Brain metastases

Acute Headache Diagnosis and Management

A clinician's goal when encountering acute headaches is to distinguish primary and secondary headache disorders. A comprehensive history, screening for warning signs of secondary headache, and a physical examination can help determine if further workup is necessary. While neurodiagnostic testing is not indicated for individuals with a history of primary headache disorders with typical symptoms, individuals with atypical signs or symptoms may warrant brain imaging with MRI brain, CT head, CT angiogram, CTV, MRV, conventional cerebral angiography, spine imaging, and/or lumbar puncture. Secondary headaches should be treated for their underlying cause. Primary headache disorders have specific evidence-based treatments that can help with acute pain relief.

Quality of life after stereotactic radiosurgery for brain metastasis: an assessment from a prospective national registry

PURPOSE

Stereotactic radiosurgery (SRS) is frequently used in the management of brain metastasis patients. However, there is an urgent need to evaluate post-treatment outcomes and quality of life metrics for patients undergoing SRS for brain metastases.

METHODS

The NeuroPoint Alliance (NPA) SRS Quality Registry conducted prospective enrollment of patients undergoing SRS from 2017 to 2024. Patients with brain metastases from lung cancer, breast cancer, and melanoma were included in the analysis. Outcomes of interest included quality of life metrics, as captured by the five-dimension Euro-QOL (EQ-5D) at 6-12 months and last record follow-up, overall survival, local progression, out-of-field progression, and overall intracranial progression.

RESULTS

522 patients comprised our analytic cohort, and 315 patients had available EQ-5D data at the time of SRS and final follow-up. 264 (47.8%), 197 (35.7%), and 91 (16.5%) patients had 1, 2-4, and 5-14 lesions pre-SRS, respectively. The median overall survival time from diagnosis was 27.3 months. The median time-to-local progression was not reached. At final follow-up, 107 (34.0%) patients had improvement, 51 (16.2%) patients had stable, and 113 patients (35.9%) had worsening EQ-5D scores when compared to baseline. For 44 (13.9%) patients mixed responses across the EQ-5D indices were reported. Linear regression analysis showed that male sex, smoking status, primary tumor type, time-to-overall progression, cumulative intracranial tumor volume (CITV), and baseline EQ-5D were statistically significantly associated with EQ-5D single index at the final follow-up.

CONCLUSION

Real-world data from the SRS NPA Registry demonstrated that most patients with brain metastasis had no change or improvement in quality of life after SRS. Baseline EQ-5D was predictive of EQ-5D single index at final follow-up, and, as such, EQ-5D at baseline would be a valuable assessment measure for brain metastasis patients undergoing SRS.

T cell induced expression of Coronin-1A facilitates blood-brain barrier transmigration of breast cancer cells

In previous work we discovered that T lymphocytes play a prominent role in the rise of brain metastases of ER-negative breast cancers. In the present study we explored how T lymphocytes promote breast cancer cell penetration through the blood brain barrier (BBB). An in vitro BBB model was employed to study the effects of T lymphocytes on BBB trespassing capacity of three different breast carcinoma cell lines. Differential protein expression was explored by comparing the proteomes of the breast cancer cells before and after co-culture with activated T lymphocytes using liquid chromatography-mass spectrometry (LC-MS). siRNA was used to silence protein expression in the breast cancer cells to study contribution to in vitro BBB passage. Furthermore, protein expression in primary breast cancer tissues was explored and related to brain-metastatic potential. Co-culturing with activated T lymphocytes or their conditioned medium (CM) resulted in increased passage through the in vitro BBB. The effects were less for cell line MDA-MB-231-B2M2 (brain affinity) as compared to MDA-MB-231 and SK-BR-7. Mass spectrometry-based proteomics revealed significant alterations in the expression of 35 proteins by the breast cancer cell lines upon T cell contact. Among the proteins is coronin-1 A, a protein related to cell motility. Knockdown of CORO1A in the breast cancer cells reduced their ability to cross the artificial BBB to 60%. The effects were significantly less for the cell line derived from breast cancer with affinity for brain. The expression of coronin-1A was confirmed by immunohistochemistry and RT-PCR of 52 breast cancer samples of patients with metastasized breast cancers, with and without brain locations. Lastly, CORO1A upregulation was validated in a publicly available mRNA expression database from 204 primary breast cancers with known metastatic sites. We conclude that T lymphocytes trigger cancer cells to express proteins including coronin-1A that enable the cancer cells to cross an in vitro BBB. In addition, a prominent role of coronin-1A in the formation of cerebral metastases in breast cancer patients is strongly suggestive by its upregulation in tissue samples of breast cancer patients with brain metastases.

Transfer Learning Approaches for Brain Metastases Screenings

BACKGROUND

In this study, we examined the effectiveness of transfer learning in improving automatic segmentation of brain metastases on magnetic resonance imaging scans, with potential applications in preventive exams and remote diagnostics.

METHODS

We trained three deep learning models on a public dataset from the ASNR-MICCAI Brain Metastasis Challenge 2024, fine-tuned them on a small private dataset, and compared their performance to models trained from scratch.

RESULTS

Results showed that models using transfer learning performed better than scratch-trained models, though the improvement was not statistically substantial. The custom Tversky and Binary Cross-Entropy loss function helped manage class imbalance and reduce false negatives, limiting missed tumor regions. Medical experts noted that, while fine-tuned models worked well with larger, well-defined tumors, they struggled with tiny, scattered tumors in complex cases.

CONCLUSIONS

This study highlights the potential of transfer learning and tailored loss functions in medical imaging, while also pointing out the models' limitations in detecting very small tumors in challenging cases.

Surgical Resection Followed by Stereotactic Radiosurgery (S+SRS) Versus SRS Alone for Large Posterior Fossa Brain Metastases: A Comparative Analysis of Outcomes and Factors Guiding Treatment Modality Selection

BACKGROUND/OBJECTIVES

Around 20% of cancer patients will develop brain metastases (BrMs), with 15-25% occurring in the posterior fossa (PF). Although the effectiveness of systemic therapies is increasing, surgery followed by stereotactic radiosurgery (S+SRS) versus definitive SRS remains the mainstay of treatment. Given the space restrictions within the PF, patients with BrMs in this location are at higher risk of brainstem compression, hydrocephalus, herniation, coma, and death. However, the criteria for treating large PF BrMs with S+SRS versus definitive SRS remains unclear.

METHODS

We reviewed a prospective registry database (2009 to 2020) and identified 64 patients with large PF BrMs (≥4 cc) treated with SRS or S+SRS. Clinical and radiological parameters were analyzed. The two endpoints were overall survival (OS) and local failure (LF).

RESULTS

Patients in the S+SRS group were more highly symptomatic than patients in the SRS group. Gait imbalance and intracranial pressure symptoms were 97% and 80%, and 47% and 35% for S+SRS and SRS, respectively. Radiologically, there were significant differences in the mean volume of the lesions [6.7 cm3 in SRS vs. 29.8 cm3 in the S+SRS cohort, (p < 0.001)]; compression of the fourth ventricle [47% in SRS vs. 96% in S+SRS cohort, (p < 0.001)]; and hydrocephalus [0% in SRS vs. 29% in S+SRS cohort, (p < 0.001)]. Patients treated with S+SRS had a higher Graded Prognostic Assessment (GPA). LF was 12 and 17 months for SRS and S+SRS, respectively. Moreover, the S+SRS group had improved OS (12 vs. 26 months, p = 0.001).

CONCLUSIONS

A higher proportion of patients treated with S+SRS presented with hydrocephalus, fourth-ventricle compression, and larger lesion volumes. SRS-alone patients had a lower KPS, a lower GPA, and more brain metastases. S+SRS correlated with improved OS, suggesting that it should be seriously considered for patients with large PF-BrM.

Brain Metastasis in the Emergency Department: Epidemiology, Presentation, Investigations, and Management

Brain metastases (BMs) are the most prevalent type of cerebral tumor, significantly affecting survival. In adults, lung cancer, breast cancer, and melanoma are the primary cancers associated with BMs. Symptoms often result from brain compression, and patients may present to the emergency department (ED) with life-threatening conditions. The goal of treatment of BMs is to maximize survival and quality of life by choosing the least toxic therapy. Surgical resection followed by cavity radiation or definitive stereotactic radiosurgery remains the standard approach, depending on the patient's condition. Conversely, whole brain radiation therapy is becoming more limited to cases with multiple inoperable BMs and is less frequently used for postoperative control. BMs often signal advanced systemic disease, and patients usually present to the ED with poorly controlled symptoms, justifying hospitalization. Over half of patients with BMs in the ED are admitted, making effective ED-based management a challenge. This article reviews the epidemiology, clinical manifestations, and current treatment options of patients with BMs. Additionally, it provides an overview of ED management and highlights the challenges faced in this setting. An improved understanding of the reasons for potentially avoidable hospitalizations in cancer patients with BMs is needed and could help emergency physicians distinguish patients who can be safely discharged from those who require observation or hospitalization.

Evaluation of brain metastasis edema in breast cancer patients as a marker for Ki-67 and cell count-A single center analysis

BACKGROUND

Peritumoral edema is an important cause of morbidity and mortality in patients with breast cancer brain metastases (BCBM). The relationship between vasogenic edema and proliferation indices or cell density in BCBM remains poorly understood.

PURPOSE

To assess the association between tumor volume and peritumoral edema volume and histopathological and immunohistochemical parameters in BCBM.

MATERIALS AND METHODS

Patients with confirmed BCBM were retrospectively identified. The tumor volume and peritumoral edema volume of each brain metastasis (BM) were semi-automatically calculated in axial T2w and axial T2-fluid attenuated inversion recovery (FLAIR) sequences using the software MIM (Cleveland, Ohio, USA). Edema volume was correlated with histological parameters, including cell count and Ki-67. Sub-analyses were conducted for luminal B, Her2-positive, and tripe negative subgroups.

RESULTS

Thirty-eight patients were included in the study. There were 24 patients with a single BM. Mean metastasis volume was 31.40 ± 32.52 mL and mean perifocal edema volume was 72.75 ± 58.85 mL. In the overall cohort, no correlation was found between tumor volume and Ki-67 (r = 0.046, p = .782) or cellularity (r = 0.028, p = .877). Correlation between edema volume and Ki-67 was r = 0.002 (p = .989), correlation with cellularity was r = 0.137 (p = .453). No relevant correlation was identified in any subgroup analysis. There was no relevant correlation between BM volume and edema volume.

CONCLUSION

In patients with breast cancer brain metastases, we did not find linear associations between edema volumes and immunohistochemical features reflecting proliferation potential. Furthermore, there was no relevant correlation between metastasis volume and edema volume.

Analysis of prognostic factors and the role of epilepsy in neurosurgical patients with brain metastases

Background

Brain metastases (BMs) represent the most frequent brain tumors in adults. The identification of key prognostic factors is essential for choosing the therapeutic strategy tailored to each patient. Epilepsy can precede several months of other clinical presentations of BMs. This work aimed to study the impact of epilepsy and other prognostic factors on BMs patients' survival.

Methods

This retrospective study included 51 patients diagnosed with BMs and who underwent neurosurgery between 2010 and 2021. The impact of BM features and patient's clinical characteristics on the overall survival (OS) was analyzed through uni- and multivariate analysis.

Results

The average OS was 25.98 months and differed according to the histology of the primary tumor. The primary tumor localization and the presence of extracranial metastases had a statistically significant impact on the OS, and patients with single BM showed a superior OS to those with multifocal lesions. The localization of BMs in the temporal lobe correlated with the highest OS. The OS was significantly higher in patients who presented seizures in their clinical onset and in those who had better post-surgical Karnofsky performance status, no post-surgical complications, and who underwent post-surgical treatment.

Conclusion

Our study has highlighted prognostically favorable patient and tumor factors. Among those, a clinical onset with epileptic seizures can help identify brain metastasis hitherto silent. This could lead to immediate diagnostic-therapeutic interventions with more aggressive therapies after appropriate multidisciplinary evaluation.

Challenges in radiological evaluation of brain metastases, beyond progression

MRI is the cornerstone in the evaluation of brain metastases. The clinical challenges lie in discriminating metastases from mimickers such as infections or primary tumors and in evaluating the response to treatment. The latter sometimes leads to growth, which must be framed as pseudo-progression or radionecrosis, both inflammatory phenomena attributable to treatment, or be considered as recurrence. To meet these needs, imaging techniques are the subject of constant research. However, an exponential growth after radiotherapy must be interpreted with caution, even in the presence of results suspicious of tumor progression by advanced techniques, because it may be due to inflammatory changes. The aim of this paper is to familiarize the reader with inflammatory phenomena of brain metastases treated with radiotherapy and to describe two related radiological signs: "the inflammatory cloud" and "incomplete ring enhancement", in order to adopt a conservative management with close follow-up.

AS602801 treatment suppresses breast cancer metastasis to the brain by interfering with gap-junction communication by regulating Cx43 expression

AS602801 has been reported as a potential drug candidate against brain metastasis by suppressing the gap-junction communication between lung cancer stem cells and astrocytes. In this study, we aimed to study the molecular mechanism underlying the role of AS602801 in the treatment of brain metastasis in breast cancer. We utilized female athymic BALB/c nude mice and MDA-MB-231/BT-474BR cells to establish experimental models. Polymerase chain reaction assays were performed to observe changes in the connexin 43 (Cx43) messenger RNA (mRNA) and c-Jun N-terminal kinase (JNK) mRNA levels. Dye transfer assay was used to observe the effect of AS602801 on cell-cell communication. An organotypic blood-brain barrier (BBB) model was utilized to observe the effect of AS602801 on transmigration through the BBB barrier. MTT (3-[4,5-dimethylthiazol-2-yl]-2,5 diphenyl tetrazolium bromide) assay and flow cytometry were performed to evaluate the proliferation and apoptosis of breast cancer cells co-cultivated with astrocytes. AS602801 inhibited the upregulation of Cx43 and JNK in brain metastasized breast cancer cells in a dose-dependent manner. Also, AS602801 significantly decreased the dye transfer rate from astrocytes to breast cancer cells, indicating the inhibitory effect of AS602801 on cell-cell communication. The transmigration ability of breast cancer cells co-cultured with astrocytes was decreased by AS602801. Furthermore, AS602801 reduced the elevated Cx43/JNK mRNA expression in the co-astrocyte group while suppressing the increased proliferation and promoting the decreased apoptosis of breast cancer cells co-cultivated with astrocytes. AS602801 also suppressed the brain metastasis of breast cancer cells and increased mouse survival. AS602801 downregulates the expressions of JNK and Cx43 to suppress the gap-junction activity. AS602801 also inhibits the communication between breast cancer cells and astrocytes, thus contributing to the treatment of brain metastasis in breast cancer.

Prevalence of asymptomatic brain metastases in metastatic nonsquamous nonsmall cell lung cancer: Treatment implications for resource-constrained settings

BACKGROUND

Brain metastases (BM) are common in metastatic nonsmall cell lung cancer (NSCLC). However, routine neuroimaging in asymptomatic patients with metastatic NSCLC is controversial as there is no conclusive evidence of benefit from the detection and treatment of asymptomatic BM. Herein, we evaluated the prevalence of asymptomatic BM and its treatment implications in a resource-limited setting.

METHODS

Consecutive patients with newly diagnosed, treatment-naïve, metastatic, nonsquamous NSCLC (NS-NSCLC) were included. Subjects who already had clinical or radiological features suggestive of BM were excluded from the study. All eligible subjects underwent contrast-enhanced magnetic resonance imaging (MRI) of the brain. Management of the detected BM was at the discretion of the treating clinicians.

RESULTS

Among 809 subjects who were screened, 100 (12.4%) were included in the study and underwent MRI. BM was present in 30 (30%) of the subjects and absent in the remaining 70 subjects. A majority of BM were multiple (70%), involved the frontal lobe commonly (73.3%), and had a mean (standard deviation) size of 13.2 (7.3) mm. Detection of BM resulted in a treatment alteration in 17 (17%) of the study subjects (brain irradiation, n = 17, change in targeted therapy, n = 3) with BM. There was no difference in survival of patients who underwent treatment alteration for management of BM compared to those who did not ( P = 0.132).

CONCLUSIONS

About one-third of patients with metastatic NS-NSCLC had BM in MRI despite the absence of symptoms. Despite treatment of the majority of the patients with BM with brain irradiation, there was no demonstrable survival benefit. Hence, we conclude that although routine neuroimaging of asymptomatic patients with newly diagnosed metastatic NSCLC may result in treatment alteration (primarily brain irradiation) in a small proportion of patients, it may not influence outcomes in resource-constrained settings.

Brain Metastases from Breast Cancer Histologically Exhibit Solid Growth Pattern with at Least Focal Comedonecrosis: A Histopathologic Study on a Monocentric Series of 30 Cases

Since there are no morphological clues capable of making a pathologist suspect a possible mammary origin of a metastatic lesion without adequate clinical information, the histologic diagnosis of brain metastasis from BC is still based on the immunohistochemical expression of mammary gland markers such as GATA-3, ERs, PgRs and HER-2. The present retrospective study aimed to select purely morphological features capable of suggesting the mammary origin of a metastatic carcinoma in the brain. The following histological features were collected from a series of 30 cases of brain metastases from breast cancer: (i) a solid growth pattern; (ii) the presence of comedonecrosis; and (iii) glandular differentiation. Our results showed that most cases histologically exhibited a solid growth pattern with at least focal comedonecrosis, producing an overall morphology closely reminiscent of mammary high-grade ductal carcinoma in situ. Although the above-mentioned morphological parameters are not strictly specific to a mammary origin, they may have an important diagnostic utility for leading pathologists to suspect a possible breast primary tumor and to include GATA-3, ERs, PgRs and HER-2 in the immunohistochemical panel.

Deep learning based automated epidermal growth factor receptor and anaplastic lymphoma kinase status prediction of brain metastasis in non-small cell lung cancer

Aim

The aim of this study was to investigate the feasibility of developing a deep learning (DL) algorithm for classifying brain metastases from non-small cell lung cancer (NSCLC) into epidermal growth factor receptor (EGFR) mutation and anaplastic lymphoma kinase (ALK) rearrangement groups and to compare the accuracy with classification based on semantic features on imaging.

Methods

Data set of 117 patients was analysed from 2014 to 2018 out of which 33 patients were EGFR positive, 43 patients were ALK positive and 41 patients were negative for either mutation. Convolutional neural network (CNN) architecture efficient net was used to study the accuracy of classification using T1 weighted (T1W) magnetic resonance imaging (MRI) sequence, T2 weighted (T2W) MRI sequence, T1W post contrast (T1post) MRI sequence, fluid attenuated inversion recovery (FLAIR) MRI sequences. The dataset was divided into 80% training and 20% testing. The associations between mutation status and semantic features, specifically sex, smoking history, EGFR mutation and ALK rearrangement status, extracranial metastasis, performance status and imaging variables of brain metastasis were analysed using descriptive analysis [chi-square test (χ2)], univariate and multivariate logistic regression analysis assuming 95% confidence interval (CI).

Results

In this study of 117 patients, the analysis by semantic method showed 79.2% of the patients belonged to ALK positive were non-smokers as compared to double negative groups (P = 0.03). There was a 10-fold increase in ALK positivity as compared to EGFR positivity in ring enhancing lesions patients (P = 0.015) and there was also a 6.4-fold increase in ALK positivity as compared to double negative groups in meningeal involvement patients (P = 0.004). Using CNN Efficient Net DL model, the study achieved 76% accuracy in classifying ALK rearrangement and EGFR mutations without manual segmentation of metastatic lesions. Analysis of the manually segmented dataset resulted in improved accuracy of 89% through this model.

Conclusions

Both semantic features and DL model showed comparable accuracy in classifying EGFR mutation and ALK rearrangement. Both methods can be clinically used to predict mutation status while biopsy or genetic testing is undertaken.

Cost-effectiveness analysis of 3 radiation treatment strategies for patients with multiple brain metastases

Background

Patients diagnosed with multiple brain metastases often survive for less than 2 years, and clinicians must carefully evaluate the impact of interventions on quality of life. Three types of radiation treatment are widely accepted for patients with multiple brain metastases: Whole brain radiation therapy (WBRT), hippocampal avoidance whole-brain radiation therapy (HA-WBRT), and stereotactic radiosurgery (SRS). WBRT, the standard option, is less costly than its newer alternatives but causes more severe adverse effects such as memory loss. To determine whether the cost-effectiveness ratio of HA-WBRT and SRS are superior to WBRT, we used published data to simulate cases of multiple brain metastases.

Methods

We designed a Markov model using data from previously published studies to simulate the disease course of patients with 5 to 15 brain metastases and determine the cost-effectiveness of HA-WBRT and SRS relative to WBRT. Incremental cost-effectiveness ratios (ICERs) were calculated and compared against a willingness-to-pay threshold of $100 000 per quality-adjusted life year.

Results

SRS met the threshold for cost-effectiveness, with ICERs ranging $41 198-$54 852 for patients with 5 to 15 brain metastases; however, HA-WBRT was not cost-effective, with an ICER of $163 915 for all simulated patients. Model results were robust to sensitivity analyses.

Conclusions

We propose that SRS, but not HA-WBRT, should be offered to patients with multiple brain metastases as a treatment alternative to standard WBRT. Incorporating these findings into clinical practice will help promote patient-centered care and decrease national healthcare expenditures, thereby addressing issues around health equity and access to care.

Fractionated Stereotactic Radiotherapy with Helical Tomotherapy for Brain Metastases: A Mono-Institutional Experience

Background: The present study reports on the outcomes of our mono-institutional experience of Helical Tomotherapy (HT)-based SRT for brain metastases. The use of this linac is less frequently reported for this kind of treatment. Methods: This retrospective study displays a series of patients treated with HT-SRT. The eligibility of using SRT for brain metastases was defined by a Karnofsky performance status of >70, a life expectancy of >6 months, and controlled extra-cranial disease; no SRT was allowed in the case of a number of brain metastases larger than 10. All the cases were discussed by a multidisciplinary board. Toxicity assessments were performed based on CTCAE v5.0. Survival endpoints were assessed using the Kaplan-Meier method, and univariate and multivariate analyses were carried out to identify any potential predictive factor for an improved outcome. Results: Sixty-four lesions in 37 patients were treated using HT-SRT with a median total dose of 30 Gy in five fractions. The median follow-up was 7 months, and the 1- and 2-year LC rates were both 92.5%. The IPFS rates were and 56.75% and 51.35%. The OS rates were 54% and 40%. The UA showed better IPFS rates significantly related to male sex (p = 0.049), a BED₁₂ of ≥42 Gy (p = 0.006), and controlled extracranial disease (p = 0.03); in the MA, a favorable trend towards LC (p = 0.11) and higher BED (p = 0.11) schedules maintained a correlation with improved IPFS rates, although statistical significance was not reached. Conclusions: HT-based SRT for brain metastases showed safety and efficacy in our monoinstiutional experience. Higher RT doses showed statistical significance for improved outcomes of LC and OS.

Stereotactic Radiosurgery as Treatment for Brain Metastases: An Update

Stereotactic radiosurgery (SRS) is a mainstay treatment option for brain metastasis (BM). While guidelines for SRS use have been outlined by professional societies, consideration of these guidelines should be weighed in the context of emerging literature, novel technology platforms, and contemporary treatment paradigms. Here, we review recent advances in prognostic scale development for SRS-treated BM patients and survival outcomes as a function of the number of BM and cumulative intracranial tumor volume. Focus is placed on the role of stereotactic laser thermal ablation in the management of BM that recur after SRS and the management of radiation necrosis. Neoadjuvant SRS prior to surgical resection as a means of minimizing leptomeningeal spread is also discussed.

Rectum to Medulla Oblongata: Colorectal Cancer Metastasizing to the Brainstem

Metastasis with colorectal cancer (CRC) is commonly seen in the liver, lungs and peritoneal cavity. Brainstem involvement with CRC is not studied with no prior reported cases. We report a case of CRC, admitted for apneic spells and dry cough and later found to have metastasis to the left anterolateral medulla oblongata. A 28-year-old male, with a past medical history of asthma, and colorectal adenocarcinoma metastatic to the brain, presented to the emergency department with complaints of a dry cough, altered mental status and shortness of breath. He was seen at urgent care before and was given a week of oral levofloxacin for presumptive pneumonia without any relief. Physical examination was concerning for stridor with clear lung fields. MRI brain showed previously noted post-operative right frontoparietal craniotomy changes and a new 9 x 8 x 8 mm ring-enhancing intra-axial lesion centered at the left anterolateral medulla oblongata indicative of brainstem metastatic disease. The patient was intubated for airway protection and underwent a suboccipital craniotomy for resection of the left pontomedullary mass, and histopathology was positive for metastatic adenocarcinoma, colorectal primary with hemorrhagic necrosis. He had a tracheostomy placed post multiple failed extubation trials and a gastrostomy tube for oral feeds. Goals of care were addressed with the patient and family, and a decision was made for home hospice.

High-grade glioma and solitary metastasis: differentiation by spectroscopy and advanced magnetic resonance techniques

Background

The differentiation by means of magnetic resonance between high-grade gliomas and intracranial solitary single metastasis is of the utmost importance since they condition both surgical and complementary treatment.

Results

Retrospective study that analyzes the parameters of advanced magnetic resonance imaging: spectroscopy, diffusion and perfusion, specifically focused on the differences in the coefficients of the metabolites Cho/Cr, Cho/NAA and NAA/Cr in peritumoral edema between high-grade gliomas and metastases. The data have been statistically analyzed using ROC (receiver operating characteristic) curves, and cutoff values were obtained.

A total of 79 patients with histologically analyzed tumors were analyzed: 49 high-grade gliomas (40 multiform glioblastomas and 9 anaplastic astrocytomas) and 30 metastases. A statistically significant mean difference was obtained in the three metabolite ratios. The area under the curve for the Cho/NAA ratio was 0.958 (CI: 0.903–1), for Cho/Cr 0.922 (CI: 0.859–0.985) and for NAA/Cr 0.163 (CI: 0.068–0.258; p < 0.001). The cutoff values were 1.115 for Cho/NAA (sensitivity 93.87%, specificity 93.33%, global precision 93.67%); 1.18 for the Cho/Cr ratio (sensitivity 89.79%, specificity 93.33% and precision 91.13%) and 1.155 for the NAA/Cr ratio (sensitivity 67.34%, specificity 93.33%, global precision 44.30%).

Conclusion

The results of the study support the premise that spectroscopy at the level of peritumoral edema is able to differentiate between high-grade gliomas and metastases by showing tumor infiltration in peritumoral edema.

Automated Color-Coding of Lesion Changes in Contrast-Enhanced 3D T1-Weighted Sequences for MRI Follow-up of Brain Metastases

BACKGROUND AND PURPOSE

MR imaging is the technique of choice for follow-up of patients with brain metastases, yet the radiologic assessment is often tedious and error-prone, especially in examinations with multiple metastases or subtle changes. This study aimed to determine whether using automated color-coding improves the radiologic assessment of brain metastases compared with conventional reading.

MATERIALS AND METHODS

One hundred twenty-one pairs of follow-up examinations of patients with brain metastases were assessed. Two radiologists determined the presence of progression, regression, mixed changes, or stable disease between the follow-up examinations and indicated subjective diagnostic certainty regarding their decisions in a conventional reading and a second reading using automated color-coding after an interval of 8 weeks.

RESULTS

The rate of correctly classified diagnoses was higher (91.3%, 221/242, versus 74.0%, 179/242, P < .01) when using automated color-coding, and the median Likert score for diagnostic certainty improved from 2 (interquartile range, 2-3) to 4 (interquartile range, 3-5) (P < .05) compared with the conventional reading. Interrater agreement was excellent (κ = 0.80; 95% CI, 0.71-0.89) with automated color-coding compared with a moderate agreement (κ = 0.46; 95% CI, 0.34-0.58) with the conventional reading approach. When considering the time required for image preprocessing, the overall average time for reading an examination was longer in the automated color-coding approach (91.5 [SD, 23.1] seconds versus 79.4 [SD, 34.7 ] seconds, P < .001).

CONCLUSIONS

Compared with the conventional reading, automated color-coding of lesion changes in follow-up examinations of patients with brain metastases significantly increased the rate of correct diagnoses and resulted in higher diagnostic certainty.

Tumor treating fields: An emerging treatment modality for thoracic and abdominal cavity cancers

Tumor treating fields (TTFields)-an intermediate-frequency, electric field therapy-has emerged as a promising alternative therapy for the treatment of solid cancers. Since the first publication describing the anticancer effects of TTFields in 2004 there have been numerous follow-up studies by other groups, either to confirm the efficacy of TTFields or to study the primary mechanism of interaction. The overwhelming conclusion from these in vitro studies is that TTFields reduce the viability of aggressively replicating cell lines. However, there is still speculation as to the primary mechanism for this effect; moreover, observations both in vitro and in vivo of inhibited migration and metastases have been made, which may be unrelated to the originally proposed hypothesis of replication stress. Adding to this, the in vivo environment is much more complex spatially, structurally, and involves intricate networks of cell signaling, all of which could change the efficacy of TTFields in the same way pharmaceutical interventions often struggle transitioning in vivo. Despite this, TTFields have shown promise in clinical practice on multiple cancer types, which begs the question: has the primary mechanism carried over from in vitro to in vivo or are there new mechanisms at play? The goal of this review is to highlight the current proposed mechanism of action of TTFields based primarily on in vitro experiments and animal models, provide a summary of the clinical efficacy of TTFields, and finally, propose future directions of research to identify all possible mechanisms in vivo utilizing novel tumor-on-a-chip platforms.

Factors Prognostic for Brain Metastases from Colorectal Cancer: A Single-Center Experience in China

Purpose

This study aimed to analyze clinicopathological, survival, prognostic factors, as well as the timing of brain metastases (BM) in colorectal cancer (CRC) using data from a Chinese center.

Patients and Methods

Data of 65 consecutive CRC patients with BM were collected from a single institution in China. The time from primary tumor surgery to the occurrence of BM was calculated. Kaplan-Meier analysis was used to evaluate cumulative survival of patients. Factors associated with prognosis of overall survival (OS) were explored using Cox's proportional hazard regression models.

Results

The median time interval from CRC surgery to the diagnosis of BM was 24 months. After diagnosis of BM, median OS values for patients were 11 months. Extracranial metastases occurred in 45 cases (69.2%) when BM was diagnosed, and 58.5% of these patients with lung metastases Time of BMs (P=0.018), presence of extracranial metastases (P=0.033), treatment (P=0.003), CA199 (P=0.034), CA125 (P<0.001), CA242 (P=0.018), and CA211 (P=0.012) were associated with OS of patients through univariate analysis. Multivariate analysis using a Cox regression model showed that only treatment was an independent predictor for OS (conservative treatment; HR=1.861, 95% CI=1.077-3.441; P=0.048).

Conclusion

Surgical treatment of metastatic lesions may be an alternative choice for CRC patients with BM. Identifying the timing of brain metastases can help to detect this disease early, leading to a better survival outcome.

Stereotactic Radiosurgery (SRS) experience on brain metastases: A 3-year retrospective study at King Abdulaziz University Hospital

Objectives

Stereotactic radiosurgery (SRS), a non-invasive surgical procedure had been utilized for treatment of patients with brain metastases. This study aims to determine the survival, local control of brain metastases and treatment outcome to SRS-treated patients based on radiological imaging.

Methods

The MRI scans of SRS-treated patients with brain metastases (n = 24) from the Radiology Department of King Abdulaziz University from January 2016 to September 2019 were examined. The data was analyzed using descriptive statistics and Chi-square test.

Results

Out of 24 patients, most had brain metastases (95.8%, n = 23) with mean interval development (after primary site) of 21.88 ± 25.2 months. Radiological imaging revealed tumor characteristics of smallest (n = 11) and biggest lesions (n = 24) of patients to be 0.98 ± 0.7 and 2.23 ± 0.9, respectively and number of lesion to be 4-5 lesions (n = 3), 3 lesions (n = 6), 2 lesions (n = 4) and 1 lesion (n = 11). After SRS treatment, findings showed 17.6% (n = 3) no recurrence among the patients. Those with recurrences have decrease in lesion enhancement (11.8%, n = 2), decrease in size (29.4%, n = 5) and decrease in both enhancement and size (29.4%). Overall survival obtained was 16.7% (n = 2) at 313.83 ± 376.0 days (n = 23) survival period. Chi-square test showed that radiological findings were significantly associated with tumor recurrence (p = 0.010), having SRS-treated patients with recurrences (n = 12) to experience significant decrease (p = 0.010) in tumor enhancement, size, and both enhancement and size.

Conclusion

A significant decrease in tumor size and enhancement was observed in SRS-treated patients, suggesting SRS treatment to have associated benefit with prolonged survival duration.

Pathological Features of Brain Metastases

Metastases are the most common intracranial tumors in adults. Lung cancer, melanoma, renal cell carcinoma, and breast cancer are the most common primary tumors that metastasize to the brain. Improved detection of small metastases by MRI, and improved systemic therapy for primary tumors, resulted in increased incidence of brain metastasis. Advances in neuroanesthesia and neurosurgery have significantly improved the safety of surgical resection of brain metastases. Surgical approach and active management have become applicable for many patients. Subsequently, brain metastases diagnosis no longer equals palliative treatment. Moreover, the demand for diagnosing brain masses has increased with its associated challenges.

Dysregulation of lncRNA-CCRR contributes to brain metastasis of breast cancer by intercellular coupling via regulating connexin 43 expression

Cardiac conduction regulatory RNA (CCRR) is down‐regulated in the pathogenesis of heart failure (HF), which accordingly suppresses cardiac conduction while promoting arrhythmogenicity. Meanwhile, CX43 was reported to play a role in the pathogenesis of metastatic breast cancer and melanoma brain colonization. In this study, we studied the role of long non‐coding RNA CCRR and its interaction with CX43 in brain metastasis of breast cancer. Breast cancer patients were grouped according to the metastasis status. Real‐time PCR and IHC assay were used to measure the expression of lncRNA‐CCRR and CX43 in patients. Western blot was conducted to observe the effect of lncRNA‐CCRR on the expression of CX43 in MDA‐MB‐231BR and BT‐474BR cells. Compared with the non‐metastasis group, the mRNA expression of tissue lncRNA‐CCRR, cerebrospinal fluid (CSF) lncRNA‐CCRR, tissue CX43 and tissue protein expression of CX43 were both evidently up‐regulated in metastasis patients, especially in patients with brain metastasis. The expression of lncRNA‐CCRR was positively correlated with the up‐regulated expression of CX43. Moreover, CX43 expression was significantly lower in MDA‐MB‐231WT cells compared with that in MDA‐MB‐231BR cells. Also, the overexpression of lncRNA‐CCRR evidently increased dye transfer rate from astrocytes to MDA‐MB‐231BR/BT‐474BR cells but reduced lncRNA‐CCRR expression and suppressed the transmigration of MDA‐MB‐231BR/BT‐474BR cells in a blood‐brain barrier (BBB) model. In this study, we demonstrated that the presence of lncRNA‐CCRR could up‐regulate the expression of CX43, which promoted gap junction formation in brain metastasis of breast cancer. Accordingly, the communication between breast cancer cells and astrocytes was also promoted.

Identification of markers associated with brain metastasis from breast cancer through bioinformatics analysis and verification in clinical samples

Background

Brain metastasis from breast cancer (BC) is an important cause of BC-related death. The present study aimed to identify markers of brain metastasis from BC.

Methods

Datasets were downloaded from the public databases Gene Expression Omnibus (GEO) and The Cancer Genome Atlas (TCGA). Weighted gene co-expression network analysis (WGCNA) was performed to identify metastasis-associated genes (MAGs). Least absolute shrinkage and selection operator (LASSO) Cox proportional hazards regression models were constructed for screening key MAGs. Survival analysis and receiver operating characteristic (ROC) curves were used for evaluating the prognostic value. The factors associated with tumor metastasis were integrated to create a nomogram of TCGA data using R software. Gene Set Enrichment Analyses (GSEA) was performed for detecting the potential mechanisms of identified MAGs. Immunohistochemistry (IHC) was used to verify the expression of the key genes in clinical samples.

Results

The genes in 2 modules were identified to be significantly associated with metastasis through WGCNA. LASSO Cox proportional hazards regression models were constructed successfully. Subsequently, a clinical prediction model was constructed, and a nomogram was mapped, which had better sensitivity and specificity for BC metastasis. Two key genes, discs large homolog 3 (DLG3) and growth factor independence 1 (GFI1), were highly expressed in clinical samples, and the expression of these 2 genes was associated with patients' survival time.

Conclusions

We successfully constructed a clinical prediction model for brain metastasis from BC, and identified that the expression of DLG3 and GFI1 were strongly associated with brain metastasis from BC.

Ventriculoperitoneal Shunt for CNS Metastasis in Breast Cancer: Clinical Outcomes Based on Intrinsic Subtype

BACKGROUND

Leptomeningeal metastasis (LM) is associated with a grave prognosis in breast cancer (BC) and can be controlled with a ventriculoperitoneal shunt (VPS). Information regarding LM and VPS based on intrinsic subtype is limited; thus, we investigated the clinical outcomes of BC treated with VPS.

PATIENTS AND METHODS

The present retrospective study comprised 70 patients diagnosed with LM who received a VPS. The patients were divided into 4 groups based on BC subtype: hormone receptor (HR)⁺/human epidermal growth factor receptor 2 (HER2)^-, HR⁺/HER2⁺, HR^-/HER2⁺, and triple negative BC (TNBC).

RESULTS

The most common indications for VPS were uncontrolled intracranial pressure (57.1%) and uncontrolled headache (55.7%), which improved in 54 (77.1%) of 70 patients after VPS. The median overall survival (OS) after brain or LM and overall survival after VPS were 7.6 and 2.3 months, respectively. Anti-HER2 treatment was a significant prognostic factor for better OS after brain or LM based on multivariate analysis (hazard ratio, 0.15; 95% confidence interval, 0.04-0.57; P = .005), whereas TNBC was correlated with shorter OS after central nervous system metastasis (hazard ratio, 2.82; 95% confidence interval, 1.46-5.48; P = .002).

CONCLUSIONS

There were significant differences in clinical outcome based on the intrinsic subtype of patients with BC with LM who received a VPS. Anti-HER2 treatment in patients with HER2⁺ BC was associated with better survival in patients with metastatic BC with VPS insertion compared with those without. Survival of metastatic BC with VPS remained poor, especially in the TNBC subgroup.

Use of radiotherapy in breast cancer patients with brain metastases: a retrospective 11-year single center study

AIM

To analyse the use of radiotherapy (RT) and factors affecting overall survival (OS) after RT in breast cancer patients with brain metastases.

METHODS

Breast cancer patients treated from 2008 to 2018 with whole brain RT (WBRT) or stereotactic radiosurgery (SRS) at a large regional cancer referral center were identified from the hospital's RT register. Clinical variables were extracted from medical records. OS was calculated from date of first RT until death or last follow up. Potential factors affecting OS were analyzed.

RESULTS

255 females with WBRT (n = 206) or SRS (n = 49) as first RT were included. An increased use of initial SRS was observed in the second half of the study period. The most common WBRT fractionation regimen was 3 Gy × 10. SRS was most often single fractions; 18 or 25 Gy between 2009 and 2016, while fractionated SRS was mostly used in 2017 and 2018. Median OS in the WBRT group was 6 months (CI 1-73) relative to 23 (CI 0-78) in the SRS group. Age, performance status, initial RT technique, extracranial disease, brain metastasis surgery, number of brain metastases and DS-GPA score had significant impact on OS. Only ECOG 0 and brain metastasis surgery were associated with superior OS in multivariate analysis.

CONCLUSION

WBRT was the most frequent primary RT. An increased use of initial SRS was observed in the second half of the study period. Only ECOG 0 and brain metastasis surgery were associated with superior OS in multivariate analysis.

Treatment of Brain Metastases of Non-Small Cell Lung Carcinoma

Lung cancer is one of the most common malignant neoplasms. As a result of the disease's progression, patients may develop metastases to the central nervous system. The prognosis in this location is unfavorable; untreated metastatic lesions may lead to death within one to two months. Existing therapies-neurosurgery and radiation therapy-do not improve the prognosis for every patient. The discovery of Epidermal Growth Factor Receptor (EGFR)-activating mutations and Anaplastic Lymphoma Kinase (ALK) rearrangements in patients with non-small cell lung adenocarcinoma has allowed for the introduction of small-molecule tyrosine kinase inhibitors to the treatment of advanced-stage patients. The Epidermal Growth Factor Receptor (EGFR) is a transmembrane protein with tyrosine kinase-dependent activity. EGFR is present in membranes of all epithelial cells. In physiological conditions, it plays an important role in the process of cell growth and proliferation. Binding the ligand to the EGFR causes its dimerization and the activation of the intracellular signaling cascade. Signal transduction involves the activation of MAPK, AKT, and JNK, resulting in DNA synthesis and cell proliferation. In cancer cells, binding the ligand to the EGFR also leads to its dimerization and transduction of the signal to the cell interior. It has been demonstrated that activating mutations in the gene for EGFR-exon19 (deletion), L858R point mutation in exon 21, and mutation in exon 20 results in cancer cell proliferation. Continuous stimulation of the receptor inhibits apoptosis, stimulates invasion, intensifies angiogenesis, and facilitates the formation of distant metastases. As a consequence, the cancer progresses. These activating gene mutations for the EGFR are present in 10-20% of lung adenocarcinomas. Approximately 3-7% of patients with lung adenocarcinoma have the echinoderm microtubule-associated protein-like 4 (EML4)/ALK fusion gene. The fusion of the two genes EML4 and ALK results in a fusion gene that activates the intracellular signaling pathway, stimulates the proliferation of tumor cells, and inhibits apoptosis. A new group of drugs-small-molecule tyrosine kinase inhibitors-has been developed; the first generation includes gefitinib and erlotinib and the ALK inhibitor crizotinib. These drugs reversibly block the EGFR by stopping the signal transmission to the cell. The second-generation tyrosine kinase inhibitor (TKI) afatinib or ALK inhibitor alectinib block the receptor irreversibly. Clinical trials with TKI in patients with non-small cell lung adenocarcinoma with central nervous system (CNS) metastases have shown prolonged, progression-free survival, a high percentage of objective responses, and improved quality of life. Resistance to treatment with this group of drugs emerging during TKI therapy is the basis for the detection of resistance mutations. The T790M mutation, present in exon 20 of the EGFR gene, is detected in patients treated with first- and second-generation TKI and is overcome by Osimertinib, a third-generation TKI. The I117N resistance mutation in patients with the ALK mutation treated with alectinib is overcome by ceritinib. In this way, sequential therapy ensures the continuity of treatment. In patients with CNS metastases, attempts are made to simultaneously administer radiation therapy and tyrosine kinase inhibitors. Patients with lung adenocarcinoma with CNS metastases, without activating EGFR mutation and without ALK rearrangement, benefit from immunotherapy. This therapeutic option blocks the PD-1 receptor on the surface of T or B lymphocytes or PD-L1 located on cancer cells with an applicable antibody. Based on clinical trials, pembrolizumab and all antibodies are included in the treatment of non-small cell lung carcinoma with CNS metastases.

Laser Interstitial Thermal Therapy in the treatment of brain metastases and radiation necrosis

Stereotactic Radiosurgery has become the main treatment for patients with limited number of brain metastases (BM). Recently, with the increasing use of this modality, there is a growth in recurrence cases. Recurrence after radiation therapy can be divided in changes favoring either tumor recurrence or radiation necrosis (RN). Laser Interstitial Thermal Therapy (LITT) is minimally invasive treatment modality that has been used to treat primary and metastatic brain tumors. When associated with real-time thermometry using Magnetic Resonance Imaging, the extent of ablation can be controlled to provide maximum coverage and avoid eloquent areas. The objective of this study was to investigate the use of LITT in the treatment of BM. An extensive review of the relevant literature was conducted and the outcome results are discussed. There is an emphasis on safety and local control rate of patients treated with this modality. The findings of our study suggest that LITT is a viable safe technique to treat recurrent BM, especially in patients with deep-seated lesions where surgical resection is not an option.

Validation of recursive partitioning analysis, graded prognostic assessment and basic score for brain metastases as prognostic indices among patients with brain metastases treated with radiotherapy in Indonesia

Introduction:

Metastatic brain disease is still a major contributor to cancer treatment failure. Various treatments have improved in the recent decades, which allow for better control of brain metastatic lesions. Various prognostic scoring tools have been developed and used worldwide to stratify patients with brain metastases to determine who will benefit most from aggressive treatment. The three most commonly used prognostic scoring tools are recursive partitioning analysis (RPA), basic score for brain metastases (BSBM) and graded prognostic assessment (GPA). The aim of this study is to validate these scoring tools using an Indonesian cancer patient population.

Method:

A retrospective analysis of all patients presenting with brain metastases from January 2012 until December 2014, through using hospital medical records, was conducted. All patients receiving whole brain radiotherapy during this period were included in this study. A follow-up with a telephone call was carried out to determine the patient’s health and survival status. Uncontactable patients were excluded from the analysis. Survival analysis was carried out by stratifying patients based on the three prognostic scoring systems.

Result:

A total of 80 patients were eligible to be included in the study, with 18 excluded due to being uncontactable. The remaining 62 patients’ data were analysed and stratified with all three scoring systems. The RPA was found to confer better stratification than BSBM and GPA in our study population.

Conclusion:

GPA was non-prognostic in our study population and BSBM was less prognostic, especially in the middle group, class 1 and class 2. Those BSBM class 1 and class 2 did not provide good prognostic stratification in our study population, whereas RPA was proven to be the best in stratifying patients’ prognosis with brain metastases in our study population.

Brigatinib and Alectinib for ALK Rearrangement-Positive Advanced Non-Small Cell Lung Cancer With or Without Central Nervous System Metastasis: A Systematic Review and Network Meta-Analysis

To date, no head-to-head trials have compared the efficacy of brigatinib and alectinib against anaplastic lymphoma kinase (ALK) rearrangement-positive (ALK-p), ALK-inhibitor-naïve, advanced non-small cell lung cancer (NSCLC) with central nervous system (CNS) metastasis. We conducted an indirect treatment comparison (ITC) between brigatinib and alectinib, with crizotinib as a common comparator, using a Bayesian model with non-informative prior distribution and assessed the between-study heterogeneity of the studies. The primary efficacy endpoint was progression-free survival (PFS), and efficacy was ranked using the surface under the cumulative ranking (SUCRA) curve values. ITC analysis showed that there were no significant differences in PFS between the brigatinib and alectinib arms. However, the SUCRA values revealed that alectinib ranked the highest by efficacy in the overall patient population, whereas brigatinib ranked the highest by efficacy in the CNS metastasis sub-group. Although there were no significant differences in the incidence of G3–5 adverse events between the brigatinib and alectinib arms in the overall patient population, the data were deemed insufficient for the CNS metastasis sub-group analysis. This study provides critical information to clinicians regarding the efficacy of brigatinib for ALK-p, ALK-inhibitor-naïve, advanced NSCLC patients, with and without CNS metastasis. Larger randomized, controlled trials are warranted to confirm our results.

Clinical outcome of patients with brain metastases from breast cancer - A population based study over 21 years

BACKGROUND

Brain metastases (BM) are a feared progression of breast cancer (BC) with impact on quality of life and survival. Despite improved treatments, it is believed patients suffering from BM are increasing.

AIMS

To study potential changes in the number of BM, the possible links between BC subgroup and extent of BM with prognosis. To investigate the interval between primary BC/extra cranial recurrence, and diagnosis of BM in the years 1994-2014.

PATIENTS AND METHODS

Clinical data from 191 patients with BM diagnosed 1994-2014, was retrieved from charts. Primary tumours where re-evaluated histologically.

RESULTS

There was an increase of BM in 5 years cohorts (1994-99 (n = 9); 2000-04 (n = 36); 2005-09 (n = 60); 2010-14 (n = 86)). We found no difference in the time interval from primary BC to BM but an insignificant increase in time from extra cranial relapse to development of BM in the time periods 1994-2004 and 2005-2014 of 15.5 and 25.0 months (p = 0.0612). Survival after BM was 7 months (95% CI 6-10) with a statistically significant difference between HER2 positive and TNBC with an inferior outcome for the latter (p = 0.018) whilst no differences were present when Luminal BC were compared with HER2 positive BC (p = 0.073).

CONCLUSIONS

We show an increase of BM over time whilst the time span from primary BC to BM is unchanged supports earlier findings that adjuvant treatments have little preventive function. Time from extra cranial recurrence to BM was prolonged with one year. Patients with TNBC or more advance extent of BM had the shortest survival with BM.

Specific chromatin landscapes and transcription factors couple breast cancer subtype with metastatic relapse to lung or brain

Background

Few somatic mutations have been linked to breast cancer metastasis, whereas transcriptomic differences among primary tumors correlate with incidence of metastasis, especially to the lungs and brain. However, the epigenomic alterations and transcription factors (TFs) which underlie these alterations remain unclear.

Methods

To identify these, we performed RNA-seq, Chromatin Immunoprecipitation and sequencing (ChIP-seq) and Assay for Transposase-Accessible Chromatin using sequencing (ATAC-seq) of the MDA-MB-231 cell line and its brain (BrM2) and lung (LM2) metastatic sub-populations. We incorporated ATAC-seq data from TCGA to assess metastatic open chromatin signatures, and gene expression data from human metastatic datasets to nominate transcription factor biomarkers.

Results

Our integrated epigenomic analyses found that lung and brain metastatic cells exhibit both shared and distinctive signatures of active chromatin. Notably, metastatic sub-populations exhibit increased activation of both promoters and enhancers. We also integrated these data with chromosome conformation capture coupled with ChIP-seq (HiChIP) derived enhancer-promoter interactions to predict enhancer-controlled pathway alterations. We found that enhancer changes are associated with endothelial cell migration in LM2, and negative regulation of epithelial cell proliferation in BrM2. Promoter changes are associated with vasculature development in LM2 and homophilic cell adhesion in BrM2. Using ATAC-seq, we identified a metastasis open-chromatin signature that is elevated in basal-like and HER2-enriched breast cancer subtypes and associates with worse prognosis in human samples. We further uncovered TFs associated with the open chromatin landscapes of metastatic cells and whose expression correlates with risk for metastasis. While some of these TFs are associated with primary breast tumor subtypes, others more specifically correlate with lung or brain metastasis.

Conclusions

We identify distinctive epigenomic properties of breast cancer cells that metastasize to the lung and brain. We also demonstrate that signatures of active chromatin sites are partially linked to human breast cancer subtypes with poor prognosis, and that specific TFs can independently distinguish lung and brain relapse.

Targeted Delivery of Secretory Promelittin via Novel Poly(lactone-co-β-amino ester) Nanoparticles for Treatment of Breast Cancer Brain Metastases

Breast cancer brain metastases (BCBM) is a devastating disease with dismal prognosis. Although chemotherapy is widely used for clinical management of most tumors, it is often ineffective for BCBM. Therefore, alternative approaches for improved treatment of BCBM are in great demand. Here, an innovative gene therapy regimen is reported that is designed for effective treatment of BCBM. First, poly(lactone-co-β-amino ester) nanoparticles that are capable of efficient gene delivery are synthesized and are engineered for targeted delivery to BCBM through surface conjugation of AMD3100, which interacts with CXCR4 enriched in the tumor microenvironment. Next, an artificial gene, proMel, is designed for the expression of secretory promelittin protein, which has limited toxicity on its own but releases cytolytic melittin after activation by MMP-2 accumulated in tumors. It is demonstrated that delivery of the proMel via the AMD3100-conjugated nanoparticles effectively inhibits tumor progression in a BCBM mouse model. This study suggests a new direction to treat BCBM through targeted delivery of promelittin-mediated gene therapy.

Palliative external beam radiotherapy for advanced breast cancer patients with brain metastasis in the university college hospital Ibadan

Background

Brain metastasis is a dreaded complication that significantly reduces the quality of life in breast cancer patients. The treatment options are limited by the inability of many chemotherapeutic agents to cross the blood-brain barrier. Surgery also has a limited role, except in few selected patients with oligometastasis. Therefore, whole-brain radiotherapy (WBRT) remains the available option that gives a gratifying result. However, the benefit of this treatment modality in our resource-poor environment needs to be investigated.

Materials and Methods

The data of breast cancer patients with brain metastasis who were treated with WBRT using cobalt-60 equipment between 2005 and 2009 were retrospectively collected from the departmental medical record unit. The information extracted included biodata, presenting symptoms, imaging modality for confirmation of brain metastasis, treatment records, performance status pre-WBRT and 4 weeks post-WBRT, and other supportive treatments.

Results

A total of 52 female patients were reviewed between 2005 and 2009. The mean age of patients was 44.7 years. The common clinical features on presentation were headache, nausea, and visual impairment in 30.8% of patients with the WHO performance status score ranging between 2 and 4. Patients with more than three brain deposits accounted for 71.2% of all the brain metastases. The mean radiation dose used for WBRT was 30 Gy in 10 fractions, and total responses recorded were 86.5% with 53.8% complete improvement in patients' performance status 4 weeks after WBRT treatment.

Conclusion

WBRT is an effective treatment modality for patients with brain metastasis in our resource-poor environment. However, improvement of patients' performance status declined with advancing age.

The impact of systemic precision medicine and immunotherapy treatments on brain metastases

Metastases from melanoma, lung and breast cancer are among the most common causes of intracranial malignancy. Standard of care for brain metastases include a combination of surgical resection, stereotactic radiosurgery, and whole-brain radiation. However, evidence continues to accumulate regarding the efficacy of molecularly-targeted systemic treatments and immunotherapy. For non-small cell lung cancer (NSCLC), numerous clinical trials have demonstrated intracranial activity for inhibitors of EGFR and ALK. Patients with melanoma brain metastases may benefit from systemic therapy using BRAF-inhibitors with and without trametinib. Several targeted options are available for breast cancer brain metastases that overexpress HER2, although agents with intracranial activity are still needed for other molecular subtypes. Immune checkpoint inhibitors including anti-CTLA-4 and anti-PD-1/PD-L1 antibodies are yielding impressive responses in intracranial manifestations of metastatic melanoma and NSCLC. Given the promising early results with these emerging therapies, management of eligible patients will require increased multidisciplinary discussion incorporating novel systemic treatment approaches prior or in addition to local therapy.

Radiosurgery for brain metastases from ovarian cancer: an analysis of 25 years' experience with Gamma Knife treatment

Purpose

We present our results in the treatment of brain metastases (BM) from ovarian cancer using Gamma Knife Radiosurgery (GKRS) over the last 25 years in a single institution.

Background

Gamma Knife Radiosurgery has become increasingly important in the management of brain metastases from ovarian cancer due to improving results from systemic disease and the need for better outcomes.

Material and methods

The medical records of 9 patients with brain metastases from ovarian cancer treated with GKRS between 1993 and 2018 were reviewed. Median age at first treatment was 57 years (range 39-76). Forty-two brain metastases were treated with 16 procedures. Median tumor volume was 1.8cc ranging from 0.2 to 30.3cc (there were five patients with a tumor volume exceeding 10cc). Median prescription dose was 16 Gy.

Results

Using Kaplan Meier estimates, the median OS after diagnosis was 48.1 months and the median OS after GKRS was 10.6 months (ranging from 2.5 to 81 months). The Kaplan Meier survival rates were 31.3%, and 6.5% at 2 and 5 years after GKRS, respectively. Treatment procedure was well tolerated and no patient presented with acute or chronic toxicity. Two of 9 patients had a tumor requiring retreatment (local control of 95% 40/42). Two out of the 7 patients evaluated for cause of death expired due to progression of brain metastases and the remaining ones died of systemic disease with brain control.

Conclusions

GKRS for BM from ovarian cancer is a safe and effective modality. Our findings are in agreement with the recent literature indicating that women with brain metastases from ovarian cancer will benefit with radiosurgery and may achieve long term survival with brain control.

Systemic therapy for brain metastases

Metastases from cells outside of the central nervous system are the most common cancer found in the brain and are commonly associated with poor prognosis. Although cancer treatment is improving overall, central nervous system metastases are becoming more prevalent and require finesse to properly treat. Physicians must consider the biology of the primary tumor and the complex neurological environment that the metastasis resides in. This can be further complicated by the fact that the practice of cancer management is constantly evolving and therapy that works outside of the blood-brain barrier may not be effective inside of it. Therefore, this review seeks to update the reader on recent advancements made on the three most common sources of brain metastases: lung cancer, breast cancer, and melanoma. Each of these malignancies has been the subject of intriguing and novel avenues of therapy which are reviewed here.

Clinical prognostic factors associated with survival and a survival score for patients with brain metastases

Aim: To identify prognostic factors of survival in patients with brain metastases (BM) and to devise a prognostic score. Patients & methods: In this single-institution retrospective study, we analyzed potential clinical prognostic factors in 1363 patients with BM. Based on the Cox proportional hazard model, we devised a BM score with three classes (score <5, 5-6 and >6). Results: The 1-year overall survival (OS) was 26%. Independent prognostic factors of OS were: age, gender, Karnofski performance status, number of BM, control of primary, presence of extracerebral metastases and type of primary tumor. The 1-year OS was 56% for score <5; 21% for score 5-6 and 4% for score >6 (p < 0.01). Conclusion: The BM score we propose is effective in grouping patients according to their prognosis and can help decision making regarding treatment adjustments.

Immunomodulatory Drugs in Melanoma Brain Metastases

Brain metastases are about ten times more frequent than a brain primary tumor, being present in 20-40% of adults with systemic cancer. Together with lung cancer and breast cancer, skin cancers such as melanoma are top primary tumors which metastasizes to the brain. Advanced melanoma is well known for its propensity to metastasize to the brain, with 80% of patients presenting brain metastasis at the autopsy. However, current therapies are not very efficient and brain metastases are in most of the cases lethal. Treatment of melanoma brain metastases with surgery and/or radiation therapy results in a median overall survival of only about four months after diagnosis. New immunotherapies such as targeted or immunomodulatory drugs, many in clinical trials, have shown promise, with some immunomodulatory drugs being able to at least double the overall survival rates for patients with melanoma brain metastases. This review focuses on the recent advances and future potential of using immunotherapy, such as the newly developed immunomodulatory drugs, for melanoma brain metastases therapy. Immunomodulatory drugs bring a great promise as new tools for melanoma treatment in particular and for the treatment of other types of malignancies in general.

Multidisciplinary expert opinion on the treatment consensus for patients with EGFR mutated NSCLC with brain metastases

The presence of an epidermal growth factor receptor (EGFR) mutation is associated with higher incidence of brain metastases in patients with non-small cell lung cancer (NSCLC); however, patients with synchronous brain metastases at diagnosis have generally been excluded from clinical trials. As there is limited clinical evidence for managing this patient population, a multidisciplinary group of Spanish medical and radiation oncologists, and neuro-oncologist with expertise treating brain metastases in lung cancer patients met with the aim of reaching and developing an expert opinion consensus on the management of patients with EGFR mutated NSCLC with brain metastases. This consensus contains 26 recommendations and 20 conclusion statements across 21 questions in 7 areas, as well as a first-line treatment algorithm.

Health-related quality of life of patients with brain metastases selected for stereotactic radiosurgery

Purpose

Information on health-related quality of life (HRQoL) of patients with brain metastases (BM) before stereotactic radiosurgery (SRS) is very relevant to improve communication between patients and clinicians and to be able to interpret changes in HRQoL after SRS. The aim of this study was to evaluate the prevalence and severity of complaints on different aspects of pre-SRS HRQoL among patients with BM and to identify predictors thereof.

Methods

Patients with 1–10 newly diagnosed BM, expected survival > 3 months, Karnofsky Performance Status ≥ 70, and scheduled to undergo SRS were included. HRQoL was measured with the Functional Assessment of Cancer Therapy-Brain (FACT-Br) questionnaire. One-sample z-tests were conducted to analyze differences between patients with BM and published normative data of a general adult sample and of an adult cancer sample. Multiple regression analyses were run to identify predictors of pre-SRS HRQoL.

Results

On the individual level, most patients with BM (57.6% of 92 included patients) reported complaints regarding emotional well-being. As a group, patients with BM reported significantly lower emotional well-being compared to both control groups and significantly higher social well-being compared to the general population. Worse psychological factors, e.g. physical fatigue, depression, mental fatigue and anxiety, predicted aspects of pre-SRS HRQoL.

Conclusions

An increased understanding of pre-SRS HRQoL and predictors hereof, provides us with more insight into the well-being of our patients with BM and is necessary for the interpretation of (changes in) HRQoL after SRS.

Electronic supplementary material

The online version of this article (10.1007/s11060-019-03186-z) contains supplementary material, which is available to authorized users.

Perspectives on the role of brain cellular players in cancer-associated brain metastasis: translational approach to understand molecular mechanism of tumor progression

Brain metastasis is one of the leading causes of death among cancer patients. Cancer cells migrate to various sites and harbor different niche in the body which help cancer cells in their survival. The brain is one of the safest place where cancer cells are protected from immune cells. Breast, lung, and melanoma cancer cells have high propensity to migrate towards the brain. To enter the brain, cancer cells have to cross the blood brain barrier. Survival and finding new niche in the brain are directed by several mechanisms in which different cellular players take part such as astrocytes, microglia, Schwann cells, satellite cells, oligodendrocytes, and ependymal cells. Usually, cancer cells highjack the machinery of brain cellular players to survive in the brain environment. It has been shown that co-culture of M2 macrophage with cancer cells leads to increased proliferation and survival of cancer cells. One of the challenges of understanding brain metastasis is appropriate model system to understand dynamic interaction of cancer cells and brain cellular players. To meet this challenge, microfluidic-based devices are employed which can mimic the dynamic conditions as well as can be used for culturing human cells for personalized therapy. In this review, we have systematically reviewed the current status of the role of cellular players in brain metastasis along with explaining how translational approach of microfluidics can be employed for finding new drug target as well as biomarker for brain metastasis. Finally, we have also commented on the mechanism of action of drugs against brain metastasis.

The Utility of Whole Body Imaging in the Evaluation of Solitary Brain Tumors

BACKGROUND

Solitary brain tumors can propose a diagnostic dilemma owing to the difficulty in differentiating between primary brain tumors and metastatic disease. The similar radiologic appearance on routine magnetic resonance imaging will necessitate the need for additional noninvasive testing. We sought to determine the clinical utility of preoperative whole body screening with computed tomography (CT) to detect metastatic disease in patients with solitary brain tumors.

METHODS

A prospectively maintained surgical database for a large quaternary care academic institution was retrospectively reviewed for all patients undergoing craniotomy for a new diagnosis of enhancing solitary brain lesion from January 2011 to January 2016. Patients were excluded if the imaging findings had demonstrated multiple brain tumors, they had a known diagnosis of malignancy, or they had undergone previous craniotomy. The demographic and radiographic information and clinical and histopathologic data were collected and tallied.

RESULTS

A total of 218 patients with solitary brain tumors met the inclusion criteria and were included in the present study. Histopathologic analysis confirmed primary central nervous system tumors in 152 patients (74.4%) and metastatic disease in 66 (25.6%). Preoperative screening with whole body CT had a sensitivity of 0.92 and specificity of 0.95 for detecting systemic metastases in the patients. Preoperative whole body CT correctly identified systemic malignancy in 88% of the patients ultimately diagnosed with metastasis (positive predictive value, 88%). Of those with negative whole body imaging findings, 97% had a diagnosis of a primary central nervous system neoplasm (negative predictive value, 97%).

CONCLUSIONS

Preoperative whole body CT had a positive predictive value of 88% and negative predictive value of 97% in the present study and was both sensitive (92%) and specific (95%) for the detection of extracranial tumors. The identification of extracranial tumors on whole body CT screening might alter management.

Natural history, clinical course and predictors of interval time from initial diagnosis to development of subsequent NSCLC brain metastases

PURPOSE

Non-small cell lung cancer (NSCLC) brain metastases are associated with substantial morbidity and mortality. During recent years, accompanying dramatic improvements in systemic disease control, NSCLC brain metastases have emerged as an increasingly relevant clinical problem. However, optimal surveillance practices remain poorly defined. This purpose of this study was to further characterize the natural history, clinical course and risk factors associated with earlier development of subsequent NSCLC brain metastases to better inform clinical practice and help guide survivorship care.

METHODS

We retrospectively reviewed all institutional NSCLC brain metastasis cases treated with radiotherapy between 1997 and 2015. Exclusion criteria included presence of brain metastases at initial NSCLC diagnosis and incomplete staging information. Interval time to brain metastases and subsequent survival were characterized using Kaplan-Meier and multivariate Cox regression analyses.

RESULTS

Among 105 patients within this cohort, median interval time to development of brain metastases was 16 months. Median interval times were 29, 19, 16 and 13 months for Stage I-IV patients, respectively (P = 0.016). Additional independent predictors for earlier development of NSCLC brain metastases included non-adenocarcinomatous histopathology (HR 3.036, P < 0.001), no prior surgical resection (HR 1.609, P = 0.036) and no prior systemic therapy (HR 3.560, P = 0.004). Median survival following intracranial progression was 16 months. Delayed development of brain metastases was associated with better prognosis (HR 0.970, P < 0.001) but not survival following intracranial disease onset.

CONCLUSIONS

Collectively, our results provide valuable insights into the natural history of NSCLC brain metastases. NSCLC stage, histology, prior surgical resection and prior systemic therapy emerged as independent predictors for interval time to brain metastases.

Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list

A minority of headache patients have a secondary headache disorder. The medical literature presents and promotes red flags to increase the likelihood of identifying a secondary etiology. In this review, we aim to discuss the incidence and prevalence of secondary headaches as well as the data on sensitivity, specificity, and predictive value of red flags for secondary headaches. We review the following red flags: (1) systemic symptoms including fever; (2) neoplasm history; (3) neurologic deficit (including decreased consciousness); (4) sudden or abrupt onset; (5) older age (onset after 65 years); (6) pattern change or recent onset of new headache; (7) positional headache; (8) precipitated by sneezing, coughing, or exercise; (9) papilledema; (10) progressive headache and atypical presentations; (11) pregnancy or puerperium; (12) painful eye with autonomic features; (13) posttraumatic onset of headache; (14) pathology of the immune system such as HIV; (15) painkiller overuse or new drug at onset of headache. Using the systematic SNNOOP10 list to screen new headache patients will presumably increase the likelihood of detecting a secondary cause. The lack of prospective epidemiologic studies on red flags and the low incidence of many secondary headaches leave many questions unanswered and call for large prospective studies. A validated screening tool could reduce unneeded neuroimaging and costs.

Brain metastases in ALK-positive NSCLC - time to adjust current treatment algorithms

The progress in molecular biology has revolutionized systemic treatment of advanced non-small-cell lung cancer (NSCLC) from conventional chemotherapy to a treatment stratified by histology and genetic aberrations. Tumors harboring a translocation of the anaplastic-lymphoma-kinase (ALK) gene constitute a distinct genetic and clinico-pathologic NSCLC subtype with patients with ALK-positive disease being at a higher risk for developing brain metastases. Due to the introduction of effective targeted therapy with ALK-inhibitors, today, patients with advanced ALK-positive NSCLC achieve high overall response rates and remain progression-free for long time intervals. Moreover, ALK-inhibitors seem to exhibit efficacy in the treatment of brain metastases. In the light of this, it needs to be discussed how treatment algorithms for managing patients with brain metastases should be modified. By integrating systemic ALK-inhibitor therapy, radiotherapy, in particular whole brain radiotherapy might be postponed deferring potential long-term impairment by neurocognitive deficits to a later time point in the course of the disease. An early treatment of asymptomatic brain metastases might offer patients a longer time without impairment of cerebral symptoms or radiotherapeutic interventions. Based on an updated extensive review of the literature this article provides an overview on the epidemiology and the treatment of patients’ brain metastases. It describes the specifics of ALK-positive disease and proposes an algorithm for the treatment of patients with advanced ALK-positive NSCLC and brain metastases.

Surgery versus stereotactic radiotherapy for people with single or solitary brain metastasis

BACKGROUND

Brain metastases occur when cancer cells spread from their original site to the brain and are a frequent cause of morbidity and death in people with cancer. They occur in 20% to 40% of people during the course of their disease. Brain metastases are also the most frequent type of brain malignancy. Single and solitary brain metastasis is infrequent and choosing the most appropriate treatment is a clinical challenge. Surgery and stereotactic radiotherapy are two options. For surgery, tumour resection is performed using microsurgical techniques, while in stereotactic radiotherapy, external ionising radiation beams are precisely focused on the brain metastasis. Stereotactic radiotherapy may be given as a single dose, also known as single dose radiosurgery, or in a number of fractions, also known as fractionated stereotactic radiotherapy. There is uncertainty regarding which treatment (surgery or stereotactic radiotherapy) is more effective for people with single or solitary brain metastasis.

OBJECTIVES

To assess the effectiveness and safety of surgery versus stereotactic radiotherapy for people with single or solitary brain metastasis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, March 2018), MEDLINE and Embase up to 25 March 2018 for relevant studies. We also searched trials databases, grey literature and handsearched relevant literature.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing surgery versus stereotactic radiotherapy, either a single fraction (stereotactic radiosurgery) or multiple fractions (fractionated stereotactic radiotherapy) for treatment of single or solitary brain metastasis.

DATA COLLECTION AND ANALYSIS

Two review authors screened all references, evaluated the quality of the included studies using the Cochrane tool for assessing risk of bias, and performed data extraction. The primary outcomes were overall survival and adverse events. Secondary outcomes included progression-free survival and quality of life . We analysed overall survival and progression-free survival as hazard ratios (HRs) with 95% confidence intervals (CIs), and analysed adverse events as risk ratios (RRs). For quality of life we used mean difference (MD).

MAIN RESULTS

Two RCTs including 85 participants met our inclusion criteria. One study included people with single untreated brain metastasis (n = 64), and the other included people with solitary brain metastasis (22 consented to randomisation and 21 were analysed). We identified a third trial reported as completed and pending results this may be included in future updates of this review. The two included studies were prematurely closed due to poor participant accrual. One study compared surgery plus whole brain radiotherapy (WBRT) versus stereotactic radiosurgery alone, and the second study compared surgery plus WBRT versus stereotactic radiosurgery plus WBRT. Meta-analysis was not possible due to clinical heterogeneity between trial interventions. The overall certainty of evidence was low or very low for all outcomes due to high risk of bias and imprecision.We found no difference in overall survival in either of the two comparisons. For the comparison of surgery plus WBRT versus stereotactic radiosurgery alone: HR 0.92, 95% CI 0.48 to 1.77; 64 participants, very low-certainty evidence. We downgraded the certainty of the evidence to very low due to risk of bias and imprecision. For the comparison of surgery plus WBRT versus stereotactic radiosurgery plus WBRT: HR 0.53, 95% CI 0.20 to 1.42; 21 participants, low-certainty evidence. We downgraded the certainty of the evidence to low due to imprecision. Adverse events were reported in both trial groups in the two studies, showing no differences for surgery plus WBRT versus stereotactic radiosurgery alone (RR 0.31, 95% CI 0.07 to 1.44; 64 participants) and for surgery plus WBRT versus stereotactic radiosurgery plus WBRT (RR 0.37, 95% CI 0.05 to 2.98; 21 participants). Most of the adverse events were related to radiation toxicities. We considered the certainty of the evidence from the two comparisons to be very low due to risk of bias and imprecision.There was no difference in progression-free survival in the study comparing surgery plus WBRT versus stereotactic radiosurgery plus WBRT (HR 0.55, 95% CI 0.22 to 1.38; 21 participants, low-certainty evidence). We downgraded the evidence to low certainty due to imprecision. This outcome was not clearly reported for the other comparison. In general, there were no differences in quality of life between the two studies. The study comparing surgery plus WBRT versus stereotactic radiosurgery plus WBRT found no differences after two months using the QLQ-C30 global scale (MD -10.80, 95% CI -44.67 to 23.07; 14 participants, very low-certainty evidence). We downgraded the certainty of evidence to very low due to risk of bias and imprecision.

AUTHORS' CONCLUSIONS

Currently, there is no definitive evidence regarding the effectiveness and safety of surgery versus stereotactic radiotherapy on overall survival, adverse events, progression-free survival and quality of life in people with single or solitary brain metastasis, and benefits must be decided on a case-by-case basis until well powered and designed trials are available. Given the difficulties in participant accrual, an international multicentred approach should be considered for future studies.