Individual patient data meta-analysis of prophylactic cranial irradiation in locally advanced non-small cell lung cancer

Analysis of high‑risk factors for brain metastasis and prognosis after prophylactic cranial irradiation in limited‑stage small cell lung cancer

Small cell lung cancer (SCLC) is an aggressive malignancy with a high propensity for brain metastases (BM). Limited-stage SCLC (LS-SCLC) can be effectively treated with chemoradiotherapy and prophylactic cranial irradiation (PCI) to enhance patient outcomes. The aim of the present study was to assess the risk factors and prognostic significance of brain metastases (BM) in patients with limited-stage small cell lung cancer (LS-SCLC) who attained complete remission (CR) or partial remission (PR) following combined chemoradiotherapy and subsequent prophylactic cranial irradiation (PCI). Data for 290 patients diagnosed with LS-SCLC and treated at Chengde Central Hospital and Hebei Cangzhou Hospital of Integrated Traditional Chinese and Western Medicine (Chengde, China), who achieved CR or PR and underwent PCI between 2015 and 2023, were retrospectively analyzed. BM rates and overall survival (OS) were estimated using the Kaplan-Meier method, whilst differences were assessed using the log-rank test. Risk factors affecting BM and OS were assessed using univariate and multivariate Cox regression analyses. The overall incidence of BM after PCI was 16.6% (48/290), with annual rates of 1.4, 6.6 and 12.8% at 1, 2 and 3 years, respectively. Multivariate Cox regression analysis identified an initial tumor size of >5 cm [hazard ratio (HR)=15.031; 95% confidence interval (CI): 5.610-40.270; P<0.001] as a significant independent risk factor for BM following PCI. The median OS was 28.8 months and the 5-year OS rate was 27.9%. The median OS for patients with and without BM at 27.55 and 32.5 months, respectively, and the corresponding 5-year OS rates were 8.3 and 31.8%, respectively (P=0.001). Median OS rates for stages I, II and III were 61.15, 48.5 and 28.4 months, respectively, with 5-year OS rates of 62.5, 47.1 and 21.6%, respectively (P<0.001). Further multivariate Cox regression analysis indicated that BM (HR=1.934; 95% CI: 1.358-2.764; P<0.001) and clinical stage (HR=1.741; 95% CI: 1.102-2.750; P=0.018; P=0.022) were significant independent risk factors associated with patient OS. In conclusion, a tumor size of >5 cm is a significant risk factor for BM following PCI in patients with LS-SCLS achieving CR or PR through radiotherapy and chemotherapy. Furthermore, BM and clinical staging independently influence OS.

Modern Radiation Therapy for the Management of Brain Metastases From Non-Small Cell Lung Cancer: Current Approaches and Future Directions

Brain metastases (BMs) represent the most frequent event during the course of Non-Small Cell Lung Cancer (NSCLC) disease. Recent advancements in the diagnostic and therapeutic procedures result in increased incidence and earlier diagnosis of BMs, with an emerging need to optimize the prognosis of these patients through the adoption of tailored treatment solutions. Nowadays a personalized and multidisciplinary approach should rely on several clinical and molecular factors like patient’s performance status, extent and location of brain involvement, extracranial disease control and the presence of any “druggable” molecular target. Radiation therapy (RT), in all its focal (radiosurgery and fractionated stereotactic radiotherapy) or extended (whole brain radiotherapy) declinations, is a cornerstone of BMs management, either alone or combined with surgery and systemic therapies. Our review aims to provide an overview of the many modern RT solutions available for the treatment of BMs from NSCLC in the different clinical scenarios (single lesion, oligo and poly-metastasis, leptomeningeal carcinomatosis). This includes a detailed review of the current standard of care in each setting, with a presentation of the literature data and of the possible technical solutions to offer a “state-of-art” treatment to these patients. In addition to the validated treatment options, we will also discuss the future perspectives on emerging RT technical strategies (e.g., hippocampal avoidance whole brain RT, simultaneous integrated boost, radiosurgery for multiple lesions), and present the innovative and promising findings regarding the combination of novel targeted agents such as tyrosine kinase inhibitors and immune checkpoint inhibitors with brain irradiation.

Association of different fractionation schedules for prophylactic cranial irradiation with toxicity and brain metastases-free survival in stage III non-small cell lung cancer: A pooled analysis of individual patient data from three randomized trials

We assessed the impact of different PCI fractionation schedules (30 Gy in 10 versus 15 fractions) on brain metastases-free survival (BMFS) and toxicity in stage III NSCLC. Our results suggest that 30 Gy in 10 fractions is associated with increased toxicity, while no conclusive evidence of improving BMFS was seen with this schedule.

Factors associated with cognitive impairment and cognitive concerns in patients with metastatic non-small cell lung cancer

Background

Knowledge regarding cognitive problems in metastatic non-small cell lung cancer (mNSCLC) is limited. Such problems may include both patient-reported cognitive concerns and demonstrable cognitive impairment. Greater understanding of these outcomes is needed to inform rehabilitation strategies for these difficulties. We aimed to identify the frequency of cognitive problems and associated factors in patients with mNSCLC.

Methods

In this cross-sectional study, adults with mNSCLC completed validated neuropsychological tests and self-report questionnaires measuring cognitive concerns, neurobehavioral concerns, depression, demoralization, illness intrusiveness, self-esteem, and physical symptoms. Cognitive impairment (performance based) was defined according to International Cancer and Cognition Task Force criteria. Clinically significant cognitive concerns were defined by a score ≥1.5 SD below the normative mean on the Functional Assessment of Cancer Therapy-Cognitive Function Perceived Cognitive Impairment (FACT-Cog PCI). Univariate and multivariate logistic regression analyses were performed to identify associated factors.

Results

Of 238 patients approached, 77 participated (median age: 62 years; range: 37-82). Brain metastases were present in 41 patients (53%), and 23 (29%) received cranial irradiation. Cognitive impairment and cognitive concerns were present in 31 (40%) and 20 patients (26%), respectively. Cognitive impairment and cognitive concerns co-occurred in 10 patients (13%), but their severity was unrelated. Cognitive impairment was associated with cranial irradiation (odds ratio [OR] = 2.89; P = .04), whereas cognitive concerns were associated with greater illness intrusiveness (OR = 1.04; P = .03) and lower self-esteem (OR = 0.86; P = .03).

Conclusions

Cognitive impairment and cognitive concerns are both common in patients with mNSCLC but are not necessarily related, and their risk factors differ. The association of illness intrusiveness and self-esteem with cognitive concerns can inform therapeutic interventions in this population.