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Flores-Paco P, Vargas-Aliaga A, Guevara MG, Lopera I, Ruiz LR, López-Herrero M, Camús JA, López-González J, Inga-Saavedra E, Montero M, Barneto I, Gómez-España MA, Ruiz E, Ruza M, Armenta A, Palacios A, De La Haba-Rodríguez JR, Aranda E. A new updated prognostic index for patients with brain metastases (BMs) treated with palliative whole brain radiotherapy (WBRT) in the era of precision oncology. METASNCore project. J Neurooncol 2024; 167:407-413. [PMID: 38539006 DOI: 10.1007/s11060-024-04618-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 02/22/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Palliative WBRT is the main treatment for multiple BMs. Recent studies report no benefit in survival after WBRT compared to palliative supportive care in patients (pts) with poor prognosis. A new era of systemic treatment strategies based on targeted therapies are improving the prognosis of patients with BMs. The purpose of this study is to develop a prognostic score in palliative pts with BMs who undergo WBRT in this new setting. METHODS 239 pts with BMs who received palliative WBRT between 2013-2022 in our center were analyzed retrospectively. The score was designed according to the value of the β coefficient of each variable with statistical significance in the multivariate model using Cox regression. Once the score was established, a comparison was performed according to Kaplan-Meier and was analyzed by log-rank test. RESULTS 149 pts (62.3%) were male and median (m) age was 60 years. 139 (58,2%) were lung cancer and 35 (14,6%) breast cancer. All patients received 30Gys in 10 sessions. m overall survival (OS) was 3,74 months (ms). 37 pts (15,5%) had a specific target mutation. We found that 62 pts were in group < 4 points with mOS 6,89 ms (CI 95% 3,18-10,62), 84 in group 4-7 points with mOS 4,01 ms (CI 95% 3,40-4,62) and 92 pts in group > 7 points with mOS 2,72 ms (CI 95% 1,93-3,52) (p < 0,001). CONCLUSIONS METASNCore items are associated with OS and they could be useful to select palliative pts to receive WBRT. More studies are necessary to corroborate our findings.
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Affiliation(s)
- Pablo Flores-Paco
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Alicia Vargas-Aliaga
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - María Geraldina Guevara
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | | | - Lucía Rodríguez Ruiz
- Radiation Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - María López-Herrero
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Juan Adrián Camús
- Radiation Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Javier López-González
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Elizabeth Inga-Saavedra
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Marina Montero
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Isidoro Barneto
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Mª Auxiliadora Gómez-España
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Estela Ruiz
- Radiation Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Marta Ruza
- Radiation Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Ana Armenta
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Amalia Palacios
- Radiation Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Juan R De La Haba-Rodríguez
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain.
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain.
- Medical School, University of Cordoba, Cordoba, Spain.
- Medical Oncology Department, Hospital Universitario Reina Sofía, Av. Menendez Pidal, s/n, 14004, Córdoba, Spain.
| | - Enrique Aranda
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
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Laktionov KK, Artamonova EV, Borisova TN, Breder VV, Bychkov IM, Vladimirova LI, Volkov NM, Ergnian SM, Zhabina AS, Kononets PV, Kuzminov AE, Levchenko EV, Malikhova OA, Marinov DT, Miller SV, Moiseenko FV, Mochal’nikova VV, Novikov SN, Pikin OV, Reutova EV, Rodionov EO, Sakaeva DD, Sarantseva KA, Semenova AI, Smolin AV, Sotnikov VM, Tuzikov SA, Turkin IN, Tyurin IE, Chkhikvadze VD, Kolbanov KI, Chernykh MV, Chernichenko AV, Fedenko AA, Filonenko EV, Nevol’skikh AA, Ivanov SA, Khailova ZV, Gevorkian TG, Butenko AV, Gil’mutdinova IR, Gridneva IV, Eremushkin MA, Zernova MA, Kasparov BS, Kovlen DV, Kondrat’eva KO, Konchugova TV, Korotkova SB, Krutov AA, Obukhova OA, Ponomarenko GN, Semiglazova TI, Stepanova AM, Khulamkhanova MM. Malignant neoplasm of the bronchi and lung: Russian clinical guidelines. JOURNAL OF MODERN ONCOLOGY 2022. [DOI: 10.26442/18151434.2022.3.201848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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Gondi V, Bauman G, Bradfield L, Burri SH, Cabrera AR, Cunningham DA, Eaton BR, Hattangadi-Gluth JA, Kim MM, Kotecha R, Kraemer L, Li J, Nagpal S, Rusthoven CG, Suh JH, Tomé WA, Wang TJC, Zimmer AS, Ziu M, Brown PD. Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2022; 12:265-282. [PMID: 35534352 DOI: 10.1016/j.prro.2022.02.003] [Citation(s) in RCA: 89] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/07/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE This guideline provides updated evidence-based recommendations addressing recent developments in the management of patients with brain metastases, including advanced radiation therapy techniques such as stereotactic radiosurgery (SRS) and hippocampal avoidance whole brain radiation therapy and the emergence of systemic therapies with central nervous system activity. METHODS The American Society for Radiation Oncology convened a task force to address 4 key questions focused on the radiotherapeutic management of intact and resected brain metastases from nonhematologic solid tumors. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS Strong recommendations are made for SRS for patients with limited brain metastases and Eastern Cooperative Oncology Group performance status 0 to 2. Multidisciplinary discussion with neurosurgery is conditionally recommended to consider surgical resection for all tumors causing mass effect and/or that are greater than 4 cm. For patients with symptomatic brain metastases, upfront local therapy is strongly recommended. For patients with asymptomatic brain metastases eligible for central nervous system-active systemic therapy, multidisciplinary and patient-centered decision-making to determine whether local therapy may be safely deferred is conditionally recommended. For patients with resected brain metastases, SRS is strongly recommended to improve local control. For patients with favorable prognosis and brain metastases receiving whole brain radiation therapy, hippocampal avoidance and memantine are strongly recommended. For patients with poor prognosis, early introduction of palliative care for symptom management and caregiver support are strongly recommended. CONCLUSIONS The task force has proposed recommendations to inform best clinical practices on the use of radiation therapy for brain metastases with strong emphasis on multidisciplinary care.
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Affiliation(s)
- Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center and Proton Center, Warrenville, Illinois.
| | - Glenn Bauman
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre & Western University, London, Ontario, Canada
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Stuart H Burri
- Department of Radiation Oncology, Atrium Health, Charlotte, North Carolina
| | - Alvin R Cabrera
- Department of Radiation Oncology, Kaiser Permanente, Seattle, Washington
| | | | - Bree R Eaton
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | | | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | | | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Seema Nagpal
- Division of Neuro-oncology, Department of Neurology, Stanford University, Stanford, California
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - John H Suh
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Wolfgang A Tomé
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University, New York, New York
| | - Alexandra S Zimmer
- Women's Malignancies Branch, National Institutes of Health/National Cancer Institute, Bethesda, Maryland
| | - Mateo Ziu
- Department of Neurosciences, INOVA Neuroscience and INOVA Schar Cancer Institute, Falls Church, Virginia
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Mampre D, Mehkri Y, Rajkumar S, Sriram S, Hernandez J, Lucke-Wold B, Chandra V. Treatment of breast cancer brain metastases: radiotherapy and emerging preclinical approaches. DIAGNOSTICS AND THERAPEUTICS 2022; 1:25-38. [PMID: 35782783 PMCID: PMC9249118 DOI: 10.55976/dt.1202216523-36] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The breast is one of the common primary sites of brain metastases (BM). Radiotherapy for BM from breast cancer may include whole brain radiation therapy (WBRT), stereotactic radiosurgery (SRS), and stereotactic radiotherapy (SRT), but a consensus is difficult to reach because of the wide and varied protocols, indications, and outcomes of these interventions. Overall, dissemination of disease, patient functional status, and tumor size are all important factors in the decision of treatment with WBRT or SRS. Thus far, previous studies indicate that WBRT can improve tumor control compared to SRS, but increase side effects, however no randomized trials have compared the efficacy of these therapies in BM from breast cancer. Therapies targeting long non-coding RNAs and transcription factors, such as MALAT1, HOTAIR, lnc-BM, TGL1, and ATF3, have the potential to both prevent metastatic spread and treat BM with improved radiosensitivity. Given the propensity for HER2+ breast cancer to develop BM, the above-mentioned cell lines may represent an important target for future investigations, and the development of everolimus and pyrotinib are equally important.
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Affiliation(s)
- David Mampre
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | - Yusuf Mehkri
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | | | - Sai Sriram
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | - Jairo Hernandez
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | | | - Vyshak Chandra
- Department of Neurosurgery, University of Florida, Gainesville, FL
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Radiation Therapy for Brain Metastases: A Systematic Review. Pract Radiat Oncol 2021; 11:354-365. [PMID: 34119447 DOI: 10.1016/j.prro.2021.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/13/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE This evidence report synthesizes the available evidence on radiation therapy for brain metastases. METHODS AND MATERIALS The literature search included PubMed, EMBASE, Web of Science, Scopus, CINAHL, clinicaltrials.gov, and published guidelines in July 2020; independently submitted data, expert consultation, and contacting authors. Included studies were randomized controlled trials (RCTs) and large observational studies (for safety assessments), evaluating whole brain radiation therapy (WBRT) and stereotactic radiosurgery (SRS) alone or in combination, as initial or postoperative treatment, with or without systemic therapy for adults with brain metastases due to lung cancer, breast cancer, or melanoma. RESULTS Ninety-seven studies reported in 189 publications were identified, but the number of analyses was limited owing to different intervention and comparator combinations as well as insufficient reporting of outcome data. Risk of bias varied, and 25 trials were terminated early, predominantly owing to poor accrual. The combination of SRS plus WBRT compared with SRS alone or WBRT alone showed no statistically significant difference in overall survival (hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.69%-1.73%; 4 RCTs) or death owing to brain metastases (relative risk [RR], 0.93; 95% CI, 0.48%-1.81%; 3 RCTs). Radiation therapy after surgery did not improve overall survival compared with surgery alone (HR, 0.98; 95% CI, 0.76%-1.26%; 5 RCTs). Data for quality of life, functional status, and cognitive effects were insufficient to determine effects of WBRT, SRS, or postsurgery interventions. We did not find systematic differences across interventions in serious adverse events, number of adverse events, radiation necrosis, fatigue, or seizures. WBRT plus systemic therapy (RR 1.44; 95% CI, 1.03%-2.00%; 14 studies) was associated with increased risks for vomiting compared with WBRT alone. CONCLUSIONS Despite the substantial research literature on radiation therapy, comparative effectiveness information is limited. There is a need for more data on patient-relevant outcomes such as quality of life, functional status, and cognitive effects.
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Simcock R, Thomas TV, Estes C, Filippi AR, Katz MA, Pereira IJ, Saeed H. COVID-19: Global radiation oncology's targeted response for pandemic preparedness. Clin Transl Radiat Oncol 2020; 22:55-68. [PMID: 32274425 PMCID: PMC7102593 DOI: 10.1016/j.ctro.2020.03.009] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 03/22/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023] Open
Abstract
As the global COVID-19 pandemic escalates there is a need within radiation oncology to work to support our patients in the best way possible. Measures are required to reduce infection spread between patients and within the workforce. Departments need contingency planning to create capacity and continue essential treatments despite a reduced workforce. The #radonc community held an urgent online journal club on Twitter in March 2020 to discuss these issues and create some consensus on crucial next steps. There were 121 global contributors. This document summarises these discussions around themes of infection prevention, rationalisation of workload and working practice in the presence of infection.
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Affiliation(s)
| | | | | | - Andrea R Filippi
- Radiation Oncology, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
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Popp I, Rau S, Hintz M, Schneider J, Bilger A, Fennell JT, Heiland DH, Rothe T, Egger K, Nieder C, Urbach H, Grosu AL. Hippocampus-avoidance whole-brain radiation therapy with a simultaneous integrated boost for multiple brain metastases. Cancer 2020; 126:2694-2703. [PMID: 32142171 DOI: 10.1002/cncr.32787] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/12/2020] [Accepted: 01/27/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND The current study was aimed at investigating the feasibility of hippocampus-avoidance whole-brain radiation therapy with a simultaneous integrated boost (HA-WBRT+SIB) for metastases and at assessing tumor control in comparison with conventional whole-brain radiation therapy (WBRT) in patients with multiple brain metastases. METHODS Between August 2012 and December 2016, 66 patients were treated within a monocentric feasibility trial with HA-WBRT+SIB: hippocampus-avoidance WBRT (30 Gy in 12 fractions, dose to 98% of the hippocampal volume ≤ 9 Gy) and a simultaneous integrated boost (51 or 42 Gy in 12 fractions) for metastases/resection cavities. Intracranial tumor control, hippocampal failure, and survival were subsequently compared with a retrospective cohort treated with WBRT via propensity score matching analysis. RESULTS After 1:1 propensity score matching, there were 62 HA-WBRT+SIB patients and 62 WBRT patients. Local tumor control (LTC) of existing metastases was significantly higher after HA-WBRT+SIB (98% vs 82% at 1 year; P = .007), whereas distant intracranial tumor control was significantly higher after WBRT (82% vs 69% at 1 year; P = .016); this corresponded to higher biologically effective doses. Intracranial progression-free survival (PFS; 13.5 vs 6.4 months; P = .03) and overall survival (9.9 vs 6.2 months; P = .001) were significantly better in the HA-WBRT+SIB cohort. Four patients (6.5%) developed hippocampal metastases after hippocampus avoidance. The neurologic death rate after HA-WBRT+SIB was 27.4%. CONCLUSIONS HA-WBRT+SIB can be an efficient therapeutic option for patients with multiple brain metastases and is associated with improved LTC of existing metastases, higher intracranial PFS, a reduction of the neurologic death rate, and an acceptable risk of radiation necrosis. The therapy has the potential to prevent neurocognitive adverse effects, which will be further evaluated in the multicenter, phase 2 HIPPORAD trial.
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Affiliation(s)
- Ilinca Popp
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stephan Rau
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mandy Hintz
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Julius Schneider
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Angelika Bilger
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jamina Tara Fennell
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dieter Henrik Heiland
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Rothe
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karl Egger
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Anca Ligia Grosu
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium, Partner Site Freiburg, German Cancer Research Center Heidelberg, Freiburg, Germany
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Gaspar LE, Prabhu RS, Hdeib A, McCracken DJ, Lasker GF, McDermott MW, Kalkanis SN, Olson JJ. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Role of Whole Brain Radiation Therapy in Adults With Newly Diagnosed Metastatic Brain Tumors. Neurosurgery 2019; 84:E159-E162. [PMID: 30629211 DOI: 10.1093/neuros/nyy541] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/18/2018] [Indexed: 11/13/2022] Open
Abstract
TARGET POPULATION Adult patients (older than 18 yr of age) with newly diagnosed brain metastases. QUESTION If whole brain radiation therapy (WBRT) is used, is there an optimal dose/fractionation schedule? RECOMMENDATIONS Level 1: A standard WBRT dose/fractionation schedule (ie, 30 Gy in 10 fractions or a biological equivalent dose [BED] of 39 Gy10) is recommended as altered dose/fractionation schedules do not result in significant differences in median survival or local control. Level 3: Due to concerns regarding neurocognitive effects, higher dose per fraction schedules (such as 20 Gy in 5 fractions) are recommended only for patients with poor performance status or short predicted survival. Level 3: WBRT can be recommended to improve progression-free survival for patients with more than 4 brain metastases. QUESTION What impact does tumor histopathology or molecular status have on the decision to use WBRT, the dose fractionation scheme to be utilized, and its outcomes? RECOMMENDATIONS There is insufficient evidence to support the choice of any particular dose/fractionation regimen based on histopathology. Molecular status may have an impact on the decision to delay WBRT in subgroups of patients, but there is not sufficient data to make a more definitive recommendation. QUESTION Separate from survival outcomes, what are the neurocognitive consequences of WBRT, and what steps can be taken to minimize them? RECOMMENDATIONS Level 2: Due to neurocognitive toxicity, local therapy (surgery or SRS) without WBRT is recommended for patients with ≤4 brain metastases amenable to local therapy in terms of size and location. Level 2: Given the association of neurocognitive toxicity with increasing total dose and dose per fraction of WBRT, WBRT doses exceeding 30 Gy given in 10 fractions, or similar biologically equivalent doses, are not recommended, except in patients with poor performance status or short predicted survival. Level 2: If prophylactic cranial irradiation (PCI) is given to prevent brain metastases for small cell lung cancer, the recommended WBRT dose/fractionation regimen is 25 Gy in 10 fractions, and because this can be associated with neurocognitive decline, patients should be told of this risk at the same time they are counseled about the possible survival benefits. Level 3: Patients having WBRT (given for either existing brain metastases or as PCI) should be offered 6 mo of memantine to potentially delay, lessen, or prevent the associated neurocognitive toxicity. QUESTION Does the addition of WBRT after surgical resection or radiosurgery improve progression-free or overall survival outcomes when compared to surgical resection or radiosurgery alone? RECOMMENDATIONS Level 2: WBRT is not recommended in WHO performance status 0 to 2 patients with up to 4 brain metastases because, compared to surgical resection or radiosurgery alone, the addition of WBRT improves intracranial progression-free survival but not overall survival. Level 2: In WHO performance status 0 to 2 patients with up to 4 brain metastases where the goal is minimizing neurocognitive toxicity, as opposed to maximizing progression-free survival and overall survival, local therapy (surgery or radiosurgery) without WBRT is recommended. Level 3: Compared to surgical resection or radiosurgery alone, the addition of WBRT is not recommended for patients with more than 4 brain metastases unless the metastases' volume exceeds 7 cc, or there are more than 15 metastases, or the size or location of the metastases are not amenable to surgical resection or radiosurgery.The full guideline can be found at: https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_3.
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Affiliation(s)
- Laurie E Gaspar
- Department of Radiation Oncology, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group and Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Alia Hdeib
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - D Jay McCracken
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - George F Lasker
- Departments of Neurological Surgery, Radiation Oncology, Otolaryngology, University of California San Francisco, San Francisco, California
| | - Michael W McDermott
- Departments of Neurological Surgery, Radiation Oncology, Otolaryngology, University of California San Francisco, San Francisco, California
| | - Steven N Kalkanis
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University, Atlanta, Georgia
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Li Z, Shen D, Zhang J, Zhang J, Yang F, Kong D, Kong J, Zhang A. Relationship between WBRT total dose, intracranial tumor control, and overall survival in NSCLC patients with brain metastases - a single-center retrospective analysis. BMC Cancer 2019; 19:1104. [PMID: 31727054 PMCID: PMC6854885 DOI: 10.1186/s12885-019-6307-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 10/29/2019] [Indexed: 12/25/2022] Open
Abstract
Background The relationship between whole brain radiotherapy (WBRT) dose with intracranial tumor control and overall survival (OS) in patients with non-small cell lung cancer (NSCLC) brain metastases (BM) is largely unknown. Methods We retrospectively analyzed 595 NSCLC BM patients treated consecutively at the Fourth Hospital of Hebei Medical University between 2013 to 2015. We assigned the patients into 4 dose groups of WBRT: none, < 30, 30–39, and ≥ 40 Gy and assessed their relationship with OS and intracranial progression-free survival (iPFS). Cox models were utilized. Covariates included sex, age, KPS, BM lesions, extracranial metastasis, BM and lung tumor resection, chemotherapy, targeted therapy, and focal radiotherapy modalities. Results Patients had a mean age of 59 years and were 44% female. Their median survival time (MST) of OS and iPFS were 9.3 and 8.9 months. Patients receiving none (344/58%), < 30 (30/5%), 30–39 (93/16%), and ≥ 40 (128/22%) Gy of WBRT had MST of OS (iPFS) of 7.3 (6.8), 6.0 (5.4), 10.3 (11.9) and 11.9 (11.9) months, respectively. Compared to none, other WBRT groups had adjusted HRs for OS - 1.23 (p > 0.20), 0.72 (0.08), 0.61 (< 0.00) and iPFS - 1.63 (0.03), 0.71 (0.06), 0.67 (< 0.01). Compared to 30–39 Gy, WBRT dose ≥40 Gy was not associated with improved OS and iPFS (all p > 0.40). Stratified analyses by 1–3 and ≥ 4 BM lesions and adjustment analyses by each prognostic index of RPA class, Lung-GPA and Lung-molGPA supported these relationships as well. Conclusions Compared to none, WBRT doses ≥30 Gy are invariably associated with improved intracranial tumor control and survival in NSCLC BM patients.
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Affiliation(s)
- Zhensheng Li
- Department of Radiation Oncology, the Fourth Hospital of Hebei Medical University, 169 Tianshan Street, Shijiazhuang, 050035, China.
| | - Dongxing Shen
- Department of Radiation Oncology, the Fourth Hospital of Hebei Medical University, 169 Tianshan Street, Shijiazhuang, 050035, China
| | - Jian Zhang
- Department of Radiation Oncology, the Fourth Hospital of Hebei Medical University, 169 Tianshan Street, Shijiazhuang, 050035, China
| | - Jun Zhang
- Department of Radiation Oncology, the Fourth Hospital of Hebei Medical University, 169 Tianshan Street, Shijiazhuang, 050035, China
| | - Fang Yang
- Department of Radiation Oncology, the Fourth Hospital of Hebei Medical University, 169 Tianshan Street, Shijiazhuang, 050035, China
| | - Deyou Kong
- Department of Radiation Oncology, the Fourth Hospital of Hebei Medical University, 169 Tianshan Street, Shijiazhuang, 050035, China
| | - Jie Kong
- Department of Radiation Oncology, the Fourth Hospital of Hebei Medical University, 169 Tianshan Street, Shijiazhuang, 050035, China
| | - Andu Zhang
- Department of Radiation Oncology, the Fourth Hospital of Hebei Medical University, 169 Tianshan Street, Shijiazhuang, 050035, China
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10
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Jessurun CAC, Hulsbergen AFC, Cho LD, Aglio LS, Nandoe Tewarie RDS, Broekman MLD. Evidence-based dexamethasone dosing in malignant brain tumors: what do we really know? J Neurooncol 2019; 144:249-264. [PMID: 31346902 PMCID: PMC6700052 DOI: 10.1007/s11060-019-03238-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/13/2019] [Indexed: 12/19/2022]
Abstract
Purpose The present study aims to conduct a systematic review of literature reporting on the dose and dosing schedule of dexamethasone (DXM) in relation to clinical outcomes in malignant brain tumor patients, with particular attention to evidence-based practice. Methods A systematic search was performed in PubMed, Embase, Web of Science, Cochrane, Academic Search Premier, and PsycINFO to identify studies that reported edema volume reduction, symptomatic relief, adverse events and survival in relation to dexamethasone dose in glioma or brain metastasis (BM) patients. Results After screening 1812 studies, fifteen articles were included for qualitative review. Most studies reported a dose of 16 mg, mostly in a schedule of 4 mg four times a day. Due to heterogeneity of studies, it was not possible to perform quantitative meta-analysis. For BMs, best available evidence suggests that higher doses of DXM may give more adverse events, but may not necessarily result in better clinical condition. Some studies suggest that higher DXM doses are associated with shorter survival in the palliative setting. For glioma, DXM may lead to symptomatic improvement, yet no studies directly compare different doses. Results regarding edema reduction and survival in glioma patients are conflicting. Conclusions Evidence on the safety and efficacy of different DXM doses in malignant brain tumor patients is scarce and conflicting. Best available evidence suggests that low DXM doses may be noninferior to higher doses in certain circumstances, but more comparative research in this area is direly needed, especially in light of the increasing importance of immunotherapy for brain tumors. Electronic supplementary material The online version of this article (10.1007/s11060-019-03238-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Charissa A C Jessurun
- Faculty of Medicine, University of Amsterdam/Amsterdam University Medical Center, Location Academic Medical Center (AMC), Meibergdreef 9, 1105 AZ, Amsterdam, Noord-Holland, The Netherlands
| | - Alexander F C Hulsbergen
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512VA, The Hague, Zuid-Holland, The Netherlands.,Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, Zuid-Holland, The Netherlands
| | - Logan D Cho
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Brown University, 69 Brown Street, Providence, RI, 02912, USA
| | - Linda S Aglio
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Rishi D S Nandoe Tewarie
- Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512VA, The Hague, Zuid-Holland, The Netherlands.,Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, Zuid-Holland, The Netherlands
| | - Marike L D Broekman
- Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512VA, The Hague, Zuid-Holland, The Netherlands. .,Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, Zuid-Holland, The Netherlands. .,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
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11
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From Whole-Brain Radiotherapy to Immunotherapy: A Multidisciplinary Approach for Patients with Brain Metastases from NSCLC. JOURNAL OF ONCOLOGY 2019; 2019:3267409. [PMID: 30853981 PMCID: PMC6378013 DOI: 10.1155/2019/3267409] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 01/15/2019] [Indexed: 12/25/2022]
Abstract
Non-small cell lung cancer patients with brain metastases have a multitude of treatment options, but there is currently no international and multidisciplinary consensus concerning their optimal treatment. Local therapies have the principal role, especially in symptomatic patients. Advances in surgery and radiation therapy manage considerable local control. Systemic treatments have shown effect in clinical trials and in real life clinical settings; yet, at present, this is restricted to patients with asymptomatic or stable intracranial lesions. Targeted agents can have a benefit only in patients with EGFR mutations or ALK rearrangement. Immunotherapy has shown impressive results in patients with PD-L1 expression in tumor cells. Its effects can be further enhanced by a synergy with radiotherapy, possibly by increasing the percentage of responders. The present review summarizes the need for more effective systemic treatments, so that the increased intracranial control achieved by local treatments can be translated in an increase in overall survival.
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12
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Kumar A, Mukundan H, Bhatnagar S, Sarin A, Taneja S, Sahoo S. Radiation for Palliation: Role of Palliative Radiotherapy in Allevieating Pain/Symptoms in a Prospective Observational Study at Two Tertiary Care Centers. Indian J Palliat Care 2019; 25:391-397. [PMID: 31413454 PMCID: PMC6659517 DOI: 10.4103/ijpc.ijpc_35_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Purpose Approximately one-third of patients attending the tertiary care center require palliative management. The purpose of this study was to investigate the role of palliative radiation in alleviating the pain and symptoms and improvement in quality of life (QOL). Methods This was a prospective study aimed to evaluate patients attending two oncology centers and those who require palliative radiation. During 3 years, 1365 patients attended radiation oncology center for various malignancies. Of these patients, 304 patients were treated with palliative radiation for various indications. These patients were followed up for a period of up to 6 months for symptom relief and improved QOL. Results About 22% of patients received palliative radiation primarily for carcinoma lung, breast, and prostate malignancy. Analysis revealed elderly patients in the age group of 50-70 being the most commonly affected and most common presentation was pain, swelling, and headache. The most common site of metastases was bone including the spine and brain. Most commonly employed schedule of palliative radiation was 30 Gy in 10 fractions and 20 Gy in 5 fractions. Patients responded well to palliative radiation and had improved pain relief and QOL. Conclusions Palliative radiation is an important part of the management of cancer care and when given improves QOL, and significant pain relief.
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Affiliation(s)
- Ashok Kumar
- Department of Radiation Oncology, Army Hospital R and R, Delhi, India
| | - Hari Mukundan
- Department of Radiation Oncology, INHS Aswini, Mumbai, Maharashtra, India
| | - Sharad Bhatnagar
- Department of Radiation Oncology, Army Hospital R and R, Delhi, India
| | - Arti Sarin
- Department of Radiation Oncology, INHS Aswini, Mumbai, Maharashtra, India
| | - Sachin Taneja
- Department of Radiation Oncology, INHS Aswini, Mumbai, Maharashtra, India
| | - Srimukta Sahoo
- Department of Radiation Oncology, Command Hospital, Lucknow, Uttar Pradesh, India
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13
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Ulahannan D, Khalifa J, Faivre-Finn C, Lee SM. Emerging treatment paradigms for brain metastasis in non-small-cell lung cancer: an overview of the current landscape and challenges ahead. Ann Oncol 2018; 28:2923-2931. [PMID: 29045549 DOI: 10.1093/annonc/mdx481] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Advances in the last decade in genomic profiling and the identification of druggable targets amenable to biological agents have transformed the management and survival of a subgroup of patients with brain metastasis in non-small-cell lung cancer. In parallel, clinicians have reevaluated the role of whole brain radiotherapy in selected patients with brain metastases to reduce neurocognitive toxicity. Continual progress in this understudied field is required: optimization of the sequence of schedules for therapies in patients with brain metastases of differing genomic profiles, focusing on new strategies to overcome mechanisms of biological resistance and increasing drug penetrability into the central nervous system. This review summarizes the field to date and possible treatment strategies based on current evidence.
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Affiliation(s)
- D Ulahannan
- Department of Oncology, University College London Hospital, London, UK
| | - J Khalifa
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - C Faivre-Finn
- Division of Cancer Sciences, Manchester Cancer Research Centre, University of Manchester, Manchester, UK.,CRUK Lung Cancer Centre of Excellence, Christie Hospital Manchester and University College London, UK
| | - S-M Lee
- Department of Oncology, University College London Hospital, London, UK.,CRUK Lung Cancer Centre of Excellence, Christie Hospital Manchester and University College London, UK
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14
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Tsao MN, Xu W, Wong RKS, Lloyd N, Laperriere N, Sahgal A, Rakovitch E, Chow E. Whole brain radiotherapy for the treatment of newly diagnosed multiple brain metastases. Cochrane Database Syst Rev 2018; 1:CD003869. [PMID: 29365347 PMCID: PMC6491334 DOI: 10.1002/14651858.cd003869.pub4] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND This is an update to the review published in the Cochrane Library (2012, Issue 4).It is estimated that 20% to 40% of people with cancer will develop brain metastases during the course of their illness. The burden of brain metastases impacts quality and length of survival. OBJECTIVES To assess the effectiveness and adverse effects of whole brain radiotherapy (WBRT) given alone or in combination with other therapies to adults with newly diagnosed multiple brain metastases. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase to May 2017 and the National Cancer Institute Physicians Data Query for ongoing trials. SELECTION CRITERIA We included phase III randomised controlled trials (RCTs) comparing WBRT versus other treatments for adults with newly diagnosed multiple brain metastases. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and abstracted information in accordance with Cochrane methods. MAIN RESULTS We added 10 RCTs to this updated review. The review now includes 54 published trials (45 fully published reports, four abstracts, and five subsets of data from previously published RCTs) involving 11,898 participants.Lower biological WBRT doses versus controlThe hazard ratio (HR) for overall survival (OS) with lower biological WBRT doses as compared with control (3000 cGy in 10 daily fractions) was 1.21 (95% confidence interval (CI) 1.04 to 1.40; P = 0.01; moderate-certainty evidence) in favour of control. The HR for neurological function improvement (NFI) was 1.74 (95% CI 1.06 to 2.84; P = 0.03; moderate-certainty evidence) in favour of control fractionation.Higher biological WBRT doses versus controlThe HR for OS with higher biological WBRT doses as compared with control (3000 cGy in 10 daily fractions) was 0.97 (95% CI 0.83 to 1.12; P = 0.65; moderate-certainty evidence). The HR for NFI was 1.14 (95% CI 0.92 to 1.42; P = 0.23; moderate-certainty evidence).WBRT and radiosensitisersThe addition of radiosensitisers to WBRT did not confer additional benefit for OS (HR 1.05, 95% CI 0.99 to 1.12; P = 0.12; moderate-certainty evidence) or for brain tumour response rates (odds ratio (OR) 0.84, 95% CI 0.63 to 1.11; P = 0.22; high-certainty evidence).Radiosurgery and WBRT versus WBRT aloneThe HR for OS with use of WBRT and radiosurgery boost as compared with WBRT alone for selected participants was 0.61 (95% CI 0.27 to 1.39; P = 0.24; moderate-certainty evidence). For overall brain control at one year, the HR was 0.39 (95% CI 0.25 to 0.60; P < 0.0001; high-certainty evidence) favouring the WBRT and radiosurgery boost group.Radiosurgery alone versus radiosurgery and WBRTThe HR for local brain control was 2.73 (95% CI 1.87 to 3.99; P < 0.00001; high-certainty evidence)favouring the addition of WBRT to radiosurgery. The HR for distant brain control was 2.34 (95% CI 1.73 to 3.18; P < 0.00001; high-certainty evidence) favouring WBRT and radiosurgery. The HR for OS was 1.00 (95% CI 0.80 to 1.25; P = 0.99; moderate-certainty evidence). Two trials reported worse neurocognitive outcomes and one trial reported worse quality of life outcomes when WBRT was added to radiosurgery.We could not pool data from trials related to chemotherapy, optimal supportive care (OSC), molecular targeted agents, neurocognitive protective agents, and hippocampal sparing WBRT. However, one trial reported no differences in quality-adjusted life-years for selected participants with brain metastases from non-small-cell lung cancer randomised to OSC and WBRT versus OSC alone. AUTHORS' CONCLUSIONS None of the trials with altered higher biological WBRT dose-fractionation schemes reported benefit for OS, NFI, or symptom control compared with standard care. However, OS and NFI were worse for lower biological WBRT dose-fractionation schemes than for standard dose schedules.The addition of WBRT to radiosurgery improved local and distant brain control in selected people with brain metastases, but data show worse neurocognitive outcomes and no differences in OS.Selected people with multiple brain metastases from non-small-cell lung cancer may show no difference in OS when OSC is given and WBRT is omitted.Use of radiosensitisers, chemotherapy, or molecular targeted agents in conjunction with WBRT remains experimental.Further trials are needed to evaluate the use of neurocognitive protective agents and hippocampal sparing with WBRT. As well, future trials should examine homogeneous participants with brain metastases with focus on prognostic features and molecular markers.
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Affiliation(s)
- May N Tsao
- University of TorontoDepartment of Radiation Oncology2075 Bayview AvenueTorontoOntarioCanadaM4N 3M5
| | - Wei Xu
- University of TorontoDepartment of BiostatisticsUniversity Health NetworkTorontoOntarioCanada
| | - Rebecca KS Wong
- Princess Margaret Cancer CentreDepartment of Radiation Oncology5th Floor, 610 University AvenueTorontoONCanadaM5G 2M9
| | - Nancy Lloyd
- McMaster UniversityDepartment of Clinical Epidemiology and Biostatistics1280 Main Street WestCourthouse T‐27, 3rd FloorHamiltonOntarioCanadaL8S 4L8
| | - Normand Laperriere
- Princess Margaret Cancer CentreDepartment of Radiation Oncology5th Floor, 610 University AvenueTorontoONCanadaM5G 2M9
| | - Arjun Sahgal
- Odette Cancer CentreDepartment of Radiation OncologySunnybrook Health Sciences Centre2075 Bayview Avenue, T‐WingTorontoCanadaM4N 3M5
| | - Eileen Rakovitch
- Odette Cancer CentreDepartment of Radiation OncologySunnybrook Health Sciences Centre2075 Bayview Avenue, T‐WingTorontoCanadaM4N 3M5
| | - Edward Chow
- Odette Cancer CentreDepartment of Radiation OncologySunnybrook Health Sciences Centre2075 Bayview Avenue, T‐WingTorontoCanadaM4N 3M5
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15
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Greystoke A, Mulvenna P. Metastatic Brain Disease from Non-small Cell Lung Cancer - Getting Back to the Drawing Board. Clin Oncol (R Coll Radiol) 2018; 30:137-143. [PMID: 29352644 DOI: 10.1016/j.clon.2017.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/17/2017] [Accepted: 11/20/2017] [Indexed: 10/18/2022]
Affiliation(s)
- A Greystoke
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - P Mulvenna
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK.
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16
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Yang JJ, Zhou C, Huang Y, Feng J, Lu S, Song Y, Huang C, Wu G, Zhang L, Cheng Y, Hu C, Chen G, Zhang L, Liu X, Yan HH, Tan FL, Zhong W, Wu YL. Icotinib versus whole-brain irradiation in patients with EGFR-mutant non-small-cell lung cancer and multiple brain metastases (BRAIN): a multicentre, phase 3, open-label, parallel, randomised controlled trial. THE LANCET RESPIRATORY MEDICINE 2017; 5:707-716. [PMID: 28734822 DOI: 10.1016/s2213-2600(17)30262-x] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/13/2017] [Accepted: 06/13/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND For patients with non-small-cell lung cancer (NSCLC) and multiple brain metastases, whole-brain irradiation (WBI) is a standard-of-care treatment, but its effects on neurocognition are complex and concerning. We compared the efficacy of an epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI), icotinib, versus WBI with or without chemotherapy in a phase 3 trial of patients with EGFR-mutant NSCLC and multiple brain metastases. METHODS We did a multicentre, open-label, parallel randomised controlled trial (BRAIN) at 17 hospitals in China. Eligible participants were patients with NSCLC with EGFR mutations, who were naive to treatment with EGFR-TKIs or radiotherapy, and had at least three metastatic brain lesions. We randomly assigned participants (1:1) to either icotinib 125 mg orally (three times per day) or WBI (30 Gy in ten fractions of 3 Gy) plus concurrent or sequential chemotherapy for 4-6 cycles, until unacceptable adverse events or intracranial disease progression occurred. The randomisation was done by the Chinese Thoracic Oncology Group with a web-based allocation system applying the Pocock and Simon minimisation method; groups were stratified by EGFR gene mutation status, treatment line (first line or second line), brain metastases only versus both intracranial and extracranial metastases, and presence or absence of symptoms of intracranial hypertension. Clinicians and patients were not masked to treatment assignment, but individuals involved in the data analysis did not participate in the treatments and were thus masked to allocation. Patients receiving icotinib who had intracranial progression only were switched to WBI plus either icotinib or chemotherapy until further progression; those receiving icotinib who had extracranial progression only were switched to icotinib plus chemotherapy. Patients receiving WBI who progressed were switched to icotinib until further progression. Icotinib could be continued beyond progression if a clinical benefit was observed by the investigators (eg, an improvement in cognition or intracranial pressure). The primary endpoint was intracranial progression-free survival (PFS), defined as the time from randomisation to either intracranial disease progression or death from any cause. We assessed efficacy and safety in the intention-to-treat population (all participants who received at least one dose of study treatment), hypothesising that intracranial PFS would be 40% longer (hazard ratio [HR] 0·60) with icotinib compared with WBI. This trial is registered with ClinicalTrials.gov, number NCT01724801. FINDINGS Between Dec 10, 2012, and June 30, 2015, we assigned 176 participants to treatment: 85 to icotinib and 91 to WBI. 18 withdrew from the WBI group before treatment, leaving 73 for assessment. Median follow-up was 16·5 months (IQR 11·5-21·5). Median intracranial PFS was 10·0 months (95% CI 5·6-14·4) with icotinib versus 4·8 months (2·4-7·2) with WBI (equating to a 44% risk reduction with icotinib for an event of intracranial disease progression or death; HR 0·56, 95% CI 0·36-0·90; p=0·014). Adverse events of grade 3 or worse were reported in seven (8%) of 85 patients in the icotinib group and 28 (38%) of 73 patients in the WBI group. Raised concentrations of alanine aminotransferase and rash were the most common adverse events of any grade in both groups, occurring in around 20-30% of each group. At the time of final analysis, 42 (49%) patients in the icotinib group and 37 (51%) in the WBI group had died. 78 of these patients died from disease progression, and one patient in the WBI group died from thrombogenesis related to chemotherapy. INTERPRETATION In patients with EGFR-mutant NSCLC and multiple brain metastases, icotinib was associated with significantly longer intracranial PFS than WBI plus chemotherapy, indicating that icotinib might be a better first-line therapeutic option for this patient population. FUNDING Guangdong Provincial Key Laboratory of Lung Cancer Translational Medicine, National Health and Family Planning Commission of China, Guangzhou Science and Technology Bureau, Betta Pharmaceuticals, and the Chinese Thoracic Oncology Group.
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Affiliation(s)
- Jin-Ji Yang
- Guangdong Lung Cancer Institute, Guangdong General Hospital, and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Caicun Zhou
- Department of Oncology, Shanghai Pulmonary Hospital, Shanghai, China
| | - Yisheng Huang
- Department of Medical Oncology, Affiliated Zhongshan Hospital of Guangdong Medical University, Zhongshan, China
| | - Jifeng Feng
- Department of Medical Oncology, Jiangsu Provincial Cancer Hospital, Nanjing, China
| | - Sun Lu
- Shanghai Lung Tumor Clinical Medical Center, Shanghai Chest Hospital, Shanghai, China
| | - Yong Song
- Nanjing Military General Hospital, Nanjing, China
| | - Cheng Huang
- Department of Medical Oncology, Fujian Provincial Tumor Hospital, Fuzhou, China
| | - Gang Wu
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Zhang
- Sun Yat-Sen University, Guangzhou, China
| | - Ying Cheng
- Jilin Province Cancer Hospital, Changchun, China
| | - Chengping Hu
- Xiangya Hospital of Central South University, Changsha, China
| | - Gongyan Chen
- Harbin Medical University Cancer Hospital, Harbin, China
| | - Li Zhang
- Department of Pulmonology, Beijing Union Medical College Hospital, Beijing, China
| | - Xiaoqing Liu
- Cancer Center of 307 Hospital of the Academy of Military Medical Sciences, Beijing, China
| | - Hong Hong Yan
- Guangdong Lung Cancer Institute, Guangdong General Hospital, and Guangdong Academy of Medical Sciences, Guangzhou, China
| | | | - Wenzhao Zhong
- Guangdong Lung Cancer Institute, Guangdong General Hospital, and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong General Hospital, and Guangdong Academy of Medical Sciences, Guangzhou, China.
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Chung SY, Chang JH, Kim HR, Cho BC, Lee CG, Suh CO. Optimal dose and volume for postoperative radiotherapy in brain oligometastases from lung cancer: a retrospective study. Radiat Oncol J 2017; 35:153-162. [PMID: 28712276 PMCID: PMC5518455 DOI: 10.3857/roj.2017.00094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 03/20/2017] [Accepted: 03/24/2017] [Indexed: 01/12/2023] Open
Abstract
PURPOSE To evaluate intracranial control after surgical resection according to the adjuvant treatment received in order to assess the optimal radiotherapy (RT) dose and volume. MATERIALS AND METHODS Between 2003 and 2015, a total of 53 patients with brain oligometastases from non-small cell lung cancer (NSCLC) underwent metastasectomy. The patients were divided into three groups according to the adjuvant treatment received: whole brain radiotherapy (WBRT) ± boost (WBRT ± boost group, n = 26), local RT/Gamma Knife surgery (local RT group, n = 14), and the observation group (n = 13). The most commonly used dose schedule was WBRT (25 Gy in 10 fractions, equivalent dose in 2 Gy fractions [EQD2] 26.04 Gy) with tumor bed boost (15 Gy in 5 fractions, EQD2 16.25 Gy). RESULTS The WBRT ± boost group showed the lowest 1-year intracranial recurrence rate of 30.4%, followed by the local RT and observation groups, at 66.7%, and 76.9%, respectively (p = 0.006). In the WBRT ± boost group, there was no significant increase in the 1-year new site recurrence rate of patients receiving a lower dose of WBRT (EQD2) <27 Gy compared to that in patients receiving a higher WBRT dose (p = 0.553). The 1-year initial tumor site recurrence rate was lower in patients receiving tumor bed dose (EQD2) of ≥42.3 Gy compared to those receiving <42.3 Gy, although the difference was not significant (p = 0.347). CONCLUSIONS Adding WBRT after resection of brain oligometastases from NSCLC seems to enhance intracranial control. Furthermore, combining lower-dose WBRT with a tumor bed boost may be an attractive option.
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Affiliation(s)
- Seung Yeun Chung
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Ryun Kim
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Byoung Chul Cho
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Geol Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
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Rancoule C, Vallard A, Guy JB, Espenel S, Diao P, Chargari C, Magné N. Brain metastases from non-small cell lung carcinoma: Changing concepts for improving patients' outcome. Crit Rev Oncol Hematol 2017; 116:32-37. [PMID: 28693798 DOI: 10.1016/j.critrevonc.2017.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/16/2017] [Indexed: 11/29/2022] Open
Abstract
The management of Non Small Cell Lung Cancer (NSCLC) brain metastases is challenging, as this frequent complication negatively impacts patients' quality of life, and can be a life-threatening event. Through a review of the literature, we discuss the main therapeutic options and the recent developments that improved (and complicated) the management of NSCLC brain metastases patients. Most current validated approaches are local with exclusive or combined surgery, whole brain radiotherapy (WBRT) and stereotactic radiotherapy (SRT). At the same time, there is a growing role for systemic treatments that might significantly postpone WBRT. Targeted therapies efficacy/toxicity profile remains to be defined but predictive and prognostic molecular factors integration could help to select treatments fully adapted to life expectancy and progression risk.
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Affiliation(s)
- Chloé Rancoule
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, 108 bis, Avenue Albert Raimond, BP 60008, 42271 Saint-Priest en Jarez, France
| | - Alexis Vallard
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, 108 bis, Avenue Albert Raimond, BP 60008, 42271 Saint-Priest en Jarez, France
| | - Jean-Baptiste Guy
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, 108 bis, Avenue Albert Raimond, BP 60008, 42271 Saint-Priest en Jarez, France; Laboratoire de Radiobiologie Cellulaire et Moléculaire, CNRS UMR 5822, Institut de Physique Nucléaire de Lyon, IPNL, 69622 Villeurbanne, France
| | - Sophie Espenel
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, 108 bis, Avenue Albert Raimond, BP 60008, 42271 Saint-Priest en Jarez, France
| | - Peng Diao
- Department of Radiotherapy, Sichuan Cancer Hospital, 55 Renmin Nan Lu, Sect 4. Wuhou District, Chengdu, 610041, China
| | - Cyrus Chargari
- Department of Radiotherapy, Institut Gustave Roussy, 114, Rue Edouard Vaillant, 94805 Villejuif, France; Institut de Recherche Biomédicale des Armées, D19, 91220 Brétigny sur Orge, France; French Military Health Services Academy, Ecole du Val-de-Grâce, Paris, France
| | - Nicolas Magné
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, 108 bis, Avenue Albert Raimond, BP 60008, 42271 Saint-Priest en Jarez, France; Laboratoire de Radiobiologie Cellulaire et Moléculaire, CNRS UMR 5822, Institut de Physique Nucléaire de Lyon, IPNL, 69622 Villeurbanne, France.
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How J, Mann J, Laczniak AN, Baggstrom MQ. Pulsatile Erlotinib in EGFR-Positive Non-Small-Cell Lung Cancer Patients With Leptomeningeal and Brain Metastases: Review of the Literature. Clin Lung Cancer 2017; 18:354-363. [PMID: 28245967 DOI: 10.1016/j.cllc.2017.01.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/24/2017] [Accepted: 01/31/2017] [Indexed: 02/08/2023]
Abstract
Patients with epidermal growth factor receptor (EGFR)-positive (EGFR+) non-small-cell lung cancer (NSCLC) show improved response rates when treated with tyrosine kinase inhibitors (TKIs) such as erlotinib. However, standard daily dosing of erlotinib often does not reach therapeutic concentrations within the cerebrospinal fluid (CSF), resulting in progression of central nervous system (CNS) disease. Intermittent, high-dose administration of erlotinib reaches therapeutic concentrations within the CSF and is well tolerated in patients. Experience with "pulsatile" dosing, however, is limited. We review the literature on the pharmacology and clinical outcomes of pulsatile erlotinib in the treatment of EGFR+ NSCLC with brain and leptomeningeal metastases, and include available data on the use of next-generation TKIs in CNS progression. We also provide our institution's experience with patients treated with pulsatile erlotinib for CNS metastasis, and propose clinical criteria for its use. Pulsatile erlotinib is a reasonable alternative in EGFR+ patients with new or worsening CNS disease, without evidence of systemic progression, and without confirmed T790M resistance mutations within the CNS.
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Affiliation(s)
- Joan How
- Barnes-Jewish Hospital, St Louis, MO
| | - Janelle Mann
- Mallinckrodt Institute of Radiology at Washington University, St Louis, MO
| | - Andrew N Laczniak
- Division of Pharmacology, Washington University School of Medicine, St Louis, MO
| | - Maria Q Baggstrom
- Division of Oncology, Washington University School of Medicine, St Louis, MO.
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Proto C, Imbimbo M, Gallucci R, Brissa A, Signorelli D, Vitali M, Macerelli M, Corrao G, Ganzinelli M, Greco FG, Garassino MC, Lo Russo G. Epidermal growth factor receptor tyrosine kinase inhibitors for the treatment of central nervous system metastases from non-small cell lung cancer: the present and the future. Transl Lung Cancer Res 2016; 5:563-578. [PMID: 28149752 DOI: 10.21037/tlcr.2016.10.16] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Lung cancer is one of the major causes of cancer related mortality worldwide. Brain metastases (BM) complicate clinical evolution of non-small cell lung cancer (NSCLC) in approximately 25-40% of cases, adversely influencing quality of life (QoL) and overall survival (OS). Systemic therapy remains the standard strategy for metastatic disease. Nevertheless, the blood-brain barrier (BBB) makes central nervous system (CNS) a sanctuary site. To date, the combination of chemotherapy with whole brain radiation therapy (WBRT), surgery and/or stereotactic radiosurgery (SRS) represents the most used treatment for patients (pts) with intracranial involvement. However, due to their clinical conditions, many pts are not able to undergo local treatments. Targeted therapies directed against epidermal growth factor receptor (EGFR), such as gefitinib, erlotinib and afatinib, achieved important improvements in EGFR mutated NSCLC with favorable toxicity profile. Although their role is not well defined, the reported objective response rate (ORR) and the good tolerance make EGFR-tyrosine kinase inhibitors (TKIs) an interesting valid alternative for NSCLC pts with BM, especially for those harboring EGFR mutations. Furthermore, new-generation TKIs, such as osimertinib and rociletinib, have already shown important activity on intracranial disease and several trials are still ongoing to evaluate their efficacy. In this review we want to highlight literature data about the use and the effectiveness of EGFR-TKIs in pts with BM from NSCLC.
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Affiliation(s)
- Claudia Proto
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Martina Imbimbo
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Rosaria Gallucci
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Angela Brissa
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Diego Signorelli
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Milena Vitali
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Marianna Macerelli
- Department of Medical Oncology, University-Hospital of Santa Maria delle Grazie, Udine, Italy
| | - Giulia Corrao
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Monica Ganzinelli
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | | | - Marina Chiara Garassino
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Giuseppe Lo Russo
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
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Mulvenna P, Nankivell M, Barton R, Faivre-Finn C, Wilson P, McColl E, Moore B, Brisbane I, Ardron D, Holt T, Morgan S, Lee C, Waite K, Bayman N, Pugh C, Sydes B, Stephens R, Parmar MK, Langley RE. Dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ): results from a phase 3, non-inferiority, randomised trial. Lancet 2016; 388:2004-2014. [PMID: 27604504 PMCID: PMC5082599 DOI: 10.1016/s0140-6736(16)30825-x] [Citation(s) in RCA: 409] [Impact Index Per Article: 51.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Whole brain radiotherapy (WBRT) and dexamethasone are widely used to treat brain metastases from non-small cell lung cancer (NSCLC), although there have been no randomised clinical trials showing that WBRT improves either quality of life or overall survival. Even after treatment with WBRT, the prognosis of this patient group is poor. We aimed to establish whether WBRT could be omitted without a significant effect on survival or quality of life. METHODS The Quality of Life after Treatment for Brain Metastases (QUARTZ) study is a non-inferiority, phase 3 randomised trial done at 69 UK and three Australian centres. NSCLC patients with brain metastases unsuitable for surgical resection or stereotactic radiotherapy were randomly assigned (1:1) to optimal supportive care (OSC) including dexamethasone plus WBRT (20 Gy in five daily fractions) or OSC alone (including dexamethasone). The dose of dexamethasone was determined by the patients' symptoms and titrated downwards if symptoms improved. Allocation to treatment group was done by a phone call from the hospital to the Medical Research Council Clinical Trials Unit at University College London using a minimisation programme with a random element and stratification by centre, Karnofsky Performance Status (KPS), gender, status of brain metastases, and the status of primary lung cancer. The primary outcome measure was quality-adjusted life-years (QALYs). QALYs were generated from overall survival and patients' weekly completion of the EQ-5D questionnaire. Treatment with OSC alone was considered non-inferior if it was no more than 7 QALY days worse than treatment with WBRT plus OSC, which required 534 patients (80% power, 5% [one-sided] significance level). Analysis was done by intention to treat for all randomly assigned patients. The trial is registered with ISRCTN, number ISRCTN3826061. FINDINGS Between March 2, 2007, and Aug 29, 2014, 538 patients were recruited from 69 UK and three Australian centres, and were randomly assigned to receive either OSC plus WBRT (269) or OSC alone (269). Baseline characteristics were balanced between groups, and the median age of participants was 66 years (range 38-85). Significantly more episodes of drowsiness, hair loss, nausea, and dry or itchy scalp were reported while patients were receiving WBRT, although there was no evidence of a difference in the rate of serious adverse events between the two groups. There was no evidence of a difference in overall survival (hazard ratio 1·06, 95% CI 0·90-1·26), overall quality of life, or dexamethasone use between the two groups. The difference between the mean QALYs was 4·7 days (46·4 QALY days for the OSC plus WBRT group vs 41·7 QALY days for the OSC group), with two-sided 90% CI of -12·7 to 3·3. INTERPRETATION Although the primary outcome measure result includes the prespecified non-inferiority margin, the combination of the small difference in QALYs and the absence of a difference in survival and quality of life between the two groups suggests that WBRT provides little additional clinically significant benefit for this patient group. FUNDING Cancer Research UK, Medical Research Council Clinical Trials Unit at University College London, and the National Health and Medical Research Council in Australia.
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Affiliation(s)
- Paula Mulvenna
- Northern Centre for Cancer Care, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Matthew Nankivell
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Rachael Barton
- Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Hull, UK
| | - Corinne Faivre-Finn
- Institute of Cancer Sciences, The University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - Paula Wilson
- Bristol Haematology and Oncology Centre, Bristol, UK
| | - Elaine McColl
- Newcastle Clinical Trials Unit and Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Iona Brisbane
- The Beatson West of Scotland Cancer Centre, Greater Glasgow Health Board and Clyde, Glasgow, UK
| | | | - Tanya Holt
- Trans Tasman Radiation Oncology Group, Waratah, NSW, Australia; University of Queensland, QLD, Australia
| | | | | | | | - Neil Bayman
- Institute of Cancer Sciences, The University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - Cheryl Pugh
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Benjamin Sydes
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Richard Stephens
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Mahesh K Parmar
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Ruth E Langley
- Medical Research Council Clinical Trials Unit at University College London, London, UK.
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Results of a Phase II Study of Short-Course Accelerated Radiation Therapy (SHARON) for Multiple Brain Metastases. Am J Clin Oncol 2015. [DOI: 10.1097/coc.0b013e3182a0e826] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Goyal S, Silk AW, Tian S, Mehnert J, Danish S, Ranjan S, Kaufman HL. Clinical Management of Multiple Melanoma Brain Metastases: A Systematic Review. JAMA Oncol 2015; 1:668-76. [PMID: 26181286 PMCID: PMC5726801 DOI: 10.1001/jamaoncol.2015.1206] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE The treatment of multiple brain metastases (MBM) from melanoma is controversial and includes surgical resection, stereotactic radiosurgery (SRS), and whole-brain radiation therapy (WBRT). Several new classes of agents have revolutionized the treatment of metastatic melanoma, allowing some subsets of patients to have long-term survival. Given this, management of MBM from melanoma is continually evolving. OBJECTIVE To review the current evidence regarding the treatment of MBM from melanoma. EVIDENCE REVIEW The PubMed database was searched using combinations of search terms and synonyms for melanoma, brain metastases, radiation, chemotherapy, immunotherapy, and targeted therapy published between January 1, 1995, and January 1, 2015. Articles were selected for inclusion on the basis of targeted keyword searches, manual review of bibliographies, and whether the article was a clinical trial, large observational study, or retrospective study focusing on melanoma brain metastases. Of 2243 articles initially identified, 110 were selected for full review. Of these, the most pertinent 73 articles were included. FINDINGS Patients with newly diagnosed MBM can be treated with various modalities, either alone or in combination. Level 1 evidence supports the use of SRS alone, WBRT, and SRS with WBRT. Although the addition of WBRT to SRS improves the overall brain relapse rate, WBRT has no significant impact on overall survival and has detrimental neurocognitive outcomes. Cytotoxic chemotherapy has largely been ineffective; targeted therapies and immunotherapies have been reported to have high response rates and deserve further attention in larger clinical trials. Further studies are needed to fully evaluate the efficacy of these novel regimens in combination with radiation therapy. CONCLUSIONS AND RELEVANCE At this time, the standard management for patients with MBM from melanoma includes SRS, WBRT, or a combination of both. Emerging data exist to support the notion that SRS in combination with targeted therapies or immune therapy may obviate the need for WBRT; prospective studies are required to fully evaluate the efficacy of these novel regimens in combination with radiation therapy.
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Affiliation(s)
- Sharad Goyal
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Ann W. Silk
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Sibo Tian
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Janice Mehnert
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Shabbar Danish
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Sinthu Ranjan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Howard L. Kaufman
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
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Wong E, Tsao M, Zhang L, Danjoux C, Barnes E, Pulenzas N, Vuong S, Chow E. Survival of patients with multiple brain metastases treated with whole-brain radiotherapy. CNS Oncol 2015; 4:213-24. [PMID: 26118428 DOI: 10.2217/cns.15.17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To report the survival outcomes of patients with multiple brain metastases treated with whole-brain radiotherapy. PATIENTS & METHODS From 2004 to 2012, patients with brain metastases treated with whole-brain radiotherapy were included. Overall survival (OS) was calculated from the start of radiation treatment. Univariate and multivariate proportional hazard model of OS was conducted. Generalized R(2) statistic (ranged from 0 to 1) was calculated to determine the association with the outcome. RESULTS Nine-hundred-ninety-one patients were included. The actuarial median OS time was 2.7 months (95% CI: 2.5-2.9). Patients of older age (>65 years), lower Karnofsky performance status, not postoperative and patients with gastrointestinal, genitourinary or lung as opposed to breast cancer were more likely to have a shorter survival. CONCLUSION Short median survival of 2.7 months may reflect poorer prognosis of patients referred due to large amount of referrals for radiosurgery. Prognostic factors for survival should be considered at consultation.
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Affiliation(s)
- Erin Wong
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - May Tsao
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Liying Zhang
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Cyril Danjoux
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Elizabeth Barnes
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Natalie Pulenzas
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Sherlyn Vuong
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Edward Chow
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
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The treatment of patients with 1-3 brain metastases: is there a place for whole brain radiotherapy alone, yet? A retrospective analysis. Radiol Med 2015; 120:1146-52. [PMID: 25917339 DOI: 10.1007/s11547-015-0542-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 04/16/2015] [Indexed: 10/23/2022]
Abstract
AIM To evaluate the efficacy of whole brain radiotherapy (WBRT) with or without other treatments in patients (pts) with 1-3 brain metastases (BM). MATERIALS AND METHODS Toxicities and survival of 134 pts treated between 2009 and 2013 with WBRT alone (58 pts), WBRT plus surgery (SUR-WBRT: 42 pts) or WBRT followed by stereotactic or integrated boost radiotherapy (SRT-WBRT: 34 pts) were analyzed. Differences in toxicity (acute and late) incidence and in overall (OS), disease-free (DFS) and disease-specific survival (DSS) were evaluated (χ(2)-test, uni- and multivariate analysis). RESULTS Pts given intensified treatments (SUR- and SBRT-WBRT) had better 3-month local response compared to WBRT alone group (p < 0.045). Better 1-year local control was evident only in SRT-WBRT pts (p < 0.035). Univariate OS analysis confirmed, as favorable prognostic factors, RPA class I (p < 0.001), GPA class III and IV (p < 0.001), single metastasis (p = 0.045), stable primary disease (p = 0.03), intensified treatment (p = 0.000), systemic therapy after radiotherapy (p = 0.04) and response of metastatic lesions (p = 0.002). At multivariate analysis, OS was better in RPA class I pts (p = 0.002), who had more aggressive radiotherapy treatments (p = 0.001), chemotherapy after radiotherapy (p < 0.001) and response to RT (p = 0.003). Response to radiotherapy (p = 0.002) and BM number (p < 0.001) resulted independently prognostic for DFS. About 60 % of patients had mild acute toxicity (G1), especially headache (51 %) and fatigue (34 %); only 2 patients (2 %) had severe (G3) headache and 5 patients (4 %) severe fatigue (G3) reversible with oral steroids. No differences were evident between the different treatment groups. Among 80 pts followed up with MRI, 12 (15 %) had leukoencephalopathy (equally distributed across subgroups) and 5 (6 %) radionecroses, 4/5 asymptomatic, 5/5 in pts given intensified treatments. CONCLUSIONS This analysis confirms the known prognostic factors for BM, emphasizing the importance of intensified treatments in a population with favorable features.
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Tang WH, Alip A, Saad M, Phua VCE, Chandran H, Tan YH, Tan YY, Kua VF, Wahid MI, Tho LM. Prognostic factors in patients with non-small cell lung carcinoma and brain metastases: a Malaysian perspective. Asian Pac J Cancer Prev 2015; 16:1901-6. [PMID: 25773842 DOI: 10.7314/apjcp.2015.16.5.1901] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Brain metastases occur in about 20-40% of patients with non-small-cell lung carcinoma (NSCLC), and are usually associated with a poor outcome. Whole brain radiotherapy (WBRT) is widely used but increasingly, more aggressive local treatments such as surgery or stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT) are being employed. In our study we aimed to describe the various factors affecting outcomes in NSCLC patients receiving local therapy for brain metastases. MATERIALS AND METHODS The case records of 125 patients with NSCLC and brain metastases consecutively treated with radiotherapy at two tertiary centres from January 2006 to June 2012 were analysed for patient, tumour and treatment-related prognostic factors. Patients receiving SRS/SRT were treated using Cyberknife. Variables were examined in univariate and multivariate testing. RESULTS Overall median survival was 3.4 months (95%CI: 1.7-5.1). Median survival for patients with multiple metastases receiving WBRT was 1.5 months, 1-3 metastases receiving WBRT was 3.6 months and 1-3 metastases receiving surgery or SRS/SRT was 8.9 months. ECOG score (≤2 vs >2, p=0.001), presence of seizure (yes versus no, p=0.031), treatment modality according to number of brain metastases (1-3 metastases+surgery or SRS/SRT±WBRT vs 1-3 metastases+WBRT only vs multiple metastases+WBRT only, p=0.007) and the use of post-therapy systemic treatment (yes versus no, p=0.001) emerged as significant on univariate analysis. All four factors remained statistically significant on multivariate analysis. CONCLUSIONS ECOG ≤2, presence of seizures, oligometastatic disease treated with aggressive local therapy (surgery or SRS/SRT) and the use of post-therapy systemic treatment are favourable prognostic factors in NSCLC patients with brain metastases.
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Affiliation(s)
- Weng Heng Tang
- Clinical Oncology Unit, University of Malaya Medical Centre, Kuala Lumpur, Malaysia E-mail :
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Management of Cerebral Brain Metastasis. CURRENT SURGERY REPORTS 2014. [DOI: 10.1007/s40137-014-0074-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Gangopadhyay A, Das J, Nath P, Maji T, Biswas J. Incidence of hospitalization in patients receiving short course palliative cranial radiotherapy on outpatient basis in a limited resource setting - Experience from a regional cancer center in India. Rep Pract Oncol Radiother 2014; 19:428-32. [PMID: 25337417 DOI: 10.1016/j.rpor.2014.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 02/05/2014] [Accepted: 04/05/2014] [Indexed: 10/25/2022] Open
Abstract
AIM To investigate incidence of toxicity and related hospitalization among patients treated at our institute by a short course of palliative cranial radiotherapy against a longer, widely established schedule. BACKGROUND Shorter schedule palliative cranial radiotherapy is more convenient for patients and reduce waiting times. Although many studies have established safety of short schedules, the need for hospitalization due to acute treatment toxicity remains under-explored. Hospital admissions are an economic burden both for the patient and healthcare system in a limited resource setting. Delivery of treatment on an outpatient basis and within shorter times is preferred by patients, caregivers and healthcare staff. MATERIALS AND METHODS This was a prospective study on 68 patients treated with palliative whole brain radiotherapy between November 2010 and October 2012. One group received 20 Gy in 5 fractions over 1 week and the other group, 30 Gy in 10 fractions over 2 weeks. Treatment toxicity due to cranial radiotherapy was assessed as per RTOG acute and late toxicity criteria. Need for hospitalization owing to acute toxicity was also noted. Significant differences in the study parameters between the two groups were calculated by Fisher's t-test. RESULTS Requirement for hospital stay due to acute toxicity was not significantly different between the two groups. Patients in both groups experienced similar toxicity both during and after treatment. CONCLUSIONS The shorter course entailed no significant increase in toxicity related admissions, suitable for limited resource settings where patient transport is difficult, there are financial constraints, and the healthcare system is overburdened.
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Affiliation(s)
- Aparna Gangopadhyay
- Dept. of Radiation Oncology, Chittaranjan National Cancer Institute, Kolkata, India
| | - Joydeep Das
- Dept. of Radiation Oncology, Chittaranjan National Cancer Institute, Kolkata, India
| | - Partha Nath
- Dept. of Medical Oncology, Chittaranjan National Cancer Institute, Kolkata, India
| | - Tapas Maji
- Dept. of Radiation Oncology, Chittaranjan National Cancer Institute, Kolkata, India
| | - Jaydip Biswas
- Dept. of Medical Oncology, Chittaranjan National Cancer Institute, Kolkata, India
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Epidermal growth factor receptor tyrosine kinase inhibitors in the treatment of central nerve system metastases from non-small cell lung cancer. Cancer Lett 2014; 351:6-12. [PMID: 24861428 DOI: 10.1016/j.canlet.2014.04.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 04/10/2014] [Accepted: 04/19/2014] [Indexed: 12/12/2022]
Abstract
Brain metastases (BM) are common and disastrous occurrence in patients with non-small cell lung cancer (NSCLC). Currently increasing studies suggest remarkable efficacy and mild toxicity of the epidermal growth factor tyrosine kinase inhibitor (EGFR TKI) in these patients, making targeted therapy an attractive option to BM from NSCLC. We here present a review about the use of EGFR-TKIs in this context and the following questions would be discussed: Are TKIs capable of permeating across brain-blood barrier (BBB)? How to boost exposure of EGFR TKI in cerebrospinal fluid to overcome the resistance of refractory metastases? Would the combination with other treatment like radiotherapy bring about advanced effect? And which patients with BM is the fittest population to EGFR-TKI treatment? In fact, though the administration of EGFR TKI only could achieve certain effect with limited penetration across BBB, increasing dose and combined radiotherapy would carry out better outcome. Unsurprisingly EGFR mutations were still the most important predictor of the sensitivity.
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Dawe DE, Greenspoon JN, Ellis PM. Brain metastases in non-small-cell lung cancer. Clin Lung Cancer 2014; 15:249-57. [PMID: 24954227 DOI: 10.1016/j.cllc.2014.04.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 04/04/2014] [Accepted: 04/08/2014] [Indexed: 12/25/2022]
Abstract
Up to 50% of patients with advanced non-small-cell lung cancer will develop brain metastases at some point during their illness. These metastases cause a substantial burden in morbidity and mortality, which has motivated research and technological innovation over the past 2 decades. Surgery, radiotherapy, and systemic therapies have each played a role in management, with the greatest changes associated with the popularization of stereotactic radiosurgery. In this review, the evidence behind each modality used in the management of brain metastases for non-small-cell lung cancer patients is examined, and recommendations regarding the current standards of care and areas of future research focus are provided.
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Affiliation(s)
- David E Dawe
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
| | | | - Peter M Ellis
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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Stereotactic radiosurgery in the treatment of brain metastases: the current evidence. Cancer Treat Rev 2013; 40:48-59. [PMID: 23810288 DOI: 10.1016/j.ctrv.2013.05.002] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 05/08/2013] [Accepted: 05/08/2013] [Indexed: 11/22/2022]
Abstract
Chemotherapy has made substantial progress in the therapy of systemic cancer, but the pharmacological efficacy is insufficient in the treatment of brain metastases. Fractionated whole brain radiotherapy (WBRT) has been a standard treatment of brain metastases, but provides limited local tumor control and often unsatisfactory clinical results. Stereotactic radiosurgery using Gamma Knife, Linac or Cyberknife has overcome several of these limitations, which has influenced recent treatment recommendations. This present review summarizes the current literature of single session radiosurgery concerning survival and quality of life, specific responses, tumor volumes and numbers, about potential treatment combinations and radioresistant metastases. Gamma Knife and Linac based radiosurgery provide consistent results with a reproducible local tumor control in both single and multiple brain metastases. Ideally minimum doses of ≥18Gy are applied. Reported local control rates were 90-94% for breast cancer metastases and 81-98% for brain metastases of lung cancer. Local tumor control rates after radiosurgery of otherwise radioresistant brain metastases were 73-90% for melanoma and 83-96% for renal cell cancer. Currently, there is a tendency to treat a larger number of brain metastases in a single radiosurgical session, since numerous studies document high local tumor control after radiosurgical treatment of >3 brain metastases. New remote brain metastases are reported in 33-42% after WBRT and in 39-52% after radiosurgery, but while WBRT is generally applied only once, radiosurgery can be used repeatedly for remote recurrences or new metastases after WBRT. Larger metastases (>8-10cc) should be removed surgically, but for smaller metastases Gamma Knife radiosurgery appears to be equally effective as surgical tumor resection (level I evidence). Radiosurgery avoids the impairments in cognition and quality of life that can be a consequence of WBRT (level I evidence). High local efficacy, preservation of cerebral functions, short hospitalization and the option to continue a systemic chemotherapy are factors in favor of a minimally invasive approach with stereotactic radiosurgery.
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Simoff MJ, Lally B, Slade MG, Goldberg WG, Lee P, Michaud GC, Wahidi MM, Chawla M. Symptom Management in Patients With Lung Cancer. Chest 2013; 143:e455S-e497S. [DOI: 10.1378/chest.12-2366] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Abstract
Brain metastases are the leading cause of intracranial malignancy and a major cause of mortality and morbidity. From 20 to 40% of cancer patients develop brain metastases. The irradiation of the whole brain remains the most commonly undertaken treatment, but should be discussed in relation to other therapeutic alternatives such as stereotactic radiotherapy or the use of new chemotherapy drugs. Its use according to pathology should be discussed. It can lead to a long-term neurocognitive toxicity that should be evaluated more precisely. This literature review aims to highlight the role of whole-brain radiotherapy used alone or in combination with other treatments.
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Langley RE, Stephens RJ, Nankivell M, Pugh C, Moore B, Navani N, Wilson P, Faivre-Finn C, Barton R, Parmar MKB, Mulvenna PM. Interim data from the Medical Research Council QUARTZ Trial: does whole brain radiotherapy affect the survival and quality of life of patients with brain metastases from non-small cell lung cancer? Clin Oncol (R Coll Radiol) 2012; 25:e23-30. [PMID: 23211715 DOI: 10.1016/j.clon.2012.11.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Revised: 10/01/2012] [Accepted: 10/02/2012] [Indexed: 10/27/2022]
Abstract
AIMS Over 30% of patients with non-small cell lung cancer (NSCLC) develop brain metastases. If inoperable, optimal supportive care (OSC), including steroids, and whole brain radiotherapy (WBRT) are generally considered to be standard care, although there is no randomised evidence demonstrating that the addition of WBRT to OSC improves survival or quality of life. MATERIALS AND METHODS QUARTZ is a randomised, non-inferiority, phase III trial comparing OSC + WBRT versus OSC in patients with inoperable brain metastases from NSCLC. The primary outcome measure is quality-adjusted life years (QALYs). QUARTZ was threatened with both loss of funding and early closure due to poor accrual. A lack of preliminary randomised data supporting the trial's hypotheses was thought to underlie the poor accrual, so, with no knowledge of the data, the independent trial steering committee agreed to the unusual step of releasing interim data. RESULTS Between March 2007 and April 2010, 151 (of the planned 534) patients were randomised (75 OSC + WBRT, 76 OSC). Participants' baseline demographics included median age 67 years (interquartile range 62-73), 60% male, 50% with a Karnofsky performance status <70; steroid usage was similar in the two groups; 64/75 (85%) received WBRT (20 Gy in five fractions). Median survival was: OSC + WBRT 49 days (95% confidence interval 39-61), OSC 51 days (95% confidence interval 27-57) - hazard ratio 1.11 (95% confidence interval 0.80-1.53) in favour of WBRT. Quality of life assessed using EQ-5D showed no evidence of a difference. The estimated mean QALYs was: OSC + WBRT 31 days and OSC 30 days, difference -1 day (95% confidence interval -12.0 to +13.2 days). CONCLUSION These interim data indicate no early evidence of detriment to quality of life, overall survival or QALYs for patients allocated to OSC alone. They provide key information for discussing the trial with patients and strengthen the argument for continuing QUARTZ to definitively answer this important clinical question.
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Khan E, Ismail S, Muirhead R. Incidence of symptomatic brain metastasis following radical radiotherapy for non-small cell lung cancer: is there a role for prophylactic cranial irradiation? Br J Radiol 2012; 85:1546-50. [PMID: 22993386 PMCID: PMC3611712 DOI: 10.1259/bjr/23314501] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 05/29/2012] [Accepted: 06/13/2012] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Brain metastases following radical radiotherapy for non-small cell lung cancer (NSCLC) are a recognised phenomenon; however, the incidence of symptomatic brain metastasis is currently unknown. The aim of the study was to identify the number of patients, staged in accordance with National Institute for Health and Clinical Excellence (NICE) guidance, who developed symptomatic brain metastasis following radical radiotherapy. There are two aims: to evaluate NICE guidance; and to provide vital information on the likely benefit of prophylactic cranial irradiation (PCI) in reducing neurological symptoms from brain metastasis. METHODS A retrospective review of 455 patients with NSCLC who had undergone radical radiotherapy in 2009 and 2010 was performed. Computer-based systems were used to identify patient and tumour demographics, the staging procedures performed and whether brain imaging had identified brain metastasis in the follow-up period. RESULTS The total number of patients with brain metastasis within 6 months was 3.7%. The proportion of brain metastasis within 6 months in Stage I, II and III NSCLC throughout both years was 2.8%, 1.0% and 5.7%, respectively. Within the follow-up period (median 16 months, range 6-30 months), the total number of patients who developed symptomatic brain metastasis was 7.9%. CONCLUSION Patients staged in accordance with NICE guidance, of whom only 7.7% underwent brain staging, have a minimal incidence of brain metastasis following radical radiotherapy. The number of patients developing symptoms from brain metastasis following radical radiotherapy may be less than the morbidity caused by PCI. ADVANCES IN KNOWLEDGE This finding supports the NICE guidance and brings into question the potential benefit of PCI.
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Affiliation(s)
- E Khan
- The Beatson West of Scotland Cancer Centre, Glasgow, UK
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Caravatta L, Deodato F, Ferro M, Macchia G, Massaccesi M, Cilla S, Padula GD, Mignogna S, Tambaro R, Carrozza F, Flocco M, Cantore G, Scapati A, Buwenge M, Sticca G, Valentini V, Cellini N, Morganti AG. A Phase I Study of Short-Course Accelerated Whole Brain Radiation Therapy for Multiple Brain Metastases. Int J Radiat Oncol Biol Phys 2012; 84:e463-8. [DOI: 10.1016/j.ijrobp.2012.06.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 06/12/2012] [Accepted: 06/13/2012] [Indexed: 11/16/2022]
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Ampil FL, Caldito G, Mills G, Marion J, Balandin A, Ponugupati J. Short survival after palliative radiotherapy for brain metastases in lung cancer: does the end justify the means? Am J Hosp Palliat Care 2012; 30:331-3. [PMID: 22743230 DOI: 10.1177/1049909112450940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
People with lung cancer (LCa) and symptomatic metastatic disease deserve palliative radiotherapy to promote a better quality of remaining life. On the other hand, in the case being described that of a LCa patient with brain and spinal metastases who died shortly after irradiation-- could management consisting of hospice and/or supportive care have been a better choice? Prognostic factors were analyzed in this retrospective study of the early deaths of 20 LCa patients with brain metastases in order to assist in a more rational decision making regarding treatment.
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Affiliation(s)
- Federico L Ampil
- Department of Radiology, Louisiana State University Health and Feist-Weiller Cancer Center, Shreveport, LA, USA.
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Tsao MN, Lloyd N, Wong RKS, Chow E, Rakovitch E, Laperriere N, Xu W, Sahgal A. Whole brain radiotherapy for the treatment of newly diagnosed multiple brain metastases. Cochrane Database Syst Rev 2012; 2012:CD003869. [PMID: 22513917 PMCID: PMC6457607 DOI: 10.1002/14651858.cd003869.pub3] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Brain metastases represent a significant healthcare problem. It is estimated that 20% to 40% of patients with cancer will develop metastatic cancer to the brain during the course of their illness. The burden of brain metastases impacts on quality and length of survival. Presenting symptoms include headache (49%), focal weakness (30%), mental disturbances (32%), gait ataxia (21%), seizures (18%), speech difficulty (12%), visual disturbance (6%), sensory disturbance (6%) and limb ataxia (6%).Brain metastases may spread from any primary site. The most common primary site is the lung, followed by the breast then gastrointestinal sites. Eighty-five per cent of brain metastases are found in the cerebral hemispheres, 10% to 15% in the cerebellum and 1% to 3% in the brainstem. Brain radiotherapy is used to treat cancer participants who have brain metastases from various primary malignancies.This is an update to the original review published in Issue 3, 2006. OBJECTIVES To assess the effectiveness and adverse effects of whole brain radiotherapy (WBRT) in adult participants with multiple metastases to the brain. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 3, 2011), MEDLINE and EMBASE to July 2011. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing WBRT either alone or with other treatments in adults with newly diagnosed multiple metastases to the brain from any primary cancer. Trials of prophylactic WBRT were excluded as well as trials that dealt with surgery or WBRT, or both, for the treatment of single brain metastasis. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and abstracted information. Adverse effects information was also collected from the trials. MAIN RESULTS Nine RCTs involving 1420 participants were added in this updated review. This updated review now includes a total of 39 trials involving 10,835 participants.Eight published reports (nine RCTs) showed no benefit of altered dose-fractionation schedules as compared to the control fractionation (3000 cGy in 10 fractions daily) of WBRT for overall survival. These studies also showed no improvement in symptom control nor neurologic improvement among the different dose-fractionation schemes as compared to 3000 cGy in 10 daily fractions of WBRT. This updated review includes two trials comparing 4000 cGy in 20 fractions given twice daily versus 2000 cGy in 4 or 5 daily fractions. Overall, there was no survival advantage (hazard ratio (HR) 1.18, 95% confidence interval (CI) 0.89 to 1.56, P = 0.25) with the use of 4000 cGy in 20 fractions given twice daily compared to 2000 cGy in 4 or 5 daily fractions.The addition of radiosensitizers in six RCTs did not confer additional benefit to WBRT in either the overall survival times (HR 1.08, 95% CI 0.98 to 1.18, P = 0.11) or brain tumour response rates (HR 0.87, 95% CI 0.60 to 1.26, P = 0.46).Two RCTs found no benefit in overall survival (HR 0.61, 95% CI 0.27 to 1.39, P = 0.24) with the use of WBRT and radiosurgery boost as compared to WBRT alone for selected participants with multiple brain metastases (up to four brain metastases). Overall, there was a statistically significant improvement in local brain control (HR 0.35, 95% CI 0.20 to 0.61, P = 0.0003) favouring the WBRT and radiosurgery boost arm. Only one trial of radiosurgery boost with WBRT reported an improved Karnofsky performance score outcome and improved ability to reduce the dexamethasone dose.In this updated review, a total of three RCTs reported on selected patients (with up to three or four brain metastases) treated with radiosurgery alone versus WBRT and radiosurgery. Based on two trials, there was no difference in overall survival (HR 0.98, 95% CI 0.71 to 1.35, P = 0.88). The addition of WBRT when added to radiosurgery significantly improved locally treated brain metasatases control (HR 2.61, 95% CI 1.68 to 4.06, P < 0.0001) and distant brain control (HR 2.15, 95% CI 1.55 to 2.99, P < 0.00001). On the other hand, one trial concluded that patients treated with WBRT and radiosurgery boost were significantly more likely to show a decline in learning and memory function as compared to those treated with radiosurgery alone.One RCT examined the use of WBRT and prednisone versus prednisone alone and produced inconclusive results. AUTHORS' CONCLUSIONS None of the RCTs with altered WBRT dose-fractionation schemes as compared to standard (3000 cGy in 10 daily fractions or 2000 cGy in 4 or 5 daily fractions) found a benefit in terms of overall survival, neurologic function, or symptom control.The use of radiosensitizers or chemotherapy in conjunction with WBRT remains experimental.Radiosurgery boost with WBRT may improve local disease control in selected participants as compared to WBRT alone, although survival remains unchanged for participants with multiple brain metastases.This updated review now includes a total of three RCTs examining the use of radiosurgery alone versus WBRT and radiosurgery. The addition of WBRT to radiosurgery improves local and distant brain control but there is no difference in overall survival. Patients treated with radiosurgery alone were found to have better neurocognitive outcomes in one trial as compared to patients treated with WBRT and radiosurgery.The benefit of WBRT as compared to supportive care alone has not been studied in RCTs. It may be that supportive care alone, without WBRT, is appropriate for some participants, particularly those with advanced disease and poor performance status.
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Affiliation(s)
- May N Tsao
- Department ofRadiationOncology,OdetteCancerCentre,Toronto,Canada.
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Chargari C, Kaloshi G, Benouaich-Amiel A, Lahutte M, Hoang-Xuan K, Ricard D. Metastasi cerebrali. Neurologia 2012. [DOI: 10.1016/s1634-7072(12)62058-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Tsao MN, Rades D, Wirth A, Lo SS, Danielson BL, Gaspar LE, Sperduto PW, Vogelbaum MA, Radawski JD, Wang JZ, Gillin MT, Mohideen N, Hahn CA, Chang EL. Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es): An American Society for Radiation Oncology evidence-based guideline. Pract Radiat Oncol 2012; 2:210-225. [PMID: 25925626 PMCID: PMC3808749 DOI: 10.1016/j.prro.2011.12.004] [Citation(s) in RCA: 412] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 12/09/2011] [Accepted: 12/15/2011] [Indexed: 12/25/2022]
Abstract
Purpose To systematically review the evidence for the radiotherapeutic and surgical management of patients newly diagnosed with intraparenchymal brain metastases. Methods and Materials Key clinical questions to be addressed in this evidence-based Guideline were identified. Fully published randomized controlled trials dealing with the management of newly diagnosed intraparenchymal brain metastases were searched systematically and reviewed. The U.S. Preventative Services Task Force levels of evidence were used to classify various options of management. Results The choice of management in patients with newly diagnosed single or multiple brain metastases depends on estimated prognosis and the aims of treatment (survival, local treated lesion control, distant brain control, neurocognitive preservation). Single brain metastasis and good prognosis (expected survival 3 months or more): For a single brain metastasis larger than 3 to 4 cm and amenable to safe complete resection, whole brain radiotherapy (WBRT) and surgery (level 1) should be considered. Another alternative is surgery and radiosurgery/radiation boost to the resection cavity (level 3). For single metastasis less than 3 to 4 cm, radiosurgery alone or WBRT and radiosurgery or WBRT and surgery (all based on level 1 evidence) should be considered. Another alternative is surgery and radiosurgery or radiation boost to the resection cavity (level 3). For single brain metastasis (less than 3 to 4 cm) that is not resectable or incompletely resected, WBRT and radiosurgery, or radiosurgery alone should be considered (level 1). For nonresectable single brain metastasis (larger than 3 to 4 cm), WBRT should be considered (level 3). Multiple brain metastases and good prognosis (expected survival 3 months or more): For selected patients with multiple brain metastases (all less than 3 to 4 cm), radiosurgery alone, WBRT and radiosurgery, or WBRT alone should be considered, based on level 1 evidence. Safe resection of a brain metastasis or metastases causing significant mass effect and postoperative WBRT may also be considered (level 3). Patients with poor prognosis (expected survival less than 3 months): Patients with either single or multiple brain metastases with poor prognosis should be considered for palliative care with or without WBRT (level 3). It should be recognized, however, that there are limitations in the ability of physicians to accurately predict patient survival. Prognostic systems such as recursive partitioning analysis, and diagnosis-specific graded prognostic assessment may be helpful. Conclusions Radiotherapeutic intervention (WBRT or radiosurgery) is associated with improved brain control. In selected patients with single brain metastasis, radiosurgery or surgery has been found to improve survival and locally treated metastasis control (compared with WBRT alone).
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Affiliation(s)
- May N Tsao
- Department of Radiation Oncology, University of Toronto, Odette Cancer Centre, Toronto, Ontario, Canada.
| | - Dirk Rades
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Luebeck, Germany (ESTRO representative)
| | - Andrew Wirth
- Peter MacCallum Cancer Center, Trans Tasman Radiation Oncology Group (TROG), East Melbourne, Australia
| | - Simon S Lo
- Department of Radiation Oncology, Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Brita L Danielson
- Department of Radiation Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Canada (CARO representative)
| | - Laurie E Gaspar
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Paul W Sperduto
- University of Minnesota Gamma Knife Center and Minneapolis Radiation Oncology, Minneapolis, Minnesota
| | | | | | - Jian Z Wang
- Department of Radiation Oncology, Ohio State University, Columbus, Ohio (deceased)
| | - Michael T Gillin
- Department of Radiation Oncology, M.D. Anderson Cancer Center, Houston, Texas
| | - Najeeb Mohideen
- Department of Radiation Oncology, Northwest Community Hospital, Arlington Heights, Illinois
| | - Carol A Hahn
- Department of Radiation Oncology, Duke University Medical School, Durham, North Carolina
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, California
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Gray M, Naredi P, Bacon N, Kerr D. Better value cancer care for the 21st century. Ann Oncol 2011; 22:2541-2545. [DOI: 10.1093/annonc/mdr457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Shorter-Course Whole-Brain Radiotherapy for Brain Metastases in Elderly Patients. Int J Radiat Oncol Biol Phys 2011; 81:e469-73. [DOI: 10.1016/j.ijrobp.2011.01.058] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 01/04/2011] [Accepted: 01/18/2011] [Indexed: 11/18/2022]
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The impact of tumour histology and recursive partitioning analysis classification on the prognosis of patients treated with whole-brain hypofractionated radiotherapy for brain metastases: analysis of 382 patients. Radiol Med 2011; 117:133-47. [PMID: 22020431 DOI: 10.1007/s11547-011-0738-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 01/28/2011] [Indexed: 10/16/2022]
Abstract
PURPOSE Recursive partitioning analysis (RPA) is a prognostic index capable of predicting survival in patients with brain metastases. Histology of the primary tumour has only recently been introduced among the factors that could potentially affect the prognosis of these patients. The main purpose of this study was to analyse the impact of RPA in correlation with histology of the primary tumour in patients with brain metastases treated with hypofractionated radiotherapy. MATERIALS AND METHODS A total of 382 patients were treated at the Department of Radiotherapy of Brescia University, and RPA classes were retrospectively assigned to all patients. Univariate and multivariate analyses were then performed to verify the role of the single prognostic variables, for the entire group and for each prognostic class, as well as in correlation with histology of the primary tumour. RESULTS Most patients were classified as RPA prognostic class 2 (48%). The majority of patients was treated with a total dose of 30 Gy delivered in ten fractions, whereas the dose of 20 Gy in four or five fractions was primarily used in patients classified as RPA class 3. At univariate analysis, the main variable correlating with overall survival (OS) was RPA class (p=0.000). Uni- and multivariate analysis performed on RPA class 1 patients only confirmed the role of general performance status, number of metastases and total radiotherapy dose for predicting OS. In the group with the worst prognosis (RPA class 3), none of the variables had a statistically significant role in improving OS. Tumour histology and radiotherapy dose influence OS, even in RPA class 1 and 2 patients. CONCLUSIONS This analysis confirms that RPA prognostic class is the factor that most predicts survival. Primary tumour histology helps determine prognosis, especially in RPA prognostic classes 1 and 2. As regards RPA class 3, no factor influences survival prognosis.
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Scoccianti S, Ricardi U. Treatment of brain metastases: review of phase III randomized controlled trials. Radiother Oncol 2011; 102:168-79. [PMID: 21996522 DOI: 10.1016/j.radonc.2011.08.041] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 07/18/2011] [Accepted: 08/29/2011] [Indexed: 11/18/2022]
Abstract
The optimal management of brain metastases remains controversial. Both whole brain radiotherapy (WBRT) and local treatment [surgery (S) or radiosurgery (RS)] are the cornerstones of treatment. The role of systemic therapy is also being explored. Randomized controlled trials (RCT) have tried to assess the individual and combined effects of different therapeutic strategies. (1) RCT in oligometastatic patients: WBRT alone vs. local treatment+WBRT. Combined treatment may improve both overall survival and local control in patients with a single metastasis, but it also leads to a local control benefit in patients with two to four lesions. Exclusive local treatment vs. WBRT plus local treatment. The addition of WBRT to local treatment may result in improved local control, improved freedom from new brain metastases and improved overall brain control. S+WBRT vs. RS+WBRT. There is no evidence of superiority of a combined treatment over the other one. (2) RCT addressing the point of improving WBRT outcome: differences in WBRT fractionation do not significantly alter outcome of treatments. Only a few systemic drugs may cause some significant advantages. (3) RCT that assessed neurocognitive impairment and quality of life: the baseline cognitive performance of most patients is significantly impaired. Intracranial tumor control is an essential factor in stabilizing neurocognitive function. The data on neurocognitive toxicity related to WBRT are still contradictory. Impairment of both neurocognitive function and quality of life of patients with brain metastases needs to be further addressed in RCT.
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Affiliation(s)
- Silvia Scoccianti
- Radiation Oncology, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
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Todd S, Sahdra M. A CASE STUDY OF THE EFFECT OF COVARIATE ADJUSTMENT IN A SEQUENTIAL SURVIVAL CLINICAL TRIAL. J Biopharm Stat 2011. [DOI: 10.1081/bip-120008850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Susan Todd
- a Department of Applied Statistics , MPS Research Unit, The University of Reading , P.O. Box 240, Earley Gate, Reading, Berkshire, RG6 6FN, U.K
- b Medical & Pharmaceutical Statistics Research Unit, The University of Reading , Reading, Berkshire, U.K
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Mulvenna P, Barton R, Wilson P, Faivre-Finn C, Nankivell M, Stephens R, Langley R, Moore B, Ardron D. Survival of Patients with Non-small Cell Lung Cancer and Brain Metastases. Clin Oncol (R Coll Radiol) 2011; 23:375-6. [DOI: 10.1016/j.clon.2011.01.508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 01/29/2011] [Indexed: 10/18/2022]
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Bailon O, Kallel A, Chouahnia K, Billot S, Ferrari D, Carpentier AF. [Management of brain metastases from non-small cell lung carcinoma]. Rev Neurol (Paris) 2011; 167:579-91. [PMID: 21546046 DOI: 10.1016/j.neurol.2011.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 01/03/2011] [Accepted: 01/17/2011] [Indexed: 01/08/2023]
Abstract
INTRODUCTION In France, approximately 30,000 new patients per year develop brain metastases (BM), most of them resulting from a lung cancer. STATE OF THE ART Surgery and radiosurgery of all the BM must be considered when possible. In other cases, whole brain radiotherapy remains the standard of care. PERSPECTIVES The role of chemotherapy, poorly investigated so far, should be revisited. CONCLUSION This review focused on BM secondary to a non-small cell lung carcinoma.
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Affiliation(s)
- O Bailon
- Service de neurologie, hôpital Avicenne, AP-HP, 125, route de Stalingrad, 93000 Bobigny, France
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