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Abstract
Prophylactic cranial irradiation (PCI) has well established place in therapy for patients with limited-disease small cell lung cancer who responded to treatment. The data from randomized trials document that PCI reduces brain metastases rate from approximately 60% to 30%, and increases 3-year overall survival by approximately 5%. Currently, the dose of 25 Gy in 10 fractions is considered as standard. In attempt to reduce neuropsychological sequelae attributable to PCI hippocampal sparing techniques are employed. The existing studies suggest the benefit of hippocampal sparing in limiting memory and higher neurocognitive function losses, but with a risk of failures in the spared region. Ongoing studies will further validate the role of hippocampal sparing, both in terms of toxicity reduction and metastases prevention. PCI for patients who have undergone resection for stage I small cell lung cancer (SCLC) is not recommended, PCI may be, however, associated with a favourable outcome in SCLC patients who have undergone complete surgery in stages II−III. The role of PCI in extensive-disease (ED) SCLC has been evolving. Most recent evidence indicate that PCI is controversial in ED patients with response to initial chemotherapy and absence of brain metastases confirmed by contrast-enhanced MRI. The patients who do not receive PCI, must, however, receive periodic MRI examination during follow-up, i.e., remain under active surveillance with access to radiotherapy at brain relapse. The assessment of safety and effectiveness of hippocampal-sparing PCI, with or without drug neuroprotection in consideration of diverse combinations of radiotherapy, chemotherapy and immunotherapy create a background for future directions of research.
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Affiliation(s)
- Rafal Suwinski
- Radiotherapy and Chemotherapy Clinic and Teaching Hospital, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Poland
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Zeng H, Hendriks LEL, van Geffen WH, Witlox WJA, Eekers DBP, De Ruysscher DKM. Risk factors for neurocognitive decline in lung cancer patients treated with prophylactic cranial irradiation: A systematic review. Cancer Treat Rev 2020; 88:102025. [PMID: 32512415 DOI: 10.1016/j.ctrv.2020.102025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/21/2020] [Accepted: 04/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prophylactic cranial irradiation (PCI) reduces brain metastasis incidence in lung cancer, however with risk of neurocognitive decline. Nevertheless, risk factors for neurocognitive decline after PCI remain unclear. METHODS We systematically reviewed the PubMed database according to the PRISMA guideline. Inclusion criteria were: randomized clinical trials (RCTs) and observational/single arm trials evaluating PCI, including ≥20 patients, reporting neurocognitive test results for lung cancer. Primary aim: evaluate risk factors associated with neurocognitive decline after PCI. RESULTS Twenty records were eligible (8 different RCTs, 8 observational studies), including 3553 patients in total (858 NSCLC, 2695 SCLC) of which 73.6% received PCI. Incidence of mild/moderate cognitive decline after PCI varied from 8 to 89% (grading not always provided); for those without PCI, this was 3.4-42%. Interestingly, 23-95% had baseline cognitive impairment. Risk factors were often not reported. In one trial, both age (>60 years) and higher PCI dose (36 Gy) including twice-daily PCI were associated with a higher risk of cognitive decline. In one trial, white matter abnormalities were more frequent in the concurrent or sandwiched PCI arm, but without significant neuropsychological differences. One trial identified hippocampal sparing PCI to limit the neurocognitive toxicities of PCI and another reported an association between hippocampal dose volume effects and memory decline. As neurocognition was a secondary endpoint in most RCTs, and was assessed by various instruments with often poor/moderate compliance, high-quality data is lacking. CONCLUSIONS Age, PCI dose, regimen and timing might be associated with cognitive impairment after PCI in lung cancer patients, but high-quality data is lacking. Future PCI trials should collect and evaluate possible risk factors systematically.
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Affiliation(s)
- Haiyan Zeng
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.
| | - Lizza E L Hendriks
- Department of Pulmonary Diseases, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands.
| | - Wouter H van Geffen
- Department of Respiratory Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands.
| | - Willem J A Witlox
- Department of Clinical Epidemiology and Medical Technology Assessment, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands.
| | - Danielle B P Eekers
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.
| | - Dirk K M De Ruysscher
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.
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Chung JH, Kang SY, Wu HG, Seo YS, Kim DW, Kang KW, Kim HJ, Cheon GJ. Risk stratification of symptomatic brain metastases by clinical and FDG PET parameters for selective use of prophylactic cranial irradiation in patients with extensive disease of small cell lung cancer. Radiother Oncol 2020; 143:81-87. [PMID: 32044172 DOI: 10.1016/j.radonc.2020.01.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/06/2019] [Accepted: 01/08/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE To identify risk factors for developing symptomatic brain metastases and evaluate the impact of prophylactic cranial irradiation (PCI) on brain metastasis-free survival (BMFS) and overall survival (OS) in extensive disease small cell lung cancer (ED-SCLC). MATERIALS AND METHODS Among 190 patients diagnosed with ED-SCLC who underwent FDG PET/CT and brain Magnetic Resonance Imaging (MRI) prior to treatment, 53 (27.9%) received PCI while 137 (72.1%) did not. Prognostic index predicting a high risk of symptomatic brain metastases was calculated for the group without receiving PCI (observation group, n = 137) with Cox regression model. RESULTS Median follow-up time was 10.6 months. Multivariate Cox regression showed that the following three factors were associated with a high risk of symptomatic brain metastases: the presence of extrathoracic metastases (p = 0.004), hypermetabolism of bone marrow or spleen on FDG PET (p < 0.001), and high neutrophil-to-lymphocyte ratio (p = 0.018). PCI significantly improved BMFS in high-risk patients (1-year rate: 94.7% vs. 62.1%, p = 0.001), but not in low-risk patients (1-year rate: 100.0% vs. 87.7%, p = 0.943). However, PCI did not improve OS in patients at high risk for symptomatic brain metastases (1-year rate: 65.2% vs. 50.0%, p = 0.123). CONCLUSION Three prognostic factors (the presence of extrathoracic metastases, hypermetabolism of bone marrow or spleen on FDG PET, and high neutrophil-to-lymphocyte ratio) were associated with a high risk of symptomatic brain metastases in ED-SCLC. PCI was beneficial for patients at a high risk of symptomatic brain metastases in terms of BMFS, but not OS. Thus, selective use of PCI in ED-SCLC according to the risk stratification is recommended.
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Affiliation(s)
- Joo-Hyun Chung
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, South Korea
| | - Seo Young Kang
- Department of Nuclear Medicine, Seoul National University Hospital, Seoul, South Korea; Department of Molecular Medicine and Biopharmaceutical Science, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea
| | - Hong-Gyun Wu
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, South Korea; Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, South Korea
| | - Young Seok Seo
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, South Korea
| | - Dong-Wan Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Keon Wook Kang
- Department of Nuclear Medicine, Seoul National University Hospital, Seoul, South Korea; Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, South Korea; Cancer Research Institute, Seoul National University, Seoul, South Korea
| | - Hak Jae Kim
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, South Korea; Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, South Korea; Cancer Research Institute, Seoul National University, Seoul, South Korea.
| | - Gi Jeong Cheon
- Department of Nuclear Medicine, Seoul National University Hospital, Seoul, South Korea; Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, South Korea; Cancer Research Institute, Seoul National University, Seoul, South Korea.
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Zhang P, Chen Y, Zhu H, Yan L, Sun C, Pei S, Lodhi AF, Ren H, Gao Y, Manzoor R, Li B, Deng Y, Ma H. The Effect of Gamma-Ray-Induced Central Nervous System Injury on Peripheral Immune Response: An In Vitro and In Vivo Study. Radiat Res 2019; 192:440-450. [PMID: 31393823 DOI: 10.1667/rr15378.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Radiotherapy to treat brain tumors can potentially harm the central nervous system (CNS). The radiation stimulates a series of immune responses in both the CNS as well as peripheral immune system. To date, studies have mostly focused on the changes occurring in the immune response within the CNS. In this study, we investigated the effect of γ-ray-induced CNS injury on the peripheral immune response using a cell co-culture model and a whole-brain irradiation (WBI) rat model. Nerve cells (SH-SY5Y and U87 MG cells) were γ-ray irradiated, then culture media of the irradiated cells (conditioned media) was used to culture immune cells (THP-1 cells or Jurkat cells). Analyses were performed based on the response of immune cells in conditioned media. Sprague-Dawley rats received WBI at different doses, and were fed for one week to one month postirradiation. Spleen and peripheral blood were then isolated and analyzed. We observed that the number of monocytes in peripheral blood, and the level of NK cells and NKT cells in spleen increased after CNS injury. However, the level of T cells in spleen did not change and the level of B cells in the spleen decreased after γ-ray-induced CNS injury. These findings indicate that CNS injury caused by ionizing radiation induces a series of changes in the peripheral immune system.
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Affiliation(s)
- Peng Zhang
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China
| | - Yu Chen
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China
| | - Huiyang Zhu
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China
| | - Liben Yan
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China
| | - Chunli Sun
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China
| | - Sizhu Pei
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China
| | - Adil Farooq Lodhi
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China.,Department of Microbiology, Faculty of Health Sciences, Hazara University, Mansehra, Pakistan
| | - Hao Ren
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China
| | - Yanan Gao
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China
| | - Robina Manzoor
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China
| | - Bo Li
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China
| | - Yulin Deng
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China
| | - Hong Ma
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China
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