patients who presented with BM at initial cancer diagnosis. RESULTS 994 patients were treated with upfront SRS without WBRT between 2000 and 2017. Median OS was 8.5 mos. 595 (60%) patients developed BM after cancer diagnosis and median time to first SRS from time of initial diagnosis was 2.2 years. Median iBMV was 0.79 BM/year. iBMV correlated with BMV (β = 1.57 p = 0.021) and independently predicted for mortality [Cox proportional hazard ratio (HR) 1.11, p = 0.036] after accounting for histology, number of initial brain metastases (HR 1.03, p = 0.32), time from cancer diagnosis to SRS (HR 0.98, p = 0.157) in a multivariate model. CONCLUSION iBMV correlates with BMV and OS. With further validation, iBMV could serve as a metric to risk stratify patients for WBRT or SRS at time of first BM presentation.
Collapse
Affiliation(s)
- Michael H Soike
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA.
- Department of Radiation Oncology, Wake Forest Baptist Medical Center, Winston-Salem, NC, 27103, USA.
| | - Emory R McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Ryan T Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Michael Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Michael C LeCompte
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Claire M Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Jing Su
- Department of Diagnostic Radiology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - J Daniel Bourland
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Michael T Munley
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Stacey O'Neill
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| |
Collapse
|
27
|
Nieder C, Mehta MP, Geinitz H, Grosu AL. Prognostic and predictive factors in patients with brain metastases from solid tumors: A review of published nomograms. Crit Rev Oncol Hematol 2018; 126:13-18. [PMID: 29759555 DOI: 10.1016/j.critrevonc.2018.03.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/19/2018] [Accepted: 03/25/2018] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To review published nomograms that predict endpoints such as overall survival (OS) or risk of intracranial relapse in patients with brain metastases from solid tumors. METHODS The methods and results of nomogram studies identified by a systematic search were extracted and compared, stratified by endpoint predicted by the respective nomograms. In particular, validation strategies (external/internal), concordance indices (cut-off 0.75) and comparisons to older models were analyzed. RESULTS Six publications reported on prediction of OS. Most of these analyses focused on one particular primary tumor site, e.g., breast cancer or hepatocellular carcinoma, while the largest study included different primary tumor sites. The median number of patients was 244. Three of six studies included external validation cohorts. With few exceptions, concordance indices <0.75 were reported. In all studies reporting this endpoint, the nomogram outperformed older prognostic scores. Two nomograms focused on development of new brain metastases after radiosurgery (one externally validated), one on survival free from salvage whole brain radiotherapy (WBRT) after radiosurgery, and one on neurologic and non-neurologic death in patients receiving radiosurgery after WBRT failure. All concordance indices of these 4 nomograms were <0.70. CONCLUSION Taking into account concordance indices and comparisons to older prognostic models, the most promising, externally validated nomograms are the breast cancer and the non-small cell lung cancer nomogram predicting OS, and the distant brain failure after radiosurgery nomogram. Additional validation studies as well as continuous monitoring of the models' performance appear necessary to ensure their clinical applicability in the present era of rapidly changing treatment paradigms.
Collapse
Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodø, Norway; Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway.
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Hans Geinitz
- Department of Radiation Oncology, St. Vincent's Hospital, Linz, Austria
| | - Anca L Grosu
- Department of Radiation Oncology, University Medical Center, Medical Faculty, University of Freiburg, Germany; German Cancer Consortium (DKTK) Partner Site Freiburg, Germany
| |
Collapse
|
28
|
Kotecha R, Damico N, Miller JA, Suh JH, Murphy ES, Reddy CA, Barnett GH, Vogelbaum MA, Angelov L, Mohammadi AM, Chao ST. Three or More Courses of Stereotactic Radiosurgery for Patients with Multiply Recurrent Brain Metastases. Neurosurgery 2018; 80:871-879. [PMID: 28327948 DOI: 10.1093/neuros/nyw147] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 12/14/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although patients with brain metastasis are treated with primary stereotactic radiosurgery (SRS), the use of salvage therapies and their consequence remains understudied. OBJECTIVE To study the intracranial recurrence patterns and salvage therapies for patients who underwent multiple SRS courses. METHODS A retrospective review was performed of 59 patients with brain metastases who underwent ≥3 SRS courses for new lesions. Cox regression analyzed factors predictive for overall survival. RESULTS The median age at diagnosis was 52 years. Over time, patients underwent a median of 3 courses of SRS (range: 3-8) to a total of 765 different brain metastases. The 6-month risk of distant intracranial recurrence after the first SRS treatment was 64% (95% confidence interval: 52%-77%). Overall survival was 40% (95% confidence interval: 28%-53%) at 24 months. Only 24 patients (41%) had a decline in their Karnofsky Performance Status ≤70 at last office visit. Quality of life was preserved among 77% of patients at 12 months, with 45% experiencing clinically significant improvement during clinical follow-up. Radiation necrosis developed in 10 patients (17%). On multivariate analysis, gender (males, Hazard Ratio [HR]: 2.0, P < .05), Karnofsky Performance Status ≤80 (HR 3.2, P < .001), extracranial metastases (HR: 3.6, P < .001), and a distant intracranial recurrence ≤3 months from initial to repeat SRS (HR: 3.8, P < .001) were associated with a poorer survival. CONCLUSION In selected patients, performing ≥3 SRS courses controls intracranial disease. Patients may need salvage SRS for distant intracranial relapse, but focal retreatments are associated with modest toxicity, do not appear to negatively affect a patient's performance status, and help preserve quality of life.
Collapse
Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicholas Damico
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jacob A Miller
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Erin S Murphy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Vogelbaum
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alireza M Mohammadi
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samuel T Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
29
|
Lanier CM, McTyre E, LeCompte M, Cramer CK, Hughes R, Watabe K, Lo HW, O'Neill S, Munley MT, Laxton AW, Tatter SB, Ruiz J, Chan MD. The number of prior lines of systemic therapy as a prognostic factor for patients with brain metastases treated with stereotactic radiosurgery: Results of a large single institution retrospective analysis. Clin Neurol Neurosurg 2018; 165:24-28. [PMID: 29289917 DOI: 10.1016/j.clineuro.2017.12.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 11/25/2017] [Accepted: 12/25/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES It is presently unknown whether patients with brain metastases from heavily pre-treated cancers have a significantly different prognosis than those with less pre-treatment. In this study we sought to identify whether the number of prior lines of systemic therapy are associated with clinical outcomes in patients with brain metastases who received stereotactic radiosurgery (SRS). PATIENTS AND METHODS Between July 2000 and July 2017, 377 patients with brain metastases were treated with upfront SRS. We performed a large, single institution retrospective analysis of these patients. Kaplan Meier analysis was used to estimate survival times. Competing risk analysis was used to estimate times to local failure (LF) and distant brain failure (DBF). Multivariate analysis was performed to estimate the hazard ratios (HRs) for overall survival (OS), neurologic and non-neurologic death for patients with 1, 2 and 3+ lines of prior systemic therapy. RESULTS Of the 1077 patients with brain metastases treated with SRS, 377 received prior systemic therapy with a median of 1 (range: 1-9) lines of prior therapy. Median OS was 8.70 months (95% CI, 7.9-9.5). Median OS for patients with 1 prior line of therapy, 2 prior lines of therapy and 3 or greater lines of therapy were 9.93-, 9.05-, and 6.18-months, respectively (log rank p = .04). Lines of therapy as a continuous variable was not associated with LF or DBF on competing risk analysis. The percentage of patients that died of neurological death was 36%. Greater prior lines of therapy (1 vs. 2 vs. 3 and greater) was associated with a greater likelihood of dying of non-neurologic death (gray's p = .01), but was not associated with likelihood of dying of neurologic death (p = .57). CONCLUSION Lines of therapy are associated with OS and non-neurologic death but are not associated with neurologic death, LF or DBF.
Collapse
Affiliation(s)
- Claire M Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States.
| | - Emory McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Michael LeCompte
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Ryan Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Hui-Wen Lo
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Stacey O'Neill
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Michael T Munley
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC 27157, United States; W.G. (Bill) Hefner Veteran Administration Medical Center, Cancer Center, Salisbury, NC, 28144, United States
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| |
Collapse
|
30
|
Shenker RF, Hughes RT, McTyre ER, Lanier C, Lo HW, Metheny-Barlow L, Su J, Thomas A, Brown DR, Avery T, Pasche B, Cramer CK, Laxton AW, Tatter SB, Watabe K, Chan MD. Potential prognostic markers for survival and neurologic death in patients with breast cancer brain metastases who receive upfront SRS alone. JOURNAL OF RADIOSURGERY AND SBRT 2018; 5:277-283. [PMID: 30538888 PMCID: PMC6255726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/26/2018] [Indexed: 06/09/2023]
Abstract
PURPOSE/OBJECTIVES Stereotactic radiosurgery (SRS) is used as a treatment option for breast cancer brain metastases. It is unclear what factors predict neurologic death for these patients. MATERIALS/METHODS A total of 128 patients with breast cancer brain metastases were treated with upfront SRS alone in this study. Survival was estimated using the Kaplan-Meier method. Clinicopathologic factors evaluated included age, ER/PR status, Her2 status, numbers of brain metastases treated, minimum SRS dose, disease-specific GPA, extracranial disease status and systemic disease burden. RESULTS ER or PR positivity was associated with a trend towards decreased neurologic death (subdistribution hazard ratio (sHR) = 0.54, p=0.06). Factors associated with non-neurologic death include extracranial disease status (sHR = 2.02, p=0.02) and dose (sHR = 1.11, p=0.02); Her2-positivity was associated with reduced hazard of non-neurologic death (sHR 0.52, p=0.05). CONCLUSIONS ER/PR positivity was associated with a trend towards less neurologic death. HER2 positivity was associated with a trend towards less non-neurologic death.
Collapse
Affiliation(s)
- Rachel F Shenker
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Ryan T Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Emory R McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Claire Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Hui-Wen Lo
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Linda Metheny-Barlow
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Jing Su
- Department of Biostatistics, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Alexandra Thomas
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Doris R Brown
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Tiffany Avery
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Boris Pasche
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| |
Collapse
|
31
|
McTyre ER, Johnson AG, Ruiz J, Isom S, Lucas JT, Hinson WH, Watabe K, Laxton AW, Tatter SB, Chan MD. Predictors of neurologic and nonneurologic death in patients with brain metastasis initially treated with upfront stereotactic radiosurgery without whole-brain radiation therapy. Neuro Oncol 2017; 19:558-566. [PMID: 27571883 DOI: 10.1093/neuonc/now184] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 07/22/2016] [Indexed: 11/13/2022] Open
Abstract
Background In this study we attempted to discern the factors predictive of neurologic death in patients with brain metastasis treated with upfront stereotactic radiosurgery (SRS) without whole brain radiation therapy (WBRT) while accounting for the competing risk of nonneurologic death. Methods We performed a retrospective single-institution analysis of patients with brain metastasis treated with upfront SRS without WBRT. Competing risks analysis was performed to estimate the subdistribution hazard ratios (HRs) for neurologic and nonneurologic death for predictor variables of interest. Results Of 738 patients treated with upfront SRS alone, neurologic death occurred in 226 (30.6%), while nonneurologic death occurred in 309 (41.9%). Multivariate competing risks analysis identified an increased hazard of neurologic death associated with diagnosis-specific graded prognostic assessment (DS-GPA) ≤ 2 (P = .005), melanoma histology (P = .009), and increased number of brain metastases (P<.001), while there was a decreased hazard associated with higher SRS dose (P = .004). Targeted agents were associated with a decreased HR of neurologic death in the first 1.5 years (P = .04) but not afterwards. An increased hazard of nonneurologic death was seen with increasing age (P =.03), nonmelanoma histology (P<.001), presence of extracranial disease (P<.001), and progressive systemic disease (P =.004). Conclusions Melanoma, DS-GPA, number of brain metastases, and SRS dose are predictive of neurologic death, while age, nonmelanoma histology, and more advanced systemic disease are predictive of nonneurologic death. Targeted agents appear to delay neurologic death.
Collapse
Affiliation(s)
- Emory R McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Adam G Johnson
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,W. G. (Bill) Hefner Veteran Administration Medical Center, Cancer Center, Salisbury, North Carolina, USA
| | - Scott Isom
- Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, North Carolina, USA
| | - John T Lucas
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - William H Hinson
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| |
Collapse
|
32
|
Alphonse-Sullivan N, Taksler GB, Lycan T, Weaver KE, McTyre ER, Shenker RF, Page BR, Isom S, Johnson A, Munley MT, Laxton AW, Tatter SB, Watabe K, Chan MD, Ruiz J. Sociodemographic predictors of patients with brain metastases treated with stereotactic radiosurgery. Oncotarget 2017; 8:101005-101011. [PMID: 29254141 PMCID: PMC5731851 DOI: 10.18632/oncotarget.22291] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 10/13/2017] [Indexed: 11/26/2022] Open
Abstract
Background Patient sociodemographic factors such income, race, health insurance coverage, and rural residence impact a variety of outcomes in patients with cancer. The role of brain metastasis at presentation and its subsequent outcomes have not been well characterized in this patient population. Results Multivariate analysis revealed that median income lower than $50,000 was associated with higher presenting symptom grade for brain metastasis (mean RTOG grade 1.2 vs 1.0, SE = 0.1, p = 0.04) and higher chronic symptom grade (mean RTOG grade 1.3 vs 0.9, SE = 0.1, p = 0.002). Higher area-level median income was associated with a lower symptom grade at diagnosis of brain metastasis (p = 0.0008) and likelihood of hospitalization (p = 0.004). Other sociodemographic factors were not significantly associated with survival, neurologic death, or patterns of failure after stereotactic radiosurgery for brain metastases. Conclusions Lower median income was associated with a greater symptom burden at the time of diagnosis and need for hospitalization for patients with brain metastases, suggesting a delayed time to presentation. These differences in symptom burden persisted during treatment. Methods Between January 2000 and December 2013, we identified 737 patients treated with stereotactic radiosurgery for brain metastases. They were characterized by 4 sociodemographic factors: median income, race, rural-urban residence, and health insurance status. Clinical outcomes included stage at diagnosis, symptom grade at presentation, likelihood of hospitalization from brain metastasis, overall survival, local failure, distant brain failure, and neurologic death. Multivariate cox proportional hazards model for each outcome was performed controlling for age, sex, number of brain metastases, and dose to brain metastases.
Collapse
Affiliation(s)
| | - Glen B Taksler
- Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Thomas Lycan
- Department of Medicine (Hematology and Oncology), Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kathryn E Weaver
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Emory R McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Brandi R Page
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Scott Isom
- Division of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Adam Johnson
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael T Munley
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jimmy Ruiz
- Department of Medicine (Hematology and Oncology), Wake Forest School of Medicine, Winston-Salem, NC, USA
| |
Collapse
|
33
|
Soffietti R, Abacioglu U, Baumert B, Combs SE, Kinhult S, Kros JM, Marosi C, Metellus P, Radbruch A, Villa Freixa SS, Brada M, Carapella CM, Preusser M, Le Rhun E, Rudà R, Tonn JC, Weber DC, Weller M. Diagnosis and treatment of brain metastases from solid tumors: guidelines from the European Association of Neuro-Oncology (EANO). Neuro Oncol 2017; 19:162-174. [PMID: 28391295 DOI: 10.1093/neuonc/now241] [Citation(s) in RCA: 304] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The management of patients with brain metastases has become a major issue due to the increasing frequency and complexity of the diagnostic and therapeutic approaches. In 2014, the European Association of Neuro-Oncology (EANO) created a multidisciplinary Task Force to draw evidence-based guidelines for patients with brain metastases from solid tumors. Here, we present these guidelines, which provide a consensus review of evidence and recommendations for diagnosis by neuroimaging and neuropathology, staging, prognostic factors, and different treatment options. Specifically, we addressed options such as surgery, stereotactic radiosurgery/stereotactic fractionated radiotherapy, whole-brain radiotherapy, chemotherapy and targeted therapy (with particular attention to brain metastases from non-small cell lung cancer, melanoma and breast and renal cancer), and supportive care.
Collapse
Affiliation(s)
- Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Ufuk Abacioglu
- Department of Radiation Oncology, Neolife Medical Center, Istanbul, Turkey
| | - Brigitta Baumert
- Department of Radiation-Oncology, MediClin Robert-Janker-Klinik, Bonn, Germany
| | - Stephanie E Combs
- Department of Innovative Radiation Oncology and Radiation Sciences, Munich, Germany
| | - Sara Kinhult
- Department of Oncology, Skane University Hospital, Lund, Sweden
| | - Johan M Kros
- Department of Pathology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Christine Marosi
- Department of Internal Medicine, Division of Oncology, Medical University, Vienna, Austria
| | - Philippe Metellus
- Department of Internal Medicine, Division of Oncology, Medical University, Vienna, Austria.,Department of Neurosurgery, Clairval Hospital Center, Generale de Santé, Marseille, France
| | - Alexander Radbruch
- Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Salvador S Villa Freixa
- Department of Radiation Oncology, Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Michael Brada
- Department of Molecular and Clinical Cancer Medicine & Radiation Oncology, Liverpool, United Kingdom
| | - Carmine M Carapella
- Department of Neuroscience, Division of Neurosurgery, Regina Elena Nat Cancer Institute, Rome, Italy
| | - Matthias Preusser
- Department of Medicine I and Comprehensive Cancer Center CNS Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria
| | - Emilie Le Rhun
- Department of Neurosurgery, Neuro-oncology, University Hospital, Lille, France
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Joerg C Tonn
- Department of Neurosurgery, University of Munich LMU, Munich, Germany
| | - Damien C Weber
- Centre for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Michael Weller
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
34
|
Distant intracranial failure in melanoma brain metastases treated with stereotactic radiosurgery in the era of immunotherapy and targeted agents. Adv Radiat Oncol 2017; 2:572-580. [PMID: 29204524 PMCID: PMC5707419 DOI: 10.1016/j.adro.2017.07.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 07/12/2017] [Indexed: 12/19/2022] Open
Abstract
Purpose Stereotactic radiosurgery (SRS) in combination with immunotherapy (IMT) or targeted therapy is increasingly being used in the setting of melanoma brain metastases (MBMs). The synergistic properties of combination therapy are not well understood. We compared the distant intracranial failure rates of intact MBMs treated with SRS, SRS + IMT, and SRS + targeted therapy. Methods and materials Combination therapy was defined as delivery of SRS within 3 months of IMT (anti-CTLA-4 /anti-PD-1 therapy) or targeted therapy (BRAF/MEK inhibitors). The primary endpoint was distant intracranial failure after SRS, which was defined as any new MBM identified on brain magnetic resonance imaging. Outcomes were evaluated using the Kaplan Meier method and Cox proportional hazards. Results A total of 72 patients with melanoma with 233 MBMs were treated between April 2006 and April 2016. The number of MBMs within each treatment group was as follows: SRS: 121; SRS + IMT: 48; and SRS + targeted therapy: 64. The median follow-up was 8.9 months. One-year distant intracranial control rates for SRS, SRS + IMT, and SRS + targeted therapy were 11.5%, 60%, and 10%, respectively (P < .001). On multivariate analysis, after adjusting for steroid use and number of MBMs, SRS + IMT remained associated with a significant reduction in distant intracranial failure compared with SRS (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.29-0.80; P = .003) and compared with SRS + targeted therapy (HR, 0.41; 95% CI, 0.25-0.68; P = .001).One-year local control for SRS, SRS + IMT, and SRS + targeted therapy was 66%, 85%, and 72%, respectively (P = .044). On multivariate analysis, after adjusting for dose, SRS + IMT remained associated with a significant reduction in local failure compared with SRS alone (HR, 0.37; 95% CI, 0.14-0.95; P = .04). Conclusions SRS with immunotherapy is associated with decreased distant and local intracranial failure compared with SRS alone. Prospective studies are warranted to validate this result.
Collapse
|
35
|
Sharma M, Jia X, Ahluwalia M, Barnett GH, Vogelbaum MA, Chao ST, Suh JH, Murphy ES, Yu JS, Angelov L, Mohammadi AM. First follow-up radiographic response is one of the predictors of local tumor progression and radiation necrosis after stereotactic radiosurgery for brain metastases. Cancer Med 2017; 6:2076-2086. [PMID: 28776956 PMCID: PMC5603831 DOI: 10.1002/cam4.1149] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/09/2017] [Accepted: 06/26/2017] [Indexed: 12/11/2022] Open
Abstract
Local progression (LP) and radiation necrosis (RN) occur in >20% of cases following stereotactic radiosurgery (SRS) for brain metastases (BM). Expected outcomes following SRS for BM include tumor control/shrinkage, local progression and radiation necrosis. 1427 patients with 4283 BM lesions were treated using SRS at Cleveland Clinic from 2000 to 2012. Clinical, imaging and radiosurgery data were collected from the database. Local tumor progression and RN were the primary end points and correlated with patient and tumor‐related variables. 5.7% of lesions developed radiographic RN and 3.6% showed local progression at 6 months. Absence of new extracranial metastasis (P < 0.001), response to SRS at first follow‐up scan (local progression versus stable size (P < 0.001), partial resolution versus complete resolution at first follow up [P = 0.009]), prior SRS to the same lesion (P < 0.001), IDL% (≤55; P < 0.001), maximum tumor diameter (>0.9 cm; P < 0.001) and MD/PD gradient index (≤1.8, P < 0.001) were independent predictors of high risk of local tumor progression. Absence of systemic metastases (P = 0.029), good neurological function at 1st follow‐up (P ≤ 0.001), no prior SRS to other lesion (P = 0.024), low conformity index (≤1.9) (P = 0.009), large maximum target diameter (>0.9 cm) (P = 0.003) and response to SRS (tumor progression vs. stable size following SRS [P < 0.001]) were independent predictors of high risk of radiographic RN. Complete tumor response at first follow‐up, maximum tumor diameter <0.9 cm, tumor volume <2.4 cc and no prior SRS to the index lesion are good prognostic factors with reduced risk of LP following SRS. Complete tumor response to SRS, poor neurological function at first follow‐up, prior SRS to other lesions and high conformity index are favorable factors for not developing RN. Stable or partial response at first follow‐up after SRS have same impact on local progression and RN compared to those with complete resolution or progression.
Collapse
Affiliation(s)
- Mayur Sharma
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Xuefei Jia
- Department of Biostatistics, Cleveland Clinic, Cleveland, Ohio, 44195
| | - Manmeet Ahluwalia
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Gene H Barnett
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Michael A Vogelbaum
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Samuel T Chao
- Cleveland Clinic, Department of Radiation Oncology, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - John H Suh
- Cleveland Clinic, Department of Radiation Oncology, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Erin S Murphy
- Cleveland Clinic, Department of Radiation Oncology, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Jennifer S Yu
- Cleveland Clinic, Department of Radiation Oncology, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Lilyana Angelov
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Alireza M Mohammadi
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| |
Collapse
|
36
|
Zhang J, Peng H, Chen L, Li WF, Mao YP, Liu LZ, Tian L, Guo Y, Sun Y, Ma J. Decreased Overall and Cancer-Specific Mortality with Neoadjuvant Chemotherapy in Locoregionally Advanced Nasopharyngeal Carcinoma Treated by Intensity-modulated Radiotherapy: Multivariate Competing Risk Analysis. J Cancer 2017; 8:2587-2594. [PMID: 28900496 PMCID: PMC5595088 DOI: 10.7150/jca.20081] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/10/2017] [Indexed: 11/15/2022] Open
Abstract
Background: Value of neoadjuvant chemotherapy (NACT) is still controversial in locoregionally advanced nasopharyngeal carcinoma (LA-NPC). Based on competing risk analysis model, we aim at evaluating the efficacy of NACT in decreasing cancer-specific mortality for LA-NPC (except T3-4N0) treated by intensity-modulated radiotherapy (IMRT). Methods: Data on 957 patients with LA-NPC were retrospectively reviewed. The cumulative incidence of cancer-specific and non-cancer-specific (competing) mortality was determined by univariate and multivariate competing risk analysis. Results: 542 (56.6%) patients received NACT using docetaxel with cisplatin (TP) or fluorouracil with cisplatin (PF) regimens. The median follow-up duration was 57.23 months (range, 1.27-78.53 months). In total, 161/957 (16.8%) patients died, with 140 cancer-specific and 21 non-cancer-specific deaths were observed, respectively. In univariate analysis, the 3- and 5-year cumulative cancer-specific mortality rates for NACT vs. non-NACT group were 8.58% vs. 7.32% and 14.74% vs. 14.52% (P = 0.95), respectively. With regard to competing mortality, the 3- and 5-year cumulative rates (0.93% vs. 1.22% and 1.31% vs. 3.06%; P = 0.196) were comparable between the two groups. Multivariate competing risk analysis established NACT as an independent prognostic factor in decreasing cancer-specific mortality (HR, 0.681; 95% CI, 0.488-0.951; P = 0.016) and overall mortality (HR, 0.654; 95% CI, 0.471-0.909; P = 0.011). Conclusions: NACT may be a powerful approach in decreasing cancer-specific mortality and overall mortality in LA-NPC treated by IMRT, and our findings would strengthen the role of NACT.
Collapse
Affiliation(s)
- Jian Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, People's Republic of China
| | - Hao Peng
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, People's Republic of China
| | - Lei Chen
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, People's Republic of China
| | - Wen-Fei Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, People's Republic of China
| | - Yan-Ping Mao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, People's Republic of China
| | - Li-Zhi Liu
- Imaging Diagnosis and Interventional Center, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, People's Republic of China
| | - Li Tian
- Imaging Diagnosis and Interventional Center, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, People's Republic of China
| | - Ying Guo
- Department of Clinical Trials Center, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, People's Republic of China
| | - Ying Sun
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, People's Republic of China
| | - Jun Ma
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, People's Republic of China
| |
Collapse
|
37
|
Sharma M, Jia X, Ahluwalia M, Barnett GH, Vogelbaum MA, Chao ST, Suh JH, Murphy ES, Yu JS, Angelov L, Mohammadi AM. Cumulative Intracranial Tumor Volume and Number of Brain Metastasis as Predictors of Developing New Lesions After Stereotactic Radiosurgery for Brain Metastasis. World Neurosurg 2017; 106:666-675. [PMID: 28735139 DOI: 10.1016/j.wneu.2017.07.048] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/10/2017] [Accepted: 07/11/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To identify risk factors associated with early distant radiographic progression in patients undergoing stereotactic radiosurgery (SRS) for brain metastases (BM). METHODS Following Institutional Review Board approval, data of 1427 patients (4283 BM lesions) who were treated by SRS at the Cleveland Clinic for 2000-2012 were collected. Local tumor progression (LTP), distant tumor progression (DTP), and radiographic radiation necrosis (RN) were the primary endpoints. Patient, imaging, radiosurgery, and tumor variables and follow-up data were collected. RESULTS The median number of targets was 2 (range, 1-17); 45% of the patients had a single lesion. DTP was observed in 10% at 3 months and 19% at 6 months. Patients with 5-10 target lesions for SRS were more likely to develop new lesions at both 3 and 6 months compared to those with 2-4 lesions (odds ratio [OR], 0.83, 95% confidence interval [CI], 0.40-0.85 and OR, 0.85, 95% CI, 0.45-0.86 respectively; P < 0.05). Younger age (<65 years; P < 0.001), higher number of lesions (>1; P < 0.001), cumulative intracranial tumor volume (CITV) <2.75 cc (P = 0.023), type of SRS (upfront and salvage vs. boost; P < 0.001), and tumor pathology (radiosensitive; P < 0.001), were independent predictors of early distant tumor progression following SRS. CONCLUSIONS The number of target lesions and low CITV are both independent predictors of early DTP following SRS for BM. Radiosensitive tumor histology, younger age (<65 years), and SRS without previous whole-brain radiation therapy (upfront or salvage) were also predictors of early DTP.
Collapse
Affiliation(s)
- Mayur Sharma
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery and Neurooncology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Xuefei Jia
- Department of Medical Biostatistics, Cleveland Clinic, Cleveland, Ohio, USA
| | - Manmeet Ahluwalia
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery and Neurooncology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gene H Barnett
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery and Neurooncology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael A Vogelbaum
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery and Neurooncology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - John H Suh
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erin S Murphy
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jennifer S Yu
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lilyana Angelov
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery and Neurooncology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alireza M Mohammadi
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery and Neurooncology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.
| |
Collapse
|
38
|
Shenker RF, McTyre ER, Ruiz J, Weaver KE, Cramer C, Alphonse-Sullivan NK, Farris M, Petty WJ, Bonomi MR, Watabe K, Laxton AW, Tatter SB, Warren GW, Chan MD. The Effects of smoking status and smoking history on patients with brain metastases from lung cancer. Cancer Med 2017; 6:944-952. [PMID: 28401684 PMCID: PMC5430088 DOI: 10.1002/cam4.1058] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 02/20/2017] [Accepted: 02/21/2017] [Indexed: 01/10/2023] Open
Abstract
There is limited data on the effects of smoking on lung cancer patients with brain metastases. This single institution retrospective study of patients with brain metastases from lung cancer who received stereotactic radiosurgery assessed whether smoking history is associated with overall survival, local control, rate of new brain metastases (brain metastasis velocity), and likelihood of neurologic death after brain metastases. Patients were stratified by adenocarcinoma versus nonadenocarcinoma histologies. Kaplan-Meier analysis was performed for survival endpoints. Competing risk analysis was performed for neurologic death analysis to account for risk of nonneurologic death. Separate linear regression and multivariate analyses were performed to estimate the brain metastasis velocity. Of 366 patients included in the analysis, the median age was 63, 54% were male and, 60% were diagnosed with adenocarcinoma. Current smoking was reported by 37% and 91% had a smoking history. Current smoking status and pack-year history of smoking had no effect on overall survival. There was a trend for an increased risk of neurologic death in nonadenocarcinoma patients who continued to smoke (14%, 35%, and 46% at 6/12/24 months) compared with patients who did not smoke (12%, 23%, and 30%, P = 0.053). Cumulative pack years smoking was associated with an increase in neurologic death for nonadenocarcinoma patients (HR = 1.01, CI: 1.00-1.02, P = 0.046). Increased pack-year history increased brain metastasis velocity in multivariate analysis for overall patients (P = 0.026). Current smokers with nonadenocarcinoma lung cancers had a trend toward greater neurologic death than nonsmokers. Cumulative pack years smoking is associated with a greater brain metastasis velocity.
Collapse
Affiliation(s)
- Rachel F Shenker
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, 27157, North Carolina
| | - Emory R McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, 27157, North Carolina
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, 27157, North Carolina
| | - Kathryn E Weaver
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, 27157, North Carolina
| | - Christina Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, 27157, North Carolina
| | | | - Michael Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, 27157, North Carolina
| | - William J Petty
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, 27157, North Carolina
| | - Marcelo R Bonomi
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, 27157, North Carolina
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, 27157, North Carolina
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, 27157, North Carolina
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, 27157, North Carolina
| | - Graham W Warren
- Department of Radiation Oncology, Medical College of South Carolina, Charleston, 29425, South Carolina.,Department of Cell and Molecular Pharmacology, MUSC, Charleston, 29425, South Carolina
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, 27157, North Carolina
| |
Collapse
|
39
|
Randolph DM, McTyre E, Klepin H, Peiffer AM, Ayala-Peacock D, Lester S, Laxton AW, Dohm A, Tatter SB, Shaw EG, Chan MD. Impact of radiosurgical management of geriatric patients with brain metastases: Clinical and quality of life outcomes. JOURNAL OF RADIOSURGERY AND SBRT 2017; 5:35-42. [PMID: 29296461 PMCID: PMC5675506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 05/20/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Recent trials have shown that whole brain radiotherapy (WBRT) can worsen performance status, particularly in the geriatric population. We reviewed our institutional experience with geriatric patients (> 70 years) with brain metastases treated with radiosurgery (SRS) to determine clinical and quality of life (QOL) outcomes. METHODS Between 7/2000 and 1/2013, a retrospective review was performed on 467 patients treated with SRS (114 geriatric patients). Overall survival (OS), cause of death, and WBRT were evaluated. A retrospective review of geriatric patients was performed with assessments of Karnofsky performance score (KPS, N=69), mini-mental status examinations (MMSE, N=39), and Spitzer QOL (SQOL, N=39) at initial interview, 6, and 12 months after SRS. Repeated Measures ANOVA was used to evaluate differences in quality of life values. Kaplan-Meier analysis estimated survival and time to WBRT. RESULTS Geriatric patients had a shorter OS compared to non-geriatric patients (p<0.035). Fewer patients in the geriatric cohort received whole brain (p<0.001) or subsequent Gamma Knife stereotactic radiosurgery (GKRS) (p<0.025). No difference was seen in neurologic death rates (p<0.4). In geriatric patients, SQOL declined from 0 to 6 months (mean 6.5 to 5.9, respectively, p<0.02) and 0 to 12 months (mean 6.5 and 5.6, respectively, p<0.03). KPS and MMSE scores did not change over time. Grade 3 or 4 toxicity was 9% in geriatric patients. There was no grade 5 toxicity. CONCLUSION Geriatric patients tolerate GKRS without a significant decline in KPS or MMSE and with acceptable toxicity profile. SRS also spares a significant proportion of geriatric patients from WBRT, and its associated toxicities.
Collapse
Affiliation(s)
- David M Randolph
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Emory McTyre
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Heidi Klepin
- Department of Medical Oncology, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Ann M Peiffer
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Diandra Ayala-Peacock
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Scott Lester
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Ammoren Dohm
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Edward G Shaw
- Division of Public Health Sciences, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, NC 27157, USA
| |
Collapse
|
40
|
Tini P, Nardone V, Pastina P, Battaglia G, Sebaste L, Pirtoli L. In Regard to Kubicek et al. Int J Radiat Oncol Biol Phys 2016; 96:923-924. [PMID: 27788968 DOI: 10.1016/j.ijrobp.2016.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 08/03/2016] [Indexed: 11/13/2022]
Affiliation(s)
- Paolo Tini
- Istituto Toscano Tumori, Firenze, Italy; Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy
| | - Valerio Nardone
- Istituto Toscano Tumori, Firenze, Italy; Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy; Radiation Oncology, Department of Medicine, Surgery, and Neurological Sciences, University of Siena, Siena, Italy
| | - PierPaolo Pastina
- Istituto Toscano Tumori, Firenze, Italy; Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy; Radiation Oncology, Department of Medicine, Surgery, and Neurological Sciences, University of Siena, Siena, Italy
| | - Giuseppe Battaglia
- Istituto Toscano Tumori, Firenze, Italy; Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy; Radiation Oncology, Department of Medicine, Surgery, and Neurological Sciences, University of Siena, Siena, Italy
| | - Lucio Sebaste
- Istituto Toscano Tumori, Firenze, Italy; Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy
| | - Luigi Pirtoli
- Istituto Toscano Tumori, Firenze, Italy; Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy; Radiation Oncology, Department of Medicine, Surgery, and Neurological Sciences, University of Siena, Siena, Italy
| |
Collapse
|
41
|
Shen CJ, Rigamonti D, Redmond KJ, Kummerlowe MN, Lim M, Kleinberg LR. The strategy of repeat stereotactic radiosurgery without whole brain radiation treatment for new brain metastases: Outcomes and implications for follow-up monitoring. Pract Radiat Oncol 2016; 6:409-416. [DOI: 10.1016/j.prro.2016.04.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 04/13/2016] [Accepted: 04/21/2016] [Indexed: 12/01/2022]
|
42
|
Murray L, Menard C, Zadeh G, Au K, Bernstein M, Millar BA, Laperriere N, Chung C. Radiosurgery for brainstem metastases with and without whole brain radiotherapy: clinical series and literature review. ACTA ACUST UNITED AC 2016; 6:21-30. [PMID: 28367275 PMCID: PMC5357261 DOI: 10.1007/s13566-016-0281-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/09/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The objective of this study was to investigate outcomes for patients with brainstem metastases treated with stereotactic radiosurgery (SRS). METHODS Patients with brainstem metastases treated with SRS between April 2006 and June 2012 were identified from a prospective database. Patient and treatment-related factors were recorded. Kaplan-Meier analysis was used to calculate survival and freedom from local and distant brain progression. Univariate and multivariate Cox regression was used to identify factors important for overall survival. RESULTS In total, 44 patients received SRS for 48 brainstem metastases of whom 33 (75 %) also received whole brain radiotherapy (WBRT): 23 patients (52 %) WBRT prior to SRS, 6 (13.6 %) WBRT concurrently with SRS and 4 (9.0 %) WBRT after SRS. Eight patients received a second course of WBRT at further progression. Median target volume was 1.33 cc (range 0.04-12.17) and median prescribed marginal dose was 15 Gy (range 10-22). There were four cases of local failure, and 6-month and 1-year freedom from local failure was 84.6 and 76.9 %, respectively. Median overall survival (OS) was 5.4 months. There were four cases of radionecrosis, 2 (4.8 %) of which were symptomatic. The absence of external beam brain radiotherapy (predominantly WBRT) showed a trend towards improved OS on univariate analysis. Neither local nor distant brain failure significantly impacted OS. CONCLUSION This retrospective series of patients treated with SRS for brainstem metastases, largely in combination with at least one course of WBRT, demonstrates that this approach is safe and results in good local control. In this cohort, no variables significantly impacted OS, including intracranial control.
Collapse
Affiliation(s)
- Louise Murray
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Cynthia Menard
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, ON Canada
| | - Karolyn Au
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, ON Canada
| | - Mark Bernstein
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, ON Canada
| | - Barbara-Ann Millar
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Normand Laperriere
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Caroline Chung
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| |
Collapse
|
43
|
McKay WH, McTyre ER, Okoukoni C, Alphonse-Sullivan NK, Ruiz J, Munley MT, Qasem S, Lo HW, Xing F, Laxton AW, Tatter SB, Watabe K, Chan MD. Repeat stereotactic radiosurgery as salvage therapy for locally recurrent brain metastases previously treated with radiosurgery. J Neurosurg 2016; 127:148-156. [PMID: 27494815 DOI: 10.3171/2016.5.jns153051] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There are a variety of salvage options available for patients with brain metastases who experience local failure after stereotactic radiosurgery (SRS). These options include resection, whole-brain radiation therapy, laser thermoablation, and repeat SRS. There is little data on the safety and efficacy of repeat SRS following local failure of a prior radiosurgical procedure. This study evaluates the clinical outcomes and dosimetric characteristics of patients who experienced tumor recurrence and were subsequently treated with repeat SRS. METHODS Between 2002 and 2015, 32 patients were treated with repeat SRS for local recurrence of ≥ 1 brain metastasis following initial SRS treatment. The Kaplan-Meier method was used to estimate time-to-event outcomes including overall survival (OS), local failure, and radiation necrosis. Cox proportional hazards analysis was performed for predictor variables of interest for each outcome. Composite dose-volume histograms were constructed for each reirradiated lesion, and these were then used to develop a predictive dosimetric model for radiation necrosis. RESULTS Forty-six lesions in 32 patients were re-treated with a second course of SRS after local failure. A median dose of 20 Gy (range 14-22 Gy) was delivered to the tumor margin at the time of repeat SRS. Local control at 1 year was 79% (95% CI 67%-94%). Estimated 1-year OS was 70% (95% CI 55%-88%). Twelve patients had died at the most recent follow-up, with 8/12 patients experiencing neurological death (as described in Patchell et al.). Eleven of 46 (24%) lesions in 11 separate patients treated with repeat SRS were associated with symptomatic radiation necrosis. Freedom from radiation necrosis at 1 year was 71% (95% CI 57%-88%). Analysis of dosimetric data revealed that the volume of a lesion receiving 40 Gy (V40Gy) was the most predictive factor for the development of radiation necrosis (p = 0.003). The following V40Gy thresholds were associated with 10%, 20%, and 50% probabilities of radiation necrosis, respectively: 0.28 cm3 (95% CI 3%-28%), 0.76 cm3 (95% CI 9%-39%), 1.60 cm3 (95% CI 26%-74%). CONCLUSIONS Repeat SRS appears to be an effective salvage option for patients with brain metastases experiencing local failure following initial SRS treatment. This series demonstrates durable local control and, although rates of radiation necrosis are significant, repeat SRS may be indicated for select cases of local disease recurrence. Because the V40Gy is predictive of radiation necrosis, limiting this value during treatment planning may allow for a reduction in radiation necrosis rates.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Adrian W Laxton
- Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Stephen B Tatter
- Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | | |
Collapse
|
44
|
Shen CJ, Lim M, Kleinberg LR. Controversies in the Therapy of Brain Metastases: Shifting Paradigms in an Era of Effective Systemic Therapy and Longer-Term Survivorship. Curr Treat Options Oncol 2016; 17:46. [DOI: 10.1007/s11864-016-0423-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
45
|
Berghoff AS, Schur S, Füreder LM, Gatterbauer B, Dieckmann K, Widhalm G, Hainfellner J, Zielinski CC, Birner P, Bartsch R, Preusser M. Descriptive statistical analysis of a real life cohort of 2419 patients with brain metastases of solid cancers. ESMO Open 2016; 1:e000024. [PMID: 27843591 PMCID: PMC5070252 DOI: 10.1136/esmoopen-2015-000024] [Citation(s) in RCA: 135] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 02/04/2016] [Accepted: 02/12/2016] [Indexed: 12/25/2022] Open
Abstract
Aim We provide a descriptive statistical analysis of baseline characteristics and the clinical course of a large real-life cohort of brain metastases (BM) patients. Methods We performed a retrospective chart review for patients treated for BM of solid cancers at the Medical University of Vienna between 1990 and 2011. Results We identified a total of 2419 BM patients (50.5% male, 49.5% female, median age 59 years). The primary tumour was lung cancer in 43.2%, breast cancer in 15.7%, melanoma in 16.4%, renal cell carcinoma in 9.1%, colorectal cancer in 9.3% and unknown in 1.4% of cases. Rare tumour types associated with BM included genitourinary cancers (4.1%), sarcomas (0.7%). gastro-oesophageal cancer (0.6%) and head and neck cancers (0.2%). 48.7% of patients presented with a singular BM, 27.7% with 2–3 and 23.5% with >3 BM. Time from primary tumour to BM diagnosis was shortest in lung cancer (median 11 months; range 1–162) and longest in breast cancer (median 44 months; 1–443; p<0.001). Multiple BM were most frequent in breast cancer (30.6%) and least frequent in colorectal cancer (8.5%; p<0.001). Patients with breast cancer had the longest median overall survival times (8 months), followed by patients with lung cancer (7 months), renal cell carcinoma (7 months), melanoma (5 months) and colorectal cancer (4 months; p<0.001; log rank test). Recursive partitioning analysis and graded prognostic assessment scores showed significant correlation with overall survival (both p<0.001, log rank test). Evaluation of the disease status in the past 2 months prior to patient death showed intracranial progression in 35.9%, extracranial progression in 27.5% and combined extracranial and intracranial progression in 36.6% of patients. Conclusions Our data highlight the heterogeneity in presentation and clinical course of BM patients in the everyday clinical setting and may be useful for rational planning of clinical studies.
Collapse
Affiliation(s)
- Anna S Berghoff
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Sophie Schur
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Lisa M Füreder
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Brigitte Gatterbauer
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Karin Dieckmann
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Radiotherapy, Medical University of Vienna, Vienna, Austria
| | - Georg Widhalm
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Johannes Hainfellner
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Christoph C Zielinski
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Peter Birner
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Rupert Bartsch
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Matthias Preusser
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
46
|
Paydar I, Oermann EK, Knoll M, Lee J, Collins BT, Ewend M, Kondziolka D, Collins SP. The Value of the History and Physical for Patients with Newly Diagnosed Brain Metastases Considering Radiosurgery. Front Oncol 2016; 6:40. [PMID: 26973811 PMCID: PMC4773584 DOI: 10.3389/fonc.2016.00040] [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] [Received: 12/01/2015] [Accepted: 02/08/2016] [Indexed: 11/13/2022] Open
Abstract
Background For patients with brain metastases, systemic disease burden has historically been accepted as a major determinant of overall survival (OS). However, less research has focused on specific history and physical findings made by clinicians and how such findings pertain to patient outcomes at a given time point. The aim of this study is to determine how the initial clinical assessment of patients with brain metastases, as part of the history and physical at the time of consultation, correlates to patient prognosis. Methods We evaluated a prospective, multi-institutional database of 1523 brain metastases in 507 patients who were treated with radiosurgery (Gamma Knife or CyberKnife) from 2001 to 2014. Relevant history of present illness (HPI) and past medical history (PMH) variables included comorbidities, Eastern Cooperative Oncology Group (ECOG) performance status, and seizure history. Physical exam findings included a sensory exam, motor exam, and cognitive function. Univariate and multivariate Cox regression analyses were used to identify predictors of OS. Results Two hundred ninety-four patients were included in the final analysis with a median OS of 10.8 months (95% CI, 7.8–13.7 months). On univariate analysis, significant HPI predictors of OS included age, primary diagnosis, performance status, extracranial metastases, systemic disease status, and history of surgery. Significant predictors of OS from the PMH included cardiac, vascular, and infectious comorbidities. On a physical exam, findings consistent with cognitive deficits were predictive of worse OS. However, motor deficits or changes in vision were not predictive of worse OS. In the multivariate Cox regression analysis, predictors of worse OS were primary diagnosis (p = 0.002), ECOG performance status (OR 1.73, p < 0.001), and presence of extracranial metastases (OR 1.22, p = 0.009). Conclusion Neurological deficits and systemic comorbidities noted at presentation are not associated with worse overall prognosis for patients with brain metastases undergoing radiosurgery. When encountering new patients with brain metastases, the most informative patient-related characteristics that determine prognosis remain performance status, primary diagnosis, and extent of extracranial disease.
Collapse
Affiliation(s)
- Ima Paydar
- Department of Radiation Medicine, Georgetown University Medical Center , Washington, DC , USA
| | - Eric Karl Oermann
- Department of Neurological Surgery, Mount Sinai Health System , New York, NY , USA
| | - Miriam Knoll
- Department of Radiation Oncology, Mount Sinai Health System , New York, NY , USA
| | - James Lee
- Department of Radiation Oncology, Mount Sinai Health System , New York, NY , USA
| | - Brian Timothy Collins
- Department of Radiation Medicine, Georgetown University Medical Center , Washington, DC , USA
| | - Matthew Ewend
- Department of Neurological Surgery, The University of North Carolina at Chapel Hill , Chapel Hill, NC , USA
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center , New York, NY , USA
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Medical Center , Washington, DC , USA
| |
Collapse
|
47
|
Hughes RT, Black PJ, Page BR, Lucas JT, Qasem SA, Watabe K, Ruiz J, Laxton AW, Tatter SB, Debinski W, Chan MD. Local control of brain metastases after stereotactic radiosurgery: the impact of whole brain radiotherapy and treatment paradigm. JOURNAL OF RADIOSURGERY AND SBRT 2016; 4:89-96. [PMID: 29296433 PMCID: PMC5658880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 12/04/2015] [Indexed: 06/07/2023]
Abstract
PURPOSE We investigate clinical, pathologic, and treatment paradigm-related factors affecting local control of brain metastases after stereotactic radiosurgery (SRS) with or without whole brain radiotherapy (WBRT). METHODS AND MATERIALS Patients with brain metastases treated with SRS alone, before or after WBRT were considered to determine predictors of local failure (LF), time to failure and survival. RESULTS Among 137 patients, 411 brain metastases were analyzed. 23% of patients received SRS alone, 51% received WBRT prior to SRS, and 26% received SRS followed by WBRT. LF occurred in 125 metastases: 63% after SRS alone, 20% after WBRT then SRS, and 22% after SRS then WBRT. Median time to local failure was significantly less after SRS alone compared to WBRT then SRS (12.1 v. 22.7 months, p=0.003). Tumor volume was significantly associated with LF (HR:5.2, p<0.001, 95% CI:3.4-7.8). CONCLUSIONS WBRT+SRS results in reduced LF. Local control was not significantly different after SRS as salvage therapy versus upfront SRS.
Collapse
Affiliation(s)
- Ryan T. Hughes
- Department of Radiation Oncology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, USA
| | - Paul J. Black
- Department of Radiation Oncology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, USA
| | - Brandi R. Page
- Department of Radiation Oncology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, USA
| | - John T. Lucas
- Department of Radiation Oncology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, USA
| | - Shadi A. Qasem
- Department of Pathology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Jimmy Ruiz
- Department of Internal Medicine-Hematology/Oncology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, USA
| | - Adrian W. Laxton
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, USA
| | - Stephen B. Tatter
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, USA
| | - Waldemar Debinski
- Brain Tumor Center of Excellence, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, USA
| | - Michael D. Chan
- Department of Radiation Oncology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, USA
| |
Collapse
|