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Williams GJ, Hong AM, Thompson JF. Treatment of melanoma brain metastases with radiation and immunotherapy or targeted therapy: A systematic review with meta-analysis. Crit Rev Oncol Hematol 2024; 202:104462. [PMID: 39097248 DOI: 10.1016/j.critrevonc.2024.104462] [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: 12/21/2023] [Revised: 07/25/2024] [Accepted: 07/28/2024] [Indexed: 08/05/2024] Open
Abstract
BACKGROUND Patients with melanoma brain metastases are now frequently treated with immunotherapy (IMT) or targeted therapy (TT). The aim of this systematic review was to determine relative survival outcomes after combining radiotherapy (RT) with IMT or TT. METHODS 126 studies were identified by searching Medline, Embase and Cochrane CENTRAL (to 7Aug 2023). RESULTS Multivariable analyses showed that the risk of death was reduced by 30 % for combined stereotactic radiosurgery (SRS)+IMT compared to IMT alone, by 65 % for patients treated with SRS+anti-PD1 and by 59 % for patients treated with SRS+anti-CTLA4 and/or anti-PD1 (HR 0.41, 95 %CI 0.31-0.54) compared to SRS alone. Four studies compared SRS+anti-CTLA4 with SRS+anti-PD1, showing a 42 % reduction in risk of death with SRS+anti-PD1 treatment. Combined treatment with SRS+TT showed a 59 % reduction in risk compared to SRS alone. CONCLUSION The systematic review suggests a substantial survival benefit for combining SRS with IMT or TT for patients with melanoma brain metastases.
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Affiliation(s)
- Gabrielle J Williams
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Angela M Hong
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Chris O'Brien Lifehouse, Sydney, NSW, Australia; The Mater Hospital, North Sydney, NSW, Australia
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; The Mater Hospital, North Sydney, NSW, Australia; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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2
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Huang L, Chen S, Liu H, Meng L, Liu C, Wu X, Wang Y, Luo S, Tu H, Wang C, Zhang M, Gong X. PD-L1 inhibitors combined with whole brain radiotherapy in patients with small cell lung cancer brain metastases: Real-world evidence. Cancer Med 2024; 13:e7125. [PMID: 38613182 PMCID: PMC11015079 DOI: 10.1002/cam4.7125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 02/28/2024] [Accepted: 03/08/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Numerous studies have demonstrated that brain metastases patients may benefit from intracranial radiotherapy combined with immune checkpoint inhibitors (ICIs). However, it is unclear whether this treatment is effective for patients with small cell lung cancer brain metastases (SCLC-BMs). METHODS We conducted a retrospective study by analyzing medical records of patients with SCLC-BMs from January 1, 2017 to June 1, 2022. Data related to median overall survival (mOS), median progression-free survival (mPFS), and intracranial progression-free survival (iPFS) were analyzed. RESULTS A total of 109 patients were enrolled, of which 60 received WBRT and 49 received WBRT-ICI. Compared to the WBRT alone cohort, the WBRT-ICI cohort showed longer mOS (20.4 months vs. 29.3 months, p = 0.021), mPFS (7.9 months vs. 15.1 months, p < 0.001), and iPFS (8.3 months vs. 16.5 months, p < 0.001). Furthermore, WBRT-ICI cohort had a better response rate for both BMs. (p = 0.035) and extracranial diseases (p < 0.001) compared to those receiving WBRT alone. Notably, the use of WBRT before ICI was associated with longer mOS compared to the use of WBRT after ICI (23.3 months for the ICI-WBRT group vs. 34.8 months for the WBRT-ICI group, p = 0.020). CONCLUSION Our results indicated that WBRT combined with immunotherapy improved survival in SCLC-BMs patients compared to WBRT monotherapy. Administering WBRT prior to ICI treatment is associated with improved survival outcomes compared to WBRT following ICI treatment, for patients with SCLC-BMs. These findings highlight the significance of conducting further prospective researches on combination strategies of intracranial radiotherapy and ICI in SCLC-BMs patients.
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Affiliation(s)
- Litang Huang
- Department of Radiation Oncology, Shanghai Pulmonary Hospital, School of MedicineTongji UniversityShanghaiChina
| | - Shen Chen
- Department of Oncology, Shanghai Pulmonary HospitalTongji University, School of MedicineShanghaiChina
| | - Hui Liu
- Department of Radiation Oncology, Shanghai Pulmonary Hospital, School of MedicineTongji UniversityShanghaiChina
| | - Lu Meng
- Department of Radiation Oncology, Shanghai Pulmonary Hospital, School of MedicineTongji UniversityShanghaiChina
| | - Chengxing Liu
- Department of Cardiology, Tongji HospitalTongji University, School of MedicineShanghaiChina
| | - Xiaoting Wu
- Department of Radiation Oncology, Shanghai Pulmonary Hospital, School of MedicineTongji UniversityShanghaiChina
| | - Yingying Wang
- Department of Radiation Oncology, Shanghai Pulmonary Hospital, School of MedicineTongji UniversityShanghaiChina
| | - Shilan Luo
- Department of Radiation Oncology, Shanghai Pulmonary Hospital, School of MedicineTongji UniversityShanghaiChina
| | - Hongbin Tu
- Department of Integrated TCM and Western Medicine, Shanghai Pulmonary HospitalTongji University, School of MedicineShanghaiChina
| | - Chunlei Wang
- Department of EndocrinologyThe Fourth Affiliated Hospital of Nantong UniversityJiangsuChina
| | - Ming Zhang
- Department of Integrated Traditional Chinese and Western MedicineShanghai Jiao Tong University School of Medicine, Shanghai Chest HospitalShanghaiChina
| | - Xiaomei Gong
- Department of Radiation Oncology, Shanghai Pulmonary Hospital, School of MedicineTongji UniversityShanghaiChina
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Mayo ZS, Billena C, Suh JH, Lo SS, Chao ST. The dilemma of radiation necrosis from diagnosis to treatment in the management of brain metastases. Neuro Oncol 2024; 26:S56-S65. [PMID: 38437665 PMCID: PMC10911797 DOI: 10.1093/neuonc/noad188] [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] [Indexed: 03/06/2024] Open
Abstract
Radiation therapy with stereotactic radiosurgery (SRS) or whole brain radiation therapy is a mainstay of treatment for patients with brain metastases. The use of SRS in the management of brain metastases is becoming increasingly common and provides excellent local control. Cerebral radiation necrosis (RN) is a late complication of radiation treatment that can be seen months to years following treatment and is often indistinguishable from tumor progression on conventional imaging. In this review article, we explore risk factors associated with the development of radiation necrosis, advanced imaging modalities used to aid in diagnosis, and potential treatment strategies to manage side effects.
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Affiliation(s)
- Zachary S Mayo
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cole Billena
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - John H Suh
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
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4
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Zhou D, Gong Z, Wu D, Ma C, Hou L, Niu X, Xu T. Harnessing immunotherapy for brain metastases: insights into tumor-brain microenvironment interactions and emerging treatment modalities. J Hematol Oncol 2023; 16:121. [PMID: 38104104 PMCID: PMC10725587 DOI: 10.1186/s13045-023-01518-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023] Open
Abstract
Brain metastases signify a deleterious milestone in the progression of several advanced cancers, predominantly originating from lung, breast and melanoma malignancies, with a median survival timeframe nearing six months. Existing therapeutic regimens yield suboptimal outcomes; however, burgeoning insights into the tumor microenvironment, particularly the immunosuppressive milieu engendered by tumor-brain interplay, posit immunotherapy as a promising avenue for ameliorating brain metastases. In this review, we meticulously delineate the research advancements concerning the microenvironment of brain metastases, striving to elucidate the panorama of their onset and evolution. We encapsulate three emergent immunotherapeutic strategies, namely immune checkpoint inhibition, chimeric antigen receptor (CAR) T cell transplantation and glial cell-targeted immunoenhancement. We underscore the imperative of aligning immunotherapy development with in-depth understanding of the tumor microenvironment and engendering innovative delivery platforms. Moreover, the integration with established or avant-garde physical methodologies and localized applications warrants consideration in the prevailing therapeutic schema.
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Affiliation(s)
- Dairan Zhou
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, 200003, People's Republic of China
| | - Zhenyu Gong
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University of Munich, Munich, 81675, Germany
| | - Dejun Wu
- Department of Neurosurgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
| | - Chao Ma
- Department of Neurosurgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
| | - Lijun Hou
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, 200003, People's Republic of China
| | - Xiaomin Niu
- Department of Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, 241 Huaihai West Road, Xuhui District, Shanghai, 200030, People's Republic of China.
| | - Tao Xu
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, 200003, People's Republic of China.
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5
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James F, Lorger M. Immunotherapy in the context of immune-specialized environment of brain metastases. DISCOVERY IMMUNOLOGY 2023; 2:kyad023. [PMID: 38567052 PMCID: PMC10917168 DOI: 10.1093/discim/kyad023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/18/2023] [Accepted: 11/15/2023] [Indexed: 04/04/2024]
Abstract
Brain metastases (BrM) develop in 20-40% of patients with advanced cancer. They mainly originate from lung cancer, melanoma, breast cancer, and renal cell carcinoma, and are associated with a poor prognosis. While patients with BrM traditionally lack effective treatment options, immunotherapy is increasingly gaining in importance in this group of patients, with clinical trials in the past decade demonstrating the efficacy and safety of immune checkpoint blockade in BrM originating from specific tumor types, foremost melanoma. The brain is an immune-specialized environment with several unique molecular, cellular, and anatomical features that affect immune responses, including those against tumors. In this review we discuss the potential role that some of these unique characteristics may play in the efficacy of immunotherapy, mainly focusing on the lymphatic drainage in the brain and the role of systemic anti-tumor immunity that develops due to the presence of concurrent extracranial disease in addition to BrM.
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Affiliation(s)
- Fiona James
- School of Medicine, University of Leeds, Leeds, UK
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6
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Yoo KH, Park DJ, Choi JH, Marianayagam NJ, Lim M, Meola A, Chang SD. Optimizing the synergy between stereotactic radiosurgery and immunotherapy for brain metastases. Front Oncol 2023; 13:1223599. [PMID: 37637032 PMCID: PMC10456862 DOI: 10.3389/fonc.2023.1223599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/24/2023] [Indexed: 08/29/2023] Open
Abstract
Solid tumors metastasizing to the brain are a frequent occurrence with an estimated incidence of approximately 30% of all cases. The longstanding conventional standard of care comprises surgical resection and whole-brain radiotherapy (WBRT); however, this approach is associated with limited long-term survival and local control outcomes. Consequently, stereotactic radiosurgery (SRS) has emerged as a potential alternative approach. The primary aim of SRS has been to improve long-term control rates. Nevertheless, rare observations of abscopal or out-of-field effects have sparked interest in the potential to elicit antitumor immunity via the administration of high-dose radiation. The blood-brain barrier (BBB) has traditionally posed a significant challenge to the efficacy of systemic therapy in managing intracranial metastasis. However, recent insights into the immune-brain interface and the development of immunotherapeutic agents have shown promise in preclinical and early-phase clinical trials. Researchers have investigated combining immunotherapy with SRS to enhance treatment outcomes in patients with brain metastasis. The combination approach aims to optimize long-term control and overall survival (OS) outcomes by leveraging the synergistic effects of both therapies. Initial findings have been encouraging in the management of various intracranial metastases, while further studies are required to determine the optimal order of administration, radiation doses, and fractionation regimens that have the potential for the best tumor response. Currently, several clinical trials are underway to assess the safety and efficacy of administering immunotherapeutic agents concurrently or consecutively with SRS. In this review, we conduct a comprehensive analysis of the advantages and drawbacks of integrating immunotherapy into conventional SRS protocols for the treatment of intracranial metastasis.
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Affiliation(s)
| | | | | | | | | | | | - Steven D. Chang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
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Tian W, Chu X, Tanzhu G, Zhou R. Optimal timing and sequence of combining stereotactic radiosurgery with immune checkpoint inhibitors in treating brain metastases: clinical evidence and mechanistic basis. J Transl Med 2023; 21:244. [PMID: 37020242 PMCID: PMC10077682 DOI: 10.1186/s12967-023-04089-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/25/2023] [Indexed: 04/07/2023] Open
Abstract
Recent evidence has shown that immune checkpoint inhibitors (ICIs) are efficacious for treating brain metastases of various primary tumors. However, the immunosuppressive tumor microenvironment and the blood-brain barrier (BBB) or blood-tumor barrier (BTB) essentially restrict the efficacy of ICIs. Stereotactic radiosurgery (SRS) can be a powerful ally to ICIs due to its trait of disrupting the BBB/BTB and increasing the immunogenicity of brain metastases. The combination of SRS + ICI has shown synergy in brain metastases in several retrospective studies. Nevertheless, the optimal schedule for the combination of SRS and ICI in brain metastases is yet to be determined. In this review, we summarized the current clinical and preclinical evidence on the timing and sequence of SRS + ICI to provide insight into the current state of knowledge about this important area in patient care.
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Affiliation(s)
- Wentao Tian
- Department of Oncology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Kaifu District, Changsha, 410008, China
| | - Xianjing Chu
- Department of Oncology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Kaifu District, Changsha, 410008, China
| | - Guilong Tanzhu
- Department of Oncology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Kaifu District, Changsha, 410008, China
| | - Rongrong Zhou
- Department of Oncology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Kaifu District, Changsha, 410008, China.
- Xiangya Lung Cancer Center, Xiangya Hospital, Central South University, Changsha, 410008, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, China.
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8
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Guan H, Zhou Z, Hou X, Zhang F, Zhao J, Hu K. Safety and potential increased risk of toxicity of radiotherapy combined immunotherapy strategy. Asia Pac J Clin Oncol 2023; 19:35-50. [PMID: 35538049 DOI: 10.1111/ajco.13688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 09/14/2021] [Accepted: 09/23/2021] [Indexed: 01/20/2023]
Abstract
Accumulating interest has emerged in exploring the toxicity profiles of the combination strategy of radiotherapy (RT) and immune checkpoint inhibitors (ICIs). Much remains unknown regarding safety and the potential increased risk of toxicity of a combined treatment. ICI prolongs survival but can induce immune-related adverse events as well. To increase awareness of adverse effect and support immediate and successful management, we go over the literature on the safety of RT combined immunotherapy strategy. Representative evidence relevant to RT combined with ICI in the brain, lung, head and neck, and pelvic malignance was reviewed respectively. Given radiation doses and fractionation, the irradiated volume, the timing of RT, and ICI would significantly affect the safety and efficiency of ICI+RT combination therapy, and no consensus had been reached about how to arrange RT delivery in the combined contexture, we went over the available literature and tried to address these challenges including the timing of RT, optimal dose and fractionations, RT target and target volume, and potential biomarkers to predict toxicity. We found even though RT+ICI combination therapy might augment toxicities, the majority of patients experienced grade 4 or 5 AE are relatively rare and no significant difference could be found between combination group and monotherapy group. Sometimes the acute toxicity with ICI is much less predictable and often life threatening and in some can give rise to permanent effects. Clinicians across disciplines should be aware of these uncommon lethal complications induced by ICI+RT. Early recognition is the key to successful treatment, reversibility of organ dysfunction, and in some cases even prevention of fatal outcome. If recognized early, managed properly, and no fatal AE occurs, the development of irAE indicates a good prognosis. It should be noted that nothing is known about potential late effects because very few studies have 5-year follow-up. The nature of irAE is the attack of activated immune cells on normal tissues. The nature of RT-induced AE is the DNA damage on normal tissue, which is related with the dose delivered and volume irradiated and the tolerance of surrounding normal tissues. The immune-modulating effect of SBRT may augment the damage on normal tissues. To maximize the antitumor immune response, 8-12 Gy/fraction is preferred when conducting RT. The available clinical evidence suggest RT of this dose/fractionated strategy combined with ICI have a tolerable AE profile, which need further validation by more clinical trials in the future. The combination strategy of RT with anti-PD1/PDL1 anti-body is supposed to be concurrent or RT followed by anti-PD1/PDL1 antibody. Although RT and ipilimumab combination sequence is controversial, ipilimumab prior to or concurrent with RT might be proper, which need more clinical validation. Under the concept of immunological dose painting, SBRT work as a trigger of immune response. It has been observed that SBRT of partially radiated tumors combined with ICI could induce similar tumor control compared with total tumor irradiation. The side effects of RT may be mitigated potentially due to the reduction of irradiated volume. The antitumor efficiency and safety profile of immunological RT dose painting+ICI deserve further investigation. Clinical predictive factors for irAE risk remain unclear, and more investigation deserves to be conducted about the irAE prediction.
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Affiliation(s)
- Hui Guan
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Ziqi Zhou
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xiaorong Hou
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Fuquan Zhang
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jing Zhao
- Department of Oncology, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Ke Hu
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Bodensohn R, Werner S, Reis J, Pazos Escudero M, Kaempfel AL, Hadi I, Forbrig R, Manapov F, Corradini S, Belka C, Theurich S, Heinzerling L, Schlaak M, Niyazi M. Stereotactic radiosurgery and combined immune checkpoint therapy with ipilimumab and nivolumab in patients with melanoma brain metastases: A retrospective monocentric toxicity analysis. Clin Transl Radiat Oncol 2023; 39:100573. [PMID: 36655118 PMCID: PMC9841023 DOI: 10.1016/j.ctro.2022.100573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 12/28/2022] [Accepted: 12/28/2022] [Indexed: 01/06/2023] Open
Abstract
Purpose and objective Adding stereotactic radiosurgery (SRS) to combined immune checkpoint therapy with ipilimumab and nivolumab (IPI + NIVO) has led to promising results for patients with melanoma brain metastases (MBM). This study retrospectively analyzes the toxicity profile depending on the timing of SRS with regard to IPI + NIVO. Materials and methods For this study, the clinical database was searched for all patients with MBM who were treated with SRS and IPI + NIVO. The patients were separated into three groups: group A completed IPI + NIVO (usually up to four cycles) >14 days before SRS, in group B IPI + NIVO was initiated>14 days after SRS, and group C received SRS concurrently to IPI + NIVO. Treatment related toxicity was obtained from clinical and neuroradiological records. Analyses were performed using the Fisher-Yates-test. Results 31 patients were assessed including six (19.4 %), seven (22.6 %) and 18 (58.1 %) patients, in groups A, B and C, respectively. Baseline prognostic markers between groups were balanced. In total, five (16.1 %) patients experienced neurological grade 3 toxicities related to SRS. All of these five patients were in group C, which was near-significantly correlated with a risk for grade 3 toxicities (p = 0.058). Post-hoc analyses showed that a maximum time period of seven days between SRS and IPI + NIVO was significantly correlated with grade 3 toxicity (p = 0.048). Conclusion Application of SRS to IPI + NIVO within a seven-day span was related to higher toxicity rates in this retrospective analysis. After previous studies focused on immune checkpoint monotherapies with SRS and declared it as safe, this study indicates that concomitant application of IPI + NIVO and SRS might increase side effects. Prospective validation is warranted to corroborate these findings.
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Key Words
- AE, Adverse events
- CTCAE, Common Terminology Criteria for Adverse Events
- Checkpoint inhibition
- GPA, graded prognostic assessment
- IPI, ipilimumab
- Intracranial hemorrhage
- Ipilimumab
- LDH, lactate dehydrogenase
- MBM, Melanoma brain metastases
- MRI, magnet resonance imaging
- NIVO, nivolumab
- Nivolumab
- OS, overall survival
- PFS, progression-free survival
- RN, radiation necrosis
- Radiation necrosis
- SRS, Stereotactic radiosurgery
- SRT, Stereotactic radiotherapy
- Side effects
- Stereotactic radiosurgery
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Affiliation(s)
- Raphael Bodensohn
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Simone Werner
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Jonas Reis
- Institute of Neuroradiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Montserrat Pazos Escudero
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Anna-Lena Kaempfel
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Indrawati Hadi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Robert Forbrig
- Institute of Neuroradiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Farkhad Manapov
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany,German Cancer Consortium (DKTK), Partner Site, Munich, Germany
| | - Sebastian Theurich
- Department of Medicine III, University Hospital, LMU Munich, Ziemssenstraße 1, 80336 Munich, Germany
| | - Lucie Heinzerling
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Frauenlobstraße 9-11, 80337 Munich, Germany,Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Ulmenweg 18, 91052 Erlangen, Germany
| | - Max Schlaak
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Dermatology, Venereology and Allergology, Charitéplatz 1, 10117 Berlin, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany,German Cancer Consortium (DKTK), Partner Site, Munich, Germany,Corresponding author at: Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany.
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10
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Sussman TA, Knackstedt R, Wei W, Funchain P, Gastman BR. Outcomes of stage IV melanoma in the era of immunotherapy: a National Cancer Database (NCDB) analysis from 2014 to 2016. J Immunother Cancer 2022; 10:jitc-2022-004994. [PMID: 35998982 PMCID: PMC9403163 DOI: 10.1136/jitc-2022-004994] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND To evaluate factors affecting the utilization of immunotherapy and to stratify results based on the approval of ipilimumab in 2011 and programmed death-1 inhibitors in 2014, an analysis of available data from the National Cancer Database (NCDB) was performed. METHODS The NCDB was analyzed to identify patients with stage IV melanoma from 2004 to 2016. Patients were categorized during the time periods 2004-2010, 2011-2014, and 2015-2016. Overall survival (OS) was analyzed by Kaplan-Meier, log-rank, and Cox proportional hazard models; IO status was analyzed using logistic regression. RESULTS 24,544 patients were analyzed. Overall, 5238 patients (21.3%) who received IO had improved median OS compared with those who did not (20.2 months vs 7.4 months; p<0.0001). Between 2004 and 2010, 9.7% received immunotherapy; from 2011 to 2014, 21.9% received immunotherapy; and from 2015 to 2016, 43.5% received immunotherapy. Three-year OS significantly improved in patients treated with IO across treatment years: 31% (95% CI 29% to 34%) from 2004 to 2010, 35% (95% CI 33% to 37%) from 2011 to 2014, and 46% (95% CI 44% to 48%) from 2015 to 2016 (p<0.0001). Survival was worse in patients who did not receive IO during these treatment years: 16% (15%-17%), 21% (20%-22%), and 27% (25%-28%), respectively. In the overall cohort, age <65 years, female gender, private insurance, no comorbidities, residence in metropolitan area, and treatment at academic centers were associated with better OS (p<0.0001 for all). In the multivariate analysis, receipt of IO from 2015 to 2016 was associated with age <65 years (OR 1.27, 95% CI 1.08 to 1.50), African American race (OR 5.88, 95% CI 1.60 to 28.58), lack of comorbidities (OR 1.43, 95% CI 1.23 to 1.66), and treatment at academic centers (OR 1.44, 95% CI 1.26 to 1.65) (p<0.05 for all). CONCLUSIONS OS improved in patients with stage IV melanoma receiving IO, with the highest OS rate in 2015-2016. Our findings, which represent a real-world population, are slightly lower than recent trials, such as KEYNOTE-006 and CheckMate 067. Significant socioeconomic factors may impact receipt of IO and survival.
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Affiliation(s)
- Tamara A Sussman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Rebecca Knackstedt
- Department of Dermatology and Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Wei Wei
- Department of Quantitative Health, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Pauline Funchain
- Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Brian R Gastman
- Department of Dermatology and Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Gondi V, Bauman G, Bradfield L, Burri SH, Cabrera AR, Cunningham DA, Eaton BR, Hattangadi-Gluth JA, Kim MM, Kotecha R, Kraemer L, Li J, Nagpal S, Rusthoven CG, Suh JH, Tomé WA, Wang TJC, Zimmer AS, Ziu M, Brown PD. Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2022; 12:265-282. [PMID: 35534352 DOI: 10.1016/j.prro.2022.02.003] [Citation(s) in RCA: 102] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/07/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE This guideline provides updated evidence-based recommendations addressing recent developments in the management of patients with brain metastases, including advanced radiation therapy techniques such as stereotactic radiosurgery (SRS) and hippocampal avoidance whole brain radiation therapy and the emergence of systemic therapies with central nervous system activity. METHODS The American Society for Radiation Oncology convened a task force to address 4 key questions focused on the radiotherapeutic management of intact and resected brain metastases from nonhematologic solid tumors. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS Strong recommendations are made for SRS for patients with limited brain metastases and Eastern Cooperative Oncology Group performance status 0 to 2. Multidisciplinary discussion with neurosurgery is conditionally recommended to consider surgical resection for all tumors causing mass effect and/or that are greater than 4 cm. For patients with symptomatic brain metastases, upfront local therapy is strongly recommended. For patients with asymptomatic brain metastases eligible for central nervous system-active systemic therapy, multidisciplinary and patient-centered decision-making to determine whether local therapy may be safely deferred is conditionally recommended. For patients with resected brain metastases, SRS is strongly recommended to improve local control. For patients with favorable prognosis and brain metastases receiving whole brain radiation therapy, hippocampal avoidance and memantine are strongly recommended. For patients with poor prognosis, early introduction of palliative care for symptom management and caregiver support are strongly recommended. CONCLUSIONS The task force has proposed recommendations to inform best clinical practices on the use of radiation therapy for brain metastases with strong emphasis on multidisciplinary care.
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Affiliation(s)
- Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center and Proton Center, Warrenville, Illinois.
| | - Glenn Bauman
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre & Western University, London, Ontario, Canada
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Stuart H Burri
- Department of Radiation Oncology, Atrium Health, Charlotte, North Carolina
| | - Alvin R Cabrera
- Department of Radiation Oncology, Kaiser Permanente, Seattle, Washington
| | | | - Bree R Eaton
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | | | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | | | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Seema Nagpal
- Division of Neuro-oncology, Department of Neurology, Stanford University, Stanford, California
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - John H Suh
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Wolfgang A Tomé
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University, New York, New York
| | - Alexandra S Zimmer
- Women's Malignancies Branch, National Institutes of Health/National Cancer Institute, Bethesda, Maryland
| | - Mateo Ziu
- Department of Neurosciences, INOVA Neuroscience and INOVA Schar Cancer Institute, Falls Church, Virginia
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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12
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Palmer JD, Prasad RN, Fabian D, Wei L, Yildiz VO, Tan Y, Grecula J, Welliver M, Williams T, Elder JB, Raval R, Blakaj D, Haglund K, Bazan J, Kendra K, Arnett A, Beyer S, Liebner D, Giglio P, Puduvalli V, Chakravarti A, Wuthrick E. Phase I study of trametinib in combination with whole brain radiation therapy for brain metastases. Radiother Oncol 2022; 170:21-26. [DOI: 10.1016/j.radonc.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 03/15/2022] [Accepted: 03/25/2022] [Indexed: 11/25/2022]
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13
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Urban H, Steidl E, Hattingen E, Filipski K, Meissner M, Sebastian M, Koch A, Strzelczyk A, Forster MT, Baumgarten P, Ronellenfitsch MW, Steinbach JP, Voss M. Immune Checkpoint Inhibitor-Induced Cerebral Pseudoprogression: Patterns and Categorization. Front Immunol 2022; 12:798811. [PMID: 35046955 PMCID: PMC8761630 DOI: 10.3389/fimmu.2021.798811] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/06/2021] [Indexed: 12/18/2022] Open
Abstract
Background The inclusion of immune checkpoint inhibitors (ICIs) in therapeutic algorithms has led to significant survival benefits in patients with various metastatic cancers. Concurrently, an increasing number of neurological immune related adverse events (IRAE) has been observed. In this retrospective analysis, we examine the ICI-induced incidence of cerebral pseudoprogression and propose a classification system. Methods We screened our hospital information system to identify patients with any in-house ICI treatment for any tumor disease during the years 2007-2019. All patients with cerebral MR imaging (cMRI) of sufficient diagnostic quality were included. cMRIs were retrospectively analyzed according to immunotherapy response assessment for neuro-oncology (iRANO) criteria. Results We identified 12 cases of cerebral pseudoprogression in 123 patients treated with ICIs and sufficient MRI. These patients were receiving ICI therapy for lung cancer (n=5), malignant melanoma (n=4), glioblastoma (n=1), hepatocellular carcinoma (n=1) or lymphoma (n=1) when cerebral pseudoprogression was detected. Median time from the start of ICI treatment to pseudoprogression was 5 months. All but one patient developed neurological symptoms. Three different patterns of cerebral pseudoprogression could be distinguished: new or increasing contrast-enhancing lesions, new or increasing T2 predominant lesions and cerebral vasculitis type pattern. Conclusion Cerebral pseudoprogression followed three distinct patterns and was detectable in 3.2% of all patients during ICI treatment and in 9.75% of the patients with sufficient brain imaging follow up. The fact that all but one of the affected patients developed neurological symptoms, which would be classified as progressive disease according to iRANO criteria, mandates vigilance in the diagnosis and treatment of ICI-induced cerebral lesions.
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Affiliation(s)
- Hans Urban
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany
| | - Eike Steidl
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Elke Hattingen
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany.,Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Katharina Filipski
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany.,Institute of Neurology (Edinger Institute), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Markus Meissner
- Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Martin Sebastian
- Department of Medicine II, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Agnes Koch
- Department of Thoracic Surgery, Agaplesion Markuskrankenhaus, Frankfurt/Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (Cepter), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Marie-Thérèse Forster
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany.,Department of Neurosurgery, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Peter Baumgarten
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,Department of Neurosurgery, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Michael W Ronellenfitsch
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (Cepter), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Joachim P Steinbach
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany
| | - Martin Voss
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany
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14
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Mathis NJ, Wijetunga NA, Imber BS, Pike LRG, Yang JT. Recent Advances and Applications of Radiation Therapy for Brain Metastases. Curr Oncol Rep 2022; 24:335-342. [PMID: 35133614 DOI: 10.1007/s11912-022-01209-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Radiation therapy (RT) is a mainstay of treatment for brain metastases from solid tumors. Treatment of these patients is complex and should focus on minimizing symptoms, preserving functional status, and prolonging survival. RECENT FINDINGS Whole-brain radiotherapy (WBRT) can lead to toxicity, and while it does reduce recurrence in the CNS, this has not been shown to provide a survival benefit. Recent advances focus on reducing the toxicity of WBRT or using more targeted radiation therapy. New paradigms including the use of proton RT for leptomeningeal metastases (LM) and stereotactic radiosurgery (SRS) before craniotomy hold promise in improving treatment efficacy and reducing toxicity. Omission or replacement of WBRT is often safe and the use of SRS is expanding to include patients with more lesions and preoperative RT. Proton RT holds promise for LM. Progress is being made in improving patient-centered outcomes and reducing toxicity for patients with brain metastases.
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Affiliation(s)
- Noah J Mathis
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - N Ari Wijetunga
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Luke R G Pike
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Jonathan T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
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15
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Anvari A, Sasanpour P, Rajabzadeh Kheradmardi M. Radiotherapy and immunotherapy in melanoma brain metastases. Hematol Oncol Stem Cell Ther 2021; 16:1-20. [PMID: 36634277 DOI: 10.1016/j.hemonc.2021.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 10/29/2021] [Accepted: 11/14/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Melanoma brain metastasis (MBM) generally portends a dismal prognosis. Simultaneous use of radiotherapy (RT) and immune checkpoint inhibitor (ICI) therapy demonstrated tremendous promise and emerged as the new standard. This meta-analysis was conducted to evaluate survival outcomes and toxicities of this combination in patients with MBM. Data analyses were performed using Comprehensive Meta-Analysis software (version 2) and IBM SPSS software (version 27). METHODS A systematic literature search of PubMed, EMBASE, and the Cochrane Library (via Wiley) was conducted using PICOS/PRISMA selection protocol and included studies to evaluate survival and safety-associated outcomes of ICI + RT for the treatment of MBM. RESULTS A total 44 studies involving 2498 patients were reviewed. The pooled effect size (ES) for overall survival (OS) to compare the ICI + RT arm and ICI alone arm (HR: 0.693 [0.526-0.913, p = .001]), and compare the ICI + RT arm and brain RT alone (HR: 0.595 [0.489-0.723, p < .001)] indicated better survival outcomes in ICI + RT versus RT alone and ICI alone arms. Comparing central nervous system toxicity in the ICI + RT arm and RT alone arm, the pooled ES Grade ≥ 3 neurologic adverse events (NAEs) risk ratio ([RR] = 1.425; 95% confidence interval [CI]: 0.485-4.183; p = .519) indicated that ICI + RT nonsignificantly increased Grade 3-4 NAEs. Comparing Grade ≥ 3 radiation necrosis in the ICI + RT arm and RT alone arm, the pooled ES RR (RR = 2.73; 95% CI: 0.59-12.59; p = .199) indicated that ICI + RT nonsignificantly increased Grade ≥ 3 radiation necrosis. CONCLUSION Concurrent administration of RT and ICI evinced favorable OS outcomes and acceptable safety profile in MBM patients. Planned prospective trials are required to demonstrate the issue.
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Affiliation(s)
- Amir Anvari
- Department of Radiation Oncology, Imam Hussein Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Pegah Sasanpour
- Department of Radiation Oncology, Imam Ali Hospital, Zahedan University of Medical Science, Zahedan, Iran
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16
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Carney CP, Pandey N, Kapur A, Woodworth GF, Winkles JA, Kim AJ. Harnessing nanomedicine for enhanced immunotherapy for breast cancer brain metastases. Drug Deliv Transl Res 2021; 11:2344-2370. [PMID: 34716900 PMCID: PMC8568876 DOI: 10.1007/s13346-021-01039-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2021] [Indexed: 12/15/2022]
Abstract
Brain metastases (BMs) are the most common type of brain tumor, and the incidence among breast cancer (BC) patients has been steadily increasing over the past two decades. Indeed, ~ 30% of all patients with metastatic BC will develop BMs, and due to few effective treatments, many will succumb to the disease within a year. Historically, patients with BMs have been largely excluded from clinical trials investigating systemic therapies including immunotherapies (ITs) due to limited brain penetration of systemically administered drugs combined with previous assumptions that BMs are poorly immunogenic. It is now understood that the central nervous system (CNS) is an immunologically distinct site and there is increasing evidence that enhancing immune responses to BCBMs will improve patient outcomes and the efficacy of current treatment regimens. Progress in IT for BCBMs, however, has been slow due to several intrinsic limitations to drug delivery within the brain, substantial safety concerns, and few known targets for BCBM IT. Emerging studies demonstrate that nanomedicine may be a powerful approach to overcome such limitations, and has the potential to greatly improve IT strategies for BMs specifically. This review summarizes the evidence for IT as an effective strategy for BCBM treatment and focuses on the nanotherapeutic strategies currently being explored for BCBMs including targeting the blood-brain/tumor barrier (BBB/BTB), tumor cells, and tumor-supporting immune cells for concentrated drug release within BCBMs, as well as use of nanoparticles (NPs) for delivering immunomodulatory agents, for inducing immunogenic cell death, or for potentiating anti-tumor T cell responses.
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Affiliation(s)
- Christine P Carney
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Nikhil Pandey
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Anshika Kapur
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Graeme F Woodworth
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Jeffrey A Winkles
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Department of Surgery and Neurosurgery, University of Maryland School of Medicine, 800 West Baltimore St., Baltimore, MD, 21201, USA.
| | - Anthony J Kim
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, MD, 21201, USA.
- Departments of Neurosurgery, Pharmacology, and Pharmaceutical Sciences, University of Maryland School of Medicine, 655 W Baltimore St., Baltimore, MD, 21201, USA.
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17
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Akama-Garren EH, Morris ZS, Sikora AG, Weichselbaum R, Schoenfeld JD. Prospective Clinical Investigation of the Efficacy of Combination Radiation Therapy With Immune Checkpoint Inhibition. Int J Radiat Oncol Biol Phys 2021; 111:1165-1175. [PMID: 34411638 PMCID: PMC10960630 DOI: 10.1016/j.ijrobp.2021.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/19/2022]
Abstract
Immune checkpoint inhibitors (ICIs) lead to durable responses in a subset of patients with cancer, but most patients do not respond to ICI, prompting interest in combining immunotherapy with other therapeutic regimens. Preclinical evidence supports the potential for therapeutic synergy between immunotherapy and radiation therapy through modulation of the tumor microenvironment and antitumor immune responses. Local therapy also has the potential to overcome localized sites of relative immune suppression and resistance. Prospective clinical trials have been initiated to test these hypotheses in the clinic as well as to investigate the toxicities and adverse events associated with combination immunotherapy and radiation therapy. In this review, we discuss the emerging results from prospective clinical trials of combination immunotherapy and radiation therapy, the safety and efficacy of their combination, concordance with preclinical and retrospective data, and some of the remaining open questions to be addressed by future clinical trials.
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Affiliation(s)
- Elliot H Akama-Garren
- Harvard Medical School, Boston, Massachusetts; Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Zachary S Morris
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Andrew G Sikora
- Department of Head and Neck Surgery, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ralph Weichselbaum
- Department of Radiation and Cellular Oncology, The University of Chicago Medical Center, Chicago, Illinois; The Ludwig Center for Metastasis Research, The University of Chicago Medical Center, Chicago, Illinois
| | - Jonathan D Schoenfeld
- Harvard Medical School, Boston, Massachusetts; Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts.
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18
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Ahmed KA, Kim Y, Arrington JA, Kim S, DeJesus M, Soyano AE, Armaghani AJ, Costa RL, Khong HT, Loftus LS, Rosa M, Caudell JJ, Diaz R, Robinson TJ, Etame AB, Tran ND, Sahebjam S, Soliman HH, Czerniecki BJ, Forsyth PA, Yu HM, Han HS. Nivolumab and Stereotactic Radiosurgery for Patients With Breast Cancer Brain Metastases: A Nonrandomized, Open-Label Phase 1b Study. Adv Radiat Oncol 2021; 6:100798. [PMID: 34934864 PMCID: PMC8655428 DOI: 10.1016/j.adro.2021.100798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/12/2021] [Indexed: 02/07/2023] Open
Abstract
Purpose Methods and Materials Results Conclusions
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19
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Ben Shimol J, Guzman-Prado Y, Karlinskaya M, Davidson T. Effectiveness and safety of immune checkpoint inhibitors in combination with palliative radiotherapy in advanced melanoma: A systematic review. Crit Rev Oncol Hematol 2021; 167:103499. [PMID: 34687896 DOI: 10.1016/j.critrevonc.2021.103499] [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: 04/21/2021] [Revised: 07/08/2021] [Accepted: 10/10/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Radiotherapy is frequently added to immune checkpoint inhibitors (ICI) when treating melanoma. We sought to describe the efficacy of combination ICI and palliative radiotherapy (pRT) and assess safety, focusing on immune related adverse events (irAE). METHODS A systematic search for studies investigating the combination of pRT and ICI was conducted. RESULTS Five hundred-two articles were identified; nine met inclusion criteria. Improvements in objective response rate (p = 0.02), complete response (p = 0.04), and one-year local control (p < 0.005) were demonstrated when pRT was added to ICI. While some studies revealed improved overall and progression free survival, findings were mixed. No significant increases in adverse events or irAE were seen with the combined treatment compared with ICI alone. CONCLUSION The included studies revealed that the addition of pRT to ICI is effective and safe in patients with advanced melanoma. Measures of survival varied. More studies are warranted to identify optimal conditions for combination treatment.
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Affiliation(s)
- Jennifer Ben Shimol
- Department of Medicine, E. Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yuli Guzman-Prado
- Department of Clinical Research, International Centre for Medical Research, Dorset, United Kingdom
| | | | - Tima Davidson
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Nuclear Medicine, Sheba Medical Center, Ramat Gan, Israel
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20
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Sudmeier L, Tian S, Higgins KA. Multidisciplinary Management of Brain Metastases from Non-Small Cell Lung Cancer in the Era of Immunotherapy. Curr Treat Options Oncol 2021; 22:77. [PMID: 34213649 DOI: 10.1007/s11864-021-00871-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 12/17/2022]
Abstract
OPINION STATEMENT Brain metastases from non-small cell lung cancer often cause neurologic symptoms which lead to initial diagnosis or identification of recurrence. In other patients, they are identified on surveillance imaging or when a patient undergoing treatment develops neurological symptoms. Patients with symptomatic lesions should be started on dexamethasone and evaluated by a neurosurgeon as soon as possible. If feasible, surgery should be offered to decrease intracranial pressure, alleviate symptoms, and prevent irreversible neurological damage. Postoperative stereotactic radiosurgery (SRS) to the resection cavity and any additional brain metastases should follow within 4 weeks of surgery, as early as 2 weeks post-op. Tissue from surgery is used to confirm the diagnosis and test for targetable oncogenic driver mutations. Treatment response and surveillance for development of additional lesions is assessed with MRI of the brain 1 month after SRS and every 3 months thereafter. Patients who are not surgical candidates or who have small, asymptomatic brain metastases should proceed with SRS, the preferred treatment, or sometimes whole-brain radiation therapy (WBRT) if multifocal disease requires more extensive treatment, such as for leptomeningeal spread of disease. The number of brain metastases that warrants use of WBRT over SRS is controversial and a topic of ongoing investigation, and is discussed in this review. When possible, SRS is preferred over WBRT due to reduce morbidity and cognitive side effects. When patients are already on systemic therapy at time of brain metastases diagnosis, systemic therapy should continue, with radiation therapy occurring between cycles. Regarding systemic therapy for new diagnosis at time of brain metastases presentation, molecular testing will guide treatment choice, when available. If there is no neurosurgical intervention, biopsy of another site of disease may provide tissue for molecular testing. If there are no targetable oncogenic driver mutations, concurrent immune checkpoint blockade (ICB) and chemotherapy is preferable for patients who can tolerate it. Single-agent ICB is an alternative option for patients who cannot tolerate chemotherapy. Systemic therapy should start as soon as possible. In some patients with poor performance status, best supportive care may be the most appropriate choice. Treatment decisions should always incorporate patients' goals of care and in many cases should be discussed in a multidisciplinary setting.
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Affiliation(s)
- Lisa Sudmeier
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, 1365 Clifton Road, Atlanta, GA, 30322, USA
| | - Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, 1365 Clifton Road, Atlanta, GA, 30322, USA
| | - Kristin A Higgins
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, 1365 Clifton Road, Atlanta, GA, 30322, USA.
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21
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Tabana Y, Moon TC, Siraki A, Elahi S, Barakat K. Reversing T-cell exhaustion in immunotherapy: a review on current approaches and limitations. Expert Opin Ther Targets 2021; 25:347-363. [PMID: 34056985 DOI: 10.1080/14728222.2021.1937123] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Introduction:T cell functions are altered during chronic viral infections and tumor development. This is mainly manifested by significant changes in T cells' epigenetic and metabolic landscapes, pushing them into an 'exhausted' state. Reversing this T cell exhaustion has been emerging as a 'game-changing' therapeutic approach against cancer and chronic viral infection.Areas covered:This review discusses the cellular pathways related to T cell exhaustion, and the clinical development and possible cellular targets that can be exploited therapeutically to reverse this exhaustion. We searched various databases (e.g. Google Scholar, PubMed, Elsevier, and other scientific database sites) using the keywords T cell exhaustion, T cell activation, co-inhibitory receptors, and reversing T cell exhaustion.Expert opinion:The discovery of the immune checkpoints pathways represents a significant milestone toward understanding and reversing T cell exhaustion. Antibodies that target these pathways have already demonstrated promising activities in reversing T cell exhaustion. Nevertheless, there are still many associated limitations. In this context, next-generation alternatives are on the horizon. This includes the use of small molecules to block the immune checkpoints' receptors, combining them with other treatments, and identifying novel, safer and more effective immunotherapeutic targets.
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Affiliation(s)
- Yasser Tabana
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Tae Chul Moon
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Arno Siraki
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Shokrollah Elahi
- School of Dentistry, University of Alberta, Edmonton, AB, Canada.,Department of Oncology, University of Alberta, Edmonton, AB, Canada.,Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada
| | - Khaled Barakat
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
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22
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Mills MN, Naz A, Thawani C, Walker C, Figura NB, Kushchayev S, Oliver DE, Etame AB, Yu HHM, Robinson TJ, Liu JKC, Vogelbaum MA, Forsyth PA, Czerniecki BJ, Soliman HH, Han HS, Ahmed KA. Capecitabine and stereotactic radiation in the management of breast cancer brain metastases. BMC Cancer 2021; 21:552. [PMID: 33992087 PMCID: PMC8126143 DOI: 10.1186/s12885-021-08302-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/28/2021] [Indexed: 11/10/2022] Open
Abstract
Background Little is known about the safety and efficacy of concurrent capecitabine and stereotactic radiotherapy in the setting of breast cancer brain metastases (BCBM). Methods Twenty-three patients with BCBM underwent 31 stereotactic sessions to 90 lesions from 2005 to 2019 with receipt of capecitabine. The Kaplan-Meier method was used to calculate overall survival (OS), local control (LC), and distant intracranial control (DIC) from the date of stereotactic radiation. Imaging was independently reviewed by a neuro-radiologist. Results Median follow-up from stereotactic radiation was 9.2 months. Receptor types of patients treated included triple negative (n = 7), hormone receptor (HR)+/HER2- (n = 7), HR+/HER2+ (n = 6), and HR−/HER2+ (n = 3). Fourteen patients had stage IV disease prior to BCBM diagnosis. The median number of brain metastases treated per patient was 3 (1 to 12). The median dose of stereotactic radiosurgery (SRS) was 21 Gy (range: 15–24 Gy) treated in a single fraction and for lesions treated with fractionated stereotactic radiation therapy (FSRT) 25 Gy (24–30 Gy) in a median of 5 fractions (range: 3–5). Of the 31 stereotactic sessions, 71% occurred within 1 month of capecitabine. No increased toxicity was noted in our series with no cases of radionecrosis. The 1-year OS, LC, and DIC were 46, 88, and 30%, respectively. Conclusions In our single institution experience, we demonstrate stereotactic radiation and capecitabine to be a safe treatment for patients with BCBM with adequate LC. Further study is needed to determine the potential synergy between stereotactic radiation and capecitabine in the management of BCBM.
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Affiliation(s)
- Matthew N Mills
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr, Tampa, FL, 33612, USA
| | - Afrin Naz
- Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
| | - Chetna Thawani
- Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
| | - Chelsea Walker
- Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
| | - Nicholas B Figura
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr, Tampa, FL, 33612, USA
| | - Sergiy Kushchayev
- Department of Radiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Daniel E Oliver
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr, Tampa, FL, 33612, USA
| | - Arnold B Etame
- Department of Neuro Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Hsiang-Hsuan Michael Yu
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr, Tampa, FL, 33612, USA
| | - Timothy J Robinson
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr, Tampa, FL, 33612, USA
| | - James K C Liu
- Department of Neuro Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Michael A Vogelbaum
- Department of Neuro Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Peter A Forsyth
- Department of Neuro Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Brian J Czerniecki
- Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Hatem H Soliman
- Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Hyo S Han
- Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Kamran A Ahmed
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr, Tampa, FL, 33612, USA.
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23
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Williamson CW, Sherer MV, Zamarin D, Sharabi AB, Dyer BA, Mell LK, Mayadev J. Immunotherapy and radiation therapy sequencing: State of the data on timing, efficacy, and safety. Cancer 2021; 127:1553-1567. [PMID: 33620731 PMCID: PMC9376883 DOI: 10.1002/cncr.33424] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 01/14/2023]
Abstract
Radiation therapy exerts a tumoricidal local effect as well as both local and systemic immunomodulation. Immune checkpoint blockade has become a widely used treatment modality across cancer types with a rapidly growing list of agents and US Food and Drug Administration-approved indications. Moreover, there may be synergy between radiation therapy and immune checkpoint blockade. Various strategies have been used, but the optimal sequencing of these therapies is unclear. In this review, the authors discuss the major mechanisms of available immune checkpoint inhibitors and explore the available preclinical and clinical evidence regarding treatment sequencing. They also review safety considerations and conclude with possible future directions.
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Affiliation(s)
- Casey W Williamson
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Michael V Sherer
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Dmitriy Zamarin
- Department of Medicine, Memorial Sloan Kettering Cancer Center
| | - Andrew B Sharabi
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Brandon A Dyer
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Jyoti Mayadev
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
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24
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Fares J, Ulasov I, Timashev P, Lesniak MS. Emerging principles of brain immunology and immune checkpoint blockade in brain metastases. Brain 2021; 144:1046-1066. [PMID: 33893488 PMCID: PMC8105040 DOI: 10.1093/brain/awab012] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/12/2022] Open
Abstract
Brain metastases are the most common type of brain tumours, harbouring an immune microenvironment that can in principle be targeted via immunotherapy. Elucidating some of the immunological intricacies of brain metastases has opened a therapeutic window to explore the potential of immune checkpoint inhibitors in this globally lethal disease. Multiple lines of evidence suggest that tumour cells hijack the immune regulatory mechanisms in the brain for the benefit of their own survival and progression. Nonetheless, the role of the immune checkpoint in the complex interplays between cancers cells and T cells and in conferring resistance to therapy remains under investigation. Meanwhile, early phase trials with immune checkpoint inhibitors have reported clinical benefit in patients with brain metastases from melanoma and non-small cell lung cancer. In this review, we explore the workings of the immune system in the brain, the immunology of brain metastases, and the current status of immune checkpoint inhibitors in the treatment of brain metastases.
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Affiliation(s)
- Jawad Fares
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Ilya Ulasov
- Group of Experimental Biotherapy and Diagnostics, Institute for Regenerative Medicine, World-Class Research Center “Digital Biodesign and Personalized Healthcare”, Sechenov First Moscow State Medical University, Moscow 119991, Russia
| | - Peter Timashev
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University, Moscow 119991, Russia
| | - Maciej S Lesniak
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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25
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Wilkins A, Ost P, Sundahl N. Is There a Benefit of Combining Immunotherapy and Radiotherapy in Bladder Cancer? Clin Oncol (R Coll Radiol) 2021; 33:407-414. [PMID: 33726945 DOI: 10.1016/j.clon.2021.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/10/2021] [Accepted: 02/25/2021] [Indexed: 01/13/2023]
Abstract
Immune checkpoint inhibitors have transformed the management of patients with metastatic urothelial cancer, by leading to long-term response and prolongation of survival in a subset of patients. Unfortunately, only one in five patients with metastatic urothelial cancer responds to anti-programmed death ligand-1 ([AQ1]anti-PD-1) monotherapy. Preclinical and early clinical evidence indicates that radiotherapy not only acts locally, but also exerts systemic anti-tumour effects by modulating the immune system. It is hypothesised that combining checkpoint inhibitors with radiotherapy might enhance an anti-tumour immune response and increase response rates. So far, a handful of early phase clinical trials have been performed seeking to answer this question in urothelial cancer patients. The current review summarises the available preclinical and clinical evidence on radiotherapy/immunotherapy combinations in locally advanced and metastatic bladder cancer and suggests future avenues worthy of exploration.
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Affiliation(s)
- A Wilkins
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, UK
| | - P Ost
- Department of Radiation Oncology and Experimental Cancer Research, Ghent University Hospital, Ghent, Belgium
| | - N Sundahl
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, UK; Department of Radiation Oncology and Experimental Cancer Research, Ghent University Hospital, Ghent, Belgium.
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26
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Rouanet J, Quintana M, Auzeloux P, Cachin F, Degoul F. Benzamide derivative radiotracers targeting melanin for melanoma imaging and therapy: Preclinical/clinical development and combination with other treatments. Pharmacol Ther 2021; 224:107829. [PMID: 33662452 DOI: 10.1016/j.pharmthera.2021.107829] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 12/16/2022]
Abstract
Cutaneous melanoma arises from proliferating melanocytes, cells specialized in the production of melanin. This property means melanin can be considered as a target for monitoring melanoma patients using nuclear imaging or targeted radionuclide therapy (TRT). Since the 1970s, many researchers have shown that specific molecules can interfere with melanin. This paper reviews some such molecules: benzamide structures improved to increase their pharmacokinetics for imaging or TRT. We first describe the characteristics and biosynthesis of melanin, and the main features of melanin tracers. The second part summarizes the preclinical and corresponding clinical studies on imaging. The last section presents TRT results from ongoing protocols and discusses combinations with other therapies as an opportunity for melanoma non-responders or patients resistant to treatments.
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Affiliation(s)
- Jacques Rouanet
- Université Clermont Auvergne, INSERM, Imagerie Moléculaire et Stratégies Théranostiques, UMR1240, 58 Rue Montalembert, 63005 Clermont-Ferrand, Cedex, France; Department of Dermatology and Oncodermatology, CHU Estaing, 1 place Lucie et Raymond Aubrac, 63000 Clermont-Ferrand, France; Centre Jean Perrin, Clermont-Ferrand F-63011, France.
| | - Mercedes Quintana
- Université Clermont Auvergne, INSERM, Imagerie Moléculaire et Stratégies Théranostiques, UMR1240, 58 Rue Montalembert, 63005 Clermont-Ferrand, Cedex, France.
| | - Philippe Auzeloux
- Université Clermont Auvergne, INSERM, Imagerie Moléculaire et Stratégies Théranostiques, UMR1240, 58 Rue Montalembert, 63005 Clermont-Ferrand, Cedex, France.
| | - Florent Cachin
- Université Clermont Auvergne, INSERM, Imagerie Moléculaire et Stratégies Théranostiques, UMR1240, 58 Rue Montalembert, 63005 Clermont-Ferrand, Cedex, France; Centre Jean Perrin, Clermont-Ferrand F-63011, France.
| | - Françoise Degoul
- Université Clermont Auvergne, INSERM, Imagerie Moléculaire et Stratégies Théranostiques, UMR1240, 58 Rue Montalembert, 63005 Clermont-Ferrand, Cedex, France.
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27
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Clinical Significance of PDCD4 in Melanoma by Subcellular Expression and in Tumor-Associated Immune Cells. Cancers (Basel) 2021; 13:cancers13051049. [PMID: 33801444 PMCID: PMC7958624 DOI: 10.3390/cancers13051049] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/16/2021] [Accepted: 02/22/2021] [Indexed: 12/16/2022] Open
Abstract
Simple Summary While targeting programmed cell death (PDCD) 1 is a central treatment against melanoma, little is known about the related protein PDCD4. We defined differences in melanoma PDCD4 subcellular localization (either total cellular or nuclear-only) during oncogenesis, evaluated its presence on tumor-infiltrating immune cells, and determined its impact on survival. High PDCD4 expression resulted in improved survival in patients with primary and intracranial but not extracranial metastatic melanoma. High PDCD4 levels in surrounding tumor tissue were also associated with increased infiltrating immune cells. PDCD4 may be a potentially useful biomarker in melanoma to help guide our understanding of patient prognosis. Methods to increase PDCD4 in those with melanoma brain metastases may also help improve disease response. Abstract Little is known about the subcellular localization and function of programmed cell death 4 (PDCD4) in melanoma. Our past studies suggest PDCD4 interacts with Pleckstrin Homology Domain Containing A5 (PLEKHA5) to influence melanoma brain metastasis outcomes, as high intracranial PDCD4 expression leads to improved survival. We aimed to define the subcellular distribution of PDCD4 in melanoma and in the tumor microenvironment during neoplastic progression and its impact on clinical outcomes. We analyzed multiple tissue microarrays with well-annotated clinicopathological variables using quantitative immunofluorescence and evaluated single-cell RNA-sequencing on a brain metastasis sample to characterize PDCD4+ immune cell subsets. We demonstrate differences in PDCD4 expression during neoplastic progression, with high tumor and stromal PDCD4 levels associated with improved survival in primary melanomas and in intracranial metastases, but not in extracranial metastatic disease. While the expression of PDCD4 is well-documented on CD8+ T cells and natural killer cells, we show that it is also found on B cells and mast cells. PDCD4 expression in the tumor microenvironment is associated with increased immune cell infiltration. Further studies are needed to define the interaction of PDCD4 and PLEKHA5 and to evaluate the utility of this pathway as a therapeutic target in melanoma brain metastasis.
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28
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Borius PY, Régis J, Carpentier A, Kalamarides M, Valery CA, Latorzeff I. Safety of radiosurgery concurrent with systemic therapy (chemotherapy, targeted therapy, and/or immunotherapy) in brain metastases: a systematic review. Cancer Metastasis Rev 2021; 40:341-354. [PMID: 33392851 DOI: 10.1007/s10555-020-09949-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 12/15/2020] [Indexed: 02/07/2023]
Abstract
Stereotactic radiosurgery (SRS) is a standard option for brain metastases (BM). There is lack of consensus when patients have a systemic treatment, if a washout is necessary. The aim of this review is to analyze the toxicity of SRS when it is concurrent with chemotherapies, immunotherapy, and/or targeted therapies. From Medline and Embase databases, we searched for English literature published up to April 2020 according to the PRISMA guidelines, using for key words the list of the main systemic therapies currently in use And "radiosurgery," "SRS," "GKRS," "Gamma Knife," "toxicity," "ARE," "radiation necrosis," "safety," "brain metastases." Studies reporting safety or toxicity with SRS concurrent with systemic treatment for BM were included. Of 852 abstracts recorded, 77 were included. The main cancers were melanoma, lung, breast, and renal carcinoma. These studies cumulate 6384 patients. The median SRS dose prescription was 20 Gy [12-30] .For some, they compared a concurrent arm with a non-concurrent or a SRS-alone arm. There were no skin toxicities, no clearly increased rate of bleeding, or radiation necrosis with significant clinical impact. SRS combined with systemic therapy appears to be safe, allowing the continuation of treatment when brain SRS is considered.
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Affiliation(s)
- Pierre-Yves Borius
- Neurosurgery Department, Pitié Salpêtrière Sorbonne University Hospital, Paris, France.
| | - Jean Régis
- Aix-Marseille Université, Institut de Neuroscience des Systèmes, Functional Neurosurgery and Radiosurgery Department, Hôpital de la Timone, APHM, Marseille, France
| | - Alexandre Carpentier
- Neurosurgery Department, Pitié Salpêtrière Sorbonne University Hospital, Paris, France
| | - Michel Kalamarides
- Neurosurgery Department, Pitié Salpêtrière Sorbonne University Hospital, Paris, France
| | | | - Igor Latorzeff
- Département de radiothérapie-oncologie, bâtiment Atrium, Clinique Pasteur, 1, rue de la Petite-Vitesse, 31300, Toulouse, France
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29
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Management of Brain Metastases. Lung Cancer 2021. [DOI: 10.1007/978-3-030-74028-3_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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30
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Liu L, Chen W, Zhang R, Wang Y, Liu P, Lian X, Zhang F, Wang Y, Ma W. Radiotherapy in combination with systemic therapies for brain metastases: current status and progress. Cancer Biol Med 2020; 17:910-922. [PMID: 33299643 PMCID: PMC7721093 DOI: 10.20892/j.issn.2095-3941.2020.0109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/09/2020] [Indexed: 12/25/2022] Open
Abstract
Brain metastases (BMs) are the most common cause of intracranial neoplasms in adults with poor prognosis. Most BMs originate from lung cancer, breast cancer, or melanoma. Radiotherapy (RT), including whole brain radiotherapy (WBRT) and stereotactic radiation surgery (SRS), has been widely explored and is considered a mainstay anticancer treatment for BMs. Over the past decade, the advent of novel systemic therapies has revolutionized the treatment of BMs. In this context, there is a strong rationale for using a combination of treatments based on RT, with the aim of achieving both local disease control and extracranial disease control. This review focuses on describing the latest progress in RT as well as the synergistic effects of the optimal combinations of RT and systemic treatment modalities for BMs, to provide perspectives on current treatments.
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Affiliation(s)
- Lei Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wanqi Chen
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ruopeng Zhang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yuekun Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Penghao Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xin Lian
- Department of Radiotherapy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Fuquan Zhang
- Department of Radiotherapy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yu Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wenbin Ma
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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31
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Keilholz U, Ascierto PA, Dummer R, Robert C, Lorigan P, van Akkooi A, Arance A, Blank CU, Chiarion Sileni V, Donia M, Faries MB, Gaudy-Marqueste C, Gogas H, Grob JJ, Guckenberger M, Haanen J, Hayes AJ, Hoeller C, Lebbé C, Lugowska I, Mandalà M, Márquez-Rodas I, Nathan P, Neyns B, Olofsson Bagge R, Puig S, Rutkowski P, Schilling B, Sondak VK, Tawbi H, Testori A, Michielin O. ESMO consensus conference recommendations on the management of metastatic melanoma: under the auspices of the ESMO Guidelines Committee. Ann Oncol 2020; 31:1435-1448. [PMID: 32763453 DOI: 10.1016/j.annonc.2020.07.004] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/08/2020] [Accepted: 07/08/2020] [Indexed: 12/19/2022] Open
Abstract
The European Society for Medical Oncology (ESMO) held a consensus conference on melanoma on 5-7 September 2019 in Amsterdam, The Netherlands. The conference included a multidisciplinary panel of 32 leading experts in the management of melanoma. The aim of the conference was to develop recommendations on topics that are not covered in detail in the current ESMO Clinical Practice Guideline and where available evidence is either limited or conflicting. The main topics identified for discussion were (i) the management of locoregional disease; (ii) targeted versus immunotherapies in the adjuvant setting; (iii) targeted versus immunotherapies for the first-line treatment of metastatic melanoma; (iv) when to stop immunotherapy or targeted therapy in the metastatic setting; and (v) systemic versus local treatment for brain metastases. The expert panel was divided into five working groups to each address questions relating to one of the five topics outlined above. Relevant scientific literature was reviewed in advance. Recommendations were developed by the working groups and then presented to the entire panel for further discussion and amendment before voting. This manuscript presents the results relating to the management of metastatic melanoma, including findings from the expert panel discussions, consensus recommendations and a summary of evidence supporting each recommendation. All participants approved the final manuscript.
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Affiliation(s)
- U Keilholz
- Charité Comprehensive Cancer Center, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - P A Ascierto
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - R Dummer
- Department of Dermatology, University Hospital Zürich, Zürich, Switzerland
| | - C Robert
- Department of Dermatology, Gustave Roussy, Villejuif, France; Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - P Lorigan
- Division of Cancer Sciences, The University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | - A van Akkooi
- Department of Surgical Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - A Arance
- Department of Medical Oncology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - C U Blank
- Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - V Chiarion Sileni
- Department of Experimental and Clinical Oncology, Istituto Oncologico Veneto, IOV-IRCCS, Padova, Italy
| | - M Donia
- National Center for Cancer Immune Therapy, Department of Oncology, Herlev and Gentofte Hospital, Herlev, Denmark; University of Copenhagen, Copenhagen, Denmark
| | - M B Faries
- Department of Surgery, The Angeles Clinic, Cedars Sinai Medical Center, Los Angeles, USA
| | - C Gaudy-Marqueste
- Department of Dermatology and Skin Cancer, Aix Marseille University, Hôpital De La Timone, Marseille, France
| | - H Gogas
- First Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - J J Grob
- Department of Dermatology and Skin Cancer, Aix Marseille University, Hôpital De La Timone, Marseille, France
| | - M Guckenberger
- Department of Radio-Oncology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - J Haanen
- Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - A J Hayes
- Department of Academic Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | - C Hoeller
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - C Lebbé
- AP-HP Dermatology, Université de Paris, Paris, France; INSERM U976, Hôpital Saint Louis, Paris, France
| | - I Lugowska
- Early Phase Clinical Trials Unit, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - M Mandalà
- Department of Oncology and Haematology, Papa Giovanni XXIII Cancer Center Hospital, Bergamo, Italy
| | - I Márquez-Rodas
- Department of Medical Oncology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - P Nathan
- Department of Medical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - B Neyns
- Department of Medical Oncology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - R Olofsson Bagge
- Sahlgrenska Cancer Center, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden; Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Sweden
| | - S Puig
- Dermatology Service, Hospital Clínic of Barcelona and University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; CIBER, Instituto de Salud Carlos III, Barcelona, Spain
| | - P Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - B Schilling
- Department of Dermatology, University Hospital Würzburg, Würzburg, Germany
| | - V K Sondak
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, USA
| | - H Tawbi
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - A Testori
- Department of Dermatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - O Michielin
- Department of Oncology, University Hospital Lausanne, Lausanne, Switzerland
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32
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Hu X, Yu H, Zheng Y, Zhang Q, Lin M, Wang J, Qiu Y. Immune Checkpoint Inhibitors and Survival Outcomes in Brain Metastasis: A Time Series-Based Meta-Analysis. Front Oncol 2020; 10:564382. [PMID: 33194639 PMCID: PMC7606910 DOI: 10.3389/fonc.2020.564382] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/16/2020] [Indexed: 01/11/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have shown potential to improve the prognosis of patients with brain metastasis (BM) caused by advanced cancers. However, controversies still exist in regard to its survival benefits. In the present work, a time series-based meta-analysis based on the phase I/II/III trials and observational studies were performed to investigate the differences in mortality of ICI-treated BM patients. A number of public library databases, including MEDLINE, EMBASE, OVID, and COCHRANE, were systemically searched by March 2019. The quality of included studies was evaluated by the Newcastle-Ottawa Scale (NOS) scoring. Outcome measures here established were mortality and progression-free survival (PFS) at different follow-up endpoints. Survival rates and curve data were pooled for further analysis. To detect the data heterogeneity, subgroup analyses were conducted according to tumor and ICI types. Eighteen studies, 6 trials, and 12 controlled cohorts were assessed, involving a total of 1330 ICI-treated BM patients. The 6-month survival rate and PFS were 0.67 (95%CI: 0.59–0.74) and 0.36 (95%CI: 0.24–0.49), respectively. According to the tumor type (melanoma, NSCLC, and RCC), subgroup analyses indicated that melanoma presented the lowest survival rates among the three groups here selected. In regard to the type of ICIs, the anti-CTLA-4 combined with the anti-PD-1/PD-L1 showed the best survival outcome among these groups. The 12-month survival rate and PFS showed a consistent pattern of findings. In the long-term, the 24-month survival rate and PFS were 0.20 (95%CI: 0.12–0.31) and 0.18 (0.05–0.46) in BM patients. Hence, ICI therapy may be associated with an improved prognosis of BM patients. Nevertheless, current research presented a limited study design. Multicenter randomized trials may later assist in validating ICI-based therapies for a better outcome of BM patients.
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Affiliation(s)
- Xingjiang Hu
- Research Center of Clinical Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hui Yu
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yunliang Zheng
- Research Center of Clinical Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Qiao Zhang
- Research Center of Clinical Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Meihua Lin
- Research Center of Clinical Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jialei Wang
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yunqing Qiu
- Research Center of Clinical Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Voronova V, Lebedeva S, Sekacheva M, Helmlinger G, Peskov K. Quantification of Scheduling Impact on Safety and Efficacy Outcomes of Brain Metastasis Radio- and Immuno-Therapies: A Systematic Review and Meta-Analysis. Front Oncol 2020; 10:1609. [PMID: 32984027 PMCID: PMC7492564 DOI: 10.3389/fonc.2020.01609] [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: 02/18/2020] [Accepted: 07/24/2020] [Indexed: 12/13/2022] Open
Abstract
Objectives: The goal of this quantitative research was to evaluate the impact of various factors (e.g., scheduling or radiotherapy (RT) type) on outcomes for RT vs. RT in combination with immune checkpoint inhibitors (ICI), in the treatment of brain metastases, via a meta-analysis. Methods: Clinical studies with at least one ICI+RT treatment combination arm with brain metastasis patients were identified via a systematic literature search. Data on 1-year overall survival (OS), 1-year local control (LC) and radionecrosis rate (RNR) were extracted; for combination studies which included an RT monotherapy arm, odds ratios (OR) for the aforementioned endpoints were additionally calculated and analyzed. Mixed-effects meta-analysis models were tested to evaluate impact on outcome, for different factors such as combination treatment scheduling and the type of ICI or RT used. Results: 40 studies representing a total of 4,359 patients were identified. Higher 1-year OS was observed in ICI and RT combination vs. RT alone, with corresponding incidence rates of 59% [95% CI: 54-63%] vs. 32% [95% CI: 25-39%] (P < 0.001). Concurrent ICI and RT treatment was associated with significantly higher 1-year OS vs. sequential combinations: 68% [95% CI: 60-75%] vs. 54% [95% CI: 47-61%]. No statistically significant differences were observed in 1-year LC and RNR, when comparing combinations vs. RT monotherapies, with 1-year LC rates of 68% [95% CI: 40-90%] vs. 72% [95% CI: 63-80%] (P = 0.73) and RNR rates of 6% [95% CI: 2-13%] vs. 9% [95% CI: 5-14%] (P = 0.37). Conclusions: A comprehensive, study-level meta-analysis of brain metastasis disease treatments suggest that combinations of RT and ICI result in higher OS, yet comparable neurotoxicity profiles vs. RT alone, with a superiority of concurrent vs. sequential combination regimens. A similar meta-analysis using patient-level data from past trials, as well as future prospective randomized trials would help confirming these findings.
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Affiliation(s)
| | - Svetlana Lebedeva
- Institute of Pharmacy, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Marina Sekacheva
- Computational Oncology Group, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Gabriel Helmlinger
- Clinical Pharmacology and Toxicology, Obsidian Therapeutics, Cambridge, MA, United States
| | - Kirill Peskov
- M&S Decisions LLC, Moscow, Russia
- Computational Oncology Group, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
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34
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Jiang C, Wallington DG, Anker CJ, Lawson DH, Yushak ML, Kudchadkar RR, Tarhini A, Khan MK. Changing Therapeutic Landscape for Melanoma With Multiple Brain Metastases. Neurosurgery 2020; 87:498-515. [PMID: 32315430 DOI: 10.1093/neuros/nyaa076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 01/30/2020] [Indexed: 12/25/2022] Open
Abstract
Over 90 000 people are expected to be diagnosed with melanoma in the United States this year. The development of brain metastases is particularly difficult to manage. Over the past few years, melanoma patients with multiple unresectable brain metastases for which stereotactic surgery might also not be a viable option have fortunately experienced a dramatic expansion in available management options given improvements made to targeted agents, immunotherapy, and radiotherapy. Whole-brain radiation therapy (WBRT) is a long-standing radiation technique that has become increasingly sophisticated. In this review, we summarize retrospective and prospective studies on individual advances in targeted agents, immunotherapy, and WBRT, highlighting important variables such as overall survival, intracranial progression-free survival, control and response rates, and toxicities. We also discuss the recent integration of these therapies into a multimodality approach, which has shown promise in the clinical setting although toxicities have not been insignificant. Finally, we describe ongoing prospective trials relevant to melanoma with brain metastases, and we conclude with our own thoughts on the optimal approach for these patients.
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Affiliation(s)
- Cecilia Jiang
- Emory University School of Medicine, Atlanta, Georgia
| | - David G Wallington
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan
| | - Christopher J Anker
- Division of Radiation Oncology, University of Vermont Larner College of Medicine, Burlington, Vermont
| | - David H Lawson
- Winship Cancer Institute, Atlanta, Georgia.,Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia
| | - Melinda L Yushak
- Winship Cancer Institute, Atlanta, Georgia.,Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia
| | - Ragini R Kudchadkar
- Winship Cancer Institute, Atlanta, Georgia.,Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia
| | - Ahmad Tarhini
- H. Lee Moffitt Cancer Center, University of South Florida, Tampa, Florida
| | - Mohammad K Khan
- Winship Cancer Institute, Atlanta, Georgia.,H. Lee Moffitt Cancer Center, University of South Florida, Tampa, Florida.,Department of Radiation Oncology, Emory University, Atlanta, Georgia
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35
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Sha CM, Lehrer EJ, Hwang C, Trifiletti DM, Mackley HB, Drabick JJ, Zaorsky NG. Toxicity in combination immune checkpoint inhibitor and radiation therapy: A systematic review and meta-analysis. Radiother Oncol 2020; 151:141-148. [PMID: 32717359 DOI: 10.1016/j.radonc.2020.07.035] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/16/2020] [Accepted: 07/20/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Immune checkpoint inhibitor with radiation therapy (ICI + RT) is under investigation for improved patient outcome, so we performed a systematic review/meta-analysis of toxicities for ICI + RT compared to immune checkpoint inhibitor (ICI) therapy alone. MATERIALS AND METHODS A PRISMA-compliant systematic review of studies in MEDLINE (PubMed) and in the National Comprehensive Cancer Network guidelines was conducted, with primary outcome grade 3 + toxicity. Criteria for ICI alone were: phase III/IV trials that compared immunotherapy to placebo, chemotherapy, or alternative immunotherapy; and for ICI + RT: prospective/retrospective studies with an arm treated with ICI + RT. Meta-analysis was performed by random effects models using the DerSimonian and Laird method. The I2 statistic and Cochran's Q test were used to assess heterogeneity, while funnel plots and Egger's test assessed publication bias. RESULTS This meta-analysis included 51 studies (n = 15,398), with 35 ICI alone (n = 13,956) and 16 ICI + RT studies (n = 1,442). Our models showed comparable grade 3-4 toxicities in ICI + RT (16.3%; 95% CI, 11.1-22.3%) and ICI alone (22.3%; 95% CI, 18.1-26.9%). Stratification by timing of radiation and irradiated site showed no significant differences, but anti-CTLA-4 therapy and melanoma showed increased toxicity. The grade 5 toxicities were 1.1% and 1.9% for ICI alone and ICI + RT respectively. There was significant heterogeneity, but not publication bias. CONCLUSIONS The random effects model showed comparable grade 3-4 toxicity in using ICI + RT compared to ICI alone in CNS melanoma metastases, NSCLC, and prostate cancer. ICI + RT is safe for future clinical trials in these cancers.
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Affiliation(s)
- Congzhou M Sha
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Clara Hwang
- Department of Internal Medicine, Division of Hematology/Oncology, Henry Ford Health System, Detroit, MI, USA
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Jacksonville, Jacksonville, FL, USA
| | - Heath B Mackley
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Joseph J Drabick
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA; Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.
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Wang H, Li X, Peng R, Wang Y, Wang J. Stereotactic ablative radiotherapy for colorectal cancer liver metastasis. Semin Cancer Biol 2020; 71:21-32. [PMID: 32629077 DOI: 10.1016/j.semcancer.2020.06.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/23/2020] [Accepted: 06/25/2020] [Indexed: 12/24/2022]
Abstract
Survival improvement of colorectal liver metastasis (CRLM) benefits from systemic therapy and metastasis-directed local therapy. Stereotactic ablative body radiotherapy (SABR), as a new efficient metastasis-directed local therapy with a systematic impact, plays a vital role in CRLM multidisciplinary treatment. SABR leads to a dramatic immunological change in the tumor microenvironment (TME) via differential activation of cytoprotective and cytotoxic pathways in malignant and non-malignant cells, in addition to direct tumor cell death. The synergy of SABR and immunotherapy might increase the abscopal response rate of out-field lesions by targeting different steps of the immune-mediated response, in addition to direct intratumoral cell death. The clinical treatment and efficacy of SABR, its influence on TME, and potential molecular underpinnings of which are the topic of this review.
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Affiliation(s)
- Hao Wang
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
| | - Xuemin Li
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
| | - Ran Peng
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
| | - Yuxia Wang
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
| | - Junjie Wang
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China.
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37
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Wang J, Li Z, Wang Z, Yu Y, Li D, Li B, Ding J. Nanomaterials for Combinational Radio–Immuno Oncotherapy. ADVANCED FUNCTIONAL MATERIALS 2020; 30:1910676. [DOI: 10.1002/adfm.201910676] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 03/09/2020] [Indexed: 08/29/2023]
Affiliation(s)
- Juan Wang
- Key Laboratory of Polymer EcomaterialsChangchun Institute of Applied ChemistryChinese Academy of Sciences 5625 Renmin Street Changchun 130022 P. R. China
- Department of Radiation OncologyCancer Hospital of Shandong First Medical University 440 Jiyan Road Jinan 250117 P. R. China
| | - Zhongmin Li
- Key Laboratory of Polymer EcomaterialsChangchun Institute of Applied ChemistryChinese Academy of Sciences 5625 Renmin Street Changchun 130022 P. R. China
- Department of Gastrointestinal, Colorectal, and Anal SurgeryChina–Japan Union Hospital of Jilin University 126 Xiantai Street Changchun 130012 P. R. China
| | - Zhongtang Wang
- Department of Radiation OncologyCancer Hospital of Shandong First Medical University 440 Jiyan Road Jinan 250117 P. R. China
| | - Yonghua Yu
- Department of Radiation OncologyCancer Hospital of Shandong First Medical University 440 Jiyan Road Jinan 250117 P. R. China
| | - Di Li
- Key Laboratory of Polymer EcomaterialsChangchun Institute of Applied ChemistryChinese Academy of Sciences 5625 Renmin Street Changchun 130022 P. R. China
| | - Baosheng Li
- Department of Radiation OncologyCancer Hospital of Shandong First Medical University 440 Jiyan Road Jinan 250117 P. R. China
| | - Jianxun Ding
- Key Laboratory of Polymer EcomaterialsChangchun Institute of Applied ChemistryChinese Academy of Sciences 5625 Renmin Street Changchun 130022 P. R. China
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38
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Glitza IC, Smalley KSM, Brastianos PK, Davies MA, McCutcheon I, Liu JKC, Ahmed KA, Arrington JA, Evernden BR, Smalley I, Eroglu Z, Khushalani N, Margolin K, Kluger H, Atkins MB, Tawbi H, Boire A, Forsyth P. Leptomeningeal disease in melanoma patients: An update to treatment, challenges, and future directions. Pigment Cell Melanoma Res 2020; 33:527-541. [PMID: 31916400 PMCID: PMC10126834 DOI: 10.1111/pcmr.12861] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/26/2019] [Accepted: 01/03/2020] [Indexed: 01/31/2023]
Abstract
In February 2018, the Melanoma Research Foundation and the Moffitt Cancer Center hosted the Second Summit on Melanoma Central Nervous System Metastases in Tampa, Florida. The meeting included investigators from multiple academic centers and disciplines. A consensus summary of the progress and challenges in melanoma parenchymal brain metastases was published (Eroglu et al., Pigment Cell & Melanoma Research, 2019, 32, 458). Here, we will describe the current state of basic, translational, clinical research, and therapeutic management, for melanoma patients with leptomeningeal disease. We also outline key challenges and barriers to be overcome to make progress in this deadly disease.
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Affiliation(s)
- Isabella C. Glitza
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Keiran S. M. Smalley
- Melanoma Research Center of Excellence, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Michael A. Davies
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Ian McCutcheon
- Department of Neurosurgery, UT MD Anderson Cancer Center, Houston, TX, USA
| | - James K. C. Liu
- Department of Neuro-Oncology & Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kamran A. Ahmed
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - John A. Arrington
- Head of Neuroradiology Section, Department of Radiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Brittany R. Evernden
- Department of Neuro-Oncology & Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Inna Smalley
- Department of Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Zeynep Eroglu
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Nikhil Khushalani
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kim Margolin
- Department of Medical Oncology and Therapeutics Research, City of Hope National Medical Center, Duarte, CA, USA
| | - Harriet Kluger
- Department of Medical Oncology, Yale Cancer Center, New Haven, CT, USA
| | - Michael B. Atkins
- Department of Medical Oncology, Georgetown University Medical Center, Washington, DC, USA
| | - Hussein Tawbi
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Adrienne Boire
- Department of Neuro-Oncology, Memorial Sloan Kettering, New York, NY, USA
| | - Peter Forsyth
- Department of Neuro-Oncology & Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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McClelland S, Lautenschlaeger T, Zang Y, Hanna NH, Shiue K, Kamer AP, Agrawal N, Ellsworth SG, Rhome RM, Watson GA. Radiosurgery dose reduction for brain metastases on immunotherapy (RADREMI): A prospective phase I study protocol. Rep Pract Oncol Radiother 2020; 25:500-506. [PMID: 32477016 DOI: 10.1016/j.rpor.2020.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/10/2020] [Accepted: 04/10/2020] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Up to 20% of patients with brain metastases treated with immune checkpoint inhibitor (ICI) therapy and concomitant stereotactic radiosurgery (SRS) suffer from symptomatic radiation necrosis. The goal of this study is to evaluate Radiosurgery Dose Reduction for Brain Metastases on Immunotherapy (RADREMI) on six-month symptomatic radiation necrosis rates. METHODS This study is a prospective single arm Phase I pilot study which will recruit patients with brain metastases receiving ICI delivered within 30 days before SRS. All patients will be treated with RADREMI dosing, which involves SRS doses of 18 Gy for 0-2 cm lesions, 14 Gy for 2.1-3 cm lesions, and 12 Gy for 3.1-4 cm lesions. All patients will be monitored for six-month symptomatic radiation necrosis (defined as a six-month rate of clinical symptomatology requiring steroid administration and/or operative intervention concomitant with imaging findings consistent with radiation necrosis) and six-month local control. We expect that RADREMI dosing will significantly reduce the symptomatic radiation necrosis rate of concomitant SRS + ICI without significantly sacrificing the local control obtained by the present RTOG 90-05 SRS dosing schema. Local control will be defined according to the Response Assessment in Neuro-Oncology (RANO) criteria. DISCUSSION This study is the first prospective trial to investigate the safety of dose-reduced SRS in treatment of brain metastases with concomitant ICI. The findings should provide fertile soil for future multi-institutional collaborative efficacy trials of RADREMI dosing for this patient population. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT04047602 (registration date: July 25, 2019).
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Affiliation(s)
- Shearwood McClelland
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN 46202, US
| | - Tim Lautenschlaeger
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN 46202, US
| | - Yong Zang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, US
| | - Nasser H Hanna
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, US
| | - Kevin Shiue
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN 46202, US
| | - Aaron P Kamer
- Department of Radiology, Indiana University School of Medicine, Indianapolis, IN, US
| | - Namita Agrawal
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN 46202, US
| | - Susannah G Ellsworth
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN 46202, US
| | - Ryan M Rhome
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN 46202, US
| | - Gordon A Watson
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN 46202, US
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Racial and Socioeconomic Disparities in the Delivery of Immunotherapy for Metastatic Melanoma in the United States. J Immunother 2020; 42:228-235. [PMID: 30985445 DOI: 10.1097/cji.0000000000000264] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Immunotherapy for metastatic melanoma has rapidly expanded, but racial and/or socioeconomic factors often impact the type of therapies delivered for cancer care. This study addressed a crucial public health priority by evaluating disparities in administration of immunotherapy for metastatic melanoma. The National Cancer Database was queried for newly diagnosed metastatic melanoma. Patients were dichotomized based on receipt of immunotherapy based on National Cancer Database coding. Multivariable logistic regression ascertained factors associated with immunotherapy delivery. Subgroup analysis evaluated the interaction between race, insurance status, and income. Secondarily, Cox multivariate and propensity-matched Kaplan-Meier analyses assessed overall survival based on immunotherapy receipt. Of 15,941 patients meeting the selection criteria, 2448 (15.4%) received immunotherapy, and 13,493 (84.6%) did not. Temporal trends showed that utilization of immunotherapy was 8%-12% of patients between 2004 and 2010, with utilization increasing to 29.7% of patients in 2014. Immunotherapy was more likely administered to younger and healthier patients, at academic centers, and in the absence of chemotherapy and brain metastases (P<0.05 for all). African Americans, along with patients with Medicaid and lower incomes were less likely to receive immunotherapy (P<0.05 for all). As expected, immunotherapy was associated with improved overall survival (median 16.3 vs. 8.3 mo, P<0.001). Although immunotherapy for metastatic melanoma is markedly escalating, not all populations experience this rise equally. Because immunotherapy utilization is expected to amplify even further in the future, these public health and economic issues are essential to identify and address appropriately, and have implications on public health policy, pharmaceutical and insurance companies, and value-based oncology. Methods to address these inequalities are also discussed.
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41
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Venur VA, Chukwueke UN, Lee EQ. Advances in Management of Brain and Leptomeningeal Metastases. Curr Neurol Neurosci Rep 2020; 20:26. [PMID: 32506161 DOI: 10.1007/s11910-020-01039-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW The management of brain and leptomeningeal metastases has changed significantly over the past decade. RECENT FINDINGS Historically, radiation therapy had been the mainstay of treatment. Several strategies to limit toxicities with radiation have been developed in the recent years. Increasingly systemic therapy options are being considered an important therapeutic option for CNS metastases. Numerous novel small molecule inhibitors and immunotherapy agents have intracranial activity to varying degrees, in addition to good extracranial disease control. Overall, the prognosis of select patients with CNS metastases has improved over the past several years with advent of new therapeutic strategies. Systemic therapy options with CNS benefit should be considered in select patients with small and asymptomatic CNS metastases. Further areas of research focus on molecular alterations predisposing to CNS metastases, identification of small molecule inhibitors with CNS activity, and the combination of radiation therapy and immunotherapy.
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Affiliation(s)
- Vyshak Alva Venur
- Seattle Cancer Care Alliance, Division of Oncology, Department of Medicine, University of Washington Medicine, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Ugonma N Chukwueke
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.,Brigham and Women's Hospital, Boston, MA, 02215, USA.,Harvard Medical School, Boston, MA, 02215, USA
| | - Eudocia Q Lee
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA. .,Brigham and Women's Hospital, Boston, MA, 02215, USA. .,Harvard Medical School, Boston, MA, 02215, USA.
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Schaule J, Kroeze SGC, Blanck O, Stera S, Kahl KH, Roeder F, Combs SE, Kaul D, Claes A, Schymalla MM, Adebahr S, Eckert F, Lohaus F, Abbasi-Senger N, Henke G, Szuecs M, Geier M, Sundahl N, Buergy D, Dummer R, Guckenberger M. Predicting survival in melanoma patients treated with concurrent targeted- or immunotherapy and stereotactic radiotherapy : Melanoma brain metastases prognostic score. Radiat Oncol 2020; 15:135. [PMID: 32487100 PMCID: PMC7268472 DOI: 10.1186/s13014-020-01558-8] [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: 04/12/2020] [Accepted: 05/01/2020] [Indexed: 12/14/2022] Open
Abstract
Background Melanoma patients frequently develop brain metastases. The most widely used score to predict survival is the molGPA based on a mixed treatment of stereotactic radiotherapy (SRT) and whole brain radiotherapy (WBRT). In addition, systemic therapy was not considered. We therefore aimed to evaluate the performance of the molGPA score in patients homogeneously treated with SRT and concurrent targeted therapy or immunotherapy (TT/IT). Methods This retrospective analysis is based on an international multicenter database (TOaSTT) of melanoma patients treated with TT/IT and concurrent (≤30 days) SRT for brain metastases between May 2011 and May 2018. Overall survival (OS) was studied using Kaplan-Meier survival curves and log-rank testing. Uni- and multivariate analysis was performed to analyze prognostic factors for OS. Results One hundred ten patients were analyzed. 61, 31 and 8% were treated with IT, TT and with a simultaneous combination, respectively. A median of two brain metastases were treated per patient. After a median follow-up of 8 months, median OS was 8.4 months (0–40 months). The molGPA score was not associated with OS. Instead, cumulative brain metastases volume, timing of metastases (syn- vs. metachronous) and systemic therapy with concurrent IT vs. TT influenced OS significantly. Based on these parameters, the VTS score (volume-timing-systemic therapy) was established that stratified patients into three groups with a median OS of 5.1, 18.9 and 34.5 months, respectively (p = 0.001 and 0.03). Conclusion The molGPA score was not useful for this cohort of melanoma patients undergoing local therapy for brain metastases taking into account systemic TT/IT. For these patients, we propose a prognostic VTS score, which needs to be validated prospectively.
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Affiliation(s)
- Jana Schaule
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland. .,Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany.
| | - Stephanie G C Kroeze
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Oliver Blanck
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany.,University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Susanne Stera
- Department of Radiation Oncology, University Hospital Frankfurt, Frankfurt, Germany
| | - Klaus H Kahl
- Department of Radiation Oncology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Falk Roeder
- Department of Radiation Oncology, University Hospital Munich, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University Munich (TUM), Munich, Germany.,Institute of Radiation Medicine (IRM), Helmholtz Zentrum München (HMGU), Oberschleißheim, Germany.,German Cancer Consortium, Partner Site Munich, Munich, Germany
| | - David Kaul
- Department of Radiation Oncology, Charité-University Hospital Berlin, Berlin, Germany
| | - An Claes
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Markus M Schymalla
- Department of Radiation Oncology, Philipps-University Marburg, Marburg, Germany
| | - Sonja Adebahr
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Breisgau, Germany.,German Cancer Consortium, Partner Site Freiburg, Freiburg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Franziska Eckert
- Department of Radiation Oncology, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Fabian Lohaus
- German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,German Cancer Consortium, Partner Site Dresden, Dresden, Germany
| | | | - Guido Henke
- Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Marcella Szuecs
- Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany
| | - Michael Geier
- Department of Radiation Oncology, Ordensklinikum Linz, Linz, Austria
| | - Nora Sundahl
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Daniel Buergy
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Reinhard Dummer
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
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Current Advances in the Treatment of BRAF-Mutant Melanoma. Cancers (Basel) 2020; 12:cancers12020482. [PMID: 32092958 PMCID: PMC7072236 DOI: 10.3390/cancers12020482] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/02/2020] [Accepted: 02/14/2020] [Indexed: 12/12/2022] Open
Abstract
Melanoma is the most lethal form of skin cancer. Melanoma is usually curable with surgery if detected early, however, treatment options for patients with metastatic melanoma are limited and the five-year survival rate for metastatic melanoma had been 15-20% before the advent of immunotherapy. Treatment with immune checkpoint inhibitors has increased long-term survival outcomes in patients with advanced melanoma to as high as 50% although individual response can vary greatly. A mutation within the MAPK pathway leads to uncontrollable growth and ultimately develops into cancer. The most common driver mutation that leads to this characteristic overactivation in the MAPK pathway is the B-RAF mutation. Current combinations of BRAF and MEK inhibitors that have demonstrated improved patient outcomes include dabrafenib with trametinib, vemurafenib with cobimetinib or encorafenib with binimetinib. Treatment with BRAF and MEK inhibitors has met challenges as patient responses began to drop due to the development of resistance to these inhibitors which paved the way for development of immunotherapies and other small molecule inhibitor approaches to address this. Resistance to these inhibitors continues to push the need to expand our understanding of novel mechanisms of resistance associated with treatment therapies. This review focuses on the current landscape of how resistance occurs with the chronic use of BRAF and MEK inhibitors in BRAF-mutant melanoma and progress made in the fields of immunotherapies and other small molecules when used alone or in combination with BRAF and MEK inhibitors to delay or circumvent the onset of resistance for patients with stage III/IV BRAF mutant melanoma.
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44
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Lehrer EJ, McGee HM, Sheehan JP, Trifiletti DM. Integration of immuno-oncology with stereotactic radiosurgery in the management of brain metastases. J Neurooncol 2020; 151:75-84. [PMID: 32052355 DOI: 10.1007/s11060-020-03427-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 02/08/2020] [Indexed: 12/25/2022]
Abstract
AIM Brain metastases traditionally carried a poor prognosis with treatment being a combination of surgery, whole-brain radiation therapy, and glucocorticoids; however, this treatment paradigm carried a significant amount of morbidity. In recent years, stereotactic radiosurgery (SRS), which involves the delivery of a highly conformal dose of radiation over a single session, has been shown to be an effective alternative to WBRT with excellent rates of local control and improved quality of life; however, a survival benefit has not been demonstrated. Recent developments have challenged the traditional view of the central nervous system being "immunologically privileged" which has led to a greater focus on treating these patients with systemic therapies. Immune checkpoint inhibitors (ICI) have been shown to improve survival in multiple malignancies. As a result, there has been increased utilization in combining these therapies in this setting. METHODS We conducted a literature search of medical databases (e.g. PubMed) for articles involving the use of immune checkpoint inhibitors and stereotactic radiosurgery in managing brain metastases. RESULTS Published evidence utilizing SRS and ICI is largely limited to single institution and retrospective in nature with the most common histology being melanoma. CONCLUSION Combination therapy with SRS and ICI appears to improve survival in patients with brain metastases. The available data are largely retrospective; therefore, ongoing and planned prospective studies are needed to further validate these findings.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine At Mount Sinai, 1184 5th Avenue, 1st floor, New York, NY, USA.
| | - Heather M McGee
- Department of Radiation Oncology, Icahn School of Medicine At Mount Sinai, 1184 5th Avenue, 1st floor, New York, NY, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Daniel M Trifiletti
- Departments of Radiation Oncology and Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
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45
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Sodji QH, Gutkin PM, Swetter SM, Reddy SA, Hiniker SM, Knox SJ. Durability of response in metastatic melanoma patients after combined treatment with radiation therapy and ipilimumab. Melanoma Manag 2020; 7:MMT36. [PMID: 32399174 PMCID: PMC7212514 DOI: 10.2217/mmt-2019-0020] [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: 11/29/2019] [Accepted: 01/31/2020] [Indexed: 12/12/2022] Open
Abstract
AIM We previously reported a prospective trial evaluating the safety and efficacy of combining ipilimumab and radiation therapy in patients with metastatic melanoma. Herein, we provide a long-term update on patients with complete response (CR) or partial response (PR). PATIENTS & METHODS We continued to follow these patients with serial imaging including computed tomography, PET or MRI. RESULTS Two of the three patients with CR are still alive and without evidence of melanoma but with chronic treatment-induced hypophysitis. The third patient died of hepatocellular carcinoma, but with no evidence of melanoma. Among the three patients with PR, two achieved CR after pembrolizumab monotherapy. CONCLUSION This long-term follow up reveals the striking durability of the CRs, which appears to correlate with a grade 2-3 hypophysitis.
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Affiliation(s)
- Quaovi H Sodji
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Paulina M Gutkin
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Susan M Swetter
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA 94305, USA
- Dermatology Service, VA Palo Alto Health Care System, Palo Alto, CA 94304, USA
| | - Sunil A Reddy
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Susan M Hiniker
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Susan J Knox
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
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46
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Su Z, Zhou L, Xue J, Lu Y. Integration of stereotactic radiosurgery or whole brain radiation therapy with immunotherapy for treatment of brain metastases. Chin J Cancer Res 2020; 32:448-466. [PMID: 32963458 PMCID: PMC7491544 DOI: 10.21147/j.issn.1000-9604.2020.04.03] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The prognosis of brain metastases (BM) is traditionally poor. BM are mainly treated by local radiotherapy, including stereotactic radiosurgery (SRS) or whole brain radiation therapy (WBRT). Recently, immunotherapy (i.e., immune checkpoint inhibitors, ICI) has demonstrated a survival advantage in multiple malignancies commonly associated with BM. Individually, radiotherapy and ICI both treat BM efficiently; hence, their combination seems logical. In this review, we summarize the existing preclinical and clinical evidence that supports the applicability of radiotherapy as a sensitizer of ICI for BM. Further, we discuss the optimal timing at which radiotherapy and ICI should be administered and review the safety of the combination therapy. Data from a few clinical studies suggest that combining SRS or WBRT with ICI simultaneously rather than consecutively potentially enhances brain abscopal-like responses and survival. However, there is a lack of conclusion about the definition of "simultaneous"; the cumulative toxic effect of the combined therapies also requires further study. Thus, ongoing and planned prospective trials are needed to further explore and validate the effect, safety, and optimal timing of the combination of immunotherapy with radiotherapy for patients with BM.
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Affiliation(s)
- Zhou Su
- Department of Thoracic Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu 610041, China.,Department of Oncology, Sichuan Mianyang 404 Hospital, Mianyang 621000, China
| | - Lin Zhou
- Department of Thoracic Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jianxin Xue
- Department of Thoracic Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu 610041, China
| | - You Lu
- Department of Thoracic Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu 610041, China
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47
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Gorbet MJ, Ranjan A. Cancer immunotherapy with immunoadjuvants, nanoparticles, and checkpoint inhibitors: Recent progress and challenges in treatment and tracking response to immunotherapy. Pharmacol Ther 2019; 207:107456. [PMID: 31863820 DOI: 10.1016/j.pharmthera.2019.107456] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2019] [Indexed: 02/06/2023]
Abstract
Chemotherapy, surgery, and radiation are accepted as the preferred treatment modalities against cancer, but in recent years the use of immunotherapeutic approaches has gained prominence as the fourth treatment modality in cancer patients. In this approach, a patient's innate and adaptive immune systems are activated to achieve clearance of occult cancerous cells. In this review, we discuss the preclinical and clinical immunotherapeutic (e.g., immunoadjuvants (in-situ vaccines, oncolytic viruses, CXC antagonists, device activated agents), organic and inorganic nanoparticles, and checkpoint blockade) that are under investigation for cancer therapy and diagnostics. Additionally, the innovations in imaging of immune cells for tracking therapeutic responses and limitations (e.g., toxicity, inefficient immunomodulation, etc.) are described. Existing data suggest that if immune therapy is optimized, it can be a real and potentially paradigm-shifting cancer treatment frontier.
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Affiliation(s)
- Michael-Joseph Gorbet
- Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, OK 74074, USA
| | - Ashish Ranjan
- Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, OK 74074, USA.
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48
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Tran TT, Jilaveanu LB, Omuro A, Chiang VL, Huttner A, Kluger HM. Complications associated with immunotherapy for brain metastases. Curr Opin Neurol 2019; 32:907-916. [PMID: 31577604 PMCID: PMC7398556 DOI: 10.1097/wco.0000000000000756] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Median survival after the diagnosis of brain metastases has historically been on the order of months. With the recent development of immune checkpoint inhibitors, intracranial activity and durable responses have been observed in brain metastases on multiple phase 2 clinical trials, which have primarily been conducted in patients with melanoma. Immune-related adverse events related to checkpoint inhibitor therapy of brain metastasis can present unique challenges for the clinician and underscore the need for a multidisciplinary team in the care of these patients. The goal of this review is to address the current knowledge, limitations of understanding, and future directions in research regarding immune therapy trials and neurologic toxicities based on retrospective, prospective, and case studies. RECENT FINDINGS Immune therapy has the potential to exacerbate symptomatic edema and increase the risk of radiation necrosis in previously irradiated lesions. Neurologic toxicities will likely increase in prevalence as more patients with brain metastatic disease are eligible for immune therapy. SUMMARY An improved understanding and heightened awareness of the unique neurologic toxicities that impact this patient group is vital for mitigating treatment-related morbidity and mortality.
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Affiliation(s)
- Thuy T. Tran
- Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Yale Brain Tumor Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lucia B. Jilaveanu
- Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Yale Brain Tumor Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Antonio Omuro
- Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Yale Brain Tumor Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Veronica L. Chiang
- Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Yale Brain Tumor Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anita Huttner
- Yale Brain Tumor Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Harriet M. Kluger
- Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Yale Brain Tumor Center, Yale University School of Medicine, New Haven, Connecticut, USA
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49
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Lu J, Li L, Lan Y, Liang Y, Meng H. Immune checkpoint inhibitor-associated pituitary-adrenal dysfunction: A systematic review and meta-analysis. Cancer Med 2019; 8:7503-7515. [PMID: 31679184 PMCID: PMC6912062 DOI: 10.1002/cam4.2661] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/25/2019] [Accepted: 10/14/2019] [Indexed: 12/15/2022] Open
Abstract
With the growing use of immune checkpoint inhibitors (ICIs), case reports of rare yet life-threatening pituitary-adrenal dysfunctions, particularly for hypopituitarism, are increasingly being published. In this analysis, we focus on these events by including the most recent publications and reports from early phase I/II and phase III clinical trials and comparing the incidence and risks across different ICI regimens. PubMed, Embase, and the Cochrane Library were systematically searched from inception to April 2019 for clinical trials that reported on pituitary-adrenal dysfunction. The rates of events, odds ratios (ORs), and 95% confidence intervals (CIs) were obtained using random effects meta-analysis. The analyses included data from 160 trials involving 40 432 participants. The rate was 2.43% (95% CI, 1.73%-3.22%) for all-grade adrenal insufficiency and 3.25% (95% CI, 2.15%-4.51%) for hypophysitis. Compared with the placebo or other therapeutic regimens, ICI agents were associated with a higher incidence of serious-grade adrenal insufficiency (OR 3.19, 95% CI, 1.84 to 5.54) and hypophysitis (OR 4.77, 95% CI, 2.60 to 8.78). Among 71 serious-grade hypopituitarism instances in 12 336 patients, there was a significant association between ICIs and hypopituitarism (OR 3.62, 95% CI, 1.86 to 7.03). Substantial heterogeneity was noted across the studies for the rates of these events, which in part was attributable to the different types of ICIs and varied phases of the clinical trials. Although the rates of these events were low, the risk was increased following ICI-based treatment, particularly for CTLA-4 inhibitors, which were associated with a higher incidence of pituitary-adrenal dysfunction than PD-1/PD-L1 inhibitors.
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Affiliation(s)
- Jingli Lu
- Department of PharmacyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouHenanChina
- Henan Key Laboratory of Precision Clinical PharmacyZhengzhou UniversityZhengzhouHenanChina
| | - Lulu Li
- Department of PharmacyWuhan No.1 HospitalWuhanHubeiChina
| | - Yan Lan
- Department of PharmacyHuangshi Center HospitalHuangshiHubeiChina
| | - Yan Liang
- Department of PharmacyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouHenanChina
- Henan Key Laboratory of Precision Clinical PharmacyZhengzhou UniversityZhengzhouHenanChina
| | - Haiyang Meng
- Department of PharmacyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouHenanChina
- Henan Key Laboratory of Precision Clinical PharmacyZhengzhou UniversityZhengzhouHenanChina
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50
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van Opijnen MP, Dirven L, Coremans IEM, Taphoorn MJB, Kapiteijn EHW. The impact of current treatment modalities on the outcomes of patients with melanoma brain metastases: A systematic review. Int J Cancer 2019; 146:1479-1489. [PMID: 31583684 PMCID: PMC7004107 DOI: 10.1002/ijc.32696] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/30/2019] [Accepted: 09/11/2019] [Indexed: 12/19/2022]
Abstract
Patients with melanoma brain metastases (MBM) still have a very poor prognosis. Several treatment modalities have been investigated in an attempt to improve the management of MBM. This review aimed to evaluate the impact of current treatments for MBM on patient‐ and tumor‐related outcomes, and to provide treatment recommendations for this patient population. A literature search in the databases PubMed, Embase, Web of Science and Cochrane was conducted up to January 8, 2019. Original articles published since 2010 describing patient‐ and tumor‐related outcomes of adult MBM patients treated with clearly defined systemic therapy were included. Information on basic trial demographics, treatment under investigation and outcomes (overall and progression‐free survival, local and distant control and toxicity) were extracted. We identified 96 eligible articles, comprising 95 studies. A large variety of treatment options for MBM were investigated, either used alone or as combined modality therapy. Combined modality therapy was investigated in 71% of the studies and resulted in increased survival and better distant/local control than monotherapy, especially with targeted therapy or immunotherapy. However, neurotoxic side‐effects also occurred more frequently. Timing appeared to be an important determinant, with the best results when radiotherapy was given before or during systemic therapy. Improved tumor control and prolonged survival can be achieved by combining radiotherapy with immunotherapy or targeted therapy. However, more randomized controlled trials or prospective studies are warranted to generate proper evidence that can be used to change the standard of care for patients with MBM.
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Affiliation(s)
- Mark P van Opijnen
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands.,Department of Radiation Oncology, Leiden University Medical Center, The Netherlands
| | - Ida E M Coremans
- Department of Radiation Oncology, Leiden University Medical Center, The Netherlands
| | - Martin J B Taphoorn
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Ellen H W Kapiteijn
- Leiden University Medical Center, Department of Clinical Oncology, Leiden, The Netherlands
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