Irradiation of brain metastases from lung cancer: a retrospective study

The Effect of Intracranial Control After Intracranial Local Therapy on the Prognosis of Patients with Brain Metastasis of Lung Adenocarcinoma

Purpose

The aim of the present study was to assess the clinical outcomes and prognostic factors of lung adenocarcinoma patients with brain metastases (BMs) after intracranial local therapy.

Patients and Methods

A total of 83 lung adenocarcinoma patients with BMs who underwent craniotomy combined with radiotherapy or intracranial radiotherapy alone were retrospectively analyzed. The intracranial tumor response was determined according to the Response Assessment in Neuro-Oncology of Brain Metastases (RANO-BM) criteria. The median overall survival (OS), intracranial progression-free survival (iPFS), and related prognostic factors were analyzed with the Kaplan‒Meier estimator method and Cox proportional hazards regression model.

Results

Among 83 patients, 20 patients received craniotomy combined with radiotherapy, and 63 patients received intracranial radiotherapy alone. Following intracranial local therapy, 11 patients (13.3%) achieved complete response (CR); among them, 8 patients underwent neurosurgical resection. In addition, 32 patients (38.55%) achieved partial response (PR), 32 patients (38.55%) experienced stable disease (SD), and 8 (9.6%) experienced progressive disease (PD). The median follow-up period was 25.4 months (range 0.8-49.6 months). The median follow-up time for the iPFS was 16.2 months (range 0.6-41.2 months). The median OS, iPFS were 28.2 months and 24.7 months. Epidermal growth factor receptor (EGFR) / anaplastic lymphoma kinase (ALK) mutations (HR 3.216, 95% confidence interval (CI) 1.269-8.150, p = 0.014) and iPFS (HR 0.881, 95% CI 0.836-0.929, p < 0.001) were found to be beneficial factors for OS. An intracranial-tumor CR was associated with a longer iPFS (PR: HR 0.052, 95% CI 0.009-0.297, p = 0.001; SD: HR 0.081, 95% CI 0.025-0.259, p < 0.001; PD: HR 0.216, 95% CI 0.077-0.606, p = 0.004).

Conclusion

Prolonged iPFS was associated with better OS in lung adenocarcinoma patients with BMs following intracranial local therapy, and mutations of EGFR / ALK or an intracranial-tumor CR are independent prognostic factors for prolonged survival.

Best Supportive Care Versus Whole-Brain Irradiation, Chemotherapy Alone, or WBRT Plus Chemotherapy in Patients With Brain Metastases From Small-Cell Lung Cancer: A Case-Controlled Analysis

BACKGROUND

WBRT and systemic chemotherapy are the mainstay treatments for small-cell lung cancer (SCLC) brain metastases (BM). However, current recommendations are mainly based on evidence from retrospective analyses. A recent randomized trial found no benefits from WBRT compared with best supportive care (BSC) in patients with more than three BM from non-small-cell lung cancer (NSCLC). Herein, we aimed to evaluate the roles of WBRT and chemotherapy further in the management of BM from SCLC.

MATERIALS AND METHODS

There were 698 patients with BM from SCLC included. Of these, 580 received anti cancer treatment (Group 1), including 178 who received WBRT only (Group 1a), 129 who received chemotherapy only (Group 1b), and 273 who received WBRT plus chemotherapy (Group 1c). The other 118 received BSC (Group 2). Propensity score matching (PSM) analysis was used to compare Group 2 with each of the other groups.

RESULTS

After PSM, compared with Group 2 (n = 118), patients in Group 1 (n = 440) had a prolonged overall survival (OS) in both univariate and multivariate tests, with a median survival time of 10 months (95% CI = 9-11) in Group 1 and 3.5 months (95% CI = 2-7) in Group 2 (p < 0.001). In subgroup analyses, patients who received WBRT plus chemotherapy were more likely to benefit from treatment (p < 0.001). Chemotherapy alone or WBRT alone did not show survival benefits.

CONCLUSION

WBRT plus chemotherapy improved OS in patients with BM from SCLC as compared to BSC. Chemotherapy alone and WBRT alone did not show survival benefits. This retrospective study suggests that SCLC patients with BM who receive WBRT combined with chemotherapy have a better outcome than those receiving BSC alone.

Whole brain radiation therapy alone versus radiosurgery for patients with 1-10 brain metastases from small cell lung cancer (ENCEPHALON Trial): study protocol for a randomized controlled trial

BACKGROUND

Conventional whole brain radiotherapy (WBRT) has been established as the treatment standard in patients with cerebral metastases from small-cell lung cancer (SCLC), however, it has only modest efficacy and limited prospective data is available for WBRT as well as local treatments such as stereotactic radiosurgery (SRS).

METHODS/DESIGN

The present single-center prospective randomized study, conducted at Heidelberg University Hospital, compares neurocognitive function, as objectively measured by significant deterioration in Hopkins Verbal Learning Test - Revised total recall at 3 months. Fifty-six patients will be randomized to receive either SRS of all brain metastases (up to ten lesions) or WBRT. Secondary endpoints include intracranial progression (local tumor progression and number of new cerebral metastases), extracranial progression, overall survival, death due to brain metastases, local (neurological) progression-free survival, progression-free survival, changes in other cognitive performance measures, quality of life and toxicity.

DISCUSSION

Recent evidence suggests that SRS might be a promising treatment option for SCLC patients with brain metastases. The present trial is the first to prospectively investigate the treatment response, toxicity and neurocognition of WBRT and SRS in SCLC patients.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03297788 . Registered September 29, 2017.

Outcome and prognostic factors in patients with brain metastases from small-cell lung cancer treated with whole brain radiotherapy

The purpose of this study was to evaluate prognostic factors associated with overall survival (OS) and neurological progression free survival (nPFS) in small-cell lung cancer (SCLC) patients with brain metastases who received whole-brain radiotherapy (WBRT). From 2003 to 2015, 229 SCLC patients diagnosed with brain metastases who received WBRT were analyzed retrospectively. In this cohort 219 patients (95%) received a total photon dose of 30 Gy in 10 fractions. The prognostic factors evaluated for OS and nPFS were: age, Karnofsky Performance Status (KPS), number of brain metastases, synchronous versus metachronous disease, initial response to chemotherapy, the Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class and thoracic radiation. Median OS after WBRT was 6 months and the median nPFS after WBRT was 11 months. Patients with synchronous cerebral metastases had a significantly better median OS with 8 months compared to patients with metachronous metastases with a median survival of 3 months (p < 0.0001; HR 0.46; 95% CI 0.31-0.67). Based on RPA classification median survival after WBRT was 17 months in RPA class I, 7 months in class II and 3 months in class III (p < 0.0001). Karnofsky performance status scale (KPS < 70%) was significantly associated with OS in both univariate (HR 2.84; p < 0.001) and multivariate analyses (HR 2.56; p = 0.011). Further, metachronous brain metastases (HR 1.8; p < 0.001), initial response to first-line chemotherapy (HR 0.51, p < 0.001) and RPA class III (HR 2.74; p < 0.001) were significantly associated with OS in univariate analysis. In multivariate analysis metachronous disease (HR 1.89; p < 0.001) and initial response to chemotherapy (HR 0.61; p < 0.001) were further identified as significant prognostic factors. NPFS was negatively significantly influenced by poor KPS (HR 2.56; p = 0.011), higher number of brain metastases (HR 1.97; p = 0.02), and higher RPA class (HR 2.26; p = 0.03) in univariate analysis. In this series, the main prognostic factors associated with OS were performance status, time of appearance of intracranial disease (synchronous vs. metachronous), initial response to chemotherapy and higher RPA class. NPFS was negatively influenced by poor KPS, multiplicity of brain metastases, and higher RPA class in univariate analysis. For patients with low performance status, metachronous disease or RPA class III, WBRT should be weighed against supportive therapy with steroids alone or palliative chemotherapy.

Pooled Analysis of CNS Response to Alectinib in Two Studies of Pretreated Patients With ALK-Positive Non-Small-Cell Lung Cancer

Purpose Alectinib has shown activity in the CNS in phase I and II studies. To further evaluate this activity, we pooled efficacy and safety data from two single-arm phase II studies (NP28761 and NP28673; ClinicalTrials.gov identifiers: NCT01871805 and NCT01801111, respectively) in patients with ALK-positive non-small-cell lung cancer (NSCLC). Patients and Methods Both studies included patients with ALK-positive NSCLC who had previously received crizotinib; all patients received alectinib 600 mg twice per day. The primary end point in both studies was independent review committee (IRC)-assessed objective response rate (ORR; by Response Evaluation Criteria in Solid Tumors [RECIST] version 1.1). Additional end points (all by IRC) included CNS ORR (CORR), CNS disease control rate (CDCR), and CNS duration of response (CDOR). Results One hundred thirty-six patients had baseline CNS metastases (60% of the overall study populations); 50 patients (37%) had measurable CNS disease at baseline. Ninety-five patients (70%) had prior CNS radiotherapy; 55 patients completed the CNS radiotherapy more than 6 months before starting alectinib. Median follow-up time was 12.4 months (range, 0.9 to 19.7 months). For patients with baseline measurable CNS disease, IRC CORR was 64.0% (95% CI, 49.2% to 77.1%), CDCR was 90.0% (95% CI, 78.2% to 96.7%), and median CDOR was 10.8 months (95% CI, 7.6 to 14.1 months). For patients with measurable and/or nonmeasurable baseline CNS disease, IRC CORR was 42.6% (95% CI, 34.2% to 51.4%), CDCR was 85.3% (95% CI, 78.2% to 90.8%), and median CDOR was 11.1 months (95% CI, 10.3 months to not evaluable). CORR was 35.8% (95% CI, 26.2% to 46.3%) for patients with prior radiotherapy (n = 95) and 58.5% (95% CI, 42.1% to 73.7%) for patients without prior radiotherapy (n = 41). As previously reported, alectinib was well tolerated, regardless of baseline CNS disease. Conclusion Alectinib showed good efficacy against CNS metastases, in addition to systemic activity, in crizotinib-refractory ALK-positive NSCLC.

Clinical characteristics of brain metastases from lung cancer according to histological type: Pretreatment evaluation and survival following whole-brain radiotherapy

The histological type of lung cancer in patients with brain metastases may affect response to treatment and survival. We evaluated the clinical characteristics of brain metastases from lung cancer according to histological type in 70 consecutive patients with brain metastases from histologically confirmed lung cancer, who had been previously treated with whole-brain radiotherapy (WBRT). Histological type was divided into three categories: adenocarcinoma, small-cell lung carcinoma (SCLC) and other non-small cell lung cancer (NSCLC). The number, size and maximum diameter of brain metastases, the size and maximum diameter of peritumoral edema, the ratio of tumor and peritumoral edema, the asymptomatic ratio, the tumor size reduction rate, the complete response (CR) rate, the intracranial progression-free survival (PFS) and the overall survival (OS) were also evaluated. The median survival time for all patients was 26.2 weeks. Patients with SCLC exhibited a significantly smaller edema size and maximum diameter of edema compared to patients with other NSCLC (P=0.016 and 0.010, respectively). The ratio of tumor and peritumoral edema was also significantly lower in patients with SCLC compared to that in patients with adenocarcinoma and other NSCLC (P= 0.001). Significant differences in intracranial PFS and OS between adenocarcinoma and other NSCLC were also observed (P=0.018 and 0.004, respectively). Patients with adenocarcinoma who were treated with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) following WBRT, demonstrated a significant improvement in intracranial PFS and OS (P=0.008 and 0.004, respectively). The findings presented in this study may provide useful information for the management of brain metastases. Patients with SCLC exhibit a tendency to develop peritumoral edema to a lesser extent, compared to patients with other histological tumor types. Findings in the present study suggest that patients with adenocarcinoma, particularly those treated with EGFR-TKIs, exhibit improved survival rates.

EGFR mutations are associated with favorable intracranial response and progression-free survival following brain irradiation in non-small cell lung cancer patients with brain metastases

BACKGROUND

The presence of epidermal growth factor receptor (EGFR) mutations in non-small cell lung cancer (NSCLC) is associated with increased radiosensitivity in vitro. However, the results from clinical studies regarding the radiosensitivity in NSCLC with mutant EGFR are inconclusive. We retrospectively analyzed our NSCLC patients who had been regularly followed up by imaging studies after irradiation for brain metastases, and investigated the impact of EGFR mutations on radiotherapy (RT).

METHODS

Forty-three patients with brain metastases treated with RT, together with EGFR mutation status, demographics, smoking history, performance status, recursive partitioning analysis (RPA) class, tumor characteristics, and treatment modalities, were included. Radiological images were taken at 1 to 3 months after RT, and 3 to 6 months thereafter. Radiographic response was evaluated by RECIST criteria version 1.1 according to the intracranial images before and after RT. Log-rank test and Cox regression model were used to correlate EGFR mutation status and other clinical features with intracranial radiological progression-free survival (RPFS) and overall survival (OS).

RESULTS

The median follow-up duration was 15 months. Patients with mutant EGFR had higher response rates to brain RT than those with wild-type EGFR (80% vs. 46%; p = 0.037). Logistic regression analysis showed that EGFR mutation status is the only predictor for treatment response (p = 0.032). The median intracranial RPFS was 18 months (95% CI = 8.33-27.68 months). In Cox regression analysis, mutant EGFR (p = 0.025) and lower RPA class (p = 0.026) were associated with longer intracranial RPFS. EGFR mutation status (p = 0.061) and performance status (p = 0.076) had a trend to predict OS.

CONCLUSIONS

Mutant EGFR in NSCLC patients is an independent prognostic factor for better treatment response and longer intracranial RPFS following RT for brain metastases.

Results of the whole-brain radiotherapy for patients with brain metastases from lung cancer: the RTOG RPA intra-classes analysis

We evaluated the overall survival with respect to prognostic factors in patients with brain metastases (BM) from lung cancer in order to assess the RTOG RPA (Recursive Partitioning Analysis) classification value and to perform intra-classes analyses including pretreatment and treatment-related variables. Between 1986 and 1997, 322 consecutive patients with BM from lung cancer were treated with whole-brain radiotherapy. Patients' distribution according to the RTOG RPA classes was: Class 1--13%, Class 2--67% and Class 3--20%. Prognostic value of the following variables was tested: RTOG RPA classes, performance status, age, extracranial metastases, control of the primary tumour, gender, histology, number of BM and interval from diagnosis to the development of BM. Intra-classes analyses were performed including radiation dose and surgery of BM. Median survival was 4.0 months. Median survival for RTOG RPA classes 1, 2 and 3 were 5.2, 4.0 and 2.5 months, respectively (p = 0.003). Extracranial metastases, performance status, control of the primary and RTOG RPA classes were prognostic for survival. Within class 2 higher radiation dose, female, no extracranial metastases and surgery of BM were related to the improved survival. RTOG RPA classes maintain their prognostic significance for patients with BM from lung cancer not participating in clinical trials.

Results of a phase III study of early versus delayed whole brain radiotherapy with concurrent cisplatin and vinorelbine combination in inoperable brain metastasis of non-small-cell lung cancer: Groupe Français de Pneumo-Cancérologie (GFPC) Protocol 95-1

PURPOSE

To determine if the timing of whole brain radiotherapy (WBRT) with respect to chemotherapy with cisplatin and vinorelbine would influence survival in patients with non-small-cell lung cancer (NSCLC) and concurrent brain metastasis.

PATIENTS AND METHODS

One hundred seventy-six patients with brain metastasis from NSCLC were included in the study between July 1995 and October 1997. All patients received chemotherapy with cisplatin 100 mg/m2 on day 1 and vinorelbine 30 mg/m2 on days 1, 8, 15, 22. Cycles were repeated every four weeks. Evaluation of response was performed after two, four or six cycles. After two cycles, chemotherapy was administered to the responders to a maximum of six cycles. Patients were randomised to receive WBRT 30 Gy/10 fx/12 days and delayed corticosteroids. (arm A) for the intracranial nonresponders, or early on day 1 to 12 during the first cycle of chemotherapy (arm B).

RESULTS

One hundred seventy-one patients were eligible: eighty-six in arm A and eighty-five in arm B; none had received prior chemotherapy; seventy-six and seventy-three, respectively, were assessable for response. There was a 21% overall objective response rate (OR) (with 1 complete response and 17 partial responses) after two cycles of chemotherapy alone (arm A) and a 20% OR (with 17 partial responses) to chemotherapy and early WBRT (arm B). The intracranial OR was 27% and 33%, respectively (P = 0.12). The six months survival rate (46% and 40%) and the median survival duration (24 and 21 weeks, respectively) were not significantly different between the two arms (P = 0.83, log-rank test). The major toxicity was severe or life-threatening neutropenia (grade 4), which occurred in 35% of arm A patients and 36% of arm B patients. There were thirteen treatment-related deaths (six in arm A and seven in arm B). There was no difference between the arms for haematological and neuro-toxicities.

CONCLUSIONS

These results confirm the efficacy of chemotherapy in brain metastases of NSCLC and suggest that the timing (early or delayed) of WBRT did not influence survival of NSCLC with brain metastasis treated with concurrent chemotherapy.

Treatment of Brain Metastases in Patients with Small-Cell Lung Cancer: Lessons from Treatment of Other Tumors

Brain metastases are common in patients with small-cell lung cancer (SCLC) and are usually fatal. About half of all patients who develop brain metastases will remain symptomatic at their time of death, even if the immediate cause of death is not neurologic. While it has been argued that the obtundation that sometimes comes with brain metastases may be a relatively easy way to die, studies which have examined the quality of life of individuals developing brain metastases dispute this. For most patients and their families, the impairment of physical, cognitive, and affective function which accompanies most brain metastases is highly distressing and can be seen as a "loss" of the patient even before his/her death. Thus, improved treatment of overt brain metastases will be of palliative value, and eradication of microscopic disease in the brain may cure patients whose disease in other sites has been eradicated. Prophylactic cranial irradiation (PCI) for patients who have achieved a complete response to induction therapy markedly reduces the risk of central nervous system relapse and modestly but significantly improves survival. Despite the use of PCI, many patients with SCLC will develop brain metastases, and there is increasing interest in surgical treatment of patients with solitary lesions and the use of systemic chemotherapy in treating patients, with both SCLC and non small-cell lung cancer, who have multifocal brain metastases which are minimally symptomatic, particularly when these patients also have extracranial metastatic disease.

Prognostic factors in surgical treatment of solitary brain metastasis after resection of non-small-cell lung cancer

Patients with brain metastasis after resection of non-small-cell lung cancer usually have poor prognosis. A few such patients, however, survive for long periods after surgical resection of brain metastases. To evaluate the prognostic factors in resection of solitary brain metastasis from non-small-cell lung cancer, we reviewed 24 cases undergoing resection of solitary brain metastasis after resection of the primary site from 1977 to 1993. The patient population consisted of 20 men and four women ranging in age from 40 to 75 years old (average, 57.8 years old). None of the patients had systemic metastasis except in the brain at the time of brain surgery. The overall survival rates were 12.5% at 3 years and 8.3% at 5 years after brain surgery. The longest survival periods were 11.5 years after brain surgery and 15.4 years after lung surgery. The interval between lung and brain surgery (< or =360 days vs. >360 days), differentiation of primary cancer (poor vs. moderate), size of primary site (< or =5.0 cm vs. >5.0 cm), and operation of primary site (lobectomy vs. pneumonectomy) significantly affected survival as shown by univariate analysis (P<0.05). Other clinical factors (age, gender, histology, T- and N-status, 'resectability with curative intent' of the primary site, location of the brain metastasis and postoperative radiation therapy) did not affect survival. Multivariate analysis using Cox's proportional hazards model indicated that an interval of more than 360 days between the two surgical procedures (hazard ratio = 0.2351, P = 0.0136) and lobectomy (hazard ratio = 0.5274, P = 0.0416) were independent prognostic factors. In conclusion, patients with solitary brain metastasis from non-small-cell lung cancer without other organ metastasis, in whom relapse in the brain occurred more than 1 year after resection of the primary site and in whom lobectomy was performed, should be treated surgically to maximize the chance of prolonged survival.