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Choi A, Hunting J, Lanier C, Douglas E, Triozzi P, Ruiz J, Benayoun M, White J, Chan M. Treatment Options for Brain Metastases. Curr Treat Options Oncol 2024:10.1007/s11864-024-01195-3. [PMID: 39037617 DOI: 10.1007/s11864-024-01195-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 07/23/2024]
Abstract
OPINION STATEMENT Therapies for brain metastasis continue to evolve as the life expectancies for patients have continued to prolong. Novel advances include the use of improved technology for radiation delivery, surgical guidance, and response assessment, along with systemic therapies that can pass through the blood brain barrier. With increasing complexity of treatments and the increased need for salvage treatments, multi-disciplinary management has become significantly more important.
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Affiliation(s)
- Ariel Choi
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - John Hunting
- Department of Medicine (Hematology and Oncology), Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Claire Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Emily Douglas
- Department of Medicine (Hematology and Oncology), Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Pierre Triozzi
- Department of Medicine (Hematology and Oncology), Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jimmy Ruiz
- Department of Medicine (Hematology and Oncology), Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Marc Benayoun
- Department of Radiology at Wake Forest School of Medicine, Winston‑Salem, NC, USA
| | - Jaclyn White
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
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2
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Internò V, Sergi MC, Metta ME, Guida M, Trerotoli P, Strippoli S, Circelli S, Porta C, Tucci M. Melanoma Brain Metastases: A Retrospective Analysis of Prognostic Factors and Efficacy of Multimodal Therapies. Cancers (Basel) 2023; 15:cancers15051542. [PMID: 36900333 PMCID: PMC10001111 DOI: 10.3390/cancers15051542] [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: 12/19/2022] [Revised: 02/20/2023] [Accepted: 02/27/2023] [Indexed: 03/05/2023] Open
Abstract
Brain metastasis in cutaneous melanoma (CM) has historically been considered to be a dismal prognostic feature, although recent evidence has highlighted the intracranial activity of combined immunotherapy (IT). Herein, we completed a retrospective study to investigate the impact of clinical-pathological features and multimodal therapies on the overall survival (OS) of CM patients with brain metastases. A total of 105 patients were evaluated. Nearly half of the patients developed neurological symptoms leading to a negative prognosis (p = 0.0374). Both symptomatic and asymptomatic patients benefited from encephalic radiotherapy (eRT) (p = 0.0234 and p = 0.011). Lactate dehydrogenase (LDH) levels two times higher than the upper limit normal (ULN) at the time of brain metastasis onset was associated with poor prognosis (p = 0.0452) and identified those patients who did not benefit from eRT. Additionally, the poor prognostic role of LDH levels was confirmed in patients treated with targeted therapy (TT) (p = 0.0015) concerning those who received immunotherapy (IT) (p = 0.16). Based on these results, LDH levels higher than two times the ULN at the time of the encephalic progression identify those patients with a poor prognosis who did not benefit from eRT. The negative prognostic role of LDH levels on eRT observed in our study will require prospective evaluations.
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Affiliation(s)
- Valeria Internò
- Department of Interdisciplinary Medicine, University of Bari Aldo Moro, 70121 Bari, Italy
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria, Policlinico di Bari, 70124 Bari, Italy
- Correspondence: ; Tel.: +39-080-5593674
| | - Maria Chiara Sergi
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria, Policlinico di Bari, 70124 Bari, Italy
| | - Maria Elvira Metta
- Medical Statistic and Biometry Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, 70121 Bari, Italy
| | - Michele Guida
- IRCCS, Istituto Tumori Giovanni Paolo II, 70124 Bari, Italy
| | - Paolo Trerotoli
- Medical Statistic and Biometry Unit, Department of Interdisciplinary Medicine, University of Bari Aldo Moro, 70124 Bari, Italy
| | | | - Salvatore Circelli
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria, Policlinico di Bari, 70124 Bari, Italy
| | - Camillo Porta
- Department of Interdisciplinary Medicine, University of Bari Aldo Moro, 70121 Bari, Italy
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria, Policlinico di Bari, 70124 Bari, Italy
| | - Marco Tucci
- Department of Interdisciplinary Medicine, University of Bari Aldo Moro, 70121 Bari, Italy
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria, Policlinico di Bari, 70124 Bari, Italy
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3
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Abdulhaleem M, Johnston H, D'Agostino R, Lanier C, Cramer CK, Triozzi P, Lo HW, Xing F, Li W, Whitlow C, White JJ, Tatter SB, Laxton AW, Su J, Chan MD, Ruiz J. Patterns of Failure Outcomes for Combination of Stereotactic Radiosurgery and Immunotherapy for Melanoma Brain Metastases. NEUROSURGERY OPEN 2023. [DOI: 10.1227/neuprac.0000000000000026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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McKenzie G, Gaskins J, Rattani A, Oliver A, Southall W, Nakamura F, Yusuf M, Mistry A, Williams B, Woo S. Radiosurgery fractionation and post-treatment hemorrhage development for intact melanoma brain metastases. J Neurooncol 2022; 160:591-599. [DOI: 10.1007/s11060-022-04178-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/20/2022] [Indexed: 12/23/2022]
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Radiation therapy for melanoma brain metastases: a systematic review. Radiol Oncol 2022; 56:267-284. [PMID: 35962952 PMCID: PMC9400437 DOI: 10.2478/raon-2022-0032] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 06/17/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Radiation therapy (RT) for melanoma brain metastases, delivered either as whole brain radiation therapy (WBRT) or as stereotactic radiosurgery (SRS), is an established component of treatment for this condition. However, evidence allowing comparison of the outcomes, advantages and disadvantages of the two RT modalities is scant, with very few randomised controlled trials having been conducted. This has led to considerable uncertainty and inconsistent guideline recommendations. The present systematic review identified 112 studies reporting outcomes for patients with melanoma brain metastases treated with RT. Three were randomised controlled trials but only one was of sufficient size to be considered informative. Most of the evidence was from non-randomised studies, either specific treatment series or disease cohorts. Criteria for determining treatment choice were reported in only 32 studies and the quality of these studies was variable. From the time of diagnosis of brain metastasis, the median survival after WBRT alone was 3.5 months (IQR 2.4-4.0 months) and for SRS alone it was 7.5 months (IQR 6.7-9.0 months). Overall patient survival increased over time (pre-1989 to 2015) but this was not apparent within specific treatment groups. CONCLUSIONS These survival estimates provide a baseline for determining the incremental benefits of recently introduced systemic treatments using targeted therapy or immunotherapy for melanoma brain metastases.
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Rosenstock T, Pöser P, Wasilewski D, Bauknecht HC, Grittner U, Picht T, Misch M, Onken JS, Vajkoczy P. MRI-Based Risk Assessment for Incomplete Resection of Brain Metastases. Front Oncol 2022; 12:873175. [PMID: 35651793 PMCID: PMC9149256 DOI: 10.3389/fonc.2022.873175] [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: 02/10/2022] [Accepted: 04/07/2022] [Indexed: 11/13/2022] Open
Abstract
Object Recent studies demonstrated that gross total resection of brain metastases cannot always be achieved. Subtotal resection (STR) can result in an early recurrence and might affect patient survival. We initiated a prospective observational study to establish a MRI-based risk assessment for incomplete resection of brain metastases. Methods All patients in whom ≥1 brain metastasis was resected were prospectively included in this study (DRKS ID: DRKS00021224; Nov 2020 - Nov 2021). An interdisciplinary board of neurosurgeons and neuroradiologists evaluated the pre- and postoperative MRI (≤48h after surgery) for residual tumor. Extensive neuroradiological analyses were performed to identify risk factors for an unintended STR which were integrated into a regression tree analysis to determine the patients' individual risk for a STR. Results We included 150 patients (74 female; mean age: 61 years), in whom 165 brain metastases were resected. A STR was detected in 32 cases (19.4%) (median residual tumor volume: 1.36ml, median EORrel: 93.6%), of which 6 (3.6%) were intended STR (median residual tumor volume: 3.27ml, median EORrel: 67.3%) - mainly due to motor-eloquent location - and 26 (15.8%) were unintended STR (uSTR) (median residual tumor volume: 0.64ml, median EORrel: 94.7%). The following risk factors for an uSTR could be identified: subcortical metastasis ≥5mm distant from cortex, diffuse contrast agent enhancement, proximity to the ventricles, contact to falx/tentorium and non-transcortical approaches. Regression tree analysis revealed that the individual risk for an uSTR was mainly associated to the distance from the cortex (distance ≥5mm vs. <5mm: OR 8.0; 95%CI: 2.7 - 24.4) and the contrast agent patterns (diffuse vs. non-diffuse in those with distance ≥5mm: OR: 4.2; 95%CI: 1.3 - 13.7). The preoperative tumor volume was not substantially associated with the extent of resection. Conclusions Subcortical metastases ≥5mm distant from cortex with diffuse contrast agent enhancement showed the highest incidence of uSTR. The proposed MRI-based assessment allows estimation of the individual risk for uSTR and can help indicating intraoperative imaging.
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Affiliation(s)
- Tizian Rosenstock
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Program, Berlin, Germany
| | - Paul Pöser
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - David Wasilewski
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Hans-Christian Bauknecht
- Institute of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thomas Picht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Cluster of Excellence: "Matters of Activity. Image Space Material," Humboldt University, Berlin, Germany
| | - Martin Misch
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Julia Sophie Onken
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Tagliaferri L, Lancellotta V, Fionda B, Mangoni M, Casà C, Di Stefani A, Pagliara MM, D’Aviero A, Schinzari G, Chiesa S, Mazzarella C, Manfrida S, Colloca GF, Marazzi F, Morganti AG, Blasi MA, Peris K, Tortora G, Valentini V. Immunotherapy and radiotherapy in melanoma: a multidisciplinary comprehensive review. Hum Vaccin Immunother 2022; 18:1903827. [PMID: 33847208 PMCID: PMC9122308 DOI: 10.1080/21645515.2021.1903827] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Melanoma is an extremely aggressive tumor and is considered to be an extremely immunogenic tumor because compared to other cancers it usually presents a well-expressed lymphoid infiltration. The aim of this paper is to perform a multidisciplinary comprehensive review of the evidence available about the combination of radiotherapy and immunotherapy for melanoma. Radiation, in fact, can increase tumor antigens visibility and promote priming of T cells but can also exert immunosuppressive action on tumor microenvironment. Combining radiotherapy with immunotherapy provides an opportunity to increase immunostimulatory potential of radiation. We therefore provide the latest clinical evidence about radiobiological rationale, radiotherapy techniques, timing, and role both in advanced and systemic disease (with a special focus on ocular melanoma and brain, liver, and bone metastases) with a particular attention also in geriatric patients. The combination of immunotherapy and radiotherapy seems to be a safe therapeutic option, supported by a clear biological rationale, even though the available data confirm that radiotherapy is employed more for metastatic than for non-metastatic disease. Such a combination shows promising results in terms of survival outcomes; however, further studies, hopefully prospective, are needed to confirm such evidence.
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Affiliation(s)
- Luca Tagliaferri
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Valentina Lancellotta
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Bruno Fionda
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
- CONTACT Bruno Fionda UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli, 8, Roma00168, Italy
| | - Monica Mangoni
- Sezione di Radioterapia Oncologica, Dipartimento di Scienze Biomediche Sperimentali e Cliniche, Università di Firenze, Florence, Italy
| | - Calogero Casà
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Alessandro Di Stefani
- UOC Dermatologia, Dipartimento di Scienze mediche e chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Monica Maria Pagliara
- UOC Oncologia Oculare, Dipartimento di Scienze dell'Invecchiamento, neurologiche ortopediche e della testa collo, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Andrea D’Aviero
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Giovanni Schinzari
- UOC Oncologia Medica, Comprehensive Cancer Center, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Silvia Chiesa
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Ciro Mazzarella
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Stefania Manfrida
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Giuseppe Ferdinando Colloca
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Fabio Marazzi
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Alessio Giuseppe Morganti
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Settore Scientifico Disciplinare, Università di Bologna, Bologna, Italy
| | - Maria Antonietta Blasi
- UOC Oncologia Oculare, Dipartimento di Scienze dell'Invecchiamento, neurologiche ortopediche e della testa collo, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Ketty Peris
- UOC Dermatologia, Dipartimento di Scienze mediche e chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Giampaolo Tortora
- UOC Oncologia Medica, Comprehensive Cancer Center, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Vincenzo Valentini
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
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9
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Ganz JC. Cerebral metastases. PROGRESS IN BRAIN RESEARCH 2022; 268:229-258. [PMID: 35074082 DOI: 10.1016/bs.pbr.2021.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Brain metastases are common and deadly. Over the last 25 years GKNS has been established as an invaluable treatment. It may be used as a primary treatment or after either surgery or WBRT. Patients are assessed using one of a number of available scales. GKNS may be repeated for new metastases and for unresponsive tumors. Prescription doses are usually between 18 and 20Gy. The use of advanced MR techniques to highlight sensitive structures like the hippocampi have extended the efficacy of the treatment. More recently GKNS has been used with different target therapies with improved results. More recently frameless treatments have become more popular in this group of very sick patients. GKNS controls tumors in between 80% and over 95% of cases and may even be used for brainstem tumors.
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Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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10
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Ge Y, Che X, Gao X, Zhao S, Su J. Combination of radiotherapy and targeted therapy for melanoma brain metastases: a systematic review. Melanoma Res 2021; 31:413-420. [PMID: 34406985 DOI: 10.1097/cmr.0000000000000761] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Radiotherapy is a mainstay of efficient treatment of brain metastases from solid tumors. Immunotherapy has improved the survival of metastatic cancer patients across many tumor types. However, targeted therapy is a feasible alternative for patients unable to continue immunotherapy or with poor outcomes of immunotherapy. The combination of radiotherapy and targeted therapy for the treatment of brain metastases has a strong theoretical underpinning, but data on the efficacy and safety of this combination is still limited. A systematic search of PubMed, Embase, Web of Science and the Cochrane library database was conducted. Eleven studies were included for a total of 316 patients. Median OS was about 6.2-17.8 months from radiotherapy. Weighted survival and local control at 1 and 2 years were correlated (50.1 and 17.8%, 90.7 and 14.7% at 1 and 2 year, respectively). Radiotherapy given before or concurrently to targeted therapy provided the best effect on the outcome. For patients with brain metastases from cutaneous melanoma, the addition of concurrent targeted therapy to brain radiotherapy can increase survival and provide long-term control.
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Affiliation(s)
- Yi Ge
- Department of Dermatology, Xiangya Hospital, Central South University
- Hunan Engineering Research Center of Skin Health and Disease
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Central South University, Changsha, China
| | - Xuanlin Che
- Department of Dermatology, Xiangya Hospital, Central South University
- Hunan Engineering Research Center of Skin Health and Disease
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Central South University, Changsha, China
| | - Xin Gao
- Department of Dermatology, Xiangya Hospital, Central South University
- Hunan Engineering Research Center of Skin Health and Disease
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Central South University, Changsha, China
| | - Shuang Zhao
- Department of Dermatology, Xiangya Hospital, Central South University
- Hunan Engineering Research Center of Skin Health and Disease
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Central South University, Changsha, China
| | - Juan Su
- Department of Dermatology, Xiangya Hospital, Central South University
- Hunan Engineering Research Center of Skin Health and Disease
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Central South University, Changsha, China
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Kessel KA, Deichl A, Gempt J, Meyer B, Posch C, Diehl C, Zimmer C, Combs SE. Outcomes after stereotactic radiosurgery of brain metastases in patients with malignant melanoma and validation of the melanoma molGPA. Clin Transl Oncol 2021; 23:2020-2029. [PMID: 33993415 PMCID: PMC8390419 DOI: 10.1007/s12094-021-02607-8] [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: 01/12/2021] [Accepted: 03/22/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Malignant melanoma is the third most common primary in the diagnosis of brain metastases. Stereotactic radiosurgery (SRS) is a well-established treatment option in limited brain disease. We analyzed outcomes of SRS with a particular focus on the graded prognostic assessment (GPA, melanoma molGPA), prognostic factors, and toxicity. METHODS We evaluated 173 brain metastases in 83 patients with malignant melanoma. All were treated with SRS median dose of 20 Gy prescribed to the 80 or 100% isodose line between 2002 and 2019. All patients were followed-up regularly, including contrast-enhanced brain imaging as well as clinical examination, initially 6 weeks after treatment, then in quarterly follow-up. RESULTS The median age was 61 years (range 27-80); 36 female and 47 male patients were treated. After a median follow-up of 5.7 months, median OS (overall survival) was 9.7 months 95%-KI 4.7-14.7). LC (local control) at 6 months, 12, 24 months was 89%, 86%, and 72%, respectively (median was not reached). Median DBC (distant brain control) was 8.2 months (95%-KI 4.7-11.7). For OS, a KPS ≥ 80%, a positive BRAF mutation status, a small PTV (planning target volume), the absence of extracranial metastases, as well as a GPA and melanoma molGPA > 2 were prognostic factors. In the MVA, a small PTV and a melanoma molGPA > 2 remained significant. CONCLUSION The present survival outcomes support the use of the disease-specific melanoma molGPA as reliable prognostic score. Favorable outcomes for SRS compared to other studies were observed. In the treatment of brain metastases of malignant melanoma patients, a multidisciplinary approach consisting of surgery, SRS, chemotherapy, and immunotherapy should be considered.
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Affiliation(s)
- K A Kessel
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany.,Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site Munich, Munich, Germany
| | - A Deichl
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany.
| | - J Gempt
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site Munich, Munich, Germany.,Department of Neurosurgery, Technical University of Munich (TUM), Munich, Germany
| | - B Meyer
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site Munich, Munich, Germany.,Department of Neurosurgery, Technical University of Munich (TUM), Munich, Germany
| | - C Posch
- Department of Dermatology and Allergy, Technical University of Munich (TUM), Munich, Germany.,Faculty of Medicine, Sigmund Freud University, Vienna, Austria
| | - C Diehl
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site Munich, Munich, Germany
| | - C Zimmer
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site Munich, Munich, Germany.,Department of Neuroradiology, Technical University of Munich (TUM), Munich, Germany
| | - S E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany.,Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site Munich, Munich, Germany
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12
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Nieblas‐Bedolla E, Nayyar N, Singh M, Sullivan RJ, Brastianos PK. Emerging Immunotherapies in the Treatment of Brain Metastases. Oncologist 2021; 26:231-241. [PMID: 33103803 PMCID: PMC7930434 DOI: 10.1002/onco.13575] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 10/09/2020] [Indexed: 12/19/2022] Open
Abstract
Brain metastases account for considerable morbidity and mortality in patients with cancer. Despite increasing prevalence, limited therapeutic options exist. Recent advances in our understanding of the molecular and cellular underpinnings of the tumor immune microenvironment and the immune evasive mechanisms employed by tumor cells have shed light on how immunotherapies may provide therapeutic benefit to patients. The development and evolution of immunotherapy continue to show promise for the treatment of brain metastases. Positive outcomes have been observed in several studies evaluating the efficacy and safety of these treatments. However, many challenges persist in the application of immunotherapies to brain metastases. This review discusses the potential benefits and challenges in the development and use of checkpoint inhibitors, chimeric antigen receptor T-cell therapy, and oncolytic viruses for the treatment of brain metastases. Future studies are necessary to further evaluate and assess the potential use of each of these therapies in this setting. As we gain more knowledge regarding the role immunotherapies may play in the treatment of brain metastases, it is important to consider how these treatments may guide clinical decision making for clinicians and the impact they may have on patients. IMPLICATIONS FOR PRACTICE: Immunotherapies have produced clinically significant outcomes in early clinical trials evaluating patients with brain metastases or demonstrated promising results in preclinical models. Checkpoint inhibitors have been the most common immunotherapy studied to date in the setting of brain metastases, but novel approaches that can harness the immune system to contain and eliminate cancer cells are currently under investigation and may soon become more common in the clinical setting. An understanding of these evolving therapies may be useful in determining how the future management and treatment of brain metastases among patients with cancer will continue to advance.
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Affiliation(s)
| | - Naema Nayyar
- Program in Molecular Medicine, University of Massachusetts Medical SchoolWorcesterMassachusettsUSA
- Broad Institute of Massachusetts Institute of Technology and HarvardBostonMassachusettsUSA
- Cancer Center, Massachusetts General HospitalBostonMassachusettsUSA
| | - Mohini Singh
- Cancer Center, Massachusetts General HospitalBostonMassachusettsUSA
| | - Ryan J. Sullivan
- Cancer Center, Massachusetts General HospitalBostonMassachusettsUSA
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachustetsUSA
| | - Priscilla K. Brastianos
- Broad Institute of Massachusetts Institute of Technology and HarvardBostonMassachusettsUSA
- Cancer Center, Massachusetts General HospitalBostonMassachusettsUSA
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachustetsUSA
- Division of Neuro‐Oncology, Department of Neurology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachustetsUSA
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A Review of the Neurosurgical Management of Brain Metastases During Pregnancy. Can J Neurol Sci 2020; 48:698-707. [PMID: 33213549 PMCID: PMC8527832 DOI: 10.1017/cjn.2020.254] [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: 11/08/2022]
Abstract
OBJECTIVE Patients with pregnancy-associated secondary brain tumors (PASBT) are challenging to manage. Because no guidelines for the management of such patients currently exist, we performed a systematic review of the literature using PRISMA guidelines with a discussion of management from a neurosurgeon's perspective. METHOD Systematic review of the literature using PRISMA guidelines from 1999 to 2018. RESULTS We identified 301 studies of which 16 publications (22 patients reporting 25 pregnancies, 20 deliveries, 5 early terminations) were suitable for final analysis. The most frequent primary cancers were breast (8/22, 36.36%), skin (6/22, 27.27%), and lung (5/22, 22.73%). Four patients (18.18%) had neurosurgical procedures during their pregnancies. Five patients (22.73%) received neurosurgical resection after their pregnancies. Nine patients (40.91%) received radiation therapy and seven patients (31.82%) received chemotherapy during pregnancy while seven patients (31.82%) received chemotherapy and radiation after pregnancy. There was 1 fetal death (5%) out of 20 healthy deliveries. Five pregnancies (20%) were terminated in the first trimester due to a need for urgent neurosurgical intervention. CONCLUSION Management of PASBT remains a challenging issue. Maternal and fetal risks associated with surgical resection and teratogenicity due to adjuvant therapy should be discussed in the context of a multidisciplinary team. Timing of surgery and the use of systemic chemoradiation depends on the gestational age (GA) of the fetus, extent, and control of the mother's primary and metastatic disease. Guidelines need to be established to help neuro-oncology teams safely and effectively manage this group of patients.
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Tai P, Joseph K, Assouline A, Souied O, Leong N, Ferguson M, Yu E. Metastatic Brain Tumors: To Treat or Not to Treat, and with What? CURRENT CANCER THERAPY REVIEWS 2020. [DOI: 10.2174/1573394715666181211150849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A long time ago, metastatic brain tumors were often not treated and patients were only
given palliative care. In the past decade, researchers selected those with single or 1-3 metastases
for more aggressive treatments like surgical resection, and/or stereotactic radiosurgery (SRS),
since the addition of whole brain radiotherapy (WBRT) did not increase overall survival for the
vast majority of patients. Different studies demonstrated significantly less cognitive deterioration
in 0-52% patients after SRS versus 85-94% after WBRT at 6 months. WBRT is the treatment of
choice for leptomeningeal metastases. WBRT can lower the risk for further brain metastases, particularly
in tumors of fast brain metastasis velocity, i.e. quickly relapsing, often seen in melanoma
or small cell lung carcinoma. Important relevant literature is quoted to clarify the clinical controversies
at point of care in this review. Synchronous primary lung cancer and brain metastasis
represent a special situation whereby the oncologist should exercise discretion for curative treatments,
with reported 5-year survival rates of 7.6%-34.6%. Recent research suggests that those
patients with Karnofsky performance status less than 70, not capable of caring for themselves, are
less likely to derive benefit from aggressive treatments. Among patients with brain metastases
from non-small cell lung cancer (NSCLC), the QUARTZ trial (Quality of Life after Radiotherapy
for Brain Metastases) helps the oncologist to decide when not to treat, depending on the performance
status and other factors.
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Affiliation(s)
- Patricia Tai
- Allan Blair Cancer Center, University of Saskatchewan, Saskatoon, SK, Canada
| | - Kurian Joseph
- Cross Cancer Center, University of Alberta, Edmonton, AB, Canada
| | - Avi Assouline
- Centre Clinique de la Porte de Saint-Cloud, 30 Rue de Paris, 92100 Boulogne- Billancourt, France
| | - Osama Souied
- Allan Blair Cancer Center, University of Saskatchewan, Saskatoon, SK, Canada
| | - Nelson Leong
- Allan Blair Cancer Center, University of Saskatchewan, Saskatoon, SK, Canada
| | - Michelle Ferguson
- Allan Blair Cancer Center, University of Saskatchewan, Saskatoon, SK, Canada
| | - Edward Yu
- London Regional Cancer Program, Western University, London, ON, Canada
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Levin-Epstein R, Kumar P, Rusheen J, Fleming RG, McWatters Z, Kim W, Kaprealian TB, West B, Tobis JM. Investigation of patent foramen ovale as a mechanism for brain metastasis in patients without prior lung involvement. Clin Transl Oncol 2020; 23:783-787. [DOI: 10.1007/s12094-020-02471-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/01/2020] [Indexed: 11/30/2022]
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16
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Haydu LE, Lo SN, McQuade JL, Amaria RN, Wargo J, Ross MI, Cormier JN, Lucci A, Lee JE, Ferguson SD, Saw RP, Spillane AJ, Shannon KF, Stretch JR, Hwu P, Patel SP, Diab A, Wong MK, Glitza Oliva IC, Tawbi H, Carlino MS, Menzies AM, Long GV, Lazar AJ, Tetzlaff MT, Scolyer RA, Gershenwald JE, Thompson JF, Davies MA. Cumulative Incidence and Predictors of CNS Metastasis for Patients With American Joint Committee on Cancer 8th Edition Stage III Melanoma. J Clin Oncol 2020; 38:1429-1441. [PMID: 31990608 PMCID: PMC7193747 DOI: 10.1200/jco.19.01508] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2019] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Improved understanding of the incidence, risk factors, and timing of CNS metastasis is needed to inform surveillance strategies for patients with melanoma. PATIENTS AND METHODS Clinical data were extracted from the databases of 2 major melanoma centers in the United States and Australia for 1,918 patients with American Joint Committee on Cancer (AJCC) 8th edition stage III melanoma, diagnosed from 1998-2014, who had (negative) baseline CNS imaging within 4 months of diagnosis. The cumulative incidence of CNS metastasis was calculated in the presence of the competing risk of death, from stage III presentation and at benchmark time points 1, 2, and 5 years postdiagnosis. RESULTS At a median follow-up of 70.2 months, distant recurrence occurred in 711 patients (37.1%). The first site of distant metastasis was CNS only for 3.9% of patients, CNS and extracranial (EC) for 1.8%, and EC only for 31.4%. Overall, 16.7% of patients were diagnosed with CNS metastasis during follow-up. The cumulative incidence of CNS metastasis was 3.6% (95% CI, 2.9% to 4.6%) at 1 year, 9.6% (95% CI, 8.3% to 11.0%) at 2 years, and 15.8% (95% CI, 14.1% to 17.6%) at 5 years. The risk of CNS metastasis was significantly influenced by patient sex, age, AJCC stage, primary tumor site, and primary tumor mitotic rate in multivariable and conditional analyses. High primary tumor mitotic rate was significantly associated with increased risk of CNS metastasis at diagnosis and all subsequent time points examined. CONCLUSION Similar rates of CNS metastasis were observed in 2 large, geographically distinct cohorts of patients with stage III melanoma. The results highlight the importance of primary tumor mitotic rate. Furthermore, they provide a framework for developing evidence-based surveillance strategies and evaluating the impact of contemporary adjuvant therapies on the risk of CNS metastasis development.
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Affiliation(s)
- Lauren E. Haydu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Serigne N. Lo
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jennifer L. McQuade
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rodabe N. Amaria
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jennifer Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Merrick I. Ross
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Janice N. Cormier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anthony Lucci
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey E. Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sherise D. Ferguson
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Robyn P.M. Saw
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Andrew J. Spillane
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Kerwin F. Shannon
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jonathan R. Stretch
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Patrick Hwu
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sapna P. Patel
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Adi Diab
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael K.K. Wong
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Isabella C. Glitza Oliva
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hussein Tawbi
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matteo S. Carlino
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Medical Oncology, Westmead and Blacktown Hospitals, Sydney, New South Wales, Australia
| | - Alexander M. Menzies
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Georgina V. Long
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Alexander J. Lazar
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Translational and Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael T. Tetzlaff
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Translational and Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Richard A. Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Jeffrey E. Gershenwald
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John F. Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Michael A. Davies
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Zhang L, Hu Y, Chen W, Tian Y, Xie Y, Chen J. Pre-stereotactic radiosurgery neutrophil-to-lymphocyte ratio is a predictor of the prognosis for brain metastases. J Neurooncol 2020; 147:691-700. [PMID: 32253715 DOI: 10.1007/s11060-020-03477-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/24/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE The neutrophil-to-lymphocyte ratio (NLR) has been reported to relate to the prognosis of various cancers. The aim of this study was to elucidate the efficiency of pre-treatment NLR as a predictor of outcomes of brain metastasis underwent gamma knife radiosurgery (GKRS). METHODS We analyzed 195 cases with brain metastasis underwent GKRS at our institution between January 2015 and April 2018. Patients' clinical and radiographic data were collected. RESULTS We identified 458 brain metastases in 195 patients. Optimal dichotomous cutoff values of NLR determined by receiver operating characteristic analysis for local control, distant control and overall survival (OS) were 2.48, 2.74 and 3.13, respectively. The actuarial local control rates of patients with high NLR were 87.4% at 6 months and 76.1% at 12 months, whereas that of patients with low NLR were 94.2% at 6 months and 88.3% at 12 months (P = 0.001). The actuarial distant control rates of patients with high NLR were 31.4% at 6 months and 18.9% at 12 months, whereas that of patients with low NLR were 58.5% at 6 months and 31.3% at 12 months (P = 0.001). The median OS of patients with high and low NLR were 10.0 months and 14.5 months, respectively (P = 0.001). Multivariate analysis demonstrates that high NLR independently predicts local failure (hazard ratio [HR], 2.281; P = 0.003), distant brain failure (HR 1.775; P = 0.002) and poorer overall survival (HR 1.494; P = 0.034). CONCLUSION The pre-SRS NLR, a systemic inflammatory marker for treatment response, inversely predicts local control, distant control and OS in patients with brain metastasis.
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Affiliation(s)
- Lifeng Zhang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Yanjia Hu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Wei Chen
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Yuan Tian
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Yuebin Xie
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Jing Chen
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China.
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18
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LeCompte MC, Hughes RT, Farris M, Masters A, Soike MH, Lanier C, Glenn C, Cramer CK, Watabe K, Su J, Ruiz J, Whitlow CT, Wang G, Laxton AW, Tatter SB, Chan MD. Impact of brain metastasis velocity on neurologic death for brain metastasis patients experiencing distant brain failure after initial stereotactic radiosurgery. J Neurooncol 2020; 146:285-292. [PMID: 31894518 DOI: 10.1007/s11060-019-03368-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 12/09/2019] [Accepted: 12/11/2019] [Indexed: 01/04/2023]
Abstract
PURPOSE Patients with high rates of developing new brain metastases have an increased likelihood of dying of neurologic death. It is unclear, however, whether this risk is affected by treatment choice following failure of primary stereotactic radiosurgery (SRS). METHODS From July 2000 to March 2017, 440 patients with brain metastasis were treated with SRS and progressed to have a distant brain failure (DBF). Eighty-seven patients were treated within the immunotherapy era. Brain metastasis velocity (BMV) was calculated for each patient. In general, the institutional philosophy for use of salvage SRS vs whole brain radiotherapy (WBRT) was to postpone the use of WBRT for as long as possible and to treat with salvage SRS when feasible. No further treatment was reserved for patients with poor life expectancy and who were not expected to benefit from salvage treatment. RESULTS Two hundred and eighty-five patients were treated with repeat SRS, 91 patients were treated with salvage WBRT, and 64 patients received no salvage radiation therapy. One-year cumulative incidence of neurologic death after salvage SRS vs WBRT was 15% vs 23% for the low- (p = 0.06), 30% vs 37% for the intermediate- (p < 0.01), and 31% vs 48% (p < 0.01) for the high-BMV group. Salvage WBRT was associated with increased incidence of neurologic death on multivariate analysis (HR 1.64, 95% CI 1.13-2.39, p = 0.01) when compared to repeat SRS. One-year cumulative incidence of neurologic death for patients treated within the immunotherapy era was 9%, 38%, and 38% for low-, intermediate-, and high-BMV groups, respectively (p = 0.01). CONCLUSION Intermediate and high risk BMV groups are predictive of neurologic death. The association between BMV and neurologic death remains strong for patients treated within the immunotherapy era.
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Affiliation(s)
- Michael C LeCompte
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA.
| | - Ryan T Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Michael Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Adrianna Masters
- Department of Radiation Oncology, University Radiologists, S.C., Southern Illinois School of Medicine, Springfield, IL, 62781, USA
| | - Michael H Soike
- Hazelrig-Salter Radiation Oncology Center, University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - Claire Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Chase Glenn
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Jing Su
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA.,Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA.,W.G. (Bill) Hefner Veteran Administration Medical Center, Cancer Center, Salisbury, NC, 28144, USA
| | - Christopher T Whitlow
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Ge Wang
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY, 12180, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
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Serizawa T, Yamamoto M, Higuchi Y, Sato Y, Shuto T, Akabane A, Jokura H, Yomo S, Nagano O, Kawagishi J, Yamanaka K. Local tumor progression treated with Gamma Knife radiosurgery: differences between patients with 2-4 versus 5-10 brain metastases based on an update of a multi-institutional prospective observational study (JLGK0901). J Neurosurg 2019; 132:1480-1489. [PMID: 31026833 DOI: 10.3171/2019.1.jns183085] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 01/28/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The Japanese Leksell Gamma Knife (JLGK)0901 study proved the efficacy of Gamma Knife radiosurgery (GKRS) in patients with 5-10 brain metastases (BMs) as compared to those with 2-4, showing noninferiority in overall survival and other secondary endpoints. However, the difference in local tumor progression between patients with 2-4 and those with 5-10 BMs has not been sufficiently examined for this data set. Thus, the authors reappraised this issue, employing the updated JLGK0901 data set with detailed observation via enhanced MRI. They applied sophisticated statistical methods to analyze the data. METHODS This was a prospective observational study of 1194 patients harboring 1-10 BMs treated with GKRS alone. Patients were categorized into groups A (single BM, 455 cases), B (2-4 BMs, 531 cases), and C (5-10 BMs, 208 cases). Local tumor progression was defined as a 20% increase in the maximum diameter of the enhanced lesion as compared to its smallest documented maximum diameter on enhanced MRI. The authors compared cumulative incidence differences determined by competing risk analysis and also conducted propensity score matching. RESULTS Local tumor progression was observed in 212 patients (17.8% overall, groups A/B/C: 93/89/30 patients). Cumulative incidences of local tumor progression in groups A, B, and C were 15.2%, 10.6%, and 8.7% at 1 year after GKRS; 20.1%, 16.9%, and 13.5% at 3 years; and 21.4%, 17.4%, and not available at 5 years, respectively. There were no significant differences in local tumor progression between groups B and C. Local tumor progression was classified as tumor recurrence in 139 patients (groups A/B/C: 68/53/18 patients), radiation necrosis in 67 (24/31/12), and mixed/undetermined lesions in 6 (1/5/0). There were no significant differences in tumor recurrence or radiation necrosis between groups B and C. Multivariate analysis using the Fine-Gray proportional hazards model revealed age < 65 years, neurological symptoms, tumor volume ≥ 1 cm3, and prescription dose < 22 Gy to be significant poor prognostic factors for local tumor progression. In the subset of 558 case-matched patients (186 in each group), there were no significant differences between groups B and C in local tumor progression, nor in tumor recurrence or radiation necrosis. CONCLUSIONS Local tumor progression incidences did not differ between groups B and C. This study proved that tumor progression after GKRS without whole-brain radiation therapy for patients with 5-10 BMs was satisfactorily treated with the doses prescribed according to the JLGK0901 study protocol and that results were not inferior to those in patients with a single or 2-4 BMs.Clinical trial registration no.: UMIN000001812 (umin.ac.jp).
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Affiliation(s)
- Toru Serizawa
- 1Tokyo Gamma Unit Center, Tsukiji Neurological Clinic, Tokyo
| | | | - Yoshinori Higuchi
- 3Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba
| | - Yasunori Sato
- 4Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo
| | - Takashi Shuto
- 5Department of Neurosurgery, Yokohama Rosai Hospital, Yokohama
| | | | - Hidefumi Jokura
- 7Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Osaki
| | - Shoji Yomo
- 8Saitama Gamma Knife Center, Sanai Hospital, Saitama
| | - Osamu Nagano
- 9Gamma Knife House, Chiba Cerebral and Cardiovascular Center, Ichihara; and
| | - Jun Kawagishi
- 7Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Osaki
| | - Kazuhiro Yamanaka
- 10Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Lanier CM, Hughes R, Ahmed T, LeCompte M, Masters AH, Petty WJ, Ruiz J, Triozzi P, Su J, O'Neill S, Watabe K, Cramer CK, Laxton AW, Tatter SB, Wang G, Whitlow C, Chan MD. Immunotherapy is associated with improved survival and decreased neurologic death after SRS for brain metastases from lung and melanoma primaries. Neurooncol Pract 2019; 6:402-409. [PMID: 31555455 DOI: 10.1093/nop/npz004] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background The effect of immunotherapy on brain metastasis patients remains incompletely understood. Our goal was to evaluate its effect on survival, neurologic death, and patterns of failure after stereotactic radiosurgery (SRS) without prior whole-brain radiation therapy (WBRT) in patients with lung and melanoma primaries metastatic to the brain. Methods We performed a retrospective analysis of 271 consecutive lung or melanoma patients treated with upfront SRS for brain metastases between 2013 and 2018. Of these patients, 101 (37%) received immunotherapy and 170 (63%) did not. Forty-three percent were treated with nivolumab. Thirty-seven percent were treated with pembrolizumab. Fifteen percent were treated with ipilimumab. One percent were treated with a combination of nivolumab and ipilimumab. One percent were treated with atezolizumab. Three percent were treated with another immunotherapy regimen. Survival was estimated by the Kaplan-Meier method and cumulative incidences of neurologic death, and local and distant brain failure were estimated using death as a competing risk. Results The median overall survival (OS) of patients treated with immunotherapy vs without was 15.9 (95% CI: 13.3 to 24.8) vs 6.1 (95% CI: 5.1 to 8.8) months (P < .01). The 1-year cumulative incidence of neurologic death was 9% in patients treated with immunotherapy vs 23% in those treated without (P = .01), while nonneurologic death was not significantly different (29% vs 41%, P = .51). Median brain metastasis velocity (BMV) did not differ between groups, and rates of salvage SRS and WBRT were similar. Conclusions The use of immunotherapy in patients with lung cancer or melanoma metastatic to the brain treated with SRS is associated with improved OS and decreased incidence of neurologic death.
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Affiliation(s)
- Claire M Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Ryan Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Tamjeed Ahmed
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC
| | - Michael LeCompte
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Adrianna H Masters
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - William J Petty
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC.,W.G. (Bill) Hefner Veteran Administration Medical Center, Cancer Center, Salisbury, NC
| | - Pierre Triozzi
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC
| | - Jing Su
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Stacy O'Neill
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Kuonosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Ge Wang
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY
| | | | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
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Achrol AS, Rennert RC, Anders C, Soffietti R, Ahluwalia MS, Nayak L, Peters S, Arvold ND, Harsh GR, Steeg PS, Chang SD. Brain metastases. Nat Rev Dis Primers 2019; 5:5. [PMID: 30655533 DOI: 10.1038/s41572-018-0055-y] [Citation(s) in RCA: 529] [Impact Index Per Article: 105.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
An estimated 20% of all patients with cancer will develop brain metastases, with the majority of brain metastases occurring in those with lung, breast and colorectal cancers, melanoma or renal cell carcinoma. Brain metastases are thought to occur via seeding of circulating tumour cells into the brain microvasculature; within this unique microenvironment, tumour growth is promoted and the penetration of systemic medical therapies is limited. Development of brain metastases remains a substantial contributor to overall cancer mortality in patients with advanced-stage cancer because prognosis remains poor despite multimodal treatments and advances in systemic therapies, which include a combination of surgery, radiotherapy, chemotherapy, immunotherapy and targeted therapies. Thus, interest abounds in understanding the mechanisms that drive brain metastases so that they can be targeted with preventive therapeutic strategies and in understanding the molecular characteristics of brain metastases relative to the primary tumour so that they can inform targeted therapy selection. Increased molecular understanding of the disease will also drive continued development of novel immunotherapies and targeted therapies that have higher bioavailability beyond the blood-tumour barrier and drive advances in radiotherapies and minimally invasive surgical techniques. As these discoveries and innovations move from the realm of basic science to preclinical and clinical applications, future outcomes for patients with brain metastases are almost certain to improve.
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Affiliation(s)
- Achal Singh Achrol
- Department of Neurosurgery and Neurosciences, John Wayne Cancer Institute and Pacific Neuroscience Institute, Santa Monica, CA, USA.
| | - Robert C Rennert
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA.
| | - Carey Anders
- Division of Hematology/Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | | | - Manmeet S Ahluwalia
- Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Lakshmi Nayak
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Solange Peters
- Medical Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Nils D Arvold
- Department of Radiation Oncology, St. Luke's Cancer Center, Duluth, MN, USA
| | - Griffith R Harsh
- Department of Neurosurgery, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Patricia S Steeg
- Women's Malignancies Branch, Center for Cancer Research, National Cancer Center, Bethesda, MD, USA
| | - Steven D Chang
- Department of Neurosurgery, University of California-Davis, School of Medicine, Sacramento, CA, USA.
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22
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Saiki R, Brill A, Breeze RE. Four-year Survival (and Counting) after Stereotactic Radiosurgery to Nearly 100 Brain Metastases: A Case Report. Cureus 2018; 10:e2103. [PMID: 29581915 PMCID: PMC5866122 DOI: 10.7759/cureus.2103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Brain metastases are a relatively common consequence of Stage IV melanoma. Historically, patients with brain metastases fare poorly, with median survival of only weeks to months. Patients with multiple metastases in the brain have often been overlooked in the literature, with the focus being placed more on patients with only a small number of metastases. The authors present a case of a 42-year-old man with a total of 98 brain metastases treated over several Gamma Knife sessions. He is nearly five years out from his initial treatment. This case highlights the fact that there is a large amount of variability in survival after diagnosis with brain metastases. Selection for treatment should be based on the clinical picture and clinicians should take care to avoid selection bias in this population.
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McTyre ER, Johnson AG, Ruiz J, Isom S, Lucas JT, Hinson WH, Watabe K, Laxton AW, Tatter SB, Chan MD. Predictors of neurologic and nonneurologic death in patients with brain metastasis initially treated with upfront stereotactic radiosurgery without whole-brain radiation therapy. Neuro Oncol 2017; 19:558-566. [PMID: 27571883 DOI: 10.1093/neuonc/now184] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 07/22/2016] [Indexed: 11/13/2022] Open
Abstract
Background In this study we attempted to discern the factors predictive of neurologic death in patients with brain metastasis treated with upfront stereotactic radiosurgery (SRS) without whole brain radiation therapy (WBRT) while accounting for the competing risk of nonneurologic death. Methods We performed a retrospective single-institution analysis of patients with brain metastasis treated with upfront SRS without WBRT. Competing risks analysis was performed to estimate the subdistribution hazard ratios (HRs) for neurologic and nonneurologic death for predictor variables of interest. Results Of 738 patients treated with upfront SRS alone, neurologic death occurred in 226 (30.6%), while nonneurologic death occurred in 309 (41.9%). Multivariate competing risks analysis identified an increased hazard of neurologic death associated with diagnosis-specific graded prognostic assessment (DS-GPA) ≤ 2 (P = .005), melanoma histology (P = .009), and increased number of brain metastases (P<.001), while there was a decreased hazard associated with higher SRS dose (P = .004). Targeted agents were associated with a decreased HR of neurologic death in the first 1.5 years (P = .04) but not afterwards. An increased hazard of nonneurologic death was seen with increasing age (P =.03), nonmelanoma histology (P<.001), presence of extracranial disease (P<.001), and progressive systemic disease (P =.004). Conclusions Melanoma, DS-GPA, number of brain metastases, and SRS dose are predictive of neurologic death, while age, nonmelanoma histology, and more advanced systemic disease are predictive of nonneurologic death. Targeted agents appear to delay neurologic death.
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Affiliation(s)
- Emory R McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Adam G Johnson
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,W. G. (Bill) Hefner Veteran Administration Medical Center, Cancer Center, Salisbury, North Carolina, USA
| | - Scott Isom
- Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, North Carolina, USA
| | - John T Lucas
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - William H Hinson
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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24
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LeCompte MC, McTyre E, Henson A, Farris M, Okoukoni C, Cramer CK, Triozzi P, Ruiz J, Watabe K, Lo HW, Munley MT, Laxton AW, Tatter SB, Zhou X, Chan M. Survival and Failure Outcomes Predicted by Brain Metastasis Volumetric Kinetics in Melanoma Patients Following Upfront Treatment with Stereotactic Radiosurgery Alone. Cureus 2017; 9:e1934. [PMID: 29464141 PMCID: PMC5807024 DOI: 10.7759/cureus.1934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction The roles of early whole brain radiotherapy (WBRT) and upfront stereotactic radiosurgery (SRS) alone in the treatment of melanoma patients with brain metastasis remain uncertain. We investigated the volumetric kinetics of brain metastasis development and associations with clinical outcomes for melanoma patients who received upfront SRS alone. Methods Volumetric brain metastasis velocity (vBMV) was defined as the volume of new intracranial disease at the time of distant brain failure (DBF) for the first DBF (DBF1) and second DBF (DBF2) averaged over the time since initial or most recent SRS. Non-volumetric brain metastasis velocity (BMV) was calculated for comparison. Results Median overall survival (OS) for all patients was 7.7 months. Increasing vBMVDBF1 was associated with worsened OS (hazard ratio (HR): 1.10, confidence interval (CI): 1.02 - 1.18, p = .01). Non-volumetric BMVDBF1 was not predictive of OS after DBF1 (HR: 1.00, CI: 0.97 - 1.02, p = .77). Cumulative incidence of DBF2 at three months after DBF1 was 50.0% for vBMVDBF1 > 4 cc/yr versus (vs) 15.1% for vBMVDBF1 ≤ 4 cc/yr, (Gray’s p-value = .02). Cumulative incidence of salvage WBRT at three months after DBF1 was 50.0% for vBMVDBF1 > 4 cc/yr vs 2.3% for vBMVDBF1 ≤ 4 cc/yr (Gray’s p-value < .001). Conclusion In melanoma patients with brain metastasis, volumetric BMV was predictive of survival, shorter time to second DBF, and the need for salvage WBRT. Non-volumetric BMV, however, did not predict for these outcomes, suggesting that vBMV is a stronger predictor in melanoma.
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Affiliation(s)
| | - Emory McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine
| | - Adrianna Henson
- Department of Radiation Oncology, Wake Forest School of Medicine
| | - Michael Farris
- Department of Radiation Oncology, Wake Forest School of Medicine
| | | | | | - Pierre Triozzi
- Department of Medicine (hematology & Oncology), Wake Forest School of Medicine
| | - Jimmy Ruiz
- Department of Medicine (hematology & Oncology), Wake Forest School of Medicine
| | | | - Hui-Wen Lo
- Department of Cancer Biology, Wake Forest School of Medicine
| | - Michael T Munley
- Department of Radiation Oncology, Wake Forest School of Medicine
| | | | | | - Xiaobo Zhou
- Center for Bioinformatics & Systems Biology, Wake Forest School of Medicine
| | - Michael Chan
- Department of Radiation Oncology, Wake Forest University
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25
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Stokes WA, Binder DC, Jones BL, Oweida AJ, Liu AK, Rusthoven CG, Karam SD. Impact of immunotherapy among patients with melanoma brain metastases managed with radiotherapy. J Neuroimmunol 2017; 313:118-122. [DOI: 10.1016/j.jneuroim.2017.10.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 10/09/2017] [Indexed: 11/15/2022]
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26
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Pessina F, Navarria P, Tomatis S, Cozzi L, Franzese C, Di Guardo L, Ascolese AM, Reggiori G, Franceschini D, Del Vecchio M, Bello L, Scorsetti M. Outcome Evaluation of Patients with Limited Brain Metastasis From Malignant Melanoma, Treated with Surgery, Radiation Therapy, and Targeted Therapy. World Neurosurg 2017; 105:184-190. [DOI: 10.1016/j.wneu.2017.05.131] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 05/19/2017] [Accepted: 05/22/2017] [Indexed: 12/29/2022]
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27
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Sharma M, Jia X, Ahluwalia M, Barnett GH, Vogelbaum MA, Chao ST, Suh JH, Murphy ES, Yu JS, Angelov L, Mohammadi AM. First follow-up radiographic response is one of the predictors of local tumor progression and radiation necrosis after stereotactic radiosurgery for brain metastases. Cancer Med 2017; 6:2076-2086. [PMID: 28776956 PMCID: PMC5603831 DOI: 10.1002/cam4.1149] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/09/2017] [Accepted: 06/26/2017] [Indexed: 12/11/2022] Open
Abstract
Local progression (LP) and radiation necrosis (RN) occur in >20% of cases following stereotactic radiosurgery (SRS) for brain metastases (BM). Expected outcomes following SRS for BM include tumor control/shrinkage, local progression and radiation necrosis. 1427 patients with 4283 BM lesions were treated using SRS at Cleveland Clinic from 2000 to 2012. Clinical, imaging and radiosurgery data were collected from the database. Local tumor progression and RN were the primary end points and correlated with patient and tumor‐related variables. 5.7% of lesions developed radiographic RN and 3.6% showed local progression at 6 months. Absence of new extracranial metastasis (P < 0.001), response to SRS at first follow‐up scan (local progression versus stable size (P < 0.001), partial resolution versus complete resolution at first follow up [P = 0.009]), prior SRS to the same lesion (P < 0.001), IDL% (≤55; P < 0.001), maximum tumor diameter (>0.9 cm; P < 0.001) and MD/PD gradient index (≤1.8, P < 0.001) were independent predictors of high risk of local tumor progression. Absence of systemic metastases (P = 0.029), good neurological function at 1st follow‐up (P ≤ 0.001), no prior SRS to other lesion (P = 0.024), low conformity index (≤1.9) (P = 0.009), large maximum target diameter (>0.9 cm) (P = 0.003) and response to SRS (tumor progression vs. stable size following SRS [P < 0.001]) were independent predictors of high risk of radiographic RN. Complete tumor response at first follow‐up, maximum tumor diameter <0.9 cm, tumor volume <2.4 cc and no prior SRS to the index lesion are good prognostic factors with reduced risk of LP following SRS. Complete tumor response to SRS, poor neurological function at first follow‐up, prior SRS to other lesions and high conformity index are favorable factors for not developing RN. Stable or partial response at first follow‐up after SRS have same impact on local progression and RN compared to those with complete resolution or progression.
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Affiliation(s)
- Mayur Sharma
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Xuefei Jia
- Department of Biostatistics, Cleveland Clinic, Cleveland, Ohio, 44195
| | - Manmeet Ahluwalia
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Gene H Barnett
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Michael A Vogelbaum
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Samuel T Chao
- Cleveland Clinic, Department of Radiation Oncology, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - John H Suh
- Cleveland Clinic, Department of Radiation Oncology, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Erin S Murphy
- Cleveland Clinic, Department of Radiation Oncology, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Jennifer S Yu
- Cleveland Clinic, Department of Radiation Oncology, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Lilyana Angelov
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Alireza M Mohammadi
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
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Sharma M, Jia X, Ahluwalia M, Barnett GH, Vogelbaum MA, Chao ST, Suh JH, Murphy ES, Yu JS, Angelov L, Mohammadi AM. Cumulative Intracranial Tumor Volume and Number of Brain Metastasis as Predictors of Developing New Lesions After Stereotactic Radiosurgery for Brain Metastasis. World Neurosurg 2017; 106:666-675. [PMID: 28735139 DOI: 10.1016/j.wneu.2017.07.048] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/10/2017] [Accepted: 07/11/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To identify risk factors associated with early distant radiographic progression in patients undergoing stereotactic radiosurgery (SRS) for brain metastases (BM). METHODS Following Institutional Review Board approval, data of 1427 patients (4283 BM lesions) who were treated by SRS at the Cleveland Clinic for 2000-2012 were collected. Local tumor progression (LTP), distant tumor progression (DTP), and radiographic radiation necrosis (RN) were the primary endpoints. Patient, imaging, radiosurgery, and tumor variables and follow-up data were collected. RESULTS The median number of targets was 2 (range, 1-17); 45% of the patients had a single lesion. DTP was observed in 10% at 3 months and 19% at 6 months. Patients with 5-10 target lesions for SRS were more likely to develop new lesions at both 3 and 6 months compared to those with 2-4 lesions (odds ratio [OR], 0.83, 95% confidence interval [CI], 0.40-0.85 and OR, 0.85, 95% CI, 0.45-0.86 respectively; P < 0.05). Younger age (<65 years; P < 0.001), higher number of lesions (>1; P < 0.001), cumulative intracranial tumor volume (CITV) <2.75 cc (P = 0.023), type of SRS (upfront and salvage vs. boost; P < 0.001), and tumor pathology (radiosensitive; P < 0.001), were independent predictors of early distant tumor progression following SRS. CONCLUSIONS The number of target lesions and low CITV are both independent predictors of early DTP following SRS for BM. Radiosensitive tumor histology, younger age (<65 years), and SRS without previous whole-brain radiation therapy (upfront or salvage) were also predictors of early DTP.
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Affiliation(s)
- Mayur Sharma
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery and Neurooncology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Xuefei Jia
- Department of Medical Biostatistics, Cleveland Clinic, Cleveland, Ohio, USA
| | - Manmeet Ahluwalia
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery and Neurooncology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gene H Barnett
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery and Neurooncology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael A Vogelbaum
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery and Neurooncology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - John H Suh
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erin S Murphy
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jennifer S Yu
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lilyana Angelov
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery and Neurooncology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alireza M Mohammadi
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery and Neurooncology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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Farris M, McTyre ER, Cramer CK, Hughes R, Randolph DM, Ayala-Peacock DN, Bourland JD, Ruiz J, Watabe K, Laxton AW, Tatter SB, Zhou X, Chan MD. Brain Metastasis Velocity: A Novel Prognostic Metric Predictive of Overall Survival and Freedom From Whole-Brain Radiation Therapy After Distant Brain Failure Following Upfront Radiosurgery Alone. Int J Radiat Oncol Biol Phys 2017; 98:131-141. [DOI: 10.1016/j.ijrobp.2017.01.201] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 01/12/2017] [Accepted: 01/17/2017] [Indexed: 10/20/2022]
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Trino E, Mantovani C, Badellino S, Ricardi U, Filippi AR. Radiosurgery/stereotactic radiotherapy in combination with immunotherapy and targeted agents for melanoma brain metastases. Expert Rev Anticancer Ther 2017; 17:347-356. [PMID: 28277101 DOI: 10.1080/14737140.2017.1296764] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The clinical landscape of advanced melanoma drastically changed after the introduction of both targeted therapies and immunotherapy. This rapid development in systemic therapies led to a change in the management of patients with brain metastases, with the subsequent need to re-assess the role of local therapies, in particular stereotactic radiosurgery (SRS). Areas covered: In this non-systematic review, we report on the current knowledge on the use of SRS in combination with immunotherapy and BRAF/MEK inhibitors for patients with melanoma brain metastases, as well as ongoing trials in this field. Expert commentary: It is now more common to observe patients with melanoma brain metastases with better performance status and prolonged life expectancy. A combination of targeted therapy and immunotherapy, in different sequences, has been shown to be feasible and well tolerable, on the basis of retrospective reports. Additional data from ongoing prospective trials are however needed to confirm or not these findings and better explore the efficacy of the combination.
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Affiliation(s)
- Elisabetta Trino
- a Department of Oncology , University of Torino , Torino , Italy
| | - Cristina Mantovani
- b Radiation Oncology , Città della Salute e della Scienza University Hospital , Torino , Italy
| | - Serena Badellino
- b Radiation Oncology , Città della Salute e della Scienza University Hospital , Torino , Italy
| | - Umberto Ricardi
- a Department of Oncology , University of Torino , Torino , Italy
- b Radiation Oncology , Città della Salute e della Scienza University Hospital , Torino , Italy
| | - Andrea Riccardo Filippi
- a Department of Oncology , University of Torino , Torino , Italy
- c Radiation Oncology , San Luigi Gonzaga University Hospital , Orbassano , Italy
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31
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Choong ES, Lo S, Drummond M, Fogarty GB, Menzies AM, Guminski A, Shivalingam B, Clarke K, Long GV, Hong AM. Survival of patients with melanoma brain metastasis treated with stereotactic radiosurgery and active systemic drug therapies. Eur J Cancer 2017; 75:169-178. [PMID: 28236768 DOI: 10.1016/j.ejca.2017.01.007] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 01/04/2017] [Accepted: 01/11/2017] [Indexed: 12/28/2022]
Abstract
INTRODUCTION With new systemic therapies demonstrating activity in melanoma brain metastasis, most of the previously reported stereotactic radiosurgery (SRS) data are superseded. In this study, we report the outcomes (overall survival [OS] and brain control [BC]) and identify factors that associate with such outcomes in the era of modern systemic therapy. METHOD A total of 108 patients treated with SRS from 2010 to 2015 were included. Systemic treatment use within 6 weeks of SRS was noted. OS was defined as time from SRS to death or last follow-up, and BC was defined as absence of any active intracranial disease during follow-up. Univariate and multivariate Cox proportional hazard analyses were performed on clinico-pathological prognostic features associated with OS and BC. RESULTS The median age was 64.3 years, and the median follow-up was 8.6 months. Seventy-nine (73.1%) patients received systemic treatment. The median OS were as follows: anti-CTLA4 - 7.5 months (95% CI: 4.4-15.6), anti-PD1 - 20.4 months (95% CI: 8.8 - N/A) and BRAF inhibitor (BRAFi) ± MEK inhibitor (MEKi) - 17.8 months (95% CI: 11.8 - N/A). Median BC was as follows: anti-CTLA4 - 7.5 months (95% CI: 4.0-15.6), anti-PD1 - 12.7 months (95% CI: 5.5 - N/A) and BRAFi ± MEKi - 12.7 months (95% CI: 8.3-18.5). In multivariate analysis, age and type of systemic therapy were strongly associated with OS. Age, Eastern Cooperative Oncology Group performance status, Graded Prognostic Assessment (GPA) score, and presence of symptoms were associated with BC. CONCLUSIONS Favourable outcomes are seen in patients treated with SRS and with the best survival seen in patients treated with anti-PD1. Known independent prognostic factors for survival such as age and performance status and GPA score remain relevant in this setting.
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Affiliation(s)
| | - Serigne Lo
- Melanoma Institute Australia, The University of Sydney, NSW, Australia
| | - Martin Drummond
- Melanoma Institute Australia, The University of Sydney, NSW, Australia
| | - Gerald B Fogarty
- Melanoma Institute Australia, The University of Sydney, NSW, Australia; Genesis Cancer Care, Mater Radiation Oncology, North Sydney, Australia; Mater Hospital, North Sydney NSW, Australia
| | - Alexander M Menzies
- Melanoma Institute Australia, The University of Sydney, NSW, Australia; Mater Hospital, North Sydney NSW, Australia; Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Alexander Guminski
- Melanoma Institute Australia, The University of Sydney, NSW, Australia; Mater Hospital, North Sydney NSW, Australia; Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Brindha Shivalingam
- Melanoma Institute Australia, The University of Sydney, NSW, Australia; Royal Prince Alfred Hospital, Camperdown, NSW Australia; Mater Hospital, North Sydney NSW, Australia
| | - Kathryn Clarke
- Genesis Cancer Care, Mater Radiation Oncology, North Sydney, Australia
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, NSW, Australia; Mater Hospital, North Sydney NSW, Australia; Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Angela M Hong
- Melanoma Institute Australia, The University of Sydney, NSW, Australia; Genesis Cancer Care, Mater Radiation Oncology, North Sydney, Australia; Mater Hospital, North Sydney NSW, Australia.
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Chowdhary M, Patel KR, Danish HH, Lawson DH, Khan MK. BRAF inhibitors and radiotherapy for melanoma brain metastases: potential advantages and disadvantages of combination therapy. Onco Targets Ther 2016; 9:7149-7159. [PMID: 28003758 PMCID: PMC5161425 DOI: 10.2147/ott.s119428] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Melanoma is an aggressive malignancy that frequently spreads to the brain, resulting in rapid deterioration in both quality and quantity of life. Historically, treatment options for melanoma brain metastases (MBM) have predominantly consisted of surgery and radiotherapy. While these options can help provide local control, the majority of patients still develop intracranial progression. Indeed, novel therapeutic options, including molecularly targeted agents and immunotherapy, have improved outcomes and are now changing the role of radiotherapy. Up to 50% of melanomas contain an activating BRAF mutation, resulting in hyperactive cellular proliferation and survival. Drugs that target BRAF have been introduced for the treatment of metastatic melanoma and offer hope in improving disease outcomes; however, many of these trials either excluded or had a limited amount of patients with MBM. Recent studies have revealed that melanoma cell lines become more radiosensitive following BRAF inhibition, thus providing a potential synergistic mechanism when combining BRAF inhibitor (BRAFi) and radiotherapy. However, neurotoxicity concerns also exist with this combination. This article reviews the efficacy and limitations of BRAFi therapy for MBM, describes current evidence for combining BRAFis with radiation, discusses the rationale and evidence for combination modalities, and highlights emerging clinical trials specifically investigating this combination in MBM.
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Affiliation(s)
- Mudit Chowdhary
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL
| | - Kirtesh R Patel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Hasan H Danish
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - David H Lawson
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Mohammad K Khan
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
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Impact on overall survival of the combination of BRAF inhibitors and stereotactic radiosurgery in patients with melanoma brain metastases. J Neurooncol 2016; 127:607-15. [PMID: 26852222 DOI: 10.1007/s11060-016-2072-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 01/26/2016] [Indexed: 12/21/2022]
Abstract
The aim of this study was to evaluate the impact of BRAF inhibitors on survival outcomes in patients receiving stereotactic radiosurgery (SRS) for melanoma brain metastases. We prospectively collected treatment parameters and outcomes for 80 patients with melanoma brain metastases who underwent SRS. Thirty-five patients harbored the BRAF mutation (BRAF-M) and 45 patients did not (BRAF-WT). Univariate and multivariate analyses were performed to identify predictors of overall survival. The median overall survival from first SRS procedure was 6.7, 11.2 months if treated with a BRAF inhibitor and 4.5 months for BRAF-WT. Actuarial survival rates for BRAF-M patients on an inhibitor were 54 % at 6 months and 41 % at 12 months from the time of SRS. In contrast, BRAF-WT had overall survival rates of 28 % at 6 months and 19 % at 12 months. Overall survival was extended for patients on a BRAF inhibitor at or after the first SRS. The median time to intracranial progression was 3.9 months on a BRAF inhibitor and 1.7 months without. The local control rate for all treated tumors was 92.5 %, with no difference based on BRAF status. Patients with higher KPS, fewer treated intracranial metastases, controlled systemic disease, RPA Class 1 and BRAF-M patients had extended overall survival. Overall, patients with BRAF-M treated with both SRS and BRAF inhibitors, at or after SRS, have increased overall survival from the time of SRS. As patients live longer as a result of more effective systemic and local therapies, close surveillance and early management of intracranial disease with SRS will become increasingly important.
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Nowak-Sadzikowska J, Walasek T, Jakubowicz J, Blecharz P, Reinfuss M. Current treatment options of brain metastases and outcomes in patients with malignant melanoma. Rep Pract Oncol Radiother 2015; 21:271-7. [PMID: 27601961 DOI: 10.1016/j.rpor.2015.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/31/2015] [Accepted: 12/01/2015] [Indexed: 10/22/2022] Open
Abstract
The prognosis for patients with melanoma who have brain metastases is poor, a median survival does not exceed 4-6 months. There are no uniform standards of treatment for patients with melanoma brain metastases (MBMs). The most preferred treatment approaches include local therapy - surgical resection and/or stereotactic radiosurgery (SRS). The role of whole brain radiotherapy (WBRT) as an adjuvant to local therapy is controversial. WBRT remains a palliative approach for those patients who have multiple MBMs with contraindications for surgery or SRS, or/and poor performance status, or/and very widespread extracranial metastases. Corticosteroids have been used in palliative treatment of MBMs as relief from symptoms related to intracranial pressure and edema. In recent years, the development of new systemic therapeutic strategies has been observed. Various modalities of systemic treatment include chemotherapy, immunotherapy and targeted therapy. Also, multimodality management in different combinations is a common strategy. Decisions regarding the use of specific treatment modalities are dependent on patient's performance status, and the extent of both intracranial and extracranial disease. This review summarizes current treatment options, indications and outcomes in patients with brain metastases from melanoma.
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Affiliation(s)
- Jadwiga Nowak-Sadzikowska
- Oncology Clinic, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Kraków, Poland
| | - Tomasz Walasek
- Radiotherapy Department, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Kraków, Poland
| | - Jerzy Jakubowicz
- Oncology Clinic, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Kraków, Poland
| | - Paweł Blecharz
- Gynecologic Oncology Clinic, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Kraków, Poland
| | - Marian Reinfuss
- Radiotherapy Department, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Kraków, Poland
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Lucas JT, Colmer HG, White L, Fitzgerald N, Isom S, Bourland JD, Laxton AW, Tatter SB, Chan MD. Competing Risk Analysis of Neurologic versus Nonneurologic Death in Patients Undergoing Radiosurgical Salvage After Whole-Brain Radiation Therapy Failure: Who Actually Dies of Their Brain Metastases? Int J Radiat Oncol Biol Phys 2015; 92:1008-1015. [PMID: 26050609 PMCID: PMC4544707 DOI: 10.1016/j.ijrobp.2015.04.032] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 04/14/2015] [Accepted: 04/17/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE To estimate the hazard for neurologic (central nervous system, CNS) and nonneurologic (non-CNS) death associated with patient, treatment, and systemic disease status in patients receiving stereotactic radiosurgery after whole-brain radiation therapy (WBRT) failure, using a competing risk model. PATIENTS AND METHODS Of 757 patients, 293 experienced recurrence or new metastasis following WBRT. Univariate Cox proportional hazards regression identified covariates for consideration in the multivariate model. Competing risks multivariable regression was performed to estimate the adjusted hazard ratio (aHR) and 95% confidence interval (CI) for both CNS and non-CNS death after adjusting for patient, disease, and treatment factors. The resultant model was converted into an online calculator for ease of clinical use. RESULTS The cumulative incidence of CNS and non-CNS death at 6 and 12 months was 20.6% and 21.6%, and 34.4% and 35%, respectively. Patients with melanoma histology (relative to breast) (aHR 2.7, 95% CI 1.5-5.0), brainstem location (aHR 2.1, 95% CI 1.3-3.5), and number of metastases (aHR 1.09, 95% CI 1.04-1.2) had increased aHR for CNS death. Progressive systemic disease (aHR 0.55, 95% CI 0.4-0.8) and increasing lowest margin dose (aHR 0.97, 95% CI 0.9-0.99) were protective against CNS death. Patients with lung histology (aHR 1.3, 95% CI 1.1-1.9) and progressive systemic disease (aHR 2.14, 95% CI 1.5-3.0) had increased aHR for non-CNS death. CONCLUSION Our nomogram provides individual estimates of neurologic death after salvage stereotactic radiosurgery for patients who have failed prior WBRT, based on histology, neuroanatomical location, age, lowest margin dose, and number of metastases after adjusting for their competing risk of death from other causes.
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Affiliation(s)
- John T Lucas
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| | - Hentry G Colmer
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lance White
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nora Fitzgerald
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Scott Isom
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - John D Bourland
- Department of Radiation Oncology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Ly D, Bagshaw HP, Anker CJ, Tward JD, Grossmann KF, Jensen RL, Shrieve DC. Local control after stereotactic radiosurgery for brain metastases in patients with melanoma with and without BRAF mutation and treatment. J Neurosurg 2015; 123:395-401. [PMID: 25768829 DOI: 10.3171/2014.9.jns141425] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECT BRAF inhibitors improve progression-free and overall survival in patients with metastatic melanoma. Brain metastases are common, and stereotactic radiosurgery (SRS) has been used, resulting in excellent local control. Because BRAF inhibitors are associated with intracranial responses, the authors hypothesized that BRAF inhibitors would improve local control in patients with melanoma who are receiving SRS for brain metastases. METHODS The authors retrospectively identified patients with metastatic melanoma who had been tested for BRAF mutation and treated with SRS for brain metastases. Patients with previous resection, multiple brain metastases, or multiple courses of SRS were eligible. SRS was delivered in a single fraction to a median dose of 2000 cGy. Patients with a BRAF mutation were treated with a BRAF inhibitor on the basis of physician preference. RESULTS The authors identified 52 patients who were treated in 82 treatment sessions for 185 brain metastases and 13 tumor beds. At a median follow-up of 10.5 months, the 1-year local control rate was 69.2%. At 1 year, the local control rate for brain metastases in patients with BRAF mutation with BRAF treatment was 85.0%, and the local control rate for brain metastases in those without BRAF treatment was 51.5% (p = 0.0077). The rates of distant brain failure, freedom from whole-brain radiation, and overall survival were not different on the basis of BRAF mutation status or inhibitor therapy. The number of new intratumoral hemorrhages after SRS was increased significantly in patients with BRAF treatment. CONCLUSIONS Treatment with BRAF inhibitors was associated with improved local control after SRS in patients with melanoma and brain metastases. An increased number of intratumoral hemorrhages was associated with BRAF inhibitor therapy.
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Affiliation(s)
- David Ly
- Department of Radiation Oncology and
| | | | - Christopher J Anker
- Division of Radiation Oncology, University of Vermont Cancer Center, Burlington, Vermont
| | | | | | - Randy L Jensen
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah; and
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Anaesthetic techniques for unique cancer surgery procedures. Best Pract Res Clin Anaesthesiol 2013; 27:513-26. [DOI: 10.1016/j.bpa.2013.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 09/26/2013] [Accepted: 09/30/2013] [Indexed: 11/19/2022]
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Han JH, Kim DG, Chung HT, Paek SH, Park CK, Kim CY, Kim YH, Jung HW. Stereotactic radiosurgery for brain metastases from hepatocellular carcinoma. J Neurooncol 2013; 115:45-51. [PMID: 23813231 DOI: 10.1007/s11060-013-1192-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 06/23/2013] [Indexed: 01/11/2023]
Abstract
The purpose of this study is to investigate the possible role of stereotactic radiosurgery (SRS) in the management of patients with brain metastases from hepatocellular carcinoma (HCC). Thirty-two consecutive patients with 80 brain metastases from HCC were treated with SRS. Twenty-eight (87.5 %) patients were male, and the mean age of the patients was 54 ± 12 years (range 22-73). Twenty-seven (84.4 %) patients were classified as RTOG RPA Class 2. The mean tumor volume was 6.14 ± 11.3 cm(3) (range 0.01-67.3). The mean marginal dose prescribed was 20.1 ± 3.6 Gy (range 10.0-25.0). The median overall survival time after SRS was 11.3 ± 5.8 weeks (95 % CI 0-22.7). A greater total volume of brain metastases (>14 cm(3)) was the only independent prognostic factor (HR = 2.419; 95 % CI 1.040-5.624; p = 0.040). The actuarial control rate of brain metastases was 51.3 % at 4 months after SRS. The prescribed marginal dose (>18 Gy) was significantly related with the actuarial tumor control (HR = 0.254; 95 % CI 0.089-0.725; p = 0.010). The prognosis of patients with brain metastases from HCC is dismal even with the modern technology of radiosurgery. The marginal dose prescribed should be reevaluated to improve upon the current poor local control rates.
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Affiliation(s)
- Jung Ho Han
- Department of Neurosurgery, Seoul National University Bundang Hospital, Gyeonggi-do, Seongnam, Korea
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