1
|
Kanakarajan H, De Baene W, Gehring K, Eekers DBP, Hanssens P, Sitskoorn M. Factors associated with the local control of brain metastases: a systematic search and machine learning application. BMC Med Inform Decis Mak 2024; 24:177. [PMID: 38907265 PMCID: PMC11191176 DOI: 10.1186/s12911-024-02579-z] [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: 02/06/2024] [Accepted: 06/17/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Enhancing Local Control (LC) of brain metastases is pivotal for improving overall survival, which makes the prediction of local treatment failure a crucial aspect of treatment planning. Understanding the factors that influence LC of brain metastases is imperative for optimizing treatment strategies and subsequently extending overall survival. Machine learning algorithms may help to identify factors that predict outcomes. METHODS This paper systematically reviews these factors associated with LC to select candidate predictor features for a practical application of predictive modeling. A systematic literature search was conducted to identify studies in which the LC of brain metastases is assessed for adult patients. EMBASE, PubMed, Web-of-Science, and the Cochrane Database were searched up to December 24, 2020. All studies investigating the LC of brain metastases as one of the endpoints were included, regardless of primary tumor type or treatment type. We first grouped studies based on primary tumor types resulting in lung, breast, and melanoma groups. Studies that did not focus on a specific primary cancer type were grouped based on treatment types resulting in surgery, SRT, and whole-brain radiotherapy groups. For each group, significant factors associated with LC were identified and discussed. As a second project, we assessed the practical importance of selected features in predicting LC after Stereotactic Radiotherapy (SRT) with a Random Forest machine learning model. Accuracy and Area Under the Curve (AUC) of the Random Forest model, trained with the list of factors that were found to be associated with LC for the SRT treatment group, were reported. RESULTS The systematic literature search identified 6270 unique records. After screening titles and abstracts, 410 full texts were considered, and ultimately 159 studies were included for review. Most of the studies focused on the LC of the brain metastases for a specific primary tumor type or after a specific treatment type. Higher SRT radiation dose was found to be associated with better LC in lung cancer, breast cancer, and melanoma groups. Also, a higher dose was associated with better LC in the SRT group, while higher tumor volume was associated with worse LC in this group. The Random Forest model predicted the LC of brain metastases with an accuracy of 80% and an AUC of 0.84. CONCLUSION This paper thoroughly examines factors associated with LC in brain metastases and highlights the translational value of our findings for selecting variables to predict LC in a sample of patients who underwent SRT. The prediction model holds great promise for clinicians, offering a valuable tool to predict personalized treatment outcomes and foresee the impact of changes in treatment characteristics such as radiation dose.
Collapse
Affiliation(s)
- Hemalatha Kanakarajan
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands.
| | - Wouter De Baene
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
| | - Karin Gehring
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Daniëlle B P Eekers
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Patrick Hanssens
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Margriet Sitskoorn
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands.
| |
Collapse
|
2
|
Ottaviani MM, Fasinella MR, Di Rienzo A, Gladi M, di Somma LGM, Iacoangeli M, Dobran M. Analysis of prognostic factors and the role of epilepsy in neurosurgical patients with brain metastases. Surg Neurol Int 2024; 15:79. [PMID: 38628515 PMCID: PMC11021078 DOI: 10.25259/sni_735_2023] [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: 09/03/2023] [Accepted: 02/01/2024] [Indexed: 04/19/2024] Open
Abstract
Background Brain metastases (BMs) represent the most frequent brain tumors in adults. The identification of key prognostic factors is essential for choosing the therapeutic strategy tailored to each patient. Epilepsy can precede several months of other clinical presentations of BMs. This work aimed to study the impact of epilepsy and other prognostic factors on BMs patients' survival. Methods This retrospective study included 51 patients diagnosed with BMs and who underwent neurosurgery between 2010 and 2021. The impact of BM features and patient's clinical characteristics on the overall survival (OS) was analyzed through uni- and multivariate analysis. Results The average OS was 25.98 months and differed according to the histology of the primary tumor. The primary tumor localization and the presence of extracranial metastases had a statistically significant impact on the OS, and patients with single BM showed a superior OS to those with multifocal lesions. The localization of BMs in the temporal lobe correlated with the highest OS. The OS was significantly higher in patients who presented seizures in their clinical onset and in those who had better post-surgical Karnofsky performance status, no post-surgical complications, and who underwent post-surgical treatment. Conclusion Our study has highlighted prognostically favorable patient and tumor factors. Among those, a clinical onset with epileptic seizures can help identify brain metastasis hitherto silent. This could lead to immediate diagnostic-therapeutic interventions with more aggressive therapies after appropriate multidisciplinary evaluation.
Collapse
|
3
|
Barillaro A, Caroprese M, Cella L, Viggiano A, Buccelli F, Daponte C, Feoli C, Oliviero C, Clemente S, Farella A, Conson M, Pacelli R. Stereotactic Radiation Therapy for Brain Metastases: Factors Affecting Outcomes and Radiation Necrosis. Cancers (Basel) 2023; 15:cancers15072094. [PMID: 37046755 PMCID: PMC10093341 DOI: 10.3390/cancers15072094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Stereotactic radiation therapy (SRT) is a proven effective treatment for brain metastases (BM); however, symptomatic radiation necrosis (RN) is a late effect that may impact on patient’s quality of life. The aim of our study was to retrospectively evaluate survival outcomes and characterize the occurrence of RN in a cohort of BM patients treated with ablative SRT at Federico II University Hospital. Clinical and dosimetric factors of 87 patients bearing a total of 220 BMs treated with SRT from 2016 to 2022 were analyzed. Among them, 46 patients with 127 BMs having clinical and MRI follow-up (FUP) ≥ 6 months were selected for RN evaluation. Dosimetric parameters of the uninvolved brain (brain without GTV) were extracted. The crude local control was 91% with neither clinical factors nor prescription dose correlating with local failure (LF). At a median FUP of 9 (1–68) months, the estimated median overall survival (OS), progression-free survival (PFS), and brain progression-free survival (bPFS) were 16, 6, and 9 months, respectively. The estimated OS rates at 1 and 3 years were 59.8% and 18.3%, respectively; bPFS at 1 and 3 years was 29.9% and 13.5%, respectively; PFS at 1 and 3 years was 15.7% and 0%, respectively; and local failure-free survival (LFFS) at 1 and 3 years was 87.2% and 83.8%, respectively. Extracranial disease status was an independent factor related to OS. Fourteen (30%) patients manifested RN. At multivariate analysis, adenocarcinoma histology, left location, and absence of chemotherapy were confirmed as independent risk factors for any-grade RN. Nine (20%) patients developed symptomatic (G2) RN, which improved or stabilized after 1–16 months of steroid therapy. With prompt recognition and, when necessary, medical therapy, RN radiological and clinical amelioration can be obtained.
Collapse
Affiliation(s)
- Angela Barillaro
- Department of Advanced Biomedical Sciences, Federico II School of Medicine, 80128 Naples, Italy
| | - Mara Caroprese
- Department of Advanced Biomedical Sciences, Federico II School of Medicine, 80128 Naples, Italy
| | - Laura Cella
- National Research Council (CNR), Institute of Biostructures and Bioimaging, 80145 Naples, Italy
| | - Anna Viggiano
- Department of Advanced Biomedical Sciences, Federico II School of Medicine, 80128 Naples, Italy
| | - Francesca Buccelli
- Department of Advanced Biomedical Sciences, Federico II School of Medicine, 80128 Naples, Italy
| | - Chiara Daponte
- Department of Advanced Biomedical Sciences, Federico II School of Medicine, 80128 Naples, Italy
| | - Chiara Feoli
- Department of Advanced Biomedical Sciences, Federico II School of Medicine, 80128 Naples, Italy
| | | | | | | | - Manuel Conson
- Department of Advanced Biomedical Sciences, Federico II School of Medicine, 80128 Naples, Italy
| | - Roberto Pacelli
- Department of Advanced Biomedical Sciences, Federico II School of Medicine, 80128 Naples, Italy
| |
Collapse
|
4
|
Singh K, Saxena S, Khosla AA, McDermott MW, Kotecha RR, Ahluwalia MS. Update on the Management of Brain Metastasis. Neurotherapeutics 2022; 19:1772-1781. [PMID: 36422836 PMCID: PMC9723062 DOI: 10.1007/s13311-022-01312-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2022] [Indexed: 11/27/2022] Open
Abstract
Brain metastases occur in almost one-third of adult patients with solid tumor malignancies and lead to considerable patient morbidity and mortality. The rising incidence of brain metastases has been ascribed to the development of better imaging and screening techniques and the formulation of better systemic therapies. Until recently, the multimodal management of brain metastases focused primarily on the utilization of neurosurgical techniques, with varying combinations of whole-brain radiation therapy and stereotactic radio-surgical procedures. Over the past 2 decades, in particular, the increment in knowledge pertaining to molecular genetics and the pathogenesis of brain metastases has led to significant developments in targeted therapies and immunotherapies. This review article highlights the recent updates in the management of brain metastases with an emphasis on novel systemic therapies.
Collapse
Affiliation(s)
- Karanvir Singh
- Division of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Shreya Saxena
- Division of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Atulya A Khosla
- Division of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Michael W McDermott
- Division of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, USA
| | - Rupesh R Kotecha
- Division of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, USA
| | - Manmeet S Ahluwalia
- Division of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA.
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, USA.
| |
Collapse
|
5
|
|
6
|
Chen Z, Zhou L, Zhao M, Cao K, Li Y, Liu X, Hou Y, Li L, Wang L, Chang L, Yang M, Li W, Xia Y. Real-world analysis of different intracranial radiation therapies in non-small cell lung cancer patients with 1–4 brain metastases. BMC Cancer 2022; 22:1010. [PMID: 36153515 PMCID: PMC9508739 DOI: 10.1186/s12885-022-10083-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 09/07/2022] [Indexed: 11/10/2022] Open
Abstract
Purpose Stereotactic radiosurgery (SRS) has become a standard approach for the treatment of patients with few metastatic brain lesions. However, the optimal treatment approach for the use radiotherapy in the treatment of non-small cell lung cancer (NSCLC) patients with brain metastases (BMs) remain unclear. This study aimed to compare the survival outcomes and intracranial local control in NSCLC patients with 1–4 BMs who are treated with SRS using linear accelerators (LINAC-SRS), whole-brain radiotherapy (WBRT), or WBRT plus radiotherapy boost (WBRT + RTB). Materials and methods We retrospectively analyzed 156 NSCLC patients with 1–4 BMs who received LINAC-SRS, WBRT, and WBRT + RTB. The median overall survival (OS), intracranial progression-free survival (iPFS), and distant brain failure-free survival (DBF-FS) and related prognostic factors were analyzed. Results The median follow-up period was 31.6 months. The median OS times in the LINAC-SRS, WBRT, and WBRT + RTB groups were not reached, 33.3 months and 27.9 months, respectively. The difference in survival rate was non-significant (P = 0.909). The 2-year iPFS and DBF-FS rates in the LINAC-SRS, WBRT and WBRT + RTB groups were 51.6% and 37.5%; 42.0% and 50.4%; and 51.1% and 56.1%, respectively. There was no significant difference in 2-year iPFS or DBF-FS among the three groups (P = 0.572 for iPFS, P = 0.628 for DBF-FS). Multivariate analysis showed that the independent adverse prognostic factors for OS, iPFS, and DBF-FS were neurological symptoms, recursive partitioning analysis (RPA) class, and targeted therapy. Conclusion LINAC-SRS did not result in significantly superior survival times or intracranial local control compared to WBRT or WBRT + RTB in the treatment of NSCLC patients with 1–4 BMs. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10083-8.
Collapse
|
7
|
Yuan J, Cheng Z, Feng J, Xu C, Wang Y, Zou Z, Li Q, Guo S, Jin L, Jiang G, Shang Y, Wu J. Prognosis of lung cancer with simple brain metastasis patients and establishment of survival prediction models: a study based on real events. BMC Pulm Med 2022; 22:162. [PMID: 35477385 PMCID: PMC9047387 DOI: 10.1186/s12890-022-01936-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 03/31/2022] [Indexed: 12/11/2022] Open
Abstract
Objectives The aim of this study was to explore risk factors for the prognosis of lung cancer with simple brain metastasis (LCSBM) patients and to establish a prognostic predictive nomogram for LCSBM patients. Materials and methods Three thousand eight hundred and six cases of LCSBM were extracted from the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015 using SEER Stat 8.3.5. Lung cancer patients only had brain metastasis with no other organ metastasis were defined as LCSBM patients. Prognostic factors of LCSBM were analyzed with log-rank method and Cox proportional hazards model. Independent risk and protective prognostic factors were used to construct nomogram with accelerated failure time model. C-index was used to evaluate the prediction effect of nomogram. Results and conclusion The younger patients (18–65 years old) accounted for 54.41%, while patients aged over 65 accounted for 45.59%.The ratio of male: female was 1:1. Lung cancer in the main bronchus, upper lobe, middle lobe and lower lobe were accounted for 4.91%, 62.80%, 4.47% and 27.82% respectively; and adenocarcinoma accounted for 57.83% of all lung cancer types. The overall median survival time was 12.2 months. Survival rates for 1-, 3- and 5-years were 28.2%, 8.7% and 4.7% respectively. We found female (HR = 0.81, 95% CI 0.75–0.87), the married (HR = 0.80; 95% CI 0.75–0.86), the White (HR = 0.90, 95% CI 0.84–0.95) and primary site (HR = 0.45, 95% CI 0.39–0.52) were independent protective factors while higher age (HR = 1.51, 95% CI 1.40–1.62), advanced grade (HR = 1.19, 95% CI 1.12–1.25) and advanced T stage (HR = 1.09, 95% CI 1.05–1.13) were independent risk prognostic factors affecting the survival of LCSBM patients. We constructed the nomogram with above independent factors, and the C-index value was 0.634 (95% CI 0.622–0.646). We developed a nomogram with seven significant LCSBM independent prognostic factors to provide prognosis prediction.
Collapse
Affiliation(s)
- Jiaying Yuan
- Department of Respiratory and Critical Care Medicine, Shanghai Changhai Hospital, the First Affiliated Hospital of Naval Medical University, Shanghai, 200433, China
| | - Zhiyuan Cheng
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200240, China
| | - Jian Feng
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, 200030, China
| | - Chang Xu
- Clinical College of Xiangnan University, Chenzhou, 423043, China
| | - Yi Wang
- School of Life Sciences, Fudan University, Shanghai, 200433, China
| | - Zixiu Zou
- School of Life Sciences, Fudan University, Shanghai, 200433, China
| | - Qiang Li
- Department of Respiratory and Critical Care Medicine, Shanghai East Hospital, Tongji University, Shanghai, 200120, China
| | - Shicheng Guo
- School of Life Sciences, Fudan University, Shanghai, 200433, China
| | - Li Jin
- School of Life Sciences, Fudan University, Shanghai, 200433, China
| | - Gengxi Jiang
- Department of Thoracic Surgery, Shanghai Changhai Hospital, the First Affiliated Hospital of Naval Military Medical University, Shanghai, 200433, China.
| | - Yan Shang
- Department of Respiratory and Critical Care Medicine, Shanghai Changhai Hospital, the First Affiliated Hospital of Naval Medical University, Shanghai, 200433, China. .,Department of General Medicine, the First Affiliated Hospital of Naval Medical University, Shanghai, 200433, China.
| | - Junjie Wu
- Department of Pulmonary and Critical Care Medicine, Fudan University, Shanghai, 200032, China. .,Department of Pulmonary and Critical Care Medicine, Shanghai Geriatric Medical Center, Shanghai, 200032, China.
| |
Collapse
|
8
|
Cheung HL, Yam K. Post‐operative survival and functional status of patients with lung malignancy presented primarily with brain metastasis in a tertiary referral centre. SURGICAL PRACTICE 2022. [DOI: 10.1111/1744-1633.12566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Kwong‐yui Yam
- Department of Neurosurgery Tuen Mun Hospital Hong Kong
| |
Collapse
|
9
|
Kalita-de Croft P, Joshi V, Saunus JM, Lakhani SR. Emerging Biomarkers for Diagnosis, Prevention and Treatment of Brain Metastases-From Biology to Clinical Utility. Diseases 2022; 10:11. [PMID: 35225863 PMCID: PMC8884016 DOI: 10.3390/diseases10010011] [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: 11/09/2021] [Revised: 01/18/2022] [Accepted: 01/27/2022] [Indexed: 11/17/2022] Open
Abstract
Primary malignancies of the lung, skin (melanoma), and breast have higher propensity for metastatic spread to the brain. Advances in molecular tumour profiling have aided the development of targeted therapies, stereotactic radiotherapy, and immunotherapy, which have led to some improvement in patient outcomes; however, the overall prognosis remains poor. Continued research to identify new prognostic and predictive biomarkers is necessary to further impact patient outcomes, as this will enable better risk stratification at the point of primary cancer diagnosis, earlier detection of metastatic deposits (for example, through surveillance), and more effective systemic treatments. Brain metastases exhibit considerable inter- and intratumoural heterogeneity-apart from distinct histology, treatment history and other clinical factors, the metastatic brain tumour microenvironment is incredibly variable both in terms of subclonal diversity and cellular composition. This review discusses emerging biomarkers; specifically, the biological context and potential clinical utility of tumour tissue biomarkers, circulating tumour cells, extracellular vesicles, and circulating tumour DNA.
Collapse
Affiliation(s)
- Priyakshi Kalita-de Croft
- UQ Centre for Clinical Research, The University of Queensland Faculty of Medicine, Herston, QLD 4029, Australia; (V.J.); (J.M.S.)
| | - Vaibhavi Joshi
- UQ Centre for Clinical Research, The University of Queensland Faculty of Medicine, Herston, QLD 4029, Australia; (V.J.); (J.M.S.)
| | - Jodi M. Saunus
- UQ Centre for Clinical Research, The University of Queensland Faculty of Medicine, Herston, QLD 4029, Australia; (V.J.); (J.M.S.)
| | - Sunil R. Lakhani
- UQ Centre for Clinical Research, The University of Queensland Faculty of Medicine, Herston, QLD 4029, Australia; (V.J.); (J.M.S.)
- Pathology Queensland, The Royal Brisbane and Women’s Hospital Herston, Herston, QLD 4029, Australia
| |
Collapse
|
10
|
Zeng KL, Sahgal A, Husain ZA, Myrehaug S, Tseng CL, Detsky J, Sarfehnia A, Ruschin M, Campbell M, Foster M, Das S, Lipsman N, Bjarnason GA, Atenafu EG, Maralani PJ, Soliman H. Local control and patterns of failure for "Radioresistant" spinal metastases following stereotactic body radiotherapy compared to a "Radiosensitive" reference. J Neurooncol 2021; 152:173-182. [PMID: 33453002 DOI: 10.1007/s11060-020-03691-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 12/30/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE The concept of a radioresistant (RR) phenotype has been challenged with use of stereotactic body radiotherapy (SBRT). We compared outcomes following SBRT to RR spinal metastases to a radiosensitive cohort. METHODS Renal cell, melanoma, sarcoma, gastro-intestinal, and thyroid spinal metastases were identified as RR and prostate cancer (PCA) as radiosensitive. The primary endpoint was MRI-based local failure (LF). Secondary endpoints included overall survival (OS) and vertebral compression fracture (VCF). RESULTS From a prospectively maintained database of 1394 spinal segments in 605 patients treated with spine SBRT, 173 patients/395 RR spinal segments were compared to 94 patients/185 PCA segments. Most received 24-28 Gy in 2 fractions (68.9%) and median follow-up was 15.5 months (range, 1.4-84.2 months). 1- and 2-year LF rates were 19.2% and 22.4% for RR metastases, respectively, which were significantly greater (p < 0.001) than PCA (3.2% and 8.4%, respectively). Epidural disease (HR: 2.47, 95% CI 1.65-3.71, p < 0.001) and RR histology (HR: 2.41, 95% CI 1.45-3.99, p < 0.001) predicted for greater LF. Median OS was 17.4 and 61.0 months for RR and PCA cohorts, respectively. Lung/liver metastases, polymetastatic disease and epidural disease predicted for worse OS. 2-year VCF rates were ~ 13% in both cohorts. Coverage of the CTV V90 (clinical target volume receiving 90% of prescription dose) by ≥ 87% (HR: 2.32, 95% CI 1.29-4.18, p = 0.005), no prior spine radiotherapy (HR: 1.96, 95% CI 1.09-3.55, p = 0.025), and a greater Spinal Instability Neoplasia Score (p = 0.013) predicted for VCF. CONCLUSIONS Higher rates of LF were observed after spine SBRT in RR metastases. Optimization strategies include dose escalation and aggressive management of epidural disease.
Collapse
Affiliation(s)
- K Liang Zeng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Zain A Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Arman Sarfehnia
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Mikki Campbell
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Monica Foster
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Sunit Das
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Georg A Bjarnason
- Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada.
| |
Collapse
|
11
|
Redmond KJ, Gui C, Benedict S, Milano MT, Grimm J, Vargo JA, Soltys SG, Yorke E, Jackson A, El Naqa I, Marks LB, Xue J, Heron DE, Kleinberg LR. Tumor Control Probability of Radiosurgery and Fractionated Stereotactic Radiosurgery for Brain Metastases. Int J Radiat Oncol Biol Phys 2020; 110:53-67. [PMID: 33390244 DOI: 10.1016/j.ijrobp.2020.10.034] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/25/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE As part of the American Association of Physicists in Medicine Working Group on Stereotactic Body Radiotherapy, tumor control probability (TCP) after stereotactic radiosurgery (SRS) and fractionated stereotactic radiosurgery (fSRS) for brain metastases was modeled based on pooled dosimetric and clinical data from published English-language literature. METHODS AND MATERIALS PubMed-indexed studies published between January 1995 and September 2017 were used to evaluate dosimetric and clinical predictors of TCP after SRS or fSRS for brain metastases. Eligible studies had ≥10 patients and included detailed dose-fractionation data with corresponding ≥1-year local control (LC) data, typically evaluated as a >20% increase in diameter of the targeted lesion using the pre-SRS diameter as a reference. RESULTS Of 2951 potentially eligible manuscripts, 56 included sufficient dose-volume data for analyses. Accepting that necrosis and pseudoprogression can complicate the assessment of LC, for tumors ≤20 mm, single-fraction doses of 18 and 24 Gy corresponded with >85% and 95% 1-year LC rates, respectively. For tumors 21 to 30 mm, an 18 Gy single-fraction dose was associated with 75% LC. For tumors 31 to 40 mm, a 15 Gy single-fraction dose yielded ∼69% LC. For 3- to 5-fraction fSRS using doses in the range of 27 to 35 Gy, 80% 1-year LC has been achieved for tumors of 21 to 40 mm in diameter. CONCLUSIONS TCP for SRS and fSRS are presented. For small lesions ≤20 mm, single doses of ≈18 Gy appear generally associated with excellent rates of LC; for melanoma, higher doses seem warranted. For larger lesions >20 mm, local control rates appear to be ≈ 70% to 75% with usual doses of 15 to 18 Gy, and in this setting, fSRS regimens should be considered. Greater consistency in reporting of dosimetric and LC data is needed to facilitate future pooled analyses. As systemic and biologic therapies evolve, updated analyses will be needed to further assess the necessity, efficacy, and toxicity of SRS and fSRS.
Collapse
Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Chengcheng Gui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stanley Benedict
- Department of Radiation Oncology, University of California at Davis Comprehensive Cancer Center, Sacramento, California
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Jimm Grimm
- Department of Radiation Oncology, Geisinger Medical Center, Danville, Pennsylvania
| | - J Austin Vargo
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Ellen Yorke
- Medical Physics Department, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Medical Physics Department, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Issam El Naqa
- Department of Machine Learning and Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Lawrence B Marks
- Department of Radiation Oncology and the Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Jinyu Xue
- Department of Radiation Oncology, New York University, New York, New York
| | - Dwight E Heron
- Department of Radiation Oncology, Bon Secours Mercy Health System, Youngstown, Ohio
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
12
|
β-Elemene enhances radiosensitivity in non-small-cell lung cancer by inhibiting epithelial-mesenchymal transition and cancer stem cell traits via Prx-1/NF-kB/iNOS signaling pathway. Aging (Albany NY) 2020; 13:2575-2592. [PMID: 33316778 PMCID: PMC7880315 DOI: 10.18632/aging.202291] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 09/03/2020] [Indexed: 12/14/2022]
Abstract
Radiation therapy is widely used to treat a variety of malignant tumors, including non-small-cell lung cancer (NSCLC). However, ionizing radiation (IR) paradoxically promotes radioresistance, metastasis and recurrence by inducing epithelial-mesenchymal transition (EMT) and cancer stem cells (CSCs). Here, we developed two NSCLC radioresistant (RR) cell lines (A549-RR and H1299-RR) and characterized their motility, cell cycle distribution, DNA damage, and CSC production using migration/invasion assays, flow cytometry, comet assays, and sphere formation, respectively. We also evaluated their tumorigenicity in vivo using a mouse xenograft model. We found that invasion and spheroid formation by A549-RR and H1299-RR cells were increased as compared to their parental cells. Furthermore, as compared to radiation alone, the combination of β-elemene administration with radiation increased the radiosensitivity of A549 cells and reduced expression of EMT/CSC markers while inhibiting the Prx-1/NF-kB /iNOS signaling pathway. Our findings suggest that NSCLC radioresistance is associated with EMT, enhanced CSC phenotypes, and activation of the Prx-1/NF-kB/iNOS signaling pathway. They also suggest that combining β-elemene with radiation may be an effective means of overcoming radioresistance in NSCLC.
Collapse
|
13
|
Kim JM, Miller JA, Kotecha R, Chao ST, Ahluwalia MS, Peereboom DM, Mohammadi AM, Barnett GH, Murphy ES, Vogelbaum MA, Angelov L, Abraham J, Moore H, Budd GT, Suh JH. Stereotactic radiosurgery with concurrent HER2-directed therapy is associated with improved objective response for breast cancer brain metastasis. Neuro Oncol 2020; 21:659-668. [PMID: 30726965 DOI: 10.1093/neuonc/noz006] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Patients with breast cancer positive for human epidermal growth factor receptor 2 (HER2) remain at high risk of intracranial relapse following treatment and experience increased rates of intracranial failure after stereotactic radiosurgery (SRS). We hypothesized that the addition of concurrent lapatinib to SRS would improve intracranial complete response rates. METHODS Patients with newly diagnosed HER2-amplified breast cancer brain metastases from 2005-2014 who underwent SRS were included and divided into 2 cohorts based on timing of treatment with lapatinib. Outcome variables included the proportion of patients who achieved an intracranial complete response or progressive disease according to the RECIST 1.1 criteria, as well as individual lesion response rates, distant intracranial failure, and radiation necrosis. RESULTS Eighty-four patients with 487 brain metastases met inclusion criteria during the study period. Over 138 treatment sessions, 132 lesions (27%) were treated with SRS and concurrent lapatinib, while 355 (73%) were treated with SRS without lapatinib. Compared with patients treated with SRS alone, patients treated with concurrent lapatinib had higher rates of complete response (35% vs 11%, P = 0.008). On a per-lesion basis, best objective response was superior in the concurrent lapatinib group (median 100% vs 70% reduction, P < 0.001). Concurrent lapatinib was not associated with an increased risk of grade 2+ radiation necrosis (1.0% with concurrent lapatinib vs 3.5% without, P = 0.27). Lapatinib had no protective effect on distant intracranial failure rates (48% vs 49%, P = 0.91). CONCLUSION The addition of concurrent lapatinib to SRS was associated with improved complete response rates among patients with HER2-positive brain metastases.
Collapse
Affiliation(s)
- Joseph M Kim
- School of Medicine, Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Jacob A Miller
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford University Medical Center, Palo Alto, California
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida
| | - Samuel T Chao
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio
| | - Manmeet S Ahluwalia
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Department of Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio
| | - David M Peereboom
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Department of Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio
| | - Alireza M Mohammadi
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Erin S Murphy
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio
| | - Michael A Vogelbaum
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jame Abraham
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio
| | - Halle Moore
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio
| | - G Thomas Budd
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio
| | - John H Suh
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio
| |
Collapse
|
14
|
Abstract
Brain metastases are a very common manifestation of cancer that have historically been approached as a single disease entity given the uniform association with poor clinical outcomes. Fortunately, our understanding of the biology and molecular underpinnings of brain metastases has greatly improved, resulting in more sophisticated prognostic models and multiple patient-related and disease-specific treatment paradigms. In addition, the therapeutic armamentarium has expanded from whole-brain radiotherapy and surgery to include stereotactic radiosurgery, targeted therapies and immunotherapies, which are often used sequentially or in combination. Advances in neuroimaging have provided additional opportunities to accurately screen for intracranial disease at initial cancer diagnosis, target intracranial lesions with precision during treatment and help differentiate the effects of treatment from disease progression by incorporating functional imaging. Given the numerous available treatment options for patients with brain metastases, a multidisciplinary approach is strongly recommended to personalize the treatment of each patient in an effort to improve the therapeutic ratio. Given the ongoing controversies regarding the optimal sequencing of the available and expanding treatment options for patients with brain metastases, enrolment in clinical trials is essential to advance our understanding of this complex and common disease. In this Review, we describe the key features of diagnosis, risk stratification and modern paradigms in the treatment and management of patients with brain metastases and provide speculation on future research directions.
Collapse
|
15
|
Yang SH, Kim HY, Lee SI, Jin SJ. The Effect of Epidermal Growth Factor Receptor Mutation on Intracranial Progression-Free Survival of Non-Small Cell Lung Cancer Patients with Brain Metastasis Underwent Gamma Knife Radiosurgery. Brain Tumor Res Treat 2020; 8:103-108. [PMID: 33118342 PMCID: PMC7595855 DOI: 10.14791/btrt.2020.8.e15] [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: 05/18/2020] [Revised: 05/22/2020] [Accepted: 07/14/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The aim of this study was to survey prognostic factors, particularly those focusing on epidermal growth factor receptor (EGFR) mutations, of patients with non-small cell lung cancer (NSCLC) after Gamma Knife Radiosurgery (GKRS) for metastatic brain tumors. METHODS We retrospectively reviewed the medical records of 98 patients with NSCLC who underwent GKRS for brain metastases from August 2010 to July 2017. The primary endpoint was progression-free survival (PFS) of the intracranial disease. We analyzed variables such as age, sex, Karnofsky Performance Status, recursive partitioning analysis (RPA) class, smoking status, primary cancer pathology, EGFR mutations, and time to brain metastases as prognostic factors. RESULTS The median overall survival (OS) of the patients was 16 months [95% confidence interval (CI), 13-21 months]. Median systemic PFS and intracranial PFS were 9 months (95% CI, 8-11 months) and 11 months (95% CI, 7-14 months), respectively. Kaplan-Meier survival analysis revealed that the patients with EGFR mutations had longer intracranial PFS than those without EGFR mutation (median intracranial PFS: 19 vs. 10 months with p=0.01) while they had no benefits in OS and systemic PFS. Furthermore, the patients harboring adenocarcinoma had longer OS (p<0.01) and intracranial PFS (p<0.01) and the patients with lower RPA class had longer OS (p=0.02) and intracranial PFS (p=0.03). CONCLUSION EGFR mutations, primary cancer pathology, and RPA class may be proposed as prognostic factors for intracranial PFS in NSCLC patients after GKRS for brain metastasis in this study.
Collapse
Affiliation(s)
- Seung Hyeon Yang
- Department of Neurosurgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hae Yu Kim
- Department of Neurosurgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea.,Department of Neurosurgery, Gamma Knife Center, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea.
| | - Sun Il Lee
- Department of Neurosurgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea.,Department of Neurosurgery, Gamma Knife Center, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Seong Jin Jin
- Department of Neurosurgery, Gamma Knife Center, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| |
Collapse
|
16
|
Singh R, Lehrer EJ, Ko S, Peterson J, Lou Y, Porter AB, Kotecha R, Brown PD, Zaorsky NG, Trifiletti DM. Brain metastases from non-small cell lung cancer with EGFR or ALK mutations: A systematic review and meta-analysis of multidisciplinary approaches. Radiother Oncol 2019; 144:165-179. [PMID: 31812932 DOI: 10.1016/j.radonc.2019.11.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 11/05/2019] [Accepted: 11/11/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND PURPOSE To analyze outcomes of non-small cell lung cancer (NSCLC) patients with brain metastases harboring EGFR or ALK mutations and examine for differences between tyrosine kinase inhibitors (TKIs) alone, radiotherapy (RT) alone (either whole brain radiation therapy (WBRT) or stereotactic radiosurgery (SRS)), or combined TKIs and RT. MATERIALS AND METHODS Thirty studies were identified. PATIENTS with brain metastases from NSCLC. INTERVENTION initial TKIs alone with optional salvage RT, RT alone, or TKIs and RT. CONTROL wild-type NSCLC and TKIs alone for mutational and treatment analysis, respectively. OUTCOMES overall survival (OS) and intracranial progression-free survival (PFS). SETTING studies with mutation information. RESULTS A total of 2649 patients were included. Patients with ALK and EGFR mutations had significantly higher median OS (48.5 months, p < 0.0001; and 20.9 months; p = 0.0006, respectively) compared to wild-type patients (9.9 months). Similar median OS was noted between TKIs and RT (28.3 months), RT alone (32.2 months; p = 0.22), or TKIs alone (23.9 months; p = 0.2). Patients treated with TKIs and RT had higher median PFS (18.6 months; p = 0.06) compared to TKIs alone (13.6 months) with no difference between TKIs and RT vs. RT alone (16.9 months; p = 0.72). No PFS difference was found between WBRT and TKI (23.2 months; p = 0.72) vs. WBRT alone (24 months) or SRS and TKI (16.7 months; p = 0.56) vs. SRS alone (13.6 months). CONCLUSION NSCLC patients with brain metastases harboring EGFR or ALK mutations have superior OS compared to wild-type patients. No PFS or OS benefit was found with the addition of TKIs to RT.
Collapse
Affiliation(s)
- Raj Singh
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, USA.
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Stephen Ko
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, USA.
| | | | - Yanyan Lou
- Department of Medical Oncology, Mayo Clinic, Jacksonville, USA.
| | | | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, USA.
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA.
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, USA.
| | | |
Collapse
|
17
|
EGFR mutant locally advanced non-small cell lung cancer is at increased risk of brain metastasis. Clin Transl Radiat Oncol 2019; 18:32-38. [PMID: 31341973 PMCID: PMC6612652 DOI: 10.1016/j.ctro.2019.06.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 06/24/2019] [Indexed: 12/24/2022] Open
Abstract
Locally advanced EGFR+ NSCLC patients have a high likelihood of brain metastasis. The high likelihood of EGFR+ brain metastasis is independent of survival duration. Surveillance MRI may allow early identification and treatment of brain metastasis.
Background and purpose Small studies of primarily metastatic non-small cell lung cancer (NSCLC) have suggested an association between EGFR mutation (EGFR+) and likelihood of brain metastasis. However, these studies are confounded by follow-up time bias. We performed a competing risk analysis of brain metastasis in a more uniform locally advanced NSCLC (LA-NSCLC) cohort with known tumor genotype. Materials and methods Between 2002 and 2014, 255 patients with LA-NSCLC underwent tumor genotyping for EGFR, ALK and/or KRAS (180 patients had follow-up brain imaging). Cumulative incidence and Fine-Gray regression were performed on clinical variables including genotype and risk of brain metastasis, with death as a competing event. Results The proportion of tumors with aberrations in EGFR, ALK and KRAS were 17%, 4% and 28%, respectively. The median follow-up was 68 months. On multivariate analysis, EGFR+ was significantly associated with risk of brain metastasis in the full patient cohort (HR 2.04, 95% CI 1.22–3.39, p = 0.006) as well as in the subset of patients with brain follow-up imaging (HR 1.91. 95% CI 1.17–3.13, p = 0.01). This translated to a higher cumulative incidence of brain metastasis in EGFR+ patients at 3 and 5 years (33.3% vs. 23.2 and 43.8% vs. 24.2%, p = 0.006). Conclusion Patients with EGFR+ LA-NSCLC have a significantly higher likelihood of developing brain metastasis after standard combined modality therapy, independent of their longer overall survival. This high-risk genotypic subgroup may benefit from routine surveillance with brain MRI to allow early salvage with targeted systemic- and/or radiation-therapies.
Collapse
|
18
|
Lu F, Hou Y, Xia Y, Li L, Wang L, Cao K, Chen H, Chang L, Li W. Survival and intracranial control outcomes of whole-brain radiotherapy (WBRT) alone versus WBRT plus a radiotherapy boost in non-small-cell lung cancer with brain metastases: a single-institution retrospective analysis. Cancer Manag Res 2019; 11:4255-4272. [PMID: 31190992 PMCID: PMC6512646 DOI: 10.2147/cmar.s203461] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/09/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose: To compare the differences in survival and intracranial local control between patients treated with whole-brain radiotherapy (WBRT) and WBRT plus a radiotherapy boost (RTB) in non-small-cell lung cancer (NSCLC) patients with brain metastases (BMs). Patients and methods: Between May 2010 and October 2017, 206 NSCLC patients with BMs were treated with brain radiotherapy; among these patients, 140 patients underwent WBRT alone (group A) and 66 patients underwent WBRT plus RTB (group B). The endpoints included intracranial local progression-free survival and regional progression-free survival time (iLPFS and iRPFS, respectively) and overall survival (OS). Results: Between the two groups, not all baseline clinical factors were well-balanced. The median iLPFS was 17.9 months in group A and 22.3 months in group B. The 2-year iLPFS rates were significantly lower in group A than in group B (34.5% vs 49.3%, P=0.041); however, no significant differences were observed in OS or iRPFS. Multivariate analyses revealed that epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) therapy was significantly associated with good OS, iLPFS, and iRPFS. Among the patients treated with TKIs (n=62), there were no differences in OS (P=0.190), iLPFS (P=0.334), or iRPFS (P=0.338) between groups A and B. In the patients without TKI treatment (n=102), the median iLPFS was significantly longer in group B than in group A (16.7 vs 12.0 months, P=0.032), but no significant differences were found in OS (p=0.182) or iRPFS (P=0.837) between the two groups. Conclusion: WBRT plus RTB significantly improved iLPFS compared with WBRT alone, especially in patients without EGFR-TKI treatment. However,there were no significant differences in iRPFS or OS between the two groups. Patients treated with EGFR-TKIs may not benefit from WBRT plus RTB.
Collapse
Affiliation(s)
- Fei Lu
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, People's Republic of China.,Department of Oncology and Hematology, The First People's Hospital of Honghe State, Mengzi, Yunnan, People's Republic of China
| | - Yu Hou
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, People's Republic of China
| | - Yaoxiong Xia
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, People's Republic of China
| | - Lan Li
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, People's Republic of China
| | - Li Wang
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, People's Republic of China
| | - Ke Cao
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, People's Republic of China
| | - Haixia Chen
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, People's Republic of China
| | - Li Chang
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, People's Republic of China
| | - Wenhui Li
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, People's Republic of China
| |
Collapse
|
19
|
Motea EA, Huang X, Singh N, Kilgore JA, Williams NS, Xie XJ, Gerber DE, Beg MS, Bey EA, Boothman DA. NQO1-dependent, Tumor-selective Radiosensitization of Non-small Cell Lung Cancers. Clin Cancer Res 2019; 25:2601-2609. [PMID: 30617135 DOI: 10.1158/1078-0432.ccr-18-2560] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/30/2018] [Accepted: 01/04/2019] [Indexed: 12/30/2022]
Abstract
PURPOSE Development of tumor-specific therapies for the treatment of recalcitrant non-small cell lung cancers (NSCLC) is urgently needed. Here, we investigated the ability of β-lapachone (β-lap, ARQ761 in clinical form) to selectively potentiate the effects of ionizing radiation (IR, 1-3 Gy) in NSCLCs that overexpress NAD(P)H:Quinone Oxidoreductase 1 (NQO1). EXPERIMENTAL DESIGN The mechanism of lethality of low-dose IR in combination with sublethal doses of β-lap was evaluated in NSCLC lines in vitro and validated in subcutaneous and orthotopic xenograft models in vivo. Pharmacokinetics and pharmacodynamics (PK/PD) studies comparing single versus cotreatments were performed to validate therapeutic efficacy and mechanism of action. RESULTS β-Lap administration after IR treatment hyperactivated PARP, greatly lowered NAD+/ATP levels, and increased double-strand break (DSB) lesions over time in vitro. Radiosensitization of orthotopic, as well as subcutaneous, NSCLCs occurred with high apparent cures (>70%), even though 1/8 β-lap doses reach subcutaneous versus orthotopic tumors. No methemoglobinemia or long-term toxicities were noted in any normal tissues, including mouse liver that expresses the highest level of NQO1 (∼12 units) of any normal tissue. PK/PD responses confirm that IR + β-lap treatments hyperactivate PARP activity, greatly lower NAD+/ATP levels, and dramatically inhibit DSB repair in exposed NQO1+ cancer tissue, whereas low NQO1 levels and high levels of catalase in associated normal tissue were protective. CONCLUSIONS Our data suggest that combination of sublethal doses of β-lap and IR is a viable approach to selectively treat NQO1-overexpressing NSCLC and warrant a clinical trial using low-dose IR + β-lap against patients with NQO1+ NSCLCs.
Collapse
Affiliation(s)
- Edward A Motea
- Department of Biochemistry and Molecular Biology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana
| | - Xiumei Huang
- Department of Radiation Oncology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana
| | - Naveen Singh
- Department of Biochemistry and Molecular Biology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jessica A Kilgore
- Department of Biochemistry, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Noelle S Williams
- Department of Biochemistry, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Xian-Jin Xie
- Department of Biostatistics, UT Southwestern Medical Center, Dallas, Texas
| | - David E Gerber
- Department of Internal Medicine, Division of Hematology-Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Muhammad S Beg
- Department of Internal Medicine, Division of Hematology-Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Erik A Bey
- Department of Pharmaceutical Sciences, West Virginia University Cancer Institute, Morgantown, West Virginia.
| | - David A Boothman
- Department of Biochemistry and Molecular Biology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana.
| |
Collapse
|