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Pike LRG, Miao E, Boe LA, Patil T, Imber BS, Myall NJ, Pollom EL, Hui C, Qu V, Langston J, Chiang V, Grant M, Goldberg SB, Palmer JD, Prasad RN, Wang TJC, Lee A, Shu CA, Chen LN, Thomas NJ, Braunstein SE, Kavanagh BD, Camidge DR, Rusthoven CG. Tyrosine Kinase Inhibitors With and Without Up-Front Stereotactic Radiosurgery for Brain Metastases From EGFR and ALK Oncogene-Driven Non-Small Cell Lung Cancer (TURBO-NSCLC). J Clin Oncol 2024; 42:3606-3617. [PMID: 39047224 DOI: 10.1200/jco.23.02668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/09/2024] [Accepted: 04/05/2024] [Indexed: 07/27/2024] Open
Abstract
PURPOSE Newer-generation tyrosine kinase inhibitors (TKIs) for non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK) rearrangements have demonstrated high CNS activity. The optimal use of up-front stereotactic radiosurgery (SRS) for brain metastases (BM) in patients eligible for CNS-penetrant TKIs is controversial, and data to guide patient management are limited. MATERIALS AND METHODS Data on TKI-naïve patients with EGFR- and ALK-driven NSCLC with BM treated with CNS-penetrant TKIs with and without up-front SRS were retrospectively collected from seven academic centers in the United States. Time-to-CNS progression and overall survival (OS) were analyzed, with multivariable adjustment in Fine & Gray and Cox proportional hazards models for clinically relevant factors. RESULTS From 2013 to 2022, 317 patients were identified (200 TKI-only and 117 TKI + SRS). Two hundred fifty (79%) and 61 (19%) patients received osimertinib and alectinib, respectively. Patients receiving TKI + SRS were more likely to have BM ≥1 cm (P < .001) and neurologic symptoms (P < .001) at presentation. Median OS was similar between the TKI and TKI + SRS groups (median 41 v 40 months, respectively; P = .5). On multivariable analysis, TKI + SRS was associated with a significant improvement in time-to-CNS progression (hazard ratio [HR], 0.63 [95% CI, 0.42 to 0.96]; P = .033). Local CNS control was significantly improved with TKI + SRS (HR, 0.30 [95% CI, 0.16 to 0.55]; P < .001), whereas no significant differences were observed in distant CNS control. Subgroup analyses demonstrated a greater benefit from TKI + SRS in patients with BM ≥1 cm in diameter for time-to-CNS progression and CNS progression-free survival. CONCLUSION The addition of up-front SRS to CNS-penetrant TKI improved time-to-CNS progression and local CNS control, but not OS, in patients with BM from EGFR- and ALK-driven NSCLC. Patients with larger BM (≥1 cm) may benefit the most from up-front SRS.
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Affiliation(s)
- Luke R G Pike
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Emily Miao
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
- Albert Einstein College of Medicine, Bronx, NY
| | - Lillian A Boe
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Tejas Patil
- Division of Hematology and Oncology, Department of Medicine, University of Colorado, Aurora, CO
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nathaniel J Myall
- Division of Hematology and Oncology, Department of Medicine, Stanford University, Palo Alto, CA
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University, Palo Alto, CA
| | - Caressa Hui
- Department of Radiation Oncology, Stanford University, Palo Alto, CA
| | - Vera Qu
- Department of Radiation Oncology, Stanford University, Palo Alto, CA
| | - Jacob Langston
- Department of Radiation Oncology, University of Colorado, Aurora, CO
| | | | - Michael Grant
- Division of Medical Oncology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Sarah B Goldberg
- Division of Medical Oncology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University, Columbus, OH
| | - Rahul N Prasad
- Department of Radiation Oncology, Ohio State University, Columbus, OH
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - Albert Lee
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - Catherine A Shu
- Division of Hematology and Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Lanyi Nora Chen
- Division of Hematology and Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Nicholas J Thomas
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Brian D Kavanagh
- Department of Radiation Oncology, University of Colorado, Aurora, CO
| | - D Ross Camidge
- Division of Hematology and Oncology, Department of Medicine, University of Colorado, Aurora, CO
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Aurora, CO
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Lehrer EJ, Breen WG, Singh R, Palmer JD, Brown PD, Trifiletti DM, Sheehan JP. Hypofractionated Stereotactic Radiosurgery in the Management of Brain Metastases. Neurosurgery 2024; 95:253-258. [PMID: 38511946 DOI: 10.1227/neu.0000000000002897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 01/09/2024] [Indexed: 03/22/2024] Open
Abstract
Stereotactic radiosurgery (SRS) is an important weapon in the management of brain metastases. Single-fraction SRS is associated with local control rates ranging from approximately 70% to 100%, which are largely dependent on lesion and postoperative cavity size. The rates of local control and improved neurocognitive outcomes compared with conventional whole-brain radiation therapy have led to increased adoption of SRS in these settings. However, when treating larger targets and/or targets located in eloquent locations, the risk of normal tissue toxicity and adverse radiation effects within healthy brain tissue becomes significantly higher. Thus, hypofractionated SRS has become a widely adopted approach, which allows for the delivery of ablative doses of radiation while also minimizing the risk of toxicity. This approach has been studied in multiple retrospective reports in both the postoperative and intact settings. While there are no reported randomized data to date, there are trials underway evaluating this paradigm. In this article, we review the role of hypofractionated SRS in the management of brain metastases and emerging data that will serve to validate this treatment approach. Pertinent articles and references were obtained from a comprehensive search of PubMed/MEDLINE and clinicaltrials.gov .
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Mayo Clinic, Rochester , Minnesota , USA
| | - William G Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester , Minnesota , USA
| | - Raj Singh
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester , Minnesota , USA
| | | | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
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3
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Shen M, Lin Q, Zou X, Wu Y, Lin Z, Shao L, Hong J, Chen J. The Effect of Intracranial Control After Intracranial Local Therapy on the Prognosis of Patients with Brain Metastasis of Lung Adenocarcinoma. Cancer Manag Res 2024; 16:977-988. [PMID: 39099763 PMCID: PMC11294678 DOI: 10.2147/cmar.s476837] [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: 05/21/2024] [Accepted: 07/20/2024] [Indexed: 08/06/2024] Open
Abstract
Purpose The aim of the present study was to assess the clinical outcomes and prognostic factors of lung adenocarcinoma patients with brain metastases (BMs) after intracranial local therapy. Patients and Methods A total of 83 lung adenocarcinoma patients with BMs who underwent craniotomy combined with radiotherapy or intracranial radiotherapy alone were retrospectively analyzed. The intracranial tumor response was determined according to the Response Assessment in Neuro-Oncology of Brain Metastases (RANO-BM) criteria. The median overall survival (OS), intracranial progression-free survival (iPFS), and related prognostic factors were analyzed with the Kaplan‒Meier estimator method and Cox proportional hazards regression model. Results Among 83 patients, 20 patients received craniotomy combined with radiotherapy, and 63 patients received intracranial radiotherapy alone. Following intracranial local therapy, 11 patients (13.3%) achieved complete response (CR); among them, 8 patients underwent neurosurgical resection. In addition, 32 patients (38.55%) achieved partial response (PR), 32 patients (38.55%) experienced stable disease (SD), and 8 (9.6%) experienced progressive disease (PD). The median follow-up period was 25.4 months (range 0.8-49.6 months). The median follow-up time for the iPFS was 16.2 months (range 0.6-41.2 months). The median OS, iPFS were 28.2 months and 24.7 months. Epidermal growth factor receptor (EGFR) / anaplastic lymphoma kinase (ALK) mutations (HR 3.216, 95% confidence interval (CI) 1.269-8.150, p = 0.014) and iPFS (HR 0.881, 95% CI 0.836-0.929, p < 0.001) were found to be beneficial factors for OS. An intracranial-tumor CR was associated with a longer iPFS (PR: HR 0.052, 95% CI 0.009-0.297, p = 0.001; SD: HR 0.081, 95% CI 0.025-0.259, p < 0.001; PD: HR 0.216, 95% CI 0.077-0.606, p = 0.004). Conclusion Prolonged iPFS was associated with better OS in lung adenocarcinoma patients with BMs following intracranial local therapy, and mutations of EGFR / ALK or an intracranial-tumor CR are independent prognostic factors for prolonged survival.
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Affiliation(s)
- Minmin Shen
- Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, People’s Republic of China
- Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, People’s Republic of China
- Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, People’s Republic of China
| | - Qiaojing Lin
- Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, People’s Republic of China
- Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, People’s Republic of China
| | - Xi Zou
- Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, People’s Republic of China
- Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, People’s Republic of China
- Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, People’s Republic of China
| | - Yufan Wu
- Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, People’s Republic of China
- Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, People’s Republic of China
| | - Zhihong Lin
- Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, People’s Republic of China
- Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, People’s Republic of China
| | - Linglong Shao
- Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, People’s Republic of China
- Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, People’s Republic of China
| | - JinSheng Hong
- Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, People’s Republic of China
- Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, People’s Republic of China
- Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, People’s Republic of China
| | - Jinmei Chen
- Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, People’s Republic of China
- Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, People’s Republic of China
- Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, People’s Republic of China
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Ahmad I, Chufal KS, Miller AA, Bajpai R, Umesh P, Dawer A, Tandon S, Gandhidasan S, Dua B, Bhatia K, Gairola M. Is it too early to recommend local treatment in oligometastatic non-small cell lung cancer: a plea for equipoise. Br J Radiol 2024; 97:913-919. [PMID: 38538948 PMCID: PMC11075973 DOI: 10.1093/bjr/tqae068] [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: 09/22/2023] [Revised: 03/13/2024] [Accepted: 03/21/2024] [Indexed: 05/09/2024] Open
Abstract
Oligometastatic non-small cell lung cancer (OMD NSCLC) has been proposed to bridge the spectrum between non-metastatic and widely metastatic states and is perceived as an opportunity for potential cure if removed. Twelve clinical trials on local treatment have been reported, yet none are conclusive. These trials informed the development of a joint clinical practice guideline by the American & European Societies for Radiation Oncology, which endorses local treatment for OMD NSCLC. However, the heterogeneity between prognostic factors within these trials likely influenced outcomes and can only support guidance at this time. Caution against an uncritical acceptance of the guideline is discussed, as strong recommendations are offered based on expert opinion and inconclusive evidence. The guideline is also examined by a patient's caregiver, who emphasizes that uncertain evidence impedes shared decision making.
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Affiliation(s)
- Irfan Ahmad
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi 110085, India
| | - Kundan Singh Chufal
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi 110085, India
| | - Alexis Andrew Miller
- Department of Radiation Oncology, Illawarra Cancer Care Center, NSW 2500, Australia
| | - Ram Bajpai
- School of Medicine, Keele University, Staffordshire ST5 5BG, United Kingdom
| | - Preetha Umesh
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi 110085, India
| | - Aashita Dawer
- Jindal Global Law School, OP Jindal Global University, Haryana 131001, India
| | - Sarthak Tandon
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi 110085, India
| | | | - Bharat Dua
- Department of Radiation Oncology, Venkateshwar Hospital, New Delhi 110078, India
| | - Kratika Bhatia
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi 110085, India
| | - Munish Gairola
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi 110085, India
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Liu Q, Fu Y, Guo J, Fu C, Tang N, Zhang C, Han X, Wang Z. Efficacy and survival outcomes of alectinib vs. crizotinib in ALK‑positive NSCLC patients with CNS metastases: A retrospective study. Oncol Lett 2024; 27:224. [PMID: 38586212 PMCID: PMC10996030 DOI: 10.3892/ol.2024.14357] [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: 11/20/2023] [Accepted: 02/29/2024] [Indexed: 04/09/2024] Open
Abstract
Anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) have transformed the treatment paradigm for patients with ALK-positive non-small cell lung cancer (NSCLC). Yet the differential efficacy between alectinib and crizotinib in treating patients with NSCLC and central nervous system (CNS) metastases has been insufficiently studied. A retrospective analysis was conducted of clinical outcomes of patients with ALK-positive NSCLC and CNS metastases treated at the Shandong Cancer Centre. Based on their initial ALK-TKI treatment, patients were categorised into either the crizotinib group or the alectinib group. Efficacy, progression-free survival (PFS), intracranial PFS and overall survival (OS) were evaluated. A total of 46 eligible patients were enrolled in the present study: 33 patients received crizotinib and 13 patients received alectinib. The median OS of the entire group was 66.8 months (95% CI: 48.5-85.1). Compared with the patients in the crizotinib group, the patients in the alectinib group showed a significant improvement in both median (m)PFS (27.5 vs. 9.5 months; P=0.003) and intracranial mPFS (36.0 vs. 10.8 months; P<0.001). However, there was no significant difference in OS between the alectinib and crizotinib groups (not reached vs. 58.7 months; P=0.149). Furthermore, there were no significant differences between patients receiving TKI combined with radiotherapy (RT) vs. TKI alone with respect to mPFS (11.0 vs. 11.7 months, P=0.863) as well as intracranial mPFS (12.5 vs. 16.9 months, P=0.721). In the present study, alectinib exhibited superior efficacy to crizotinib for treating patients with ALK-positive NSCLC and CNS metastases, especially in terms of delaying disease progression and preventing CNS recurrence. Moreover, the results demonstrated that it might be beneficial to delay local RT for patients with ALK-positive NSCL and CNS metastases.
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Affiliation(s)
- Qing Liu
- Department of Medical Oncology, Shandong Cancer Hospital and Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250117, P.R. China
| | - Ying Fu
- Department of Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Jun Guo
- Department of Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Chunqiu Fu
- Department of Oncology, Changqing People's Hospital, Jinan, Shandong 250300, P.R. China
| | - Ning Tang
- Department of Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Chufeng Zhang
- Department of Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Xiao Han
- Department of Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Zhehai Wang
- Department of Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
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Morikawa K, Numata Y, Shinozaki Y, Kaneko S, Matsushima A, Nishida M, Kida H, Handa H, Nishine H, Mineshita M. High efficacy of brigatinib for brain metastases in ALK fusion gene-positive non-small cell lung cancer: A case series. Thorac Cancer 2024; 15:496-499. [PMID: 38158887 PMCID: PMC10883856 DOI: 10.1111/1759-7714.15207] [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: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024] Open
Abstract
Anaplastic lymphoma kinase (ALK) fusion gene-positive lung cancer often shows brain metastasis at initial diagnosis or during the course of treatment. However, molecular-targeted drugs are known to pass through the blood-brain barrier and present positive effects for central nervous system lesions. There are few reports suggesting how effective molecular-targeted drug therapy alone is for brain metastasis lesions of ALK fusion-positive lung cancer, especially after the first use of ALK-tyrosine kinase inhibitor (TKI) or for bulky brain metastases. A patient in his mid-fifties with stage IV pleural dissemination developed brain metastases after 10 years of crizotinib use, but showed a complete response after switching to brigatinib. Moreover, a patient in her early sixties with stage III recurrent large brain metastases 5 years after chemoradiation therapy experienced dramatic tumor shrinkage with brigatinib. In each case of ALK fusion gene-positive lung cancer with brain metastases, brigatinib showed a high efficacy and was well-tolerated after previous ALK-TKI and for bulky lesions.
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Affiliation(s)
- Kei Morikawa
- Division of Respiratory Diseases, Department of Internal MedicineSt. Marianna University School of MedicineKawasakiJapan
| | - Yu Numata
- Division of Respiratory Diseases, Department of Internal MedicineSt. Marianna University School of MedicineKawasakiJapan
| | - Yusuke Shinozaki
- Division of Respiratory Diseases, Department of Internal MedicineSt. Marianna University School of MedicineKawasakiJapan
| | - Shotaro Kaneko
- Division of Respiratory Diseases, Department of Internal MedicineSt. Marianna University School of MedicineKawasakiJapan
| | - Aya Matsushima
- Division of Respiratory Diseases, Department of Internal MedicineSt. Marianna University School of MedicineKawasakiJapan
| | - Makoto Nishida
- Division of Respiratory Diseases, Department of Internal MedicineSt. Marianna University School of MedicineKawasakiJapan
| | - Hirotaka Kida
- Division of Respiratory Diseases, Department of Internal MedicineSt. Marianna University School of MedicineKawasakiJapan
| | - Hiroshi Handa
- Division of Respiratory Diseases, Department of Internal MedicineSt. Marianna University School of MedicineKawasakiJapan
| | - Hiroki Nishine
- Division of Respiratory Diseases, Department of Internal MedicineSt. Marianna University School of MedicineKawasakiJapan
| | - Masamichi Mineshita
- Division of Respiratory Diseases, Department of Internal MedicineSt. Marianna University School of MedicineKawasakiJapan
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Viktorsson K, Rieckmann T, Fleischmann M, Diefenhardt M, Hehlgans S, Rödel F. Advances in molecular targeted therapies to increase efficacy of (chemo)radiation therapy. Strahlenther Onkol 2023; 199:1091-1109. [PMID: 37041372 PMCID: PMC10673805 DOI: 10.1007/s00066-023-02064-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/19/2023] [Indexed: 04/13/2023]
Abstract
Recent advances in understanding the tumor's biology in line with a constantly growing number of innovative technologies have prompted characterization of patients' individual malignancies and may display a prerequisite to treat cancer at its patient individual tumor vulnerability. In recent decades, radiation- induced signaling and tumor promoting local events for radiation sensitization were explored in detail, resulting the development of novel molecular targets. A multitude of pharmacological, genetic, and immunological principles, including small molecule- and antibody-based targeted strategies, have been developed that are suitable for combined concepts with radiation (RT) or chemoradiation therapy (CRT). Despite a plethora of promising experimental and preclinical findings, however, so far, only a very limited number of clinical trials have demonstrated a better outcome and/or patient benefit when RT or CRT are combined with targeted agents. The current review aims to summarize recent progress in molecular therapies targeting oncogenic drivers, DNA damage and cell cycle response, apoptosis signaling pathways, cell adhesion molecules, hypoxia, and the tumor microenvironment to impact therapy refractoriness and to boost radiation response. In addition, we will discuss recent advances in nanotechnology, e.g., RNA technologies and protein-degrading proteolysis-targeting chimeras (PROTACs) that may open new and innovative ways to benefit from molecular-targeted therapy approaches with improved efficacy.
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Affiliation(s)
- Kristina Viktorsson
- Department of Oncology/Pathology, Karolinska Institutet, Visionsgatan 4, 17164, Solna, Sweden
| | - Thorsten Rieckmann
- Department of Radiation Oncology, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Otolaryngology, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Maximilian Fleischmann
- Department of Radiotherapy and Oncology, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), University of Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Markus Diefenhardt
- Department of Radiotherapy and Oncology, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), University of Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Stephanie Hehlgans
- Department of Radiotherapy and Oncology, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Franz Rödel
- Department of Radiotherapy and Oncology, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
- Frankfurt Cancer Institute (FCI), University of Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
- German Cancer Consortium (DKTK) partner site: Frankfurt, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
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8
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Mannam SS, Bray DP, Nwagwu CD, Zhong J, Shu HK, Eaton B, Sudmeier L, Goyal S, Deibert C, Nduom EK, Olson J, Hoang KB. Examining the Effect of ALK and EGFR Mutations on Survival Outcomes in Surgical Lung Brain Metastasis Patients. Cancers (Basel) 2023; 15:4773. [PMID: 37835467 PMCID: PMC10572022 DOI: 10.3390/cancers15194773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/24/2023] [Accepted: 09/28/2023] [Indexed: 10/15/2023] Open
Abstract
In the context of the post-genomic era, where targeted oncological therapies like monoclonal antibodies (mAbs) and tyrosine-kinase inhibitors (TKIs) are gaining prominence, this study investigates whether these therapies can enhance survival for lung carcinoma patients with specific genetic mutations-EGFR-amplified and ALK-rearranged mutations. Prior to this study, no research series had explored how these mutations influence patient survival in cases of surgical lung brain metastases (BMs). Through a multi-site retrospective analysis, the study examined patients who underwent surgical resection for BM arising from primary lung cancer at Emory University Hospital from January 2012 to May 2022. The mutational statuses were determined from brain tissue biopsies, and survival analyses were conducted. Results from 95 patients (average age: 65.8 ± 10.6) showed that while 6.3% had anaplastic lymphoma kinase (ALK)-rearranged mutations and 20.0% had epidermal growth factor receptor (EGFR)-amplified mutations-with 9.5% receiving second-line therapies-these mutations did not significantly correlate with overall survival. Although the sample size of patients receiving targeted therapies was limited, the study highlighted improved overall survival and progression-free survival rates compared to earlier trials, suggesting advancements in systemic lung metastasis treatment. The study suggests that as more targeted therapies emerge, the prospects for increased overall survival and progression-free survival in lung brain metastasis patients will likely improve.
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Affiliation(s)
- Sneha Sai Mannam
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - David P. Bray
- Department of Neurosurgery, Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Chibueze D. Nwagwu
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Jim Zhong
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA (H.-K.S.)
| | - Hui-Kuo Shu
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA (H.-K.S.)
| | - Bree Eaton
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA (H.-K.S.)
| | - Lisa Sudmeier
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA (H.-K.S.)
| | - Subir Goyal
- Biostatistics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
| | - Christopher Deibert
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Edjah K. Nduom
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Jeffrey Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Kimberly B. Hoang
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA 30322, USA
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9
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Kuan AS, Chiang CL, Wu HM, Yang HC, Chen CJ, Lin CJ, Guo WY, Pan DHC, Chung WY, Lee CC. Improved survival and intracranial tumor control of EGFR-mutated NSCLC patients with newly developed brain metastases following stereotactic radiosurgery and EGFR-TKI: a large retrospective cohort study and meta-analyses. J Neurooncol 2023; 164:729-739. [PMID: 37721662 DOI: 10.1007/s11060-023-04452-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 09/12/2023] [Indexed: 09/19/2023]
Abstract
PURPOSE To examine the differential effects of SRS and TKI on EGFR-mutated NSCLC patients with brain metastases (BMs) and outcomes following continuation of the same TKI agent in case of new BMs. METHODS This study included 608 NSCLC patients (2,274 BMs) while meta-analyses included 1,651 NSCLC patients (> 3,944 BMs). Overall survival (OS) and intracranial progression free survival (iPFS) were estimated using Kaplan-Meier methods. Hazard ratios (95% CI) of prognostic factors were estimated using Cox regression models. RESULTS The median OS/iPFS (95% CI) (months) for patients with wildtype EGFR/ALK, EGFR mutations, and ALK rearrangements were 17.7 (12.9-23.6)/12.1 (9.8-15.6), 28.9 (23.8-33.3)/17.7 (14.8-21.2), and 118.0 (not reached)/71.7 (15.1-not reached), respectively. In EGFR-mutated patients, meta-analyses combining our data showed significantly improved OS and iPFS of patients who received SRS and TKI (OS:35.1 months, iPFS:20.0 months) when compared to those who have SRS alone (OS:20.8 months, iPFS:11.8 months) or TKI alone (OS:24.3 months, iPFS:13.8 months). Having SRS for newly diagnosed BMs while keeping the existing TKI agent yielded OS (30.0 vs. 32.1 months, p = 0.200) non-inferior to patients who started combined SRS and TKI therapy for their newly diagnosed NSCLC with BMs. Multivariable analyses showed that good performance score and TKI therapy were associated with improved outcomes. CONCLUSIONS Combined SRS and TKI resulted in favorable outcomes in EGFR-mutated NSCLC patients with newly diagnosed BMs. Continuation of the same TKI agent plus SRS in case of new brain metastases yielded good clinical outcomes and may be considered a standard-of-care treatment.
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Affiliation(s)
- Ai Seon Kuan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Public Health, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chi-Lu Chiang
- Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, TX, USA
| | - Chung-Jung Lin
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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10
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Kawashima M, Akabane A, Noda R, Segawa M, Tsunoda S, Inoue T. Comparing Fractionated and Single-Fraction Gamma Knife Radiosurgery for Brain Metastases From Non-Small-Cell Lung Cancer With a Focus on Driver Alterations. Cureus 2023; 15:e41849. [PMID: 37581146 PMCID: PMC10423099 DOI: 10.7759/cureus.41849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 08/16/2023] Open
Abstract
Background As the overall survival in non-small-cell lung cancer has increased, safer, long-term treatments for brain metastases are increasingly needed. This study aimed to analyze the outcomes of fractionated and single-fraction gamma knife radiosurgery for brain metastases from non-small-cell lung cancer, focusing on driver alteration status. Methodology Patients who underwent gamma knife radiosurgery as their first local treatment for brain metastases from non-small-cell lung cancer between May 2018 and December 2021 at our institution were retrospectively enrolled. Results Among the 98 patients (287 lesions), 45 (130 lesions) harbored driver alterations, including epidermal growth factor receptor mutations in 35 patients and anaplastic lymphoma kinase or ROS1 rearrangement in 10 patients. Overall, 64 and 34 patients underwent single-fraction and fractionated radiosurgery (3-15 fractions), respectively. Large tumor size was a risk factor for recurrence, while fractionated radiosurgery (subdistribution hazard ratio (sHR) = 16.47; confidence interval (CI) = 3.58-75.77; p < 0.001) and small tumor size (sHR = 1.15; CI = 1.04-1.28; p = 0.008) independently protected against radiation necrosis. In the case-matched analyses, the cumulative radiation necrosis rates were significantly lower in the fractionated group than in the single-fraction group among all lesions (p = 0.017) and among those with driver alterations (p = 0.046), whereas no significant difference was confirmed among wild-type lesions (p = 0.382). Conclusions Fractionated gamma knife radiosurgery may be an alternative therapeutic approach for reducing the risk of radiation necrosis, particularly for patients with driver alterations, even when the tumors are small. Further research is necessary to determine the optimal indications for fractionated gamma knife radiosurgery and fractionation methods.
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Affiliation(s)
| | - Atsuya Akabane
- Gamma Knife Center, NTT Medical Center Tokyo, Tokyo, JPN
| | - Ryuichi Noda
- Gamma Knife Center, NTT Medical Center Tokyo, Tokyo, JPN
| | - Masafumi Segawa
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, JPN
| | - Sho Tsunoda
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, JPN
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, JPN
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11
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Dohm AE, Tang JD, Mills MN, Liveringhouse CL, Sandoval ML, Perez BA, Robinson TJ, Creelan BC, Gray JE, Etame AB, Vogelbaum MA, Forsyth P, Yu HHM, Oliver DE, Ahmed KA. Clinical outcomes of non-small cell lung cancer brain metastases treated with stereotactic radiosurgery and immune checkpoint inhibitors, EGFR tyrosine kinase inhibitors, chemotherapy and immune checkpoint inhibitors, or chemotherapy alone. J Neurosurg 2023; 138:1600-1607. [PMID: 36681988 DOI: 10.3171/2022.9.jns221896] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/30/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Immune checkpoint inhibitors (ICIs) and epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) are commonly used in the systemic management of non-small cell lung cancer (NSCLC) brain metastases (BMs). However, optimizing control of NSCLC BM with stereotactic radiosurgery (SRS) and various systemic therapies remains an area of investigation. METHODS Between 2016 and 2019, the authors identified 171 NSCLC BM patients with 646 BMs treated with single-fraction SRS within 3 months of receiving treatment with ICIs (n = 56; 33%), EGFR-TKI (n = 30; 18%), chemotherapy and ICIs (n = 23; 14%), or standard chemotherapy alone (n = 62; 36%). Time-to-event analysis was conducted, and outcomes included distant intracranial control (DIC), local control (LC), and overall survival from SRS. RESULTS The median follow-up from BM diagnosis was 8.9 months (range 0.3-127 months). The 12-month Kaplan-Meier DIC rates were 37%, 53%, 41%, and 21% (p = 0.047) for the ICI, EGFR-TKI, ICI and chemotherapy, and chemotherapy-alone groups, respectively. On multivariate analysis, DIC was improved with EGFR-TKI (HR 0.4, 95% CI 0.3-0.8, p = 0.005) compared with conventional chemotherapy and treatment with SRS before systemic therapy (HR 0.5, 95% CI 0.3-0.9, p = 0.03) compared with after; and LC was improved with SRS before (HR 0.4, 95% CI 0.2-0.9, p = 0.03) or concurrently (HR 0.3, 95% CI 0.1-0.6, p = 0.003) compared with after. No differences in radionecrosis were noted by timing or type of systemic therapy. CONCLUSIONS The authors' analysis showed significant differences in DIC based on receipt of systemic therapy and treatment with SRS before systemic therapy improved DIC. Prospective evaluation of the potential synergism between systemic therapy and SRS in NSCLC BM management is warranted.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Peter Forsyth
- 4Neuro-Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Wandrey NE, Gao D, Robin TP, Contessa JN, Singh C, Chiang V, Li J, Chen A, Wang Y, Sheehan JP, Dutta SW, Weiss SE, Paly J, Rusthoven CG. Multicenter analysis of stereotactic radiosurgery for multiple brain metastases from EGFR and ALK driven non-small cell lung cancer. Lung Cancer 2023; 176:144-148. [PMID: 36641932 PMCID: PMC10552603 DOI: 10.1016/j.lungcan.2022.11.019] [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: 07/23/2022] [Revised: 10/02/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Patients with brain metastases (BrMs) arising from EGFR and ALK driven non-small cell lung cancer (NSCLC) have favorable prognoses and evolving treatment options. We evaluated multicenter outcomes for stereotactic radiosurgery (SRS) to multiple (≥4) BrMs, where randomized data remain limited. METHODS Data were collected retrospectively from 5 academic centers on EGFR and ALK NSCLC who received SRS to ≥4 BrMs with their first SRS treatment between 2008 and 2018. Analyzed endpoints included overall survival (OS), freedom from CNS progression (FFCNSP), and freedom from whole-brain radiotherapy (FFWBRT). RESULTS Eighty-nine patients (50 EGFR, 39 ALK) received a total of 159 SRS treatments to 1,080 BrMs, with a median follow up of 51.3 months. The median number of BrMs treated with SRS treatment-1 was 6 (range 4-26) and median for all treatments was 9 (range 4-47). Sixteen patients (18 %) had received WBRT prior to SRS treatment-1. The median OS was 24.2, 21.2, and 33.2 months for all patients, EGFR, and ALK subsets, respectively. After multivariable adjustment, only receipt of a next-generation tyrosine kinase inhibitor was associated with OS (HR 0.40, p = 0.005). No differences in OS were observed based on number of BrMs treated. The median FFCNSP was 9.4, 11.6, and 7.5 months, for all patients, EGFR, and ALK subsets, respectively. After multivariable adjustment, the number of BrMs (continuous) treated during treatment-1 was the only negative prognostic factor associated with FFCNSP (HR 1.071, p = 0.045). The 5-year FFWBRT was 73.6 %. CONCLUSIONS This multicenter analysis over a >10-year period demonstrated favorable OS, FFCNSP, and FFWBRT, in patients with EGFR and ALK driven NSCLC receiving SRS to ≥4 BrMs. These data support SRS as an option in the upfront and salvage setting for higher burden CNS disease in this population.
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Affiliation(s)
| | - Dexiang Gao
- University of Colorado, Aurora, CO, United States
| | | | | | - Charu Singh
- Yale University, New Haven, CT, United States
| | | | - Jing Li
- The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Aileen Chen
- The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Yan Wang
- The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | | | | | | | - Jonathan Paly
- Massachusetts General Hospital, Boston, MA, United States
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13
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Natural history of lung squamous cell brain metastases in patients treated with radiosurgery: a thirty-year experience at a tertiary medical center. J Neurooncol 2023; 161:135-146. [PMID: 36469189 DOI: 10.1007/s11060-022-04153-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 09/29/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE In this study we report our 30-year experience in stereotactic radiosurgery (SRS) treatment of lung squamous cell carcinoma (LUSC) brain metastases (BMs). It will serve to provide detailed longitudinal outcomes and predictors of efficacy in treating LUSC-BMs with SRS. METHOD We retrospectively reviewed 51 patients and 109 tumors treated with SRS at our center between 1993 and 2022. Patient demographics, PDL1 genotype, immunotherapy use and mortality cause were recorded. Radiological and clinical outcomes were followed at 1-3-month intervals post-SRS. Cox-regression analysis and Kaplan-Meier survival curves were performed in statistical analysis. RESULTS We included 37 male and 14 female patients (median age 62.7 years at BM diagnosis). Median overall survival (OS) time was 6.9 months, 6-month OS rate was 62.1%, and Karnofsky performance scale (KPS) was the only independent predictor. Median time for local control maintenance was 7.6 months, 6-month local control rate was 69.1%, with TKI as the only independent predictor. Median time to distant failure was 5.13 months, 6-month distant failure rate was 51.1%, and factors with significant impact included gender (p = 0.002), presence of extracranial metastases (p < 0.001), use of immunotherapy(p < 0.001), PDL1 genotype (p = 0.034), and total intracranial metastases number (p = 0.008). However, no definitive benefits of immunotherapy were identified in patients with higher PDL1 mutational tumors. CONCLUSION In this study we defined the natural history of disease progression and outcomes in SRS-treated LUSC-BM patients. We also identified predictors of OS and tumor control among these patients. The findings of this study will serve as a guide when counseling these patients for SRS.
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14
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Perng PS, Hsu HP, Lee PH, Huang CC, Lin CC, Lee JS. Correlation of EGFR mutation subtypes and survival in surgically treated brain metastasis from non-small-cell lung cancer. Asian J Surg 2023; 46:269-276. [PMID: 35393224 DOI: 10.1016/j.asjsur.2022.03.076] [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: 11/11/2021] [Revised: 03/13/2022] [Accepted: 03/22/2022] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Epidermal growth factor receptor (EGFR) mutation is a positive prognostic factor for survival in patients with non-small-cell lung cancer (NSCLC). In such patients, brain metastasis signifies negative outcomes. Patients with NSCLC brain metastasis that may benefit from neurosurgery is under investigation. We aim to investigate the impact of different mutation loci in surgically treated NSCLC brain metastasis patients. METHODS This retrospective cohort study included patients with NSCLC brain metastasis who underwent brain lesionectomy, followed by radiotherapy and chemotherapy or targeted therapy. Demographics and tumor characteristics were compared between the EGFR mutant type and wild type groups. Postoperative survival and risk factors were analyzed using log rank and Cox regression methods. RESULTS Overall, 101 patients were included, with 57 belonging to the EGFR mutant type group and 44 to the EGFR wild type group. The median postoperative survival was 17 months for the entire cohort, with the duration being 19 and 14 months for EGFR mutant type and wild type patients (p = 0.013), respectively. Multivariate analysis revealed that exon 19 del (p = 0.02) and a high Karnofsky Performance Scale score (p < 0.01) were independent positive prognostic factors to predict survival. The timing of development of the brain metastasis or the location of the intracranial metastasis was not associated with EGFR mutations. CONCLUSION EGFR mutations are associated with better survival outcomes in patients with NSCLC brain metastasis suitable for surgical treatment. This advantage was attributed to patients having a specific mutation of exon 19 deletion.
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Affiliation(s)
- Pang-Shuo Perng
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hui-Ping Hsu
- Section of General Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Hsuan Lee
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chi-Chen Huang
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chien-Chung Lin
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Biochemistry and Molecular Biology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jung-Shun Lee
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Cell Biology and Anatomy, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Li N, Xie M, Zhou Z, Sheng J, Yu X, Fan Y. Real-world treatment and prognostic factors for survival in ALK+ non-small cell lung cancer (NSCLC) patients with brain metastases in China. Thorac Cancer 2022; 14:237-245. [PMID: 36411716 PMCID: PMC9870733 DOI: 10.1111/1759-7714.14739] [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: 09/18/2022] [Revised: 11/03/2022] [Accepted: 11/06/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND To explore the efficacy and prognostic factors of different treatment modalities on anaplastic lymphoma kinase (ALK)+ non-small cell lung cancer (NSCLC) patients with brain metastases (BMs). METHODS A total of 86 patients were enrolled into the study. They were divided into two cohorts based on their history of treatment with ALK tyrosine kinase inhibitors (ALK-TKIs) prior to the incidence of BMs. ALK-TKI-naïve patients with BMs were included in cohort 1 (n = 59); patients who developed BMs after ALK-TKIs treatment were enrolled in cohort 2 (n = 27). Prognostic factors related with overall survival (OS) when treated with ALK-TKIs were assessed in multivariable analysis. RESULTS With a median follow-up of 41.8 months, the median OS was 34.8 months. In cohort 1, the OS, intracranial progression-free survival (iPFS), and progression-free survival (PFS) were 38.7 months (95% CI: 23.3 to 54.1), 18.5 months (95% CI: 9.6 to 27.4), and 19.1 months (95% CI: 13.7 to 24.5), respectively. Significantly improved OS and iPFS were noted in those patients in which second-generation ALK-TKIs versus crizotinib were initiated (OS: not reached vs. 29.0 months, p = 0.040; iPFS: 22.8 vs. 11.9 months, p = 0.035). In cohort 2, patients who experienced BMs as a result of the treatment failure of ALK-TKIs had a median OS of 27.1 months. Considerable duration of stable disease in patients with measurable BMs was observed (iPFS: 11.5 months, 95% CI: 4.4 to 18.6; PFS: 12.2 months, 95% CI: 3.2 to 21.1). CONCLUSION Second-generation ALK-TKIs further improved the duration of intracranial response and survival in ALK+ NSCLC patients with BMs in a real-world setting. The potent intracranial efficacy of second-generation ALK-TKIs might generate the lowered urgency of local treatment.
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Affiliation(s)
- Na Li
- The First Clinical Medical College of Wenzhou Medical UniversityWenzhouChina,Department of Medical Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital)Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of SciencesHangzhouChina
| | - Mingying Xie
- Department of Medical Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital)Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of SciencesHangzhouChina,The Second Clinical Medical College of Zhejiang Chinese Medical UniversityHangzhouChina
| | - Zichao Zhou
- Department of Medical Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital)Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of SciencesHangzhouChina,The Second Clinical Medical College of Zhejiang Chinese Medical UniversityHangzhouChina
| | - Jiamin Sheng
- Department of Medical Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital)Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of SciencesHangzhouChina
| | - Xiaoqing Yu
- Department of Medical Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital)Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of SciencesHangzhouChina
| | - Yun Fan
- Department of Medical Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital)Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of SciencesHangzhouChina
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Lehrer EJ, Kowalchuk RO, Ruiz-Garcia H, Merrell KW, Brown PD, Palmer JD, Burri SH, Sheehan JP, Quninoes-Hinojosa A, Trifiletti DM. Preoperative stereotactic radiosurgery in the management of brain metastases and gliomas. Front Surg 2022; 9:972727. [PMID: 36353610 PMCID: PMC9637863 DOI: 10.3389/fsurg.2022.972727] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 10/04/2022] [Indexed: 01/24/2023] Open
Abstract
Stereotactic radiosurgery (SRS) is the delivery of a high dose ionizing radiation in a highly conformal manner, which allows for significant sparing of nearby healthy tissues. It is typically delivered in 1-5 sessions and has demonstrated safety and efficacy across multiple intracranial neoplasms and functional disorders. In the setting of brain metastases, postoperative and definitive SRS has demonstrated favorable rates of tumor control and improved cognitive preservation compared to conventional whole brain radiation therapy. However, the risk of local failure and treatment-related complications (e.g. radiation necrosis) markedly increases with larger postoperative treatment volumes. Additionally, the risk of leptomeningeal disease is significantly higher in patients treated with postoperative SRS. In the setting of high grade glioma, preclinical reports have suggested that preoperative SRS may enhance anti-tumor immunity as compared to postoperative radiotherapy. In addition to potentially permitting smaller target volumes, tissue analysis may permit characterization of DNA repair pathways and tumor microenvironment changes in response to SRS, which may be used to further tailor therapy and identify novel therapeutic targets. Building on the work from preoperative SRS for brain metastases and preclinical work for high grade gliomas, further exploration of this treatment paradigm in the latter is warranted. Presently, there are prospective early phase clinical trials underway investigating the role of preoperative SRS in the management of high grade gliomas. In the forthcoming sections, we review the biologic rationale for preoperative SRS, as well as pertinent preclinical and clinical data, including ongoing and planned prospective clinical trials.
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Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Roman O. Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Kenneth W. Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Paul D. Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Joshua D. Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Stuart H. Burri
- Department of Radiation Oncology, Atrium Health, Charlotte, NC, United States
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | | | - Daniel M. Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States,Correspondence: Daniel M. Trifiletti
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Xu M, Song K, Zhou Z, Yu Z, Lv Y, Xu H. Survival and prognostic factors in patients undergoing the resection of solitary brain metastasis from non-small cell lung cancer: a retrospective cohort study. J Thorac Dis 2022; 14:4113-4124. [PMID: 36389303 PMCID: PMC9641336 DOI: 10.21037/jtd-22-1279] [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: 08/22/2022] [Accepted: 10/12/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Neurosurgery is the standard of care for resectable solitary brain metastasis (BM) from non-small cell lung cancer (NSCLC), but still with a poor outcome. Postoperative whole-brain radiotherapy (WBRT) was reported to reduce local recurrence, whether it could prolong survival was uncertain. In this study, we attempted to evaluate WBRT and other prognostic for overall survival (OS) in these patients. METHODS In this retrospective study, NSCLC patients with a solitary BM and controlled primary tumor who underwent neurosurgical resection were selected from the medical records database between January 2014 and December 2018. Clinical data, disease control/progression results and survival outcomes were obtained from the medical records, regular outpatient follow-up and telephone interviews. Univariable and multivariable Cox analyses of potential prognostic factors including patients' characteristics, BM features, tissue-based parameters and postoperative treatments were conducted. OS was illustrated using Kaplan-Meier curves, and group differences were assessed using the log-rank test. The subgroup analysis compared each variable between the WBRT group and the untreated control by the hazard ratio and its 95% confidence interval (CI). RESULTS A total of 94 patients were included, with a median OS of 812 days. Univariable analysis showed that postoperative WBRT and targeted therapy were associated with OS. Multivariable analysis demonstrated that postoperative WBRT [P<0.001, hazard ratio (HR) 0.357], chemotherapy (P=0.008, HR 0.512), targeted therapy (P<0.001, HR 0.265), and smaller tumor size (P=0.018, HR 0.553) were independent prognostic factors for prolonged OS. However, tissue-based parameters (Ki67 tumor cell proliferation index, epidermal growth factor receptor, and checkpoint levels) were identified as statistically insignificant factors. In the subgroup analysis, the beneficial effect of WBRT was only observed in patients that did not receive systematic treatments. CONCLUSIONS Postoperative WBRT and systematic treatments after solitary BM resection improve the prognosis of NSCLC patients with a controlled primary tumor. Postoperative WBRT could be considered, especially for those who not receive systematic chemotherapy or targeted therapy treatments, as they might be more likely to benefit from it.
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Affiliation(s)
- Ming Xu
- Department of Anesthesiology and Perioperative Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Kun Song
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China;,National Center for Neurological Disorders, Shanghai, China;,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China;,Neurosurgical Institute of Fudan University, Shanghai, China;,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Zhirui Zhou
- Radiation Oncology Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ziye Yu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China;,National Center for Neurological Disorders, Shanghai, China;,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China;,Neurosurgical Institute of Fudan University, Shanghai, China;,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Yizheng Lv
- Department of Anesthesiology and Perioperative Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hongzhi Xu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China;,National Center for Neurological Disorders, Shanghai, China;,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China;,Neurosurgical Institute of Fudan University, Shanghai, China;,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
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EGFR mutant status and tyrosine-kinase inhibitors affect the GKRS outcomes for NSCLC brain metastases. J Neurooncol 2022; 159:675-684. [PMID: 35976545 DOI: 10.1007/s11060-022-04110-8] [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: 05/12/2022] [Accepted: 08/01/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE Tyrosine kinase inhibitors (TKIs) is the first-line treatment for EGFR-positive non-small cell lung cancer (NSCLC); however, its applicability to patients with wild-type NSCLC remains an issue of contention. This study compared the effects of gamma knife radiosurgery (GKRS) alone versus combining GKRS and TKIs in treating two genetic forms of NSCLC. METHODS This retrospective study examined 479 NSCLC patients with 1982 brain metastases who underwent GKRS and for whom imaging follow-up data or death records were available. All our patients were consecutive. All gene mutations were confirmed by lung biopsy. The three main endpoints in this study were overall survival (OS), local intracranial tumor control (LC), and distal intracranial tumor control (DC). RESULTS There were 296 NSCLC patients with EGFR positive: TKI treatment (n = 262) and without TKI treatment (n = 34). GKRS + TKIs was more effective than GKRS alone in terms of OS (HR 0.53, p = 0.085) and DC (HR 0.51, p < 0.001). There were 150 NSCLC patients with wild-type EGFR: TKI treatment (n = 50) and without TKI treatment (n = 100). GKRS + TKIs was less effective than GKRS alone in terms of OS (HR 1.82, p = 0.049) and DC (HR: 1.40, p = 0.011). We observed no difference in terms of LC in both genetic groups. CONCLUSIONS Combining GKRS with TKIs proved effective in EGFR positive NSCLC patients; however, we do not observe the similar results when combining GKRS with TKIs for patients with wild-type NSCLC.
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London D, Patel DN, Donahue B, Navarro RE, Gurewitz J, Silverman JS, Sulman E, Bernstein K, Palermo A, Golfinos JG, Sabari JK, Shum E, Velcheti V, Chachoua A, Kondziolka D. The incidence and predictors of new brain metastases in patients with non-small cell lung cancer following discontinuation of systemic therapy. J Neurosurg 2022; 137:544-554. [PMID: 34891140 DOI: 10.3171/2021.9.jns212150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/24/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients with non-small cell lung cancer (NSCLC) metastatic to the brain are living longer. The risk of new brain metastases when these patients stop systemic therapy is unknown. The authors hypothesized that the risk of new brain metastases remains constant for as long as patients are off systemic therapy. METHODS A prospectively collected registry of patients undergoing radiosurgery for brain metastases was analyzed. Of 606 patients with NSCLC, 63 met the inclusion criteria of discontinuing systemic therapy for at least 90 days and undergoing active surveillance. The risk factors for the development of new tumors were determined using Cox proportional hazards and recurrent events models. RESULTS The median duration to new brain metastases off systemic therapy was 16.0 months. The probability of developing an additional new tumor at 6, 12, and 18 months was 26%, 40%, and 53%, respectively. There were no additional new tumors 22 months after stopping therapy. Patients who discontinued therapy due to intolerance or progression of the disease and those with mutations in RAS or receptor tyrosine kinase (RTK) pathways (e.g., KRAS, EGFR) were more likely to develop new tumors (hazard ratio [HR] 2.25, 95% confidence interval [CI] 1.33-3.81, p = 2.5 × 10-3; HR 2.51, 95% CI 1.45-4.34, p = 9.8 × 10-4, respectively). CONCLUSIONS The rate of new brain metastases from NSCLC in patients off systemic therapy decreases over time and is uncommon 2 years after cessation of cancer therapy. Patients who stop therapy due to toxicity or who have RAS or RTK pathway mutations have a higher rate of new metastases and should be followed more closely.
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Affiliation(s)
| | | | - Bernadine Donahue
- 2Radiation Oncology, and
- 3Department of Radiation Oncology, Maimonides Cancer Center, Brooklyn, New York
| | | | | | | | | | | | | | | | - Joshua K Sabari
- 4Medical Oncology, NYU Langone Health, Perlmutter Cancer Center, New York University, New York; and
| | - Elaine Shum
- 4Medical Oncology, NYU Langone Health, Perlmutter Cancer Center, New York University, New York; and
| | - Vamsidhar Velcheti
- 4Medical Oncology, NYU Langone Health, Perlmutter Cancer Center, New York University, New York; and
| | - Abraham Chachoua
- 4Medical Oncology, NYU Langone Health, Perlmutter Cancer Center, New York University, New York; and
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Zheng L, Xie H, Luo X, Yang Y, Zhang Y, Li Y, Yin S, Li H, Xie C. Radiomic Signatures for Predicting EGFR Mutation Status in Lung Cancer Brain Metastases. Front Oncol 2022; 12:931812. [PMID: 35912248 PMCID: PMC9334014 DOI: 10.3389/fonc.2022.931812] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/17/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundLung cancer is the most common primary tumor metastasizing to the brain. A significant proportion of lung cancer patients show epidermal growth factor receptor (EGFR) mutation status discordance between the primary cancer and the corresponding brain metastases, which can affect prognosis and therapeutic decision-making. However, it is not always feasible to obtain brain metastases samples. The aim of this study was to establish a radiomic model to predict the EGFR mutation status of lung cancer brain metastases.MethodsData from 162 patients with resected brain metastases originating from lung cancer (70 with mutant EGFR, 92 with wild-type EGFR) were retrospectively analyzed. Radiomic features were extracted using preoperative brain magnetic resonance (MR) images (contrast-enhanced T1-weighted imaging, T1CE; T2-weighted imaging, T2WI; T2 fluid-attenuated inversion recovery, T2 FLAIR; and combinations of these sequences), to establish machine learning-based models for predicting the EGFR status of excised brain metastases (108 metastases for training and 54 metastases for testing). The least absolute shrinkage selection operator was used to select informative features; radiomics models were built with logistic regression of the training cohort, and model performance was evaluated using an independent test set.ResultsThe best-performing model was a combination of 10 features selected from multiple sequences (two from T1CE, five from T2WI, and three from T2 FLAIR) in both the training and test sets, resulting in classification area under the curve, accuracy, sensitivity, and specificity values of 0.85 and 0.81, 77.8% and 75.9%, 83.7% and 73.1%, and 73.8% and 78.6%, respectively.ConclusionsRadiomic signatures integrating multi-sequence MR images have the potential to noninvasively predict the EGFR mutation status of lung cancer brain metastases.
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Affiliation(s)
- Lie Zheng
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Hui Xie
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Xiao Luo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Yadi Yang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Yijun Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Pathology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Yue Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Molecular Diagnostics, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Shaohan Yin
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Hui Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- *Correspondence: Chuanmiao Xie, ; Hui Li,
| | - Chuanmiao Xie
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- *Correspondence: Chuanmiao Xie, ; Hui Li,
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21
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Tsui DCC, Camidge DR, Rusthoven CG. Managing Central Nervous System Spread of Lung Cancer: The State of the Art. J Clin Oncol 2022; 40:642-660. [PMID: 34985937 DOI: 10.1200/jco.21.01715] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Brain metastases (BrM) are common in both non-small-cell lung cancer and small-cell lung cancer. Substantial progress in BrM management has occurred in the past decade related to advances in both radiation and medical oncology. Recent and ongoing radiation trials have focused on increasing the candidacy for focal therapy of BrM with stereotactic radiosurgery; reducing the toxicity and improving patient selection for whole brain radiotherapy; and, in small-cell lung cancer, evaluating brain magnetic resonance imaging surveillance without prophylactic cranial irradiation, hippocampal avoidance in prophylactic cranial irradiation and whole brain radiotherapy, and the role of upfront stereotactic radiosurgery for BrM. In medical oncology, the development of multiple tyrosine kinase inhibitors with encouraging CNS activity and emerging data on the CNS activity of immune checkpoint inhibitors in some patients have opened the door to novel systemic and multidisciplinary treatment strategies for the management of BrM. Future research will focus on more robust characterizations of the CNS activity of targeted therapy and immunotherapies, as well as optimal integration and patient selection for multidisciplinary strategies involving CNS-active drugs, radiation therapy, and CNS surveillance.
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Affiliation(s)
- David Chun Cheong Tsui
- Division of Medical Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
| | - D Ross Camidge
- Division of Medical Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
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Lehrer EJ, Ruiz-Garcia H, Nehlsen AD, Sindhu KK, Estrada RS, Borst GR, Sheehan JP, Quinones-Hinojosa A, Trifiletti DM. Preoperative Stereotactic Radiosurgery for Glioblastoma. BIOLOGY 2022; 11:194. [PMID: 35205059 PMCID: PMC8869151 DOI: 10.3390/biology11020194] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 11/16/2022]
Abstract
Glioblastoma is a devastating primary brain tumor with a median overall survival of approximately 15 months despite the use of optimal modern therapy. While GBM has been studied for decades, modern therapies have allowed for a reduction in treatment-related toxicities, while the prognosis has largely been unchanged. Adjuvant stereotactic radiosurgery (SRS) was previously studied in GBM; however, the results were disappointing. SRS is a highly conformal radiation technique that permits the delivery of high doses of ionizing radiation in 1-5 sessions while largely sparing surrounding healthy tissues. Furthermore, studies have shown that the delivery of ablative doses of ionizing radiation within the central nervous system is associated with enhanced anti-tumor immunity. While SRS is commonly used in the definitive and adjuvant settings for other CNS malignancies, its role in the preoperative setting has become a topic of great interest due to the potential for reduced treatment volumes due to the treatment of an intact tumor, and a lower risk of nodular leptomeningeal disease and radiation necrosis. While early reports of SRS in the adjuvant setting for glioblastoma were disappointing, its role in the preoperative setting and its impact on the anti-tumor adaptive immune response is largely unknown. In this review, we provide an overview of GBM, discuss the potential role of preoperative SRS, and discuss the possible immunogenic effects of this therapy.
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Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (A.D.N.); (K.K.S.)
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (R.S.E.)
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Anthony D. Nehlsen
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (A.D.N.); (K.K.S.)
| | - Kunal K. Sindhu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (A.D.N.); (K.K.S.)
| | - Rachel Sarabia Estrada
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (R.S.E.)
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Gerben R. Borst
- The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK;
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine & Health, The University of Manchester, 555 Wilmslow Road, Manchester M20 4GJ, UK
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA 22908, USA;
| | | | - Daniel M. Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (R.S.E.)
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL 32224, USA;
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Matsunaga S, Shuto T. Outcomes of Gamma Knife Radiosurgery for Brain Metastases From Anaplastic Lymphoma Kinase Rearrangement-Positive and EGFR Mutation-Positive Non-Small Cell Lung Cancer. Cureus 2021; 13:e20398. [PMID: 35047245 PMCID: PMC8757575 DOI: 10.7759/cureus.20398] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/13/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction The outcomes after gamma knife radiosurgery (GKRS) were retrospectively analysed in patients with brain metastases from anaplastic lymphoma kinase (ALK) rearrangement-positive and epidermal growth factor receptor (EGFR) mutation-positive non-small cell lung cancer (NSCLC) to evaluate the efficacy, safety and difference for overall survival and local tumor control. Methods The medical records were retrospectively reviewed of 607 patients (25 ALK-positive, 171 EGFR-positive, and 411 wild type) with 2959 tumors who had undergone GKRS. Results The median overall survival time after initial GKRS was 14 months. Driver gene mutation-positive patients had significantly longer overall survival than wild type patients (p < 0.0001), and ALK-positive patients survived significantly longer than EGFR-positive patients (p = 0.04). Multivariate analysis showed the unfavorable factors significantly affecting overall survival outcomes were older age, lower Karnofsky Performance Status score, multiple intracranial metastases, uncontrolled primary cancer, uncontrolled extracranial metastases, no administration of immune checkpoint inhibitors, and driver gene mutation-negative cases. Seventy-three patients died of uncontrolled brain metastases at a median of 12 months. Driver gene mutations had no influence (p = 0.33), and ALK-positive and EGFR-positive patients showed no significant difference in neurological survival (p = 0.83). A total of 174 patients demonstrated distant brain control failure at a median of 15 months. ALK-positive type was significant compared with EGFR-positive type (p = 0.047), but driver gene mutation-positive and -negative types showed no significant difference in the development of new brain metastases (p = 0.2). The median tumor volume was 1.06 cm3 in the driver gene mutation-positive type and 1.85 cm3 in wild type. The median marginal dose was 20 Gy in both types. The 6-, 12-, and 24-month local tumor control rates were 97.3%, 96.1%, and 95.9%, respectively. Driver gene mutations had a significantly positive impact on local tumor control (p = 0.001), and ALK-positive and EGFR-positive types showed no significant difference (p = 0.95). A total of 193 tumors had radiation injury at a median of 12 months after GKRS. The 6-, 12-, and 24-month GKRS-related complication rates were 3.3%, 8.1%, and 8.7%, respectively. Driver gene mutations significantly induced radiation damage (p = 0.021), and the ALK-positive type was affected more than the EGFR-positive type (p = 0.02). Conclusions ALK rearrangement-positive NSCLC patients tended to have significantly longer survival, but had higher incidence of new intracranial metastases due to long-term survival after GKRS, compared with EGFR mutation-negative and driver gene mutation-negative NSCLC patients. GKRS induced significantly satisfactory local tumor control in driver gene mutation-positive tumors but GKRS-related complication frequency was higher, especially in ALK-positive NSCLC patients. Therefore, more careful imaging follow-up is necessary after GKRS for patients with driver gene mutation-positive NSCLC.
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Taslimi S, Brar K, Ellenbogen Y, Deng J, Hou W, Moraes FY, Glantz M, Zacharia BE, Tan A, Ahluwalia MS, Khasraw M, Zadeh G, Mansouri A. Comparative Efficacy of Systemic Agents for Brain Metastases From Non-Small-Cell Lung Cancer With an EGFR Mutation/ALK Rearrangement: A Systematic Review and Network Meta-Analysis. Front Oncol 2021; 11:739765. [PMID: 34950579 PMCID: PMC8691653 DOI: 10.3389/fonc.2021.739765] [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: 07/11/2021] [Accepted: 11/15/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Brain metastases (BM) from non-small-cell lung cancer (NSCLC) are frequent and carry significant morbidity, and current management options include varying local and systemic therapies. Here, we performed a systematic review and network meta-analysis to determine the ideal treatment regimen for NSCLC BMs with targetable EGFR-mutations/ALK-rearrangements. METHODS We searched MEDLINE, EMBASE, Web of Science, ClinicalTrials.gov, CENTRAL and references of key studies for randomized controlled trials (RCTs) published from inception until June 2020. Comparative RCTs including ≥10 patients were selected. We used a frequentist random-effects model for network meta-analysis (NMA) and assessed the certainty of evidence using the GRADE approach. Our primary outcome of interest was intracranial progression-free survival (iPFS). RESULTS We included 24 studies representing 19 trials with 1623 total patients. Targeted tyrosine kinase inhibitors (TKIs) significantly improved iPFS, with second-and third- generation TKIs showing the greatest benefit (HR=0.25, 95%CI 0.15-0.40). Overall PFS was also improved compared to conventional chemotherapy (HR=0.47, 95%CI 0.36-0.61). In EGFR-mutant patients, osimertinib showed the greatest benefit in iPFS (HR=0.32, 95%CI 0.15-0.69) compared to conventional chemotherapy, while gefitinib + chemotherapy showed the greatest overall PFS benefit (HR=0.26, 95%CI 0.10-0.70). All ALKi improved overall PFS compared to conventional chemotherapy, with alectinib having the greatest benefit (HR=0.13, 95%CI 0.07-0.24). CONCLUSIONS In patients with NSCLC BMs and EGFR/ALK mutations, targeted TKIs improve intracranial and overall PFS compared to conventional modalities such as chemotherapy, with greater efficacy seen using newer generations of TKIs. This data is important for treatment selection and patient counseling, and highlights areas for future RCT research. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=179060.
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Affiliation(s)
- Shervin Taslimi
- Division of Neurosurgery, Department of Surgery, Queen’s University, Kingston, ON, Canada
| | - Karanbir Brar
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Yosef Ellenbogen
- Division of Neurosurgery, Department of Surgery, Queen’s University, Kingston, ON, Canada
| | - Jiawen Deng
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Winston Hou
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Fabio Y. Moraes
- Department of Oncology, Queen’s University, Kingston, ON, Canada
| | - Michael Glantz
- Department of Neurosurgery, Penn State Health, Hershey, PA, United States
- Penn State Cancer Institute, Hershey, PA, United States
| | - Brad E. Zacharia
- Department of Neurosurgery, Penn State Health, Hershey, PA, United States
- Penn State Cancer Institute, Hershey, PA, United States
| | - Aaron Tan
- Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Manmeet S. Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Mustafa Khasraw
- The Preston Robert Tisch Brain Tumor Center, Duke University, Durham, NC, United States
| | - Gelareh Zadeh
- Division of Neurosurgery, Department of Surgery, Queen’s University, Kingston, ON, Canada
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State Health, Hershey, PA, United States
- Penn State Cancer Institute, Hershey, PA, United States
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Effect of brain radiotherapy strategies on prognosis of patients with EGFR-mutant lung adenocarcinoma with brain metastasis. J Transl Med 2021; 19:486. [PMID: 34847914 PMCID: PMC8638426 DOI: 10.1186/s12967-021-03161-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 11/22/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Epidermal growth factor receptor (EGFR)-mutant lung cancers have a high risk of developing brain metastases (BM). Whole brain radiotherapy (WBRT), local radiotherapy, and WBRT + Boost are frequently used for treatment of BM. This retrospective study aimed to evaluate the difference in efficacy of these radiotherapy modes in patients with EGFR-mutant lung adenocarcinoma with BMs. Further, we determined the optimal radiotherapy regimen for patients based on Lung-molGPA. Methods and materials We retrospectively enrolled 232 patients with EGFR-mutant lung adenocarcinoma with BMs. Patients were divided into three groups based on the different modes of brain radiotherapy: WBRT group, local radiotherapy group, and WBRT + Boost group. Graded prognostic assessment for lung cancer using molecular markers (Lung molGPA), overall survival (OS), and intracranial progression-free survival (iPFS) were calculated. Kaplan–Meier was used to compare iPFS and OS in different groups. Results The median OS for the WBRT (n = 84), local radiotherapy (n = 65), and WBRT + Boost (n = 83) cohorts was 32.8, 59.1, and 41.7 months, respectively (P = 0.0002). After stratification according to the Lung-molGPA score, the median OS for the WBRT (n = 56), local radiotherapy (n = 19), and WBRT + Boost (n = 28) cohorts was 32.5, 30.9, and 30.8 months, respectively, in subgroup with score 1–2 (P = 0.5097). In subgroup with score 2.5–4, the median OS for the WBRT (n = 26), local radiotherapy (n = 45), and WBRT + Boost (n = 54) cohorts was 32, 68.4, and 51 months, respectively (P = 0.0041). Conclusion The present study showed that in patients with EGFR-mutant lung adenocarcinoma with BM, local radiotherapy and WBRT + Boost perform similarly well both in the subgroups with low and high scores of Lung-molGPA. Considering the side effect caused by whole brain radiotherapy, we recommended local radiotherapy as optimal brain radiation mode for those subtype lung cancer patients.
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Chen W, Li C, Shi Y, Zhang Y, Jin D, Zhang M, Bo M, Li G. A Comprehensive Analysis of Metabolomics and Transcriptomics Reveals Novel Biomarkers and Mechanistic Insights on Lorlatinib Crosses the Blood-Brain Barrier. Front Pharmacol 2021; 12:722627. [PMID: 34497521 PMCID: PMC8419651 DOI: 10.3389/fphar.2021.722627] [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: 06/09/2021] [Accepted: 08/05/2021] [Indexed: 12/19/2022] Open
Abstract
Of late, lorlatinib has played an increasingly pivotal role in the treatment of brain metastasis from non-small cell lung cancer. However, its pharmacokinetics in the brain and the mechanism of entry are still controversial. The purpose of this study was to explore the mechanisms of brain penetration by lorlatinib and identify potential biomarkers for the prediction of lorlatinib concentration in the brain. Detection of lorlatinib in lorlatinib-administered mice and control mice was performed using liquid chromatography and mass spectrometry. Metabolomics and transcriptomics were combined to investigate the pathway and relationships between metabolites and genes. Multilayer perceptron was applied to construct an artificial neural network model for prediction of the distribution of lorlatinib in the brain. Nine biomarkers related to lorlatinib concentration in the brain were identified. A metabolite-reaction-enzyme-gene interaction network was built to reveal the mechanism of lorlatinib. A multilayer perceptron model based on the identified biomarkers provides a prediction accuracy rate of greater than 85%. The identified biomarkers and the neural network constructed with these metabolites will be valuable for predicting the concentration of drugs in the brain. The model provides a lorlatinib to treat tumor brain metastases in the clinic.
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Affiliation(s)
- Wei Chen
- National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chunyu Li
- National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yafei Shi
- National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yujun Zhang
- National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dujia Jin
- Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingyu Zhang
- National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingming Bo
- National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guohui Li
- National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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27
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Safi M, Al‐Nusaif M, Trapani D, Mashrah MA, Kanesvaran R, Alzandani A, Al‐Azab M, Mazher SA, Al‐Danakh A, Liu J. Brain and heart-specific death in cancer patients: Population-based study. Cancer Med 2021; 10:5739-5747. [PMID: 34374226 PMCID: PMC8419745 DOI: 10.1002/cam4.4069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/22/2021] [Accepted: 05/29/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The occurrence of cardiovascular events is a major cause of death in patients with cancer. Small studies have documented a connection between specific brain alterations and autonomic cardiac dysfunctions, possibly resulting in a worse prognosis. We aimed to refine the knowledge of fatal cardiac events in patients with brain metastasis (BM). METHODS We performed a Surveillance, Epidemiology, and End Results SEER registry-based investigation (timeline: 2010-2016) and extracted all the advanced patients who had experienced fatal cardiac outcomes. Populations were compared according to the presence or not BM. Kaplan-Meier (KM) methodology was used for survival analysis and a multivariate model was developed by adjusting for multiple possible confounders. RESULTS Most related BM and cardiac death were observed at the site of lung cancer (81.4%). We extracted 3187 patients with lung cancer site, including 417 patients who had experienced fatal heart-specific with a history of BM, which is considered a BM group. The second group of heart-specific death included 2770 patients was stated as a non-BM group. Patients who had experienced heart-specific death in the BM group were predominately male, right side, upper site, and non-small type (62.11%, 54.92%, 51.56%, 69.78%), respectively. The survival outcomes between BM and the non- BM was significantly prominent (p = 0.003; median: 2 months vs. 3 months).The negative prognostic independent significance of heart-fatal events was confirmed after adjusting for multiple variables (HR = 0.76, CI = 0.68-84, p < 0.0001). The metastatic liver site was significantly associated with poorer survival rates (HR = 0.68; CI = 0.52-0.88, p = 0.005). We revealed a possible connection between the brain and heart functions. CONCLUSIONS The prognosis of heart-specific death patients in BM is unfavorable compared to non-BM settings in lung cancer. We may be at the gates of a new field of neurocardiooncology.
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Affiliation(s)
- Mohammed Safi
- Department of OncologyFirst Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Murad Al‐Nusaif
- Department of NeurologyLiaoning Provincial Key Laboratory for Research on the Pathogenic Mechanisms of Neurological Diseases, First Affiliated Hospital, Dalian Medical University
| | - Dario Trapani
- IEO ‐ Istituto Europeo di Oncologia Milan, IRCCSMilanItaly
| | - Mubarak A Mashrah
- Guangzhou Institute of Oral DiseaseStomatology Hospital of Guangzhou Medical University, GuangzhouGuangdongChina
| | | | - Aziz Alzandani
- Faculty of Medicine and Health Sciences, Thamar University
| | - Mahmoud Al‐Azab
- Guangzhou Women and Children's Medical Center, Guangzhou Medical UniversityGuangzhou510623China
| | - Syed A Mazher
- Division of Hematology/ Oncology, UT Southwestern, Clements University Hospital6201 Harry Hines BlvdDallasTexas75390
| | - Abdullah Al‐Danakh
- Department of UrologyFirst Affiliated Hospital of Dalian Medical University
| | - Jiwei Liu
- Department of OncologyFirst Affiliated Hospital of Dalian Medical UniversityDalianChina
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28
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Zhang C. Case Report: Treatment of Alectinib in NSCLC With Brain Metastasis Patient Refractory to Radiotherapy After Resistance to Crizotinib. Front Oncol 2021; 11:709188. [PMID: 34262876 PMCID: PMC8273575 DOI: 10.3389/fonc.2021.709188] [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: 05/13/2021] [Accepted: 06/10/2021] [Indexed: 11/25/2022] Open
Abstract
Background Brain metastasis is the most common form of tumor recurrence after resistance to crizotinib in patients with anaplastic lymphoma kinase (ALK)-positive non-small-cell lung cancer (NSCLC). The treatment of brain metastasis in patients with ALK-positive NSCLC requires a multidisciplinary approach, including targeted therapy, chemotherapy, and radiotherapy. At present, no optimal treatment for these patients has been identified, although radiotherapy has remained a vital treatment. Case Presentation We experienced a patient with ALK-positive NSCLC who developed brain metastasis after crizotinib therapy. ALK rearrangement was not detected in a blood sample using next-generation sequencing. In accordance with National Comprehensive Cancer Network guidance, the patient underwent whole-brain radiotherapy. However, the number of metastatic sites unexpectedly increased. In desperation, the patient was empirically given alectinib after radiotherapy failure, and unanticipated success was achieved. Conclusions This case revealed some new insights. First, liquid biopsy is complementary to tissue biopsy in patients with NSCLC, mainly in those with EGFR mutation. However, ALK rearrangement should be assessed using tissue biopsy as much as possible. Second, brain metastasis of NSCLC might respond to second-generation tyrosine kinase inhibitors (TKIs), such as alectinib and ceritinib, after resistance to crizotinib regardless of the presence or absence of ALK rearrangement in liquid biopsy. Finally, combined radiotherapy and TKI therapy appears optimal in patients with brain metastasis of NSCLC after resistance to crizotinib in the absence of a definitive driver gene.
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Affiliation(s)
- Chunzhi Zhang
- Department of Radiation Oncology, Tianjin Hospital, Tianjin, China
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29
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Tchelebi LT, Batchelder E, Wang M, Lehrer EJ, Drabick JJ, Sharma N, Machtay M, Trifiletti DM, Zaorsky NG. Radiotherapy and Receptor Tyrosine Kinase Inhibition for Solid Cancers (ROCKIT): A Meta-Analysis of 13 Studies. JNCI Cancer Spectr 2021; 5:pkab050. [PMID: 34350378 PMCID: PMC8328097 DOI: 10.1093/jncics/pkab050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/16/2021] [Accepted: 05/18/2021] [Indexed: 12/25/2022] Open
Abstract
Background We hypothesized that the addition of receptor tyrosine kinase inhibitors (RTKis, e.g., lapatinib, erlotinib, cetuximab, bevacizumab, panitumumab) to radiotherapy-based treatment for solid tumors does not increase overall survival but may increase toxicity. Methods Population, Intervention, Control, Outcome, Study Design; Preferred Reporting Items for Systematic Reviews and Meta-Analyses; and Meta-analysis of Observational Studies in Epidemiology methods were used to identify prospective randomized studies including patients with solid tumor cancers treated with radiotherapy with or without RTKis. Extracted variables included use of radiotherapy vs chemoradiotherapy, RTKi type (antibody vs small molecule), outcomes, and toxicities. The primary endpoint was overall survival; the secondary endpoint was grade 3+ toxicity. Random-effects meta-analyses were performed for each outcome measure. All statistical tests were 2-sided. Results A total of 405 studies met the initial search criteria, of which 13 prospective randomized trials of radiotherapy with or without RTKi met the inclusion criteria, encompassing 5678 patients. The trials included cancers of the head and neck (6 trials, 3295 patients), esophagus (3 trials, 762 patients), lung (2 trials, 550 patients), and brain (2 trials, 1542 patients). Three studies evaluated a small molecule and radiotherapy in 949 patients, and 10 studies evaluated antibodies and radiotherapy in 4729 patients. The addition of RTKis to radiotherapy-based treatment did not improve overall survival (hazard ratio = 1.02, 95% confidence interval = 0.90 to 1.15, P = .76) but increased grade 3+ toxicity (relative risk = 1.18, 95% confidence interval = 1.06 to 1.33, P = .009). Conclusions The addition of RTKis to radiotherapy does not improve survival and worsens toxicity.
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Affiliation(s)
- Leila T Tchelebi
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Emma Batchelder
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joseph J Drabick
- Department of Medical Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Navesh Sharma
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Mitchell Machtay
- 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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30
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Expansion of the LabBM Score: Is the LabPS the Best Tool Predicting Survival in Patients With Brain Metastases? Am J Clin Oncol 2021; 44:53-57. [PMID: 33350680 DOI: 10.1097/coc.0000000000000784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study were to improve the 3-tiered, purely biomarker-based LabBM score, which predicts the survival of patients with brain metastases, by adding the well-established prognostic factor performance status (PS), and to define its role in comparison with the recently proposed Extracranial-Graded Prognostic Assessment score, which is based on the well-known Diagnosis-specific Graded Prognostic Assessment and 2 of the same biomarkers. MATERIALS AND METHODS This was a retrospective single-institution analysis of 212 patients, managed with upfront brain irradiation. Survival was stratified by LabBM and LabPS score. Each included serum hemoglobin, platelets, albumin, C-reactive protein, and lactate dehydrogenase (plus PS for the LabPS). Zero, 0.5, or 1 point was assigned and the final point sum calculated. A higher point sum indicates shorter survival. RESULTS The new LabPS score predicted overall survival very well (median: 12.1 to 0.7 mo, 1-y rate: 52% to 0%), P=0.0001. However, the group with the poorest prognosis (3 or 3.5 points) was very small (4%). Most patients with comparably short survival had a lower point sum. The LabPS score failed to outperform the recently proposed Extracranial-Graded Prognostic Assessment score. CONCLUSIONS Integration of blood biomarkers should be considered when attempting to develop improved scores. Additional research is needed to improve the tools which predict short survival, because many of these patients continue to go undetected with all available scores.
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31
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Zhou Y, Yu F, Zhao Y, Zeng Y, Yang X, Chu L, Chu X, Li Y, Zou L, Guo T, Zhu Z, Ni J. A narrative review of evolving roles of radiotherapy in advanced non-small cell lung cancer: from palliative care to active player. Transl Lung Cancer Res 2021; 9:2479-2493. [PMID: 33489808 PMCID: PMC7815368 DOI: 10.21037/tlcr-20-1145] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Radiotherapy, along with other loco-regional interventions, is conventionally utilized as a palliative approach to alleviate symptoms and mitigate oncological emergencies in advanced non-small cell lung cancer (NSCLC). Thanks to the ongoing improvement of medical treatments in the last decade, such as targeted therapy and immunotherapy, the survival of patients with advanced NSCLC has been considerably prolonged, making it feasible and clinically beneficial for radiotherapy to play a more active role in highly selected subpopulations. In this review, we will focus on the evolving roles of radiotherapy in advanced NSCLC. First of all, among patients who are initially unable to tolerate aggressive treatment due to severe symptoms caused by metastases and/or tumor emergencies, timely radiotherapy could significantly improve their performance status (PS) and general condition, thus giving them a chance for intensive treatment and prolonged survival. The efficacy, potential candidates, and optimal dose-fractionation regimens of radiotherapy in this clinical scenario will be discussed. Additionally, radiotherapy can play a curative role as a concurrent therapy, consolidation therapy, and salvage therapy for patients with oligo-metastatic, oligo-residual, and oligo-progressive disease, respectively. Accumulating evidence from recent clinical trials, basic research, and translational investigations regarding the potentially curative roles of radiotherapy in NSCLC patients with oligo-metastatic disease will be summarized. Moreover, with the advent of various small molecular tyrosine kinase inhibitors (TKIs), the treatment efficacy and overall survival of oncogene-addicted NSCLC with brain metastases have been significantly improved, and the clinical value and optimal timing of cranial radiotherapy have become topics of much debate. Finally, synergistic antitumor interactions between radiotherapy and immunotherapy have been repeatedly demonstrated. Thus, the immune sensitizing role of radiotherapy in advanced NSCLC is also highlighted in this review.
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Affiliation(s)
- Yue Zhou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Fan Yu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yang Zhao
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ya Zeng
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xi Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Li Chu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xiao Chu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yida Li
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Liqing Zou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Tiantian Guo
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhengfei Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Institute of Thoracic Oncology, Fudan University, Shanghai, China
| | - Jianjiao Ni
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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32
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A Comparison Between First-, Second- and Third-Generation Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors in Patients with Non-Small-Cell Lung Cancer and Brain Metastases. JOURNAL OF MOLECULAR PATHOLOGY 2021. [DOI: 10.3390/jmp2010001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Patients with non-small-cell lung cancer (NSCLC), harboring Epidermal Growth Factor Receptor (EGFR) mutations, are more susceptible to brain metastases (BM). Comparisons of the efficacy of different-generation EGFR-tyrosine kinase inhibitors (TKI) on BMs from NSCLC are currently limited. We identified studies comparing different EGFR-TKIs for NSCLC through Pubmed literature search and selected those with neurological outcome data. By two retrospective analyses, Erlotinib showed longer neurological time-to-progression (30 months vs. 15.8 months, P = 0.024) and reduced the risk of central nervous system (CNS) progression (Hazard Ratio (HR) 0.25; 95% CI, 0.08–0.81; P = 0.021) compared to Gefitinib. In a phase 2b randomized trial, 16% of patients with BMs had a similar Progression Free Survival (PFS) (HR 0.76, 95% CI 0.41–1.44) or Overall Survival (OS) (HR 1.16, 95% CI 0.61–2.21) with Afatinib versus Gefitinib; a lower risk of developing subsequent BMs with Afatinib than Gefitinib (HR 0.49; 95% CI 0.34–0.71; P < 0.001) was reported by a retrospective study. A randomized phase 3 trial proved that patients with BMs treated with Osimertinib had longer PFS (HR 0.47, 95% CI 0.30–0.74) and OS (HR 0.79, 95% CI 0.61–1.01) than with Gefitinib, and lower incidence of CNS progression (6% vs. 15%, respectively). Although there is limited evidence, differences in CNS activity may exist between EGFR-TKIs.
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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: 1.0] [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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34
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Steindl A, Berghoff AS. Brain metastases in metastatic cancer: a review of recent advances in systemic therapies. Expert Rev Anticancer Ther 2020; 21:325-339. [PMID: 33196341 DOI: 10.1080/14737140.2021.1851200] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Brain metastases (BM) are a frequent complication of metastatic cancer. Due to the wider availability and application of screening procedures, an increasing fraction of patients are diagnosed at the asymptomatic stage. The introduction of immune checkpoint inhibitors and targeted therapies has revolutionized treatment in several frequently BM-causing entities like metastatic lung cancer, melanoma and breast cancer. However, registered trials of new targeted and immunotherapy mostly excluded patients with BM resulting in limited knowledge of the intracranial efficacy of new systemic agents.Areas covered: The present review highlights recent advances in systemic therapies for the treatment and prophylaxis of the three leading BM causing tumors: NSCLC, melanoma and breast cancer.Expert opinion: High intracranial efficacy was observed for several next-generation tyrosine kinase inhibitors as well as immune checkpoint inhibitors, especially in patients with asymptomatic disease. Ongoing discussions addressed the need for local therapies in patients with asymptomatic BM and the availability of systemic therapy with high intracranial efficacy. Further BM-specific studies as well as BM-specific endpoints in registered trials are needed to define the role of systemic monotherapies in patients with BM.
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Affiliation(s)
- Ariane Steindl
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Anna S Berghoff
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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35
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Ding S, Wang R, Peng S, Luo X, Zhong L, Yang H, Ma Y, Chen S, Wang W. Targeted therapies for RET-fusion cancer: Dilemmas and breakthrough. Biomed Pharmacother 2020; 132:110901. [PMID: 33125973 DOI: 10.1016/j.biopha.2020.110901] [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: 07/04/2020] [Revised: 10/04/2020] [Accepted: 10/14/2020] [Indexed: 11/29/2022] Open
Abstract
Genomic profiling has revolutionized treatment options for patients with oncogene-driven cancers, such as epidermal growth factor receptor (EGFR) mutant carcinoma. Rearranged during transfection (RET) rearrangement, as one of the main activated oncogenes, has been well studied and found to be involved in the malignant behavior of carcinogenesis, resulting in acquired resistance to EGFR tyrosine kinase inhibitors and inducing an intrinsic resistance to immunotherapy. Thus, targeted therapies have been investigated against RET arrangement cancers, including several multi-kinase inhibitors and selective RET inhibitors. However, modest efficacy, a relatively high rate of toxicity, and poor effectiveness against brain metastasis are common limitations of multi-targeted novel molecular inhibitors. A promising prospect was shown recently in selective RET inhibitors in several ongoing clinical trials. In this review, we reviewed the concurrent dilemmas of targeted therapies against RET arrangement cancer from preclinical and clinical studies and proposed several clinical considerations for clinical practice prospectively.
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Affiliation(s)
- SiJie Ding
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Rong Wang
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - ShunLi Peng
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Xiaoqing Luo
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - LongHui Zhong
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Hong Yang
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China; Department of Oncology, Hunan Provincial People's Hospital and The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, PR China
| | - YueYun Ma
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - ShiYu Chen
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Wei Wang
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China.
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36
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Singh SA, McDermott DM, Mattes MD. Impact of Systemic Therapy Type and Timing on Intracranial Tumor Control in Patients with Brain Metastasis from Non-Small-Cell Lung Cancer Treated With Stereotactic Radiosurgery. World Neurosurg 2020; 144:e813-e823. [PMID: 32956881 DOI: 10.1016/j.wneu.2020.09.082] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) can effectively control brain metastasis (BRM) from non-small-cell lung cancer (NSCLC), although intracranial recurrence from untreated micrometastatic tumor deposits is common without whole-brain radiotherapy. Our goal was to determine if immunotherapy improves distant intracranial progression-free survival (DI-PFS) compared with other systemic therapies in patients treated with SRS. METHODS All patients from 2011 to 2019 treated with SRS without previous whole-brain radiotherapy for NSCLC BRM were reviewed. DI-PFS for the entire cohort, and subgroups of patients, was estimated and compared using the Kaplan-Meier/log-rank method. RESULTS One hundred and thirty-six SRS sessions used to treat 99 patients were reviewed; 98 (72%) for previously untreated BRM and 38 (28%) for recurrent BRM. 35% received immunotherapy (77% concurrent with SRS), 46% received chemotherapy (75% concurrent), and 18% received epidermal growth factor receptor/anaplastic lymphoma kinase (ALK) targeted therapy (85% concurrent). At median follow-up of 13.7 months, 49% developed distant intracranial recurrence. One-year DI-PFS was improved with any use of immunotherapy (58% vs. 39%; P = 0.03) and concurrent immunotherapy versus chemotherapy or targeted therapy (67% vs. 37% vs. 39%, respectively; P = 0.01). In the immunotherapy cohort, 1-year DI-PFS was improved for programmed death-ligand 1 expression ≥50% versus 1%-49% versus 0% (80% vs. 49% vs. 19%, respectively; P < 0.01), and Lung Immune Prognostic Index 0-1 versus 2 (63% vs. 34%; P = 0.03). CONCLUSIONS Immunotherapy concurrent with SRS, particularly in patients with high programmed death-ligand 1 expression or low Lung Immune Prognostic Index, is associated with improved DI-PFS and no increased risk of radiation necrosis compared with other systemic therapies for NSCLC.
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Affiliation(s)
- Sarah A Singh
- Department of Radiation Oncology, West Virginia University Cancer Institute, West Virginia University, Morgantown, West Virginia, USA
| | - David M McDermott
- Department of Radiation Oncology, West Virginia University Cancer Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Malcolm D Mattes
- Department of Radiation Oncology, West Virginia University Cancer Institute, West Virginia University, Morgantown, West Virginia, USA.
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Page S, Milner-Watts C, Perna M, Janzic U, Vidal N, Kaudeer N, Ahmed M, McDonald F, Locke I, Minchom A, Bhosle J, Welsh L, O'Brien M. Systemic treatment of brain metastases in non-small cell lung cancer. Eur J Cancer 2020; 132:187-198. [PMID: 32380429 DOI: 10.1016/j.ejca.2020.03.006] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/04/2020] [Indexed: 12/20/2022]
Abstract
Brain metastases (BrMs) are associated with significant morbidity and are found in up to 50% of patients with advanced non-small cell lung cancer (NSCLC). Most of the literature focuses on symptomatic BrMs, with a lack of baseline brain imaging in asymptomatic patients. Unfortunately, much of the data on local treatments with or without systemic treatment is retrospective. Clinical trials of systemic treatments largely exclude patients with BrMs. Chemotherapy is an active treatment for BrM with response rates in the brain similar to other sites of disease. Targeted systemic treatments in patients with driver mutations (EGFR and ALK-MET to date) have impressive central nervous system (CNS) penetrance and response rates. Unfortunately, no prospective data can currently guide the timings or modality of local therapies with systemic treatments in these patients who have a high incidence of CNS disease, but retrospective data suggest that early local therapies may give better intracranial progression-free survival (ICPFS). Recent immunotherapy trials have included patients with BrMs. These patients have largely been pre-treated with local therapies and are asymptomatic. Thus, the current standard is becoming, early local therapies before or in conjunction with immunotherapy agents. The approach seems to be safe. Prospective studies are needed in NSCLC BrMs patients to make sure any benefit from local therapies on the ICPFS and quality of life is not overlooked. Here we report what we think are reasonable conclusions from the available data and make suggestions for future clinical trials in the management of NSCLC BrMs.
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Affiliation(s)
| | | | - Marco Perna
- Azienda Ospedaliero Universitaria Careggi, Italy
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Nieder C, Yobuta R, Mannsåker B. LabBM Score and Extracranial Score As New Tools for Predicting Survival in Patients with Brain Metastases Treated with Focal Radiotherapy. Cureus 2020; 12:e7633. [PMID: 32399365 PMCID: PMC7213767 DOI: 10.7759/cureus.7633] [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] [Indexed: 11/05/2022] Open
Abstract
Background Two recently validated, untraditional prognostic scores include serum albumin and lactate dehydrogenase, among other parameters. The latter are hemoglobin, platelet counts, and C-reactive protein (three-tiered LabBM score), whereas the four-tiered extracranial score includes more than one extracranial site of metastatic involvement. Until now, head-to-head comparisons of these two scores in patients treated with focal radiotherapy for newly diagnosed brain metastases are not available. Methods This was a retrospective single-institution analysis of 51 patients, most of whom were managed with first-line stereotactic radiosurgery (SRS). Survival was stratified by the LabBM score and extracranial score. Results Both scores predicted survival, but the analyses were hampered by small subgroups. In particular, very few patients belonged to the unfavorable groups. Survival shorter than two months, which was recorded in 14%, was not well predicted by the LabBM score and extracranial score. Conclusions Very few patients treated with focal radiotherapy (largely SRS) had unfavorable prognostic features according to the two untraditional scores, which do not include the number of brain metastases and performance status. Additional research is needed to improve the tools that predict short survival because overtreatment during the terminal phase of metastatic disease continues to represent a relevant issue.
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Eastman BM, Venur VA, Lo SS, Graber JJ. Stereotactic radiosurgery in the treatment of adults with metastatic brain tumors. J Neurosurg Sci 2020; 64:272-286. [PMID: 32270945 DOI: 10.23736/s0390-5616.20.04952-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Brain metastasis is the most common type of intracranial tumor affecting a significant proportion of advanced cancer patients. In recent years, stereotactic radiosurgery (SRS) has become commonly utilized. It has contributed significantly to decreased toxicity, prolonged quality of life and general improvement in outcomes of patients with brain metastases. Frequent imaging and advanced treatment techniques have allowed for the treatment of more patients with large and numerous metastases extending their overall survival. The addition of targeted therapy and immunotherapy to SRS has introduced novel treatment paradigms and has further improved our ability to effectively treat brain lesions. In this review, we examined in detail the available evidence for the use of SRS alone or in combination with surgery and systemic therapies. Given our developing understanding of the importance of primary tumor histology, the use of different treatment strategies for different metastasis is evolving. Combining SRS with immunotherapy and targeted therapy in breast cancer, lung cancer and melanoma as well as the use of preoperative SRS have shown significant promise in recent years and are investigated in multiple ongoing prospective trials. Further research is needed to guide the optimal sequence of therapies and to identify specific patient subgroups that may benefit the most from aggressive, combined treatment approaches.
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Affiliation(s)
- Boryana M Eastman
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Vyshak A Venur
- Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Jerome J Graber
- Department of Neurology and Neurosurgery, Alvord Brain Tumor Center, University of Washington School of Medicine, Seattle, WA, USA -
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