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Ersoy TF, Brainman D, Coras R, Berger B, Weissinger F, Grote A, Simon M. Defining the role of surgery for patients with multiple brain metastases. J Neurooncol 2024; 169:317-328. [PMID: 38916848 PMCID: PMC11341766 DOI: 10.1007/s11060-024-04739-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 06/10/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE To better define the role of surgery, we investigated survival and functional outcomes in patients with multiple brain metastases. METHODS Pertinent clinical and radiological data of 131 consecutive patients (156 surgeries) were analyzed retrospectively. RESULTS Surgical indications included mass effect (84.6%) and need for tissue acquisition (44.9%, for molecularly informed treatment: 10 patients). Major (i.e. CTCAE grade 3-5) neurological, surgical and medical complication were observed in 6 (3.8%), 12 (7.7%), and 12 (7.7%) surgical cases. Median preoperative and discharge KPS were 80% (IQF: 60-90%). Median overall survival (mOS) was 7.4 months. However, estimated 1 and 2 year overall survival rates were 35.6% and 25.1%, respectively. Survival was dismal (i.e. mOS ≤ 2.5 months) in patients who had no postoperative radio- and systemic therapy, or who incurred major complications. Multivariate analysis with all parameters significantly correlated with survival as univariate parameters revealed female sex, oligometastases, no major new/worsened neurological deficits, and postoperative radio- and systemic therapy as independent positive prognostic parameters. Univariate positive prognostic parameters also included histology (best survival in breast cancer patients) and less than median (0.28 cm3) residual tumor load. CONCLUSIONS Surgery is a reasonable therapeutic option in many patients with multiple brain metastases. Operations should primarily aim at reducing mass effect thereby preserving the patients' functional health status which will allow for further local (radiation) and systemic therapy. Surgery for the acquisition of metastatic tissue (more recently for molecularly informed treatment) is another important surgical indication. Cytoreductive surgery may also carry a survival benefit by itself.
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Affiliation(s)
- Tunc Faik Ersoy
- Department of Neurosurgery, University Hospital OWL, Campus Bielefeld-Bethel, Bielefeld, Germany.
| | - Daniel Brainman
- Department of Neurosurgery, University Hospital OWL, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Roland Coras
- Department of Neuropathology, University Hospital Erlangen, Erlangen, Germany
| | - Björn Berger
- Department for Neuroradiology, University Hospital OWL, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Florian Weissinger
- Department of Hematology, Oncology and Palliative Care, University Hospital OWL, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Alexander Grote
- Department of Neurosurgery, University Hospital OWL, Campus Bielefeld-Bethel, Bielefeld, Germany
- Department of Neurosurgery, University Hospital Marburg, Marburg, Germany
| | - Matthias Simon
- Department of Neurosurgery, University Hospital OWL, Campus Bielefeld-Bethel, Bielefeld, Germany
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Niedermeyer S, Schmutzer-Sondergeld M, Weller J, Katzendobler S, Kirchleitner S, Forbrig R, Harter PN, Baumgarten LV, Schichor C, Stoecklein V, Thon N. Neurosurgical resection of multiple brain metastases: outcomes, complications, and survival rates in a retrospective analysis. J Neurooncol 2024; 169:349-358. [PMID: 38904924 PMCID: PMC11341644 DOI: 10.1007/s11060-024-04744-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Accepted: 06/10/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE This study investigates the outcomes of microsurgical resection of multiple brain metastasis (BMs). METHODS This retrospective, monocentric analysis included clinical data from all consecutive BM patients, who underwent simultaneous resection of ≥ 2 BMs between January 2018 and May 2023. Postoperative neurological and functional outcomes, along with perioperative complications, as well as survival data were evaluated. RESULTS A total of 47 patients, with a median age of 61 years (IQR 48-69), underwent 73 craniotomies (median 2; range 1-3) for resection of 104 BMs. Among patients, 80.8% presented with symptomatic BMs, causing focal neurological deficits in 53% of cases. Gross total resection was achieved in 87.2% of BMs. Karnofsky Performance Scale (KPS) scores improved in 42.6% of patients, remained unchanged in 46.8%, and worsened in 10.6% after surgery. Perioperative complications were observed in 29.8% of cases, with transient complications occurring in 19.2% and permanent deficits in 10.6%. The 30-days mortality rate was 2.1%. Logistic regression identified eloquent localization (p = 0.036) and infratentorial craniotomy (p = 0.018) as significant predictors of postoperative complications. Concerning overall prognosis, patients with permanent neurological deficits post-surgery (HR 11.34, p = 0.007) or progressive extracranial disease (HR: 4.649; p = 0.006) exhibited inferior survival. CONCLUSION Microsurgical resection of multiple BMs leads to clinical stabilization or functional improvement in most patients. Although transient complications do not affect overall survival, the presence of persistent neurological deficits (> 3 months post-surgery) and progressive extracranial disease negatively impact overall survival. This highlights the importance of careful patient selection for resection of multiple BMs.
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Affiliation(s)
- Sebastian Niedermeyer
- Department of Neurosurgery, LMU Hospital, Ludwig-Maximilian-University Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - M Schmutzer-Sondergeld
- Department of Neurosurgery, LMU Hospital, Ludwig-Maximilian-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - J Weller
- Department of Neurosurgery, LMU Hospital, Ludwig-Maximilian-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - S Katzendobler
- Department of Neurosurgery, LMU Hospital, Ludwig-Maximilian-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - S Kirchleitner
- Department of Neurosurgery, LMU Hospital, Ludwig-Maximilian-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - R Forbrig
- Department of Neuroradiology, LMU Hospital, Ludwig-Maximilian-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - P N Harter
- Center for Neuropathology and Prion Research, LMU Hospital, Ludwig-Maximilian- University Munich, Feodor-Lynen Strasse 23, 81377, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - L V Baumgarten
- Department of Neurosurgery, LMU Hospital, Ludwig-Maximilian-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - C Schichor
- Department of Neurosurgery, LMU Hospital, Ludwig-Maximilian-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - V Stoecklein
- Department of Neurosurgery, LMU Hospital, Ludwig-Maximilian-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - N Thon
- Department of Neurosurgery, LMU Hospital, Ludwig-Maximilian-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
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3
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Padevit L, Zeitlberger AM, Maldaner N, Sarnthein J, Bozinov O, Regli L, Neidert MC, Serra C, Voglis S. Multiple craniotomies in patients with brain metastases: a two-center, propensity score-matched study. Neurosurg Rev 2024; 47:354. [PMID: 39060536 PMCID: PMC11281945 DOI: 10.1007/s10143-024-02578-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 05/06/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024]
Abstract
The current study addresses the question of whether the resection of more than one BM by multiple craniotomies within the same operation is associated with more adverse events (AEs) and worse functional outcome compared to cases in which only one BM was resected. All patients who underwent more than one craniotomy for resection of multiple BM at two Swiss tertiary neurosurgical care centers were included. Any AEs, functional outcome, and overall survival (OS) were analyzed after 1:1 propensity score matching with patients who underwent removal of a single BM only. A total of 94 patients were included in the final study cohort (47 of whom underwent multiple craniotomies). There was no significant difference in the incidence of AEs between the single and the multiple craniotomy group (n = 2 (4.3%) vs. n = 4 (8.5%), p = .7). Change in modified Rankin Scale (mRS) and Karnofsky Performance Status (KPS) at discharge demonstrated that slightly more single craniotomy patients improved in mRS, while the proportion of patients who worsened in mRS (16.3 vs. 16.7%) and KPS (13.6 vs. 15.2%) was similar in both groups (p = .42 for mRS and p = .92 for KPS). Survival analysis showed no significant differences in OS between patients with single and multiple craniotomies (p = .18). Resection of multiple BM with more than one craniotomy may be considered a safe option without increased AEs or worse functional outcome.
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Affiliation(s)
- Luis Padevit
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, Zurich, 8091, Switzerland
| | | | - Nicolai Maldaner
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, Zurich, 8091, Switzerland
| | - Johannes Sarnthein
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, Zurich, 8091, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, Zurich, 8091, Switzerland
| | | | - Carlo Serra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, Zurich, 8091, Switzerland
| | - Stefanos Voglis
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, Zurich, 8091, Switzerland.
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4
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Zoghbi M, Moussa MJ, Dagher J, Haroun E, Qdaisat A, Singer ED, Karam YE, Yeung SCJ, Chaftari P. Brain Metastasis in the Emergency Department: Epidemiology, Presentation, Investigations, and Management. Cancers (Basel) 2024; 16:2583. [PMID: 39061222 PMCID: PMC11274762 DOI: 10.3390/cancers16142583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 07/14/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Brain metastases (BMs) are the most prevalent type of cerebral tumor, significantly affecting survival. In adults, lung cancer, breast cancer, and melanoma are the primary cancers associated with BMs. Symptoms often result from brain compression, and patients may present to the emergency department (ED) with life-threatening conditions. The goal of treatment of BMs is to maximize survival and quality of life by choosing the least toxic therapy. Surgical resection followed by cavity radiation or definitive stereotactic radiosurgery remains the standard approach, depending on the patient's condition. Conversely, whole brain radiation therapy is becoming more limited to cases with multiple inoperable BMs and is less frequently used for postoperative control. BMs often signal advanced systemic disease, and patients usually present to the ED with poorly controlled symptoms, justifying hospitalization. Over half of patients with BMs in the ED are admitted, making effective ED-based management a challenge. This article reviews the epidemiology, clinical manifestations, and current treatment options of patients with BMs. Additionally, it provides an overview of ED management and highlights the challenges faced in this setting. An improved understanding of the reasons for potentially avoidable hospitalizations in cancer patients with BMs is needed and could help emergency physicians distinguish patients who can be safely discharged from those who require observation or hospitalization.
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Affiliation(s)
- Marianne Zoghbi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Mohammad Jad Moussa
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jim Dagher
- Faculty of Medicine, Saint Joseph University of Beirut, Beirut 1100, Lebanon
| | - Elio Haroun
- Faculty of Medicine, Saint Joseph University of Beirut, Beirut 1100, Lebanon
| | - Aiham Qdaisat
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Emad D. Singer
- Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Yara E. Karam
- Department of Behavioral Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sai-Ching J. Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Patrick Chaftari
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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5
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Hasanov E, Jonasch E. Management of Brain Metastases in Metastatic Renal Cell Carcinoma. Hematol Oncol Clin North Am 2023; 37:1005-1014. [PMID: 37270383 DOI: 10.1016/j.hoc.2023.04.020] [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] [Indexed: 06/05/2023]
Abstract
The development of brain metastases is a poor prognostic indicator in renal cell carcinoma. Regular imaging and clinical examinations are necessary to monitor the brain before or during systemic therapy. Central nervous system-targeted radiation therapy, including stereotactic radiosurgery, whole-brain radiation therapy, and surgical resection, is a standard treatment option. Clinical trials are currently investigating the role of targeted therapy and immune checkpoint inhibitor combinations in treating brain metastases and decreasing intracranial disease progression.
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Affiliation(s)
- Elshad Hasanov
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, 1400 Holcombe Boulevard FC11.3055, Houston, TX 77030, USA.
| | - Eric Jonasch
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard Unit 1374, Houston, TX 77030, USA.
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Semenescu LE, Tataranu LG, Dricu A, Ciubotaru GV, Radoi MP, Rodriguez SMB, Kamel A. A Neurosurgical Perspective on Brain Metastases from Renal Cell Carcinoma: Multi-Institutional, Retrospective Analysis. Biomedicines 2023; 11:2485. [PMID: 37760926 PMCID: PMC10526360 DOI: 10.3390/biomedicines11092485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/02/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND While acknowledging the generally poor prognostic features of brain metastases from renal cell carcinoma (BM RCC), it is important to be aware of the fact that neurosurgery still plays a vital role in managing this disease, even though we have entered an era of targeted therapies. Notwithstanding their initial high effectiveness, these agents often fail, as tumors develop resistance or relapse. METHODS The authors of this study aimed to evaluate patients presenting with BM RCC and their outcomes after being treated in the Neurosurgical Department of Clinical Emergency Hospital "Bagdasar-Arseni", and the Neurosurgical Department of the National Institute of Neurology and Neurovascular Diseases, Bucharest, Romania. The study is based on a thorough appraisal of the patient's demographic and clinicopathological data and is focused on the strategic role of neurosurgery in BM RCC. RESULTS A total of 24 patients were identified with BM RCC, of whom 91.6% had clear-cell RCC (ccRCC) and 37.5% had a prior nephrectomy. Only 29.1% of patients harbored extracranial metastases, while 83.3% had a single BM RCC. A total of 29.1% of patients were given systemic therapy. Neurosurgical resection of the BM was performed in 23 out of 24 patients. Survival rates were prolonged in patients who underwent nephrectomy, in patients who received systemic therapy, and in patients with a single BM RCC. Furthermore, higher levels of hemoglobin were associated in our study with a higher number of BMs. CONCLUSION Neurosurgery is still a cornerstone in the treatment of symptomatic BM RCC. Among the numerous advantages of neurosurgical intervention, the most important is represented by the quick reversal of neurological manifestations, which in most cases can be life-saving.
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Affiliation(s)
- Liliana Eleonora Semenescu
- Department of Biochemistry, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, Str. Petru Rares nr. 2–4, 710204 Craiova, Romania; (L.E.S.); (A.D.)
| | - Ligia Gabriela Tataranu
- Neurosurgical Department, Clinical Emergency Hospital “Bagdasar-Arseni”, Soseaua Berceni 12, 041915 Bucharest, Romania; (G.V.C.); (S.M.B.R.); (A.K.)
- Department of Neurosurgery, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, 020022 Bucharest, Romania
| | - Anica Dricu
- Department of Biochemistry, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, Str. Petru Rares nr. 2–4, 710204 Craiova, Romania; (L.E.S.); (A.D.)
| | - Gheorghe Vasile Ciubotaru
- Neurosurgical Department, Clinical Emergency Hospital “Bagdasar-Arseni”, Soseaua Berceni 12, 041915 Bucharest, Romania; (G.V.C.); (S.M.B.R.); (A.K.)
| | - Mugurel Petrinel Radoi
- Neurosurgical Department, National Institute of Neurology and Neurovascular Diseases, Soseaua Berceni 10, 041914 Bucharest, Romania;
| | - Silvia Mara Baez Rodriguez
- Neurosurgical Department, Clinical Emergency Hospital “Bagdasar-Arseni”, Soseaua Berceni 12, 041915 Bucharest, Romania; (G.V.C.); (S.M.B.R.); (A.K.)
| | - Amira Kamel
- Neurosurgical Department, Clinical Emergency Hospital “Bagdasar-Arseni”, Soseaua Berceni 12, 041915 Bucharest, Romania; (G.V.C.); (S.M.B.R.); (A.K.)
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7
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Lacalle-González C, Estrella Santos A, Landaeta Kancev LC, Castellano VM, Macia Palafox E, Paniagua Ruíz A, Luna Tirado J, Martínez-Amores B, Martínez Dhier L, Lamarca A. Management of non-hepatic distant metastases in neuroendocrine neoplasms. Best Pract Res Clin Endocrinol Metab 2023; 37:101784. [PMID: 37270333 DOI: 10.1016/j.beem.2023.101784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Neuroendocrine neoplasms represent an uncommon disease with an increasing incidence. Thanks to improvements in diagnostic and therapeutic methods, metastases previously considered uncommon, such as bone metastases, or even very rare, such as brain, orbital and cardiac metastases, are more frequently found in daily practice. Due to the great heterogeneity of these neoplasms, there is a lack of high-quality evidence on the management of patients with these types of metastases. The aim of this review is to provide the current state of the art, reviewing neuroendocrine neoplasm specific studies and useful information from other tumor types and to propose a treatment recommendation with algorithms to consider in daily clinical practice.
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Affiliation(s)
- C Lacalle-González
- Department of Medical Oncology, Fundación Jiménez Díaz University Hospital, Madrid, Spain.
| | - A Estrella Santos
- Department of Endocrinology, Fundación Jiménez Díaz University Hospital, Madrid, Spain.
| | - L C Landaeta Kancev
- Deparment of Nuclear Medicine, Fundación Jiménez Díaz University Hospital, Madrid, Spain.
| | - V M Castellano
- Deparment of Pathology, Fundación Jiménez Díaz University Hospital, Madrid, Spain.
| | - E Macia Palafox
- Deparment of Cardiology, Fundación Jiménez Díaz University Hospital, Madrid, Spain.
| | - A Paniagua Ruíz
- Department of Endocrinology, Fundación Jiménez Díaz University Hospital, Madrid, Spain.
| | - J Luna Tirado
- Deparment of Radiation Oncology, Fundación Jiménez Díaz University Hospital, Madrid, Spain.
| | - B Martínez-Amores
- Medical Oncology Department, Hospital Universitario Rey Juan Carlos, Móstoles, Spain.
| | - L Martínez Dhier
- Deparment of Nuclear Medicine, Fundación Jiménez Díaz University Hospital, Madrid, Spain.
| | - A Lamarca
- Department of Medical Oncology, Fundación Jiménez Díaz University Hospital, Madrid, Spain; Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom; Department of Medical Oncology, The Christie NHS Foundation, University of Manchester, Manchester, United Kingdom.
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8
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Bschorer M, Ricklefs FL, Sauvigny T, Westphal M, Dührsen L. Multiple craniotomies in a single surgery - the resection of scattered brain metastases. Neurosurg Rev 2023; 46:70. [PMID: 36920624 PMCID: PMC10017615 DOI: 10.1007/s10143-023-01976-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 03/01/2023] [Accepted: 03/06/2023] [Indexed: 03/16/2023]
Abstract
Patients with brain metastases (BM), who can benefit from resection of multiple scattered lesions, often will not be offered a procedure involving multiple craniotomies in one session due to the overall poor prognosis. However, carefully selected candidates may well benefit from the resection of multiple lesions using multiple craniotomies through a significantly shortened hospital stay, aggressive decompression, and rapid eligibility for adjuvant therapies. In this retrospective analysis, the records of patients, who were treated for multiple BM using one surgical session involving multiple craniotomies, were reviewed. A group of patients with multiple BM, whose surgery only involved one craniotomy, were assigned to a control group. Clinical and surgical characteristics, preoperative and postoperative Karnofsky Performance Scale (KPS), complication rate, preoperative tumor size, number of lesions, number of craniotomies, skin incisions, and intraoperative repositioning of patients were recorded. Thirty-three patients were included in the multiple-craniotomy group. Thirty patients underwent two craniotomies, while three cases involved three craniotomies. Seven patients (21%) were intraoperatively repositioned from a prone to a supine position, which required an average of 23.3 ± 9.3 min from wound closure to the following skin incision. Thirty-six patients with multiple BM and matching characteristics, who received only one craniotomy for the dominant lesion, served as the control group. No difference was detected in postoperative KPS (p = 0.269), complication rate (p = 0.612), rate of new postoperative neurological deficits (p = 0.278), length of intensive care unit (ICU) (p = 0.991), and hospital stay (p = 0.913). There was a significant difference in average preoperative tumor size (p = 0.002), duration of surgery (p < 0.001), and extent of resection (p = 0.002). In the age of personalized medicine, selected patient may benefit from a single surgery for BM using multiple craniotomies. This study shows no significant increase of the perioperative complication rate for surgeries with multiple craniotomies.
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Affiliation(s)
- Maximilian Bschorer
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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9
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Rezk EM, Mokbel E. Stereotactic biopsy for multiple intra-axial brain lesions: impact on consequent treatment Regimen. EGYPTIAN JOURNAL OF NEUROSURGERY 2023. [DOI: 10.1186/s41984-023-00193-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
Abstract
Background and objectives
Multiple brain lesions represent a serious challenge in which biopsy is commonly the first step to help overcome patients' mental anxiety and decide the following treatment step. This study presents an effective decisional algorithm that could guide in dealing with such a challenge. We evaluate the feasibility and safety of frame-based stereotactic biopsy to obtain the histopathologic diagnosis of the multiple intra-axial brain lesions and to decide the further treatment.
Patients and methods
Thirty-two patients with multiple intracerebral lesions underwent stereotactic serial biopsies for brain lesions at the Neurosurgery Department, Tanta University Hospital. All the stereotactic biopsies were obtained under local anesthesia using Riechert–Mundinger (RM) system or Cosman–Roberts–Wells (CRW) system.
Results
The histopathological diagnosis revealed multifocal malignant gliomas in 43.75% of patients (18.75% anaplastic astrocytoma and 25% multiform glioblastoma) and metastatic tumor in 37.5% of patients (all were adenocarcinoma). In addition, 12.5% had multiple brain abscesses, and 6.25% had malignant lymphoma. We reported no mortality secondary to the surgical procedure.
Conclusions
Stereotactic biopsy is considered the best choice to allow histopathologic diagnosis of multiple brain lesions with minimal morbidity and no mortality. Histopathologic findings gained with stereotactic procedures guided the choice of proper treatment thus eliminating the hazards associated with blind treatments.
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10
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Byun J, Kim JH. Revisiting the Role of Surgical Resection for Brain Metastasis. Brain Tumor Res Treat 2023; 11:1-7. [PMID: 36762802 PMCID: PMC9911712 DOI: 10.14791/btrt.2022.0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 02/05/2023] Open
Abstract
Brain metastasis (BM) is the most common type of brain tumor in adults. The contemporary management of BM remains challenging. Advancements in systemic cancer treatment have increased the survival of patients with cancer. Although the treatment of BM is still complicated, advances in radiotherapy, including stereotactic radiosurgery and chemotherapy, have improved treatment outcomes. Surgical resection is the traditional treatment for BM and its role in the surgical resection of BM has been well established. However, refinement of the surgical resection technique and strategy for BM is needed. Herein, we discuss the evolving role of surgery in patients with BM and the future of BM treatment.
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Affiliation(s)
- Joonho Byun
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jong Hyun Kim
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea.
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11
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Wolfert C, Rohde V, Hussein A, Fiss I, Hernández-Durán S, Malzahn D, Bleckmann A, Mielke D, Schatlo B. Surgery for brain metastases: radiooncology scores predict survival-score index for radiosurgery, graded prognostic assessment, recursive partitioning analysis. Acta Neurochir (Wien) 2023; 165:231-238. [PMID: 36152217 PMCID: PMC9840567 DOI: 10.1007/s00701-022-05356-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 08/25/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Radiooncological scores are used to stratify patients for radiation therapy. We assessed their ability to predict overall survival (OS) in patients undergoing surgery for metastatic brain disease. METHODS We performed a post-hoc single-center analysis of 175 patients, prospectively enrolled in the MetastaSys study data. Score index of radiosurgery (SIR), graded prognostic assessment (GPA), and recursive partitioning analysis (RPA) were assessed. All scores consider age, systemic disease, and performance status prior to surgery. Furthermore, GPA and SIR include the number of intracranial lesions while SIR additionally requires metastatic lesion volume. Predictive values for case fatality at 1 year after surgery were compared among scoring systems. RESULTS All scores produced accurate reflections on OS after surgery (p ≤ 0.003). Median survival was 21-24 weeks in patients scored in the unfavorable cohorts, respectively. In cohorts with favorable scores, median survival ranged from 42 to 60 weeks. Favorable SIR was associated with a hazard ratio (HR) of 0.44 [0.29, 0.66] for death within 1 year. For GPA, the HR amounted to 0.44 [0.25, 0.75], while RPA had a HR of 0.30 [0.14, 0.63]. Overall test performance was highest for the SIR. CONCLUSIONS All scores proved useful in predicting OS. Considering our data, we recommend using the SIR for preoperative prognostic evaluation and counseling.
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Affiliation(s)
- Christina Wolfert
- Department of Neurosurgery, University Hospital Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Hospital Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Abdelhalim Hussein
- Department of Neurosurgery, University Hospital Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Ingo Fiss
- Department of Neurosurgery, University Hospital Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Silvia Hernández-Durán
- Department of Neurosurgery, University Hospital Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Dörthe Malzahn
- mzBiostatistics, Statistical Consultancy, 37075, Göttingen, Germany
| | - Annalen Bleckmann
- Clinic for Hematology/ Medical Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
- Medical Clinic A, Haematology, Haemostasiology, Oncology and Pulmonology, University Hospital Münster, 48149, Münster, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University Hospital Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Bawarjan Schatlo
- Department of Neurosurgery, University Hospital Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
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12
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Hasanov E, Yeboa DN, Tucker MD, Swanson TA, Beckham TH, Rini B, Ene CI, Hasanov M, Derks S, Smits M, Dudani S, Heng DYC, Brastianos PK, Bex A, Hanalioglu S, Weinberg JS, Hirsch L, Carlo MI, Aizer A, Brown PD, Bilen MA, Chang EL, Jaboin J, Brugarolas J, Choueiri TK, Atkins MB, McGregor BA, Halasz LM, Patel TR, Soltys SG, McDermott DF, Elder JB, Baskaya MK, Yu JB, Timmerman R, Kim MM, Mut M, Markert J, Beal K, Tannir NM, Samandouras G, Lang FF, Giles R, Jonasch E. An interdisciplinary consensus on the management of brain metastases in patients with renal cell carcinoma. CA Cancer J Clin 2022; 72:454-489. [PMID: 35708940 DOI: 10.3322/caac.21729] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/28/2022] [Accepted: 04/11/2022] [Indexed: 12/23/2022] Open
Abstract
Brain metastases are a challenging manifestation of renal cell carcinoma. We have a limited understanding of brain metastasis tumor and immune biology, drivers of resistance to systemic treatment, and their overall poor prognosis. Current data support a multimodal treatment strategy with radiation treatment and/or surgery. Nonetheless, the optimal approach for the management of brain metastases from renal cell carcinoma remains unclear. To improve patient care, the authors sought to standardize practical management strategies. They performed an unstructured literature review and elaborated on the current management strategies through an international group of experts from different disciplines assembled via the network of the International Kidney Cancer Coalition. Experts from different disciplines were administered a survey to answer questions related to current challenges and unmet patient needs. On the basis of the integrated approach of literature review and survey study results, the authors built algorithms for the management of single and multiple brain metastases in patients with renal cell carcinoma. The literature review, consensus statements, and algorithms presented in this report can serve as a framework guiding treatment decisions for patients. CA Cancer J Clin. 2022;72:454-489.
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Affiliation(s)
- Elshad Hasanov
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Debra Nana Yeboa
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mathew D Tucker
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd A Swanson
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas Hendrix Beckham
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brian Rini
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chibawanye I Ene
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Merve Hasanov
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sophie Derks
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marion Smits
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Shaan Dudani
- Division of Oncology/Hematology, William Osler Health System, Brampton, Ontario, Canada
| | - Daniel Y C Heng
- Tom Baker Cancer Center, University of Calgary, Calgary, Alberta, Canada
| | - Priscilla K Brastianos
- Division of Neuro-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Axel Bex
- The Royal Free London National Health Service Foundation Trust, London, United Kingdom
- University College London Division of Surgery and Interventional Science, London, United Kingdom
- Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Sahin Hanalioglu
- Department of Neurosurgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Jeffrey S Weinberg
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Laure Hirsch
- Department of Medical Oncology, Cochin University Hospital, Public Assistance Hospital of Paris, Paris, France
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Maria I Carlo
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ayal Aizer
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Paul David Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Mehmet Asim Bilen
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia
- Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Eric Lin Chang
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, California, Los Angeles
| | - Jerry Jaboin
- Department of Radiation Medicine, Oregon Health & Science University, Portland, Oregon
| | - James Brugarolas
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, Texas
- Division of Hematology/Oncology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Toni K Choueiri
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Michael B Atkins
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC
| | - Bradley A McGregor
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lia M Halasz
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Toral R Patel
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Neurosurgery, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California
| | - David F McDermott
- Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - James Bradley Elder
- Department of Neurological Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mustafa K Baskaya
- Department of Neurological Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin
| | - James B Yu
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Robert Timmerman
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michelle Miran Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Melike Mut
- Department of Neurosurgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - James Markert
- Department of Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nizar M Tannir
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - George Samandouras
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
- University College London Queen Square Institute of Neurology, University College London, Queen Square, London, United Kingdom
| | - Frederick F Lang
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rachel Giles
- International Kidney Cancer Coalition, Duivendrecht, the Netherlands
| | - Eric Jonasch
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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13
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Hulsbergen AFC, Lo YT, Awakimjan I, Kavouridis VK, Phillips JG, Smith TR, Verhoeff JJC, Yu KH, Broekman MLD, Arnaout O. Survival Prediction After Neurosurgical Resection of Brain Metastases: A Machine Learning Approach. Neurosurgery 2022; 91:381-388. [PMID: 35608378 PMCID: PMC10553019 DOI: 10.1227/neu.0000000000002037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 03/24/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Current prognostic models for brain metastases (BMs) have been constructed and validated almost entirely with data from patients receiving up-front radiotherapy, leaving uncertainty about surgical patients. OBJECTIVE To build and validate a model predicting 6-month survival after BM resection using different machine learning algorithms. METHODS An institutional database of 1062 patients who underwent resection for BM was split into an 80:20 training and testing set. Seven different machine learning algorithms were trained and assessed for performance; an established prognostic model for patients with BM undergoing radiotherapy, the diagnosis-specific graded prognostic assessment, was also evaluated. Model performance was assessed using area under the curve (AUC) and calibration. RESULTS The logistic regression showed the best performance with an AUC of 0.71 in the hold-out test set, a calibration slope of 0.76, and a calibration intercept of 0.03. The diagnosis-specific graded prognostic assessment had an AUC of 0.66. Patients were stratified into regular-risk, high-risk and very high-risk groups for death at 6 months; these strata strongly predicted both 6-month and longitudinal overall survival ( P < .0005). The model was implemented into a web application that can be accessed through http://brainmets.morethanml.com . CONCLUSION We developed and internally validated a prediction model that accurately predicts 6-month survival after neurosurgical resection for BM and allows for meaningful risk stratification. Future efforts should focus on external validation of our model.
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Affiliation(s)
- Alexander F. C. Hulsbergen
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA;
- Departments of Neurosurgery, Haaglanden Medical Center and Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Yu Tung Lo
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA;
- Departments of Neurosurgery, Haaglanden Medical Center and Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Ilia Awakimjan
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA;
| | - Vasileios K. Kavouridis
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA;
| | - John G. Phillips
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA;
- Radiation Oncology, Tennessee Oncology, Nashville, Tennessee, USA
| | - Timothy R. Smith
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA;
| | - Joost J. C. Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Utrecht, The Netherlands
| | - Kun-Hsing Yu
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA;
| | - Marike L. D. Broekman
- Departments of Neurosurgery, Haaglanden Medical Center and Leiden University Medical Center, Leiden University, Leiden, The Netherlands
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Omar Arnaout
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA;
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14
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Ramos A, Giantini-Larsen A, Pannullo SC, Brandmaier A, Knisely J, Magge R, Wilcox JA, Pavlick AC, Ma B, Pisapia D, Ashamalla H, Ramakrishna R. A multidisciplinary management algorithm for brain metastases. Neurooncol Adv 2022; 4:vdac176. [PMID: 36532509 PMCID: PMC9749403 DOI: 10.1093/noajnl/vdac176] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
The incidence of brain metastases continues to present a management issue despite the advent of improved systemic control and overall survival. While the management of oligometastatic disease (ie, 1-4 brain metastases) with surgery and radiation has become fairly straightforward in the era of radiosurgery, the management of patients with multiple metastatic brain lesions can be challenging. Here we review the available evidence and provide a multidisciplinary management algorithm for brain metastases that incorporates the latest advances in surgery, radiation therapy, and systemic therapy while taking into account the latest in precision medicine-guided therapies. In particular, we argue that whole-brain radiation therapy can likely be omitted in most patients as up-front therapy.
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Affiliation(s)
- Alexander Ramos
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Alexandra Giantini-Larsen
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Susan C Pannullo
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Andrew Brandmaier
- Department of Radiation Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Jonathan Knisely
- Department of Radiation Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Rajiv Magge
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Jessica A Wilcox
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anna C Pavlick
- Department of Oncology, Weill Cornell Medicine, New York Presbyterian, New York, New York, USA
| | - Barbara Ma
- Department of Oncology, Weill Cornell Medicine, New York Presbyterian, New York, New York, USA
| | - David Pisapia
- Department of Pathology, Weill Cornell Medicine, New York Presbyterian, New York, New York, USA
| | - Hani Ashamalla
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Rohan Ramakrishna
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
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15
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Karschnia P, Le Rhun E, Vogelbaum MA, van den Bent M, Grau SJ, Preusser M, Soffietti R, von Baumgarten L, Westphal M, Weller M, Tonn JC. The evolving role of neurosurgery for central nervous system metastases in the era of personalized cancer therapy. Eur J Cancer 2021; 156:93-108. [PMID: 34425408 DOI: 10.1016/j.ejca.2021.07.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 12/13/2022]
Abstract
Recent therapeutic advances involving the use of systemic targeted treatments and immunotherapeutic agents in patients with advanced cancers have translated into improved survival rates. Despite the emergence of such promising pharmacological therapies and extended survival, the frequency of metastases in the central nervous system has steadily increased. Effective medical and surgical therapies are available for many patients with brain metastases and need to be incorporated into multi-disciplinary care protocols. The role of neurosurgeons is evolving within these multi-disciplinary care teams. Surgical resection of brain metastases can provide immediate relief from neurological symptoms due to large lesions and provides the histopathological diagnosis in cases of no known primary malignancy. In situations where immunotherapy is part of the oncological treatment plan, surgery may be proposed for expeditious relief of edema to remove the need for steroids. In patients with multiple brain metastases and mixed response to therapeutics or radiosurgery, tumour resampling allows tissue analysis for druggable targets or to distinguish radiation effects from progression. Ventriculo-peritoneal shunting may improve quality of life in patients with hydrocephalus associated with leptomeningeal tumour dissemination and may allow for time to administer more therapy thus prolonging overall survival. Addressing the limited efficacy of many oncological drugs for brain metastases due to insufficient blood-brain barrier penetrance, clinical trial protocols in which surgical specimens are analysed after pre-surgical administration of therapeutics offer pharmacodynamic insights. Comprehensive neurosurgical assessment remains an integral element of multi-disciplinary oncological care of patients with brain metastases and is integral to tumour biology research and therapeutic advancement.
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Affiliation(s)
- Philipp Karschnia
- Department of Neurosurgery, Ludwig-Maximilians-University School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Germany
| | - Emilie Le Rhun
- Department of Neurosurgery & Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | | | - Martin van den Bent
- Department of Neurology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Stefan J Grau
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Matthias Preusser
- Department of Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Louisa von Baumgarten
- Department of Neurosurgery, Ludwig-Maximilians-University School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Hospital Hamburg, Hamburg, Germany
| | - Michael Weller
- Department of Neurology & Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Joerg-Christian Tonn
- Department of Neurosurgery, Ludwig-Maximilians-University School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Germany.
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16
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Efficacy and safety of hypofractionated stereotactic radiotherapy for brain metastases using three fractions: A single-centre retrospective study. Cancer Radiother 2021; 25:763-770. [PMID: 34083125 DOI: 10.1016/j.canrad.2021.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/30/2021] [Accepted: 05/08/2021] [Indexed: 12/27/2022]
Abstract
PURPOSE Hypofractionated stereotactic radiotherapy (HFSRT) has become a standard of care for patients with a limited number of brain metastases (BM). An increasing number of linear accelerators (LA) are able to accurately perform HFSRT including VersaHD® (Elekta®) LA. The main aim of this study was to report clinical outcomes of BM treated by HFSRT using 3×7.7Gy on 70% isodose line in terms of local control (LC). PATIENTS AND METHODS Between November 2016 and October 2018, all patients suffering from histologically-proven primary with one or several newly diagnosed BM treated by HFSRT were retrospectively included and evaluated. Patients who had received prior treatment by neurosurgery or cerebral radiotherapy were excluded. RESULTS Among 44 patients, 61 BM were treated. With a median follow-up of 31.9 months, LC rates at 6 and 12 months were 93.2% and 90.9, respectively. Single-BM was independently predictive of LC (P=0.025) and overall survival (P=0.013). Acute toxicity rates were acceptable: 65.9% of patients had grade 1 and 2 and no acute grade 3 toxicity according to the NCI-CTCAE (version 5.0). Regarding delayed toxicity, one case (2.3%) of radionecrosis was confirmed by magnetic resonance spectroscopy. CONCLUSION In our single-centre retrospective analysis, BM treatment by HFSRT delivered in three fractions showed a 12-month LC rate of 90.9% without major toxicities, which suggests safety and efficiency of this technique. However, longer-term follow-up and prospective studies are still needed to confirm these results.
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17
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Proescholdt MA, Schödel P, Doenitz C, Pukrop T, Höhne J, Schmidt NO, Schebesch KM. The Management of Brain Metastases-Systematic Review of Neurosurgical Aspects. Cancers (Basel) 2021; 13:1616. [PMID: 33807384 PMCID: PMC8036330 DOI: 10.3390/cancers13071616] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 02/07/2023] Open
Abstract
The multidisciplinary management of patients with brain metastases (BM) consists of surgical resection, different radiation treatment modalities, cytotoxic chemotherapy, and targeted molecular treatment. This review presents the current state of neurosurgical technology applied to achieve maximal resection with minimal morbidity as a treatment paradigm in patients with BM. In addition, we discuss the contribution of neurosurgical resection on functional outcome, advanced systemic treatment strategies, and enhanced understanding of the tumor biology.
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Affiliation(s)
- Martin A. Proescholdt
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Petra Schödel
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Christian Doenitz
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Tobias Pukrop
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
- Department of Medical Oncology, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Julius Höhne
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Nils Ole Schmidt
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Karl-Michael Schebesch
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
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18
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Schneider M, Heimann M, Schaub C, Eichhorn L, Potthoff AL, Giordano FA, Güresir E, Ko YD, Landsberg J, Lehmann F, Radbruch A, Schwab KS, Weinhold L, Weller J, Wispel C, Herrlinger U, Vatter H, Schäfer N, Schuss P. Comorbidity Burden and Presence of Multiple Intracranial Lesions Are Associated with Adverse Events after Surgical Treatment of Patients with Brain Metastases. Cancers (Basel) 2020; 12:cancers12113209. [PMID: 33142701 PMCID: PMC7692304 DOI: 10.3390/cancers12113209] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/24/2020] [Accepted: 10/30/2020] [Indexed: 12/18/2022] Open
Abstract
Simple Summary Patients with brain metastasis must face advanced cancer diseases, and neurosurgical resection is often considered an inevitable part of treatment. However, peri- and postoperative complications might further worsen the prognosis for these vulnerable patients. It is therefore important to investigate risk factors for such unfavorable events in order to recognize high-risk patients at the earliest possible stage of disease. For this purpose, we aimed to identify risk factors for early postoperative complications following surgical resection of brain metastases. Our results showed that the presence of multiple brain metastases in a single patient and a high rate of additional comorbidities were associated with elevated levels of postoperative complications. Furthermore, patients who suffered from such unfavorable postoperative events were significantly more likely to die during the initial hospital stay. The present study therefore might help to preoperatively select for critically ill patients who are in mandatory need of advanced treatment and care. Abstract Surgical resection is a key treatment modality for brain metastasis (BM). However, peri- and postoperative adverse events (PAEs) might be associated with a detrimental impact on postoperative outcome. We retrospectively analyzed our institutional database with regard to patient safety indicators (PSIs), hospital-acquired conditions (HACs) and specific cranial surgery-related complications (CSCs) as high-quality metric profiles for PAEs in patients who had undergone surgery for BM in our department between 2013 and 2018. The comorbidity burden was assessed by means of the Charlson comorbidity index (CCI). A multivariate analysis was performed to identify independent predictors for the development of PAEs after surgical resection of BM. In total, 33 patients (8.5%) suffered from PAEs after surgery for BM. Of those, 17 PSI, 5 HAC and 11 CSC events were identified. Multiple brain metastases (p = 0.02) and a higher comorbidity burden (CCI > 10; p = 0.003) were associated with PAEs. In-hospital mortality of patients suffering from a PAE was significantly higher than that of patients without a PAE (24% vs. 0.6%; p < 0.0001). Awareness of risk factors for postoperative complications enables future prevention and optimal response, particularly in vulnerable oncological patients. The present study identified the presence of multiple brain metastases and increased comorbidity burden associated with PAEs in patients suffering from BM.
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Affiliation(s)
- Matthias Schneider
- Department of Neurosurgery, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (A.-L.P.); (E.G.); (C.W.); (H.V.); (P.S.)
- Correspondence:
| | - Muriel Heimann
- Department of Neurosurgery, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (A.-L.P.); (E.G.); (C.W.); (H.V.); (P.S.)
| | - Christina Schaub
- Division of Clinical Neuro-Oncology, Department of Neurology, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, 53127 Bonn, Germany; (C.S.); (J.W.); (U.H.); (N.S.)
| | - Lars Eichhorn
- Department of Anesthesiology and Intensive Care, University Hospital Bonn, 53127 Bonn, Germany; (L.E.); (F.L.)
| | - Anna-Laura Potthoff
- Department of Neurosurgery, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (A.-L.P.); (E.G.); (C.W.); (H.V.); (P.S.)
| | - Frank A. Giordano
- Department of Radiation Oncology, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, 53127 Bonn, Germany;
| | - Erdem Güresir
- Department of Neurosurgery, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (A.-L.P.); (E.G.); (C.W.); (H.V.); (P.S.)
| | - Yon-Dschun Ko
- Department of Oncology and Hematology, Center of Integrated Oncology (CIO) Bonn, Johanniter Hospital Bonn, 53113 Bonn, Germany;
| | - Jennifer Landsberg
- Department of Dermatology and Allergy, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, 53127 Bonn, Germany;
| | - Felix Lehmann
- Department of Anesthesiology and Intensive Care, University Hospital Bonn, 53127 Bonn, Germany; (L.E.); (F.L.)
| | - Alexander Radbruch
- Department of Neuroradiology, University Hospital Bonn, 53127 Bonn, Germany;
| | - Katjana S. Schwab
- Department of Internal Medicine III, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, 53127 Bonn, Germany;
| | - Leonie Weinhold
- Institute of Medical Biometrics, Informatics, and Epidemiology, University Hospital Bonn, 53127 Bonn, Germany;
| | - Johannes Weller
- Division of Clinical Neuro-Oncology, Department of Neurology, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, 53127 Bonn, Germany; (C.S.); (J.W.); (U.H.); (N.S.)
| | - Christian Wispel
- Department of Neurosurgery, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (A.-L.P.); (E.G.); (C.W.); (H.V.); (P.S.)
| | - Ulrich Herrlinger
- Division of Clinical Neuro-Oncology, Department of Neurology, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, 53127 Bonn, Germany; (C.S.); (J.W.); (U.H.); (N.S.)
| | - Hartmut Vatter
- Department of Neurosurgery, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (A.-L.P.); (E.G.); (C.W.); (H.V.); (P.S.)
| | - Niklas Schäfer
- Division of Clinical Neuro-Oncology, Department of Neurology, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, 53127 Bonn, Germany; (C.S.); (J.W.); (U.H.); (N.S.)
| | - Patrick Schuss
- Department of Neurosurgery, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (A.-L.P.); (E.G.); (C.W.); (H.V.); (P.S.)
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Starkweather CK, Choi BD, Alvarez-Breckenridge C, Brastianos PK, Oh K, Wang N, Shih H, Nahed BV. Initial Approach to the Patient with Multiple Newly Diagnosed Brain Metastases. Neurosurg Clin N Am 2020; 31:505-513. [PMID: 32921347 DOI: 10.1016/j.nec.2020.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Brain metastases are the most common intracranial tumor in adults, with increasing incidence owing to prolonged survival times. Roughly half of patients diagnosed with new brain metastases have greater than 1 brain metastasis at the time of diagnosis, raising the question of how to optimize patient care with multiple brain metastases. The authors review studies relevant to the care of patients with brain metastasis, with emphasis on those relevant to the care of patients with multiple brain metastases. They discuss evolving strategies involving multiple modalities and the benefit of surgical management in patients with a large symptomatic brain metastasis.
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Affiliation(s)
- Clara Kwon Starkweather
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Bryan D Choi
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | | | | | - Kevin Oh
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Nancy Wang
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Helen Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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Abstract
Brain metastases are the most common intracranial tumor and a leading cause of morbidity and mortality for patients with systemic cancer. En bloc surgical resection of brain metastases improves survival, local recurrence rates, and functional independence in patients with up to three metastases and controlled extracranial disease. Modern techniques and technologies provide the neurosurgeon with minimally invasive approaches, such as keyhole craniotomies and tubular retractors. Preoperative planning for tumors located in eloquent regions includes mapping with functional MRI and diffusion tensor imaging, and intraoperative mapping and monitoring with electrophysiologic techniques under general or awake anesthesia to preserve normal neurologic function.
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Affiliation(s)
- Joshua L Wang
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Doan Hall N1004, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - J Bradley Elder
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Doan Hall N1004, 410 West 10th Avenue, Columbus, OH 43210, USA
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21
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[What is the place of surgery in the management of brain metastases in 2020?]. Cancer Radiother 2020; 24:470-476. [PMID: 32773281 DOI: 10.1016/j.canrad.2020.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 05/22/2020] [Accepted: 05/29/2020] [Indexed: 11/23/2022]
Abstract
Brain metastases are the most common intracranial tumors and are associated with a dismal prognosis. The management of patients with brain metastases has become more important because of the increased incidence of these tumours, the better treatment of the systemic disease and the improvement of surgical techniques. The treatment requires multidisciplinary approaches and become complex because of new emerging systemic therapy and advancements in neurosurgery and radiation oncology. The surgical treatment has an indispensable role to obtain a tissue diagnosis, in relieving intracranial effect mass and improving neurological status by improving induced encephalopathy. An understanding of the role and indications of the surgery in patients with metastatic brain lesions is essential for the effective management of this growing population.
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Zhang P, Yao L, Chen M, Feng W. Prognostic factors affecting long-term outcomes in patients with brain metastasis from esophageal carcinoma. Chin J Cancer Res 2020; 32:768-777. [PMID: 33446999 PMCID: PMC7797235 DOI: 10.21147/j.issn.1000-9604.2020.06.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective The incidence of brain metastasis from esophageal cancer (BMEC) has increased in recent years. Thus, it is necessary to identify factors that affect long-term outcomes for such patients. Methods From January 1997 to July 2018, consecutive patients (10,043 patients, 31 with brain metastasis) with esophageal cancer (EC) treated at Zhejiang Cancer Hospital were recruited for retrospective analysis. Demographic, clinical, and pathological variables and the survival data were retrieved. Results The median time from diagnosis of EC to diagnosis of brain metastases was 7.67 (range, 0.43−55.20) months. The median survival time of BMEC patients from diagnosis of primary esophageal tumor was 16.7 (range, 2.33−163.30) months and the median survival time from the point of diagnosis of brain metastasis was 6.47 (range, 0.43−148.13) months. Univariate and multivariate analyses showed that the pathology type, EC without chemotherapy, and bone metastasis history were significantly associated with a shorter time interval between the first treatment of EC and brain metastasis. Chemotherapy history after brain metastasis, whole brain radiation therapy (WBRT) history, and surgery were significant predictors for better long-term survival outcomes. Conclusions Our findings indicate that the use of surgery, WBRT, and chemotherapy can achieve the best therapeutic effects for BMEC patients.
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Affiliation(s)
- Peng Zhang
- Department of Radiology Physics, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou 310022, China
| | - Lejing Yao
- Department of Radiology Physics, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou 310022, China
| | - Ming Chen
- Department of Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou 310022, China
| | - Wei Feng
- Department of Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou 310022, China
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23
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Ammirati M, Nahed BV, Andrews D, Chen CC, Olson JJ. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Treatment Options for Adults With Multiple Metastatic Brain Tumors. Neurosurgery 2019; 84:E180-E182. [PMID: 30629219 DOI: 10.1093/neuros/nyy548] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 01/08/2019] [Indexed: 11/13/2022] Open
Abstract
TARGET POPULATION These recommendations apply to adult patients newly diagnosed with multiple (more than 1) brain metastases. QUESTION 1 In what circumstances should whole brain radiation therapy be recommended to improve tumor control and survival in patients with multiple brain metastases? RECOMMENDATION Level 2: It is recommended that whole brain radiation therapy can be added to stereotactic radiosurgery to improve local and distant control keeping in mind the potential for worsened neurocognitive outcomes and that there is unlikely to be a significant impact on overall survival. QUESTION 2 In what circumstances should stereotactic radiosurgery be recommended to improve tumor control and survival in patients with multiple brain metastases? RECOMMENDATIONS Level 1: In patients with 2 to 3 brain metastases not amenable to surgery, the addition of stereotactic radiosurgery to whole brain radiation therapy is not recommended to improve survival beyond that obtained with whole brain radiation therapy alone. Level 3: The use of stereotactic radiosurgery alone is recommended to improve median overall survival for patients with more than 4 metastases having a cumulative volume < 7 cc. QUESTION 3 In what circumstances should surgery be recommended to improve tumor control and survival in patients with multiple brain metastases? RECOMMENDATION Level 3: In patients with multiple brain metastases, tumor resection is recommended in patients with lesions inducing symptoms from mass effect that can be reached without inducing new neurological deficit and who have control of their cancer outside the nervous system.The full guideline can be found at https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_6.
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Affiliation(s)
- Mario Ammirati
- Department of Neurosurgery, St. Rita Medical Center, Lima, Ohio.,Department of Biology, College of Science and Technology and Sbarro Health Research Organization, Temple University, Philadelphia, Pennsylvania
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David Andrews
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
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Fecci PE, Champion CD, Hoj J, McKernan CM, Goodwin CR, Kirkpatrick JP, Anders CK, Pendergast AM, Sampson JH. The Evolving Modern Management of Brain Metastasis. Clin Cancer Res 2019; 25:6570-6580. [PMID: 31213459 PMCID: PMC8258430 DOI: 10.1158/1078-0432.ccr-18-1624] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/23/2019] [Accepted: 06/13/2019] [Indexed: 12/11/2022]
Abstract
The incidence of brain metastases is increasing as cancer therapies improve and patients live longer, providing new challenges to the multidisciplinary teams that care for these patients. Brain metastatic cancer cells possess unique characteristics that allow them to penetrate the blood-brain barrier, colonize the brain parenchyma, and persist in the intracranial environment. In addition, brain metastases subvert the innate and adaptive immune system, permitting evasion of the antitumor immune response. Better understanding of the above mechanisms will allow for development and delivery of more effective therapies for brain metastases. In this review, we outline the molecular mechanisms underlying development, survival, and immunosuppression of brain metastases. We also discuss current and emerging treatment strategies, including surgery, radiation, disease-specific and mutation-targeted systemic therapy, and immunotherapy.
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Affiliation(s)
- Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
- Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
| | - Cosette D Champion
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
- Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
| | - Jacob Hoj
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
| | - Courtney M McKernan
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
- Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
| | - John P Kirkpatrick
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
- Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Carey K Anders
- Duke Cancer Institute, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Ann Marie Pendergast
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
| | - John H Sampson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina.
- Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
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Sankey EW, Tsvankin V, Grabowski MM, Nayar G, Batich KA, Risman A, Champion CD, Salama AKS, Goodwin CR, Fecci PE. Operative and peri-operative considerations in the management of brain metastasis. Cancer Med 2019; 8:6809-6831. [PMID: 31568689 PMCID: PMC6853809 DOI: 10.1002/cam4.2577] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 09/07/2019] [Accepted: 09/09/2019] [Indexed: 12/24/2022] Open
Abstract
The number of patients who develop metastatic brain lesions is increasing as the diagnosis and treatment of systemic cancers continues to improve, resulting in longer patient survival. The role of surgery in the management of brain metastasis (BM), particularly multiple and recurrent metastases, remains controversial and continues to evolve. However, with appropriate patient selection, outcomes after surgery are typically favorable. In addition, surgery is the only means to obtain a tissue diagnosis and is the only effective treatment modality to quickly relieve neurological complications or life-threatening symptoms related to significant mass effect, CSF obstruction, and peritumoral edema. As such, a thorough understanding of the role of surgery in patients with metastatic brain lesions, as well as the factors associated with surgical outcomes, is essential for the effective management of this unique and growing patient population.
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Affiliation(s)
- Eric W. Sankey
- Department of NeurosurgeryDuke University Medical CenterDurhamNCUSA
| | - Vadim Tsvankin
- Department of NeurosurgeryDuke University Medical CenterDurhamNCUSA
| | | | - Gautam Nayar
- Department of NeurosurgeryUniversity of Pittsburgh Medical CenterPittsburghPAUSA
| | | | - Aida Risman
- School of MedicineMedical College of GeorgiaAugustaGAUSA
| | | | | | - C. Rory Goodwin
- Department of NeurosurgeryDuke University Medical CenterDurhamNCUSA
| | - Peter E. Fecci
- Department of NeurosurgeryDuke University Medical CenterDurhamNCUSA
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Hirshman BR, Wilson B, Ali MA, Proudfoot JA, Koiso T, Nagano O, Carter BS, Serizawa T, Yamamoto M, Chen CC. Superior Prognostic Value of Cumulative Intracranial Tumor Volume Relative to Largest Intracranial Tumor Volume for Stereotactic Radiosurgery-Treated Brain Metastasis Patients. Neurosurgery 2019; 82:473-480. [PMID: 28658940 DOI: 10.1093/neuros/nyx225] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 06/16/2017] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Two intracranial tumor volume variables have been shown to prognosticate survival of stereotactic-radiosurgery-treated brain metastasis patients: the largest intracranial tumor volume (LITV) and the cumulative intracranial tumor volume (CITV). OBJECTIVE To determine whether the prognostic value of the Scored Index for Radiosurgery (SIR) model can be improved by replacing one of its components-LITV-with CITV. METHODS We compared LITV and CITV in terms of their survival prognostication using a series of multivariable models that included known components of the SIR: age, Karnofsky Performance Score, status of extracranial disease, and the number of brain metastases. Models were compared using established statistical measures, including the net reclassification improvement (NRI > 0) and integrated discrimination improvement (IDI). The analysis was performed in 2 independent cohorts, each consisting of ∼3000 patients. RESULTS In both cohorts, CITV was shown to be independently predictive of patient survival. Replacement of LITV with CITV in the SIR model improved the model's ability to predict 1-yr survival. In the first cohort, the CITV model showed an NRI > 0 improvement of 0.2574 (95% confidence interval [CI] 0.1890-0.3257) and IDI of 0.0088 (95% CI 0.0057-0.0119) relative to the LITV model. In the second cohort, the CITV model showed a NRI > 0 of 0.2604 (95% CI 0.1796-0.3411) and IDI of 0.0051 (95% CI 0.0029-0.0073) relative to the LITV model. CONCLUSION After accounting for covariates within the SIR model, CITV offers superior prognostic value relative to LITV for stereotactic radiosurgery-treated brain metastasis patients.
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Affiliation(s)
- Brian R Hirshman
- Department of Neurosurgery, Center for Translational and Applied Neuro-Oncology, University of California, San Diego, La Jolla, California
| | - Bayard Wilson
- Department of Neurosurgery, Center for Translational and Applied Neuro-Oncology, University of California, San Diego, La Jolla, California
| | - Mir Amaan Ali
- Department of Neurosurgery, Center for Translational and Applied Neuro-Oncology, University of California, San Diego, La Jolla, California
| | - James A Proudfoot
- Clinical and Translational Research Institute, University of California San Diego, San Diego, California
| | - Takao Koiso
- Department of Neurosurgery, Katsuta Hospital Mito GammaHouse, Hitachi-Naka, Japan
| | - Osamu Nagano
- Gamma Knife House, Chiba Cerebral and Cardiovascular Center, Ichihara, Japan
| | - Bob S Carter
- Department of Neurosurgery, Center for Translational and Applied Neuro-Oncology, University of California, San Diego, La Jolla, California
| | - Toru Serizawa
- Tsukiji Neurological Clinic, Tokyo Gamma Unit Center, Tokyo, Japan
| | - Masaaki Yamamoto
- Department of Neurosurgery, Katsuta Hospital Mito GammaHouse, Hitachi-Naka, Japan
| | - Clark C Chen
- Department of Neurosurgery, Center for Translational and Applied Neuro-Oncology, University of California, San Diego, La Jolla, California
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Ponce S, Bruna J, Juan O, López R, Navarro A, Ortega AL, Puente J, Verger E, Bartolomé A, Nadal E. Multidisciplinary expert opinion on the treatment consensus for patients with EGFR mutated NSCLC with brain metastases. Crit Rev Oncol Hematol 2019; 138:190-206. [PMID: 31092376 DOI: 10.1016/j.critrevonc.2019.03.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/09/2019] [Accepted: 03/26/2019] [Indexed: 12/14/2022] Open
Abstract
The presence of an epidermal growth factor receptor (EGFR) mutation is associated with higher incidence of brain metastases in patients with non-small cell lung cancer (NSCLC); however, patients with synchronous brain metastases at diagnosis have generally been excluded from clinical trials. As there is limited clinical evidence for managing this patient population, a multidisciplinary group of Spanish medical and radiation oncologists, and neuro-oncologist with expertise treating brain metastases in lung cancer patients met with the aim of reaching and developing an expert opinion consensus on the management of patients with EGFR mutated NSCLC with brain metastases. This consensus contains 26 recommendations and 20 conclusion statements across 21 questions in 7 areas, as well as a first-line treatment algorithm.
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Affiliation(s)
- Santiago Ponce
- Lung Cancer Clinical Research Unit, Hospital Universitario 12 de Octubre, Av. Cordoba, s/n, 28041 Madrid, Spain.
| | - Jordi Bruna
- Neuro-Oncology Unit, Bellvitge University Hospital-ICO, Carrer de la Feixa Llarga, s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain; Clinical Research in Solid Tumors (CReST) and Neuro-Oncology Group. Oncobell, IDIBELL, Avda Gran Via 199-203, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Oscar Juan
- Medical Oncology Service, Hospital Universitario y Politécnico La Fe, Valencia, Avda. de Fernando Abril Martorell, nº 106, 46026, Valencia, Spain.
| | - Rafael López
- Medical Oncology Unit. Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal, 3, 47003, Valladolid, Spain.
| | - Alejandro Navarro
- Medical Oncology. Hospital Vall d'Hebron, Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain.
| | - Ana Laura Ortega
- Oncology Research Unit, Complejo Hospitalario de Jaén, Av. del Ejército Español, 10, 23007, Jaén, Spain.
| | - Javier Puente
- GU, Thoracic and Melanoma Cancer Unit, Medical Oncology Department, Assistant Professor of Medicine, Complutense University. Hospital Clinico Universitario San Carlos, Calle del Prof Martín Lagos, s/n, 28040, Madrid, Spain.
| | - Eugènia Verger
- Radiation Oncology Department, Hospital Clínic de Barcelona, Carrer de Villarroel, 170, 08036, Barcelona, Spain.
| | - Adela Bartolomé
- Radiotherapy Oncology Department. Hospital Universitario 12 de Octubre, Av. Cordoba, s/n, 28041, Madrid, Spain.
| | - Ernest Nadal
- Clinical Research in Solid Tumors (CReST) and Neuro-Oncology Group. Oncobell, IDIBELL, Avda Gran Via 199-203, 08907, L'Hospitalet de Llobregat, Barcelona, Spain; Thoracic Oncology Unit, Department of Medical Oncology, Catalan Institute of Oncology. Avda Gran Via 199-203, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
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29
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Melanom. MEDIKAMENTÖSE TUMORTHERAPIE IN DER DERMATO-ONKOLOGIE 2019. [PMCID: PMC7121576 DOI: 10.1007/978-3-662-58012-7_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Das Melanom ist der gefährlichste Hautkrebs mit der höchsten Sterblichkeitsrate, der schon bei jungen Menschen auftreten kann und seit Jahrzehnten steigende Inzidenz verzeichnet (Jemal et al. 2007; Little et al. 2012). Jährlich erkranken weltweit etwa 137.000 Menschen am Melanom und 37.000 versterben an der Erkrankung (Boyle et al. 2004). Die Inzidenz liegt weltweit jährlich bei 2,3–2,6/100.000 Einwohner (Pisani et al. 2002). In Deutschland beträgt die Inzidenz 19,2/100.000 Einwohner und es verstarben 2711 Betroffene im Jahre 2010 (Statistisches Bundesamt).
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Soffietti R, Pellerino A, Rudà R. Neuro-oncology perspective of treatment options in metastatic breast cancer. Future Oncol 2018; 14:1765-1774. [PMID: 29956562 DOI: 10.2217/fon-2017-0630] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Breast cancer (BC) is a heterogeneous disease. Different subtypes of BC exhibit a peculiar natural history, metastatic potential and outcome. Stereotactic radiosurgery is the most used treatment for brain metastases (BM), while surgery is reserved for large and symptomatic lesions. Whole-brain radiotherapy is employed in multiple BM not amendable to radiosurgery or surgery, and it is not employed any more following local treatments of a limited number of BM. A critical issue is the distinction from pseudoprogression or radionecrosis, and tumor regrowth. Considering the increase of long-term survivors after combined or novel treatments for BM, cognitive dysfunctions following whole-brain radiotherapy represent an issue of utmost importance. Neuroprotective drugs and innovative radiotherapy techniques are being investigated to reduce this risk of cognitive sequelae. Leptomeningeal disease represents a devastating complication, either alone or in association to BM, thus targeted therapies are employed in HER2-positive BC brain and leptomeningeal metastases.
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Affiliation(s)
- Riccardo Soffietti
- Department of Neuro-Oncology, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Alessia Pellerino
- Department of Neuro-Oncology, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University of Turin, Via Cherasco 15, 10126 Turin, Italy
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THE ROLE OF PHOTODYNAMIC THERAPY IN THE TREATMENT OF PRIMARY, RECURRENT AND METASTATIC MALIGNANT BRAIN TUMORS. BIOMEDICAL PHOTONICS 2018. [DOI: 10.24931/2413-9432-2018-7-2-37-49] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Photodynamic therapy is a relevant and promising area for research in the field of clinical neuroonocology. Application of modern developments in the field of laser technologies and new photosensitizers allows us to refer to this field as to high-tech. According to various authors, the inclusion of photodynamic therapy in combined and complex treatments of patients with malignant brain tumors allows achieving overall survival median of patients from 11 to 26 months for primary form of glioblastoma, and from 7.5 to 15 months - for recurrent forms of glioblastoma. Certain results have been achieved in the treatment of patients with metastatic brain lesion. In this publication the authors analyzed and systematized the results of the main clinical studies in the field of fluorescent diagnostics and intraoperative photodynamic therapy of primary, recurrent and metastatic forms of malignant brain tumors.
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Franchino F, Rudà R, Soffietti R. Mechanisms and Therapy for Cancer Metastasis to the Brain. Front Oncol 2018; 8:161. [PMID: 29881714 PMCID: PMC5976742 DOI: 10.3389/fonc.2018.00161] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/30/2018] [Indexed: 12/12/2022] Open
Abstract
Advances in chemotherapy and targeted therapies have improved survival in cancer patients with an increase of the incidence of newly diagnosed brain metastases (BMs). Intracranial metastases are symptomatic in 60–70% of patients. Magnetic resonance imaging (MRI) with gadolinium is more sensitive than computed tomography and advanced neuroimaging techniques have been increasingly used in the detection, treatment planning, and follow-up of BM. Apart from the morphological analysis, the most effective tool for characterizing BM is immunohistochemistry. Molecular alterations not always reflect those of the primary tumor. More sophisticated methods of tumor analysis detecting circulating biomarkers in fluids (liquid biopsy), including circulating DNA, circulating tumor cells, and extracellular vesicles, containing tumor DNA and macromolecules (microRNA), have shown promise regarding tumor treatment response and progression. The choice of therapeutic approaches is guided by prognostic scores (Recursive Partitioning Analysis and diagnostic-specific Graded Prognostic Assessment-DS-GPA). The survival benefit of surgical resection seems limited to the subgroup of patients with controlled systemic disease and good performance status. Leptomeningeal disease (LMD) can be a complication, especially in posterior fossa metastases undergoing a “piecemeal” resection. Radiosurgery of the resection cavity may offer comparable survival and local control as postoperative whole-brain radiotherapy (WBRT). WBRT alone is now the treatment of choice only for patients with single or multiple BMs not amenable to surgery or radiosurgery, or with poor prognostic factors. To reduce the neurocognitive sequelae of WBRT intensity modulated radiotherapy with hippocampal sparing, and pharmacological approaches (memantine and donepezil) have been investigated. In the last decade, a multitude of molecular abnormalities have been discovered. Approximately 33% of patients with non-small cell lung cancer (NSCLC) tumors and epidermal growth factor receptor mutations develop BMs, which are targetable with different generations of tyrosine kinase inhibitors (TKIs: gefitinib, erlotinib, afatinib, icotinib, and osimertinib). Other “druggable” alterations seen in up to 5% of NSCLC patients are the rearrangements of the “anaplastic lymphoma kinase” gene TKI (crizotinib, ceritinib, alectinib, brigatinib, and lorlatinib). In human epidermal growth factor receptor 2-positive, breast cancer targeted therapies have been widely used (trastuzumab, trastuzumab-emtansine, lapatinib-capecitabine, and neratinib). Novel targeted and immunotherapeutic agents have also revolutionized the systemic management of melanoma (ipilimumab, nivolumab, pembrolizumab, and BRAF inhibitors dabrafenib and vemurafenib).
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Affiliation(s)
- Federica Franchino
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
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Thon N, Kreth FW, Tonn JC. The role of surgery for brain metastases from solid tumors. HANDBOOK OF CLINICAL NEUROLOGY 2018; 149:113-121. [PMID: 29307348 DOI: 10.1016/b978-0-12-811161-1.00008-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Surgery, stereotactic radiosurgery, radiotherapy, and chemotherapy including novel targeted therapy strategies and any combination thereof as well as supportive care are the key elements for treatment of brain metastases. Goals of microsurgery are to obtain tissue samples for histologic diagnosis (particularly in case of uncertainty about the unknown primary tumor but also in the context of future targeted therapies), to relieve burden from space-occupying effects, to improve local tumor control, and to prolong overall survival. Complete surgical resection improves local tumor control and may even affect overall survival. Stereotactic radiosurgery is an equal effective alternative for metastases up to 3 cm in diameter, especially in highly eloquent or deep seated location. Gross total resection (as defined by immediate postoperative MRI) does not necessarily have to be combined with whole brain radiotherapy (WBRT), at least for patients with good performance status and controlled systemic disease. Particularly in cases of incomplete resections, focal irradiation or radiosurgery of the resection cavity or tumor remnant rather than WBRT may be attempted.
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Affiliation(s)
- Niklas Thon
- Department of Neurosurgery, University of Munich LMU, Munich, Germany
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34
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Lin NU, Gaspar LE, Soffietti R. Breast Cancer in the Central Nervous System: Multidisciplinary Considerations and Management. Am Soc Clin Oncol Educ Book 2017; 37:45-56. [PMID: 28561683 DOI: 10.1200/edbk_175338] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Breast cancer is the second most common primary tumor associated with central nervous system (CNS) metastases. Patients with metastatic HER2-positive or triple-negative (estrogen receptor (ER)-negative, progesterone receptor (PR)-negative, HER2-negative) breast cancer are at the highest risk of developing parenchymal brain metastases. Leptomeningeal disease is less frequent but is distributed across breast cancer subtypes, including lobular breast cancer. Initial treatment strategies can include surgery, radiation, intravenous or intrathecal chemotherapy, and/or targeted approaches. In this article, we review the epidemiology of breast cancer brain metastases, differences in clinical behavior and natural history by tumor subtype, and important considerations in the multidisciplinary treatment of these patients. We will highlight new findings that impact current standards of care, clinical controversies, and notable investigational approaches in clinical testing.
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Affiliation(s)
- Nancy U Lin
- From the Breast Oncology Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO; Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, Turin, Italy
| | - Laurie E Gaspar
- From the Breast Oncology Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO; Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, Turin, Italy
| | - Riccardo Soffietti
- From the Breast Oncology Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO; Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, Turin, Italy
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35
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Soffietti R, Abacioglu U, Baumert B, Combs SE, Kinhult S, Kros JM, Marosi C, Metellus P, Radbruch A, Villa Freixa SS, Brada M, Carapella CM, Preusser M, Le Rhun E, Rudà R, Tonn JC, Weber DC, Weller M. Diagnosis and treatment of brain metastases from solid tumors: guidelines from the European Association of Neuro-Oncology (EANO). Neuro Oncol 2017; 19:162-174. [PMID: 28391295 DOI: 10.1093/neuonc/now241] [Citation(s) in RCA: 304] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The management of patients with brain metastases has become a major issue due to the increasing frequency and complexity of the diagnostic and therapeutic approaches. In 2014, the European Association of Neuro-Oncology (EANO) created a multidisciplinary Task Force to draw evidence-based guidelines for patients with brain metastases from solid tumors. Here, we present these guidelines, which provide a consensus review of evidence and recommendations for diagnosis by neuroimaging and neuropathology, staging, prognostic factors, and different treatment options. Specifically, we addressed options such as surgery, stereotactic radiosurgery/stereotactic fractionated radiotherapy, whole-brain radiotherapy, chemotherapy and targeted therapy (with particular attention to brain metastases from non-small cell lung cancer, melanoma and breast and renal cancer), and supportive care.
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Affiliation(s)
- Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Ufuk Abacioglu
- Department of Radiation Oncology, Neolife Medical Center, Istanbul, Turkey
| | - Brigitta Baumert
- Department of Radiation-Oncology, MediClin Robert-Janker-Klinik, Bonn, Germany
| | - Stephanie E Combs
- Department of Innovative Radiation Oncology and Radiation Sciences, Munich, Germany
| | - Sara Kinhult
- Department of Oncology, Skane University Hospital, Lund, Sweden
| | - Johan M Kros
- Department of Pathology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Christine Marosi
- Department of Internal Medicine, Division of Oncology, Medical University, Vienna, Austria
| | - Philippe Metellus
- Department of Internal Medicine, Division of Oncology, Medical University, Vienna, Austria.,Department of Neurosurgery, Clairval Hospital Center, Generale de Santé, Marseille, France
| | - Alexander Radbruch
- Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Salvador S Villa Freixa
- Department of Radiation Oncology, Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Michael Brada
- Department of Molecular and Clinical Cancer Medicine & Radiation Oncology, Liverpool, United Kingdom
| | - Carmine M Carapella
- Department of Neuroscience, Division of Neurosurgery, Regina Elena Nat Cancer Institute, Rome, Italy
| | - Matthias Preusser
- Department of Medicine I and Comprehensive Cancer Center CNS Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria
| | - Emilie Le Rhun
- Department of Neurosurgery, Neuro-oncology, University Hospital, Lille, France
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Joerg C Tonn
- Department of Neurosurgery, University of Munich LMU, Munich, Germany
| | - Damien C Weber
- Centre for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Michael Weller
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
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36
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Kothari N, Mellon E, Hoffe SE, Frakes J, Shridhar R, Pimiento J, Meredith K, Tran ND, Saeed N, Almhanna K. Outcomes in patients with brain metastasis from esophageal carcinoma. J Gastrointest Oncol 2016; 7:562-9. [PMID: 27563446 DOI: 10.21037/jgo.2016.03.12] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Brain metastases from esophageal carcinoma have historically been rare and associated with poor prognosis. With improvements in systemic disease control, the incidence of brain metastases is expected to rise. To better inform management decisions, we sought to identify factors associated with survival in patients with brain metastasis from esophageal cancer. METHODS We retrospectively identified 49 patients with brain metastasis from stage I-IV primary esophageal cancer treated with surgery, radiation, or a combination of modalities at our tertiary referral center between 1998 and 2015. Medical records were reviewed to collect demographic and clinical information. RESULTS Median age at diagnosis of the primary esophageal cancer was 60 years. Forty-one (84%) patients were male and forty patients (82%) had adenocarcinoma. Median overall survival (MS) following esophageal cancer diagnosis was 24 months (range, 3-71 months), and median survival after the identification of brain metastases was 5 months (range, 1-52 months). On univariate analysis, only patients with poor Karnofsky performance status (KPS <70), recursive partitioning analysis (RPA) classification (III), or 3 or more brain metastases were found to have worsened survival after the diagnosis of brain metastases (all P<0.01). Factors not associated with survival were age, gender, histology (adenocarcinoma vs. other), palliative-intent treatment of the primary tumor, time to diagnosis of brain metastases from initial diagnosis, uncontrolled primary tumor at time of brain metastasis diagnosis, or extracranial metastases. On multivariate analysis (MVA, KPS excluded), patients with RPA class I (MS, 14.6 months) or II (MS, 5.0 months) disease had significantly improved overall survival compared to class III disease (MS, 1.6 months, P<0.01). Also on MVA, patients with 1 (MS, 10.7 months) or 2 (MS, 4.7 months) brain metastases had significantly improved overall survival compared to patients with 3 or more brain metastases (MS, 0.3 months, P<0.01). For the 36 patients with 1-2 brain metastases and KPS ≥70, MS was 11.1 months. CONCLUSIONS While the prognosis for esophageal cancer metastatic to brain remains poor overall, we found that patients with good performance status and limited number of brain lesions have superior survival. Aggressive management may further improve outcomes in these patients.
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Affiliation(s)
- Nishi Kothari
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Eric Mellon
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Sarah E Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Jessica Frakes
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Ravi Shridhar
- Department of Radiation Oncology, Florida Hospital Cancer Institute, Orlando, FL, USA
| | - Jose Pimiento
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Ken Meredith
- Department of Gastrointestinal Oncology, First Physicians Group, Sarasota, FL, USA
| | - Nam D Tran
- Department of Neuro-oncology. H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Nadia Saeed
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Khaldoun Almhanna
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
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37
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Park Y, Kim KS, Kim K, Chie EK, Kim JH, Kim JS, Kim TH, Kim DY, Jang WI, Kim MS, Koo TR, Chang AR. Nomogram prediction of survival in patients with brain metastases from hepatocellular carcinoma treated with whole-brain radiotherapy: a multicenter retrospective study. J Neurooncol 2015; 125:377-83. [PMID: 26342711 DOI: 10.1007/s11060-015-1926-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 08/31/2015] [Indexed: 12/30/2022]
Abstract
The incidence of brain metastasis from hepatocellular carcinoma (HCC) is increasing because of the improved survival outcome of HCC patients, but the prognosis of these patients is extremely poor. HCC patients with brain metastasis were investigated to identify their prognostic factors for overall survival. Patients with brain metastasis from HCC who had been treated with whole-brain radiotherapy (WBRT) in five hospitals were enrolled in the study. The medical records of the patients were reviewed, and the clinical factors were analyzed to identify the prognostic factors for overall survival. Of the total of 97 patients who were enrolled in the study, 83 were male and the median age at the brain metastases was 56.6 years. Motor weakness (43.3 %) and headache (41.2 %) were common presenting symptoms. The median AFP level was 4180 ng/ml, and 81 patients were assessed as belonging to Child-Pugh classification A upon the diagnosis of brain metastasis. WBRT alone in 71 patients, surgery or radiosurgery combined with WBRT as the adjuvant setting in 18 patients, and WBRT as salvage treatment in 8 patients were performed. The median overall survival of the patients was 3.5 months. In the multivariate analysis, the ECOG performance status (PS), Child-Pugh classification, AFP, and treatment aim showed significant association with the overall survival of the patients. Based on these factors, a nomogram predicting the prognosis was developed. The concordance index of the nomogram was 0.74, and the prediction was well calibrated. In conclusion, the survival outcome of patients with brain metastasis from HCC can be predicted with the nomogram constructed from the ECOG PS, Child-Pugh classification, AFP, and treatment aim.
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Affiliation(s)
- Younghee Park
- Department of Radiation Oncology, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea.,Department of Radiation Oncology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Kyung Su Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Jin Ho Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Jae-Sung Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Tae Hyun Kim
- Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Dae Yong Kim
- Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Won Il Jang
- Department of Radiation Oncology, Korea Institute of Radiological & Medical Sciences, Seoul, Republic of Korea
| | - Mi-Sook Kim
- Department of Radiation Oncology, Korea Institute of Radiological & Medical Sciences, Seoul, Republic of Korea
| | - Tae Ryool Koo
- Department of Radiation Oncology, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Ah Ram Chang
- Department of Radiation Oncology, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
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Bertolini F, Spallanzani A, Fontana A, Depenni R, Luppi G. Brain metastases: an overview. CNS Oncol 2015; 4:37-46. [PMID: 25586424 DOI: 10.2217/cns.14.51] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
So far brain metastases represent a critical stage of a disease course and the frequency is increasing over the years. The treatment of brain metastases should be individualized for each patient: in case of single brain metastasis, surgery or radiosurgery should be considered as first options of treatment; in case of multiple lesions, whole-brain radiotherapy is the standard of care in association with systemic therapy or surgery/radiosurgery. Chemotherapy should be considered when surgery or radiation therapy are not possible. In the last decades, TKIs or monoclonal antibodies have shown increase in overall response rate and overall survival in Phase II-III trials. The aim of this paper is to make an overview of the current approaches in management of patients with brain metastases.
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Affiliation(s)
- F Bertolini
- Department of Oncology, Azienda Ospedaliero-Universitaria Modena, via Del Pozzo, 71, 41124, Modena, Italy
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Patel VB, Wegner RE, Heron DE, Flickinger JC, Gerszten P, Burton SA. Comparison of whole versus partial vertebral body stereotactic body radiation therapy for spinal metastases. Technol Cancer Res Treat 2015; 11:105-15. [PMID: 22335404 DOI: 10.7785/tcrt.2012.500239] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The purpose of this study is to evaluate the difference in clinical outcomes for patients with metastatic spine disease treated with a whole versus partial vertebral body contouring approach. A retrospective study was performed for the clinical outcomes of 154 metastatic lesions to the spine in 117 patients treated with stereotactic body radiation therapy (SBRT) using the Cyberknife(TM) Robotic Radiosurgery System. Each patient was treated with a single session of radiotherapy using either a whole (WB) or a partial vertebral body contour approach (PB). The primary endpoint was re-treatment rate and the secondary endpoints were pain status, neurologic status, toxicity, tumor control, and survival. The WB group had a lower re-treatment rate (11% (WB) vs. 18.6% (PB), p=0.285). Prior surgery status (β=1.953, OR=7.052, p<0.001) was correlated to the re-treatment rate. Trends for local tumor control were distinct for both treatment groups (X(2)=3.380, p-value=0.066). Treatment group (β=-1.1017, OR=0.362, p=0.029) was significantly correlated to the local tumor control rate. The 2-year survival was 25.7% in WB and 20.9% in PB (p=0.741). Contouring the whole vertebral body for stereotactic body radiation therapy treatment of metastatic spinal lesions shows potential benefits by reducing the risk of recurrence, improving symptomatic relief and providing improved local tumor control.
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Affiliation(s)
- Veeral B Patel
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
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40
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Ahmed Z, Balagamwala E, Murphy E, Angelov L, Suh J, Lo S, Chao S. Postoperative stereotactic radiosurgery for resected brain metastasis. CNS Oncol 2015; 3:199-207. [PMID: 25055128 DOI: 10.2217/cns.14.18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Despite therapeutic advances in management, the prognosis of patients with brain metastasis remains dismal. Treatment options include surgical resection, whole brain radiation therapy (WBRT), and stereotactic radiosurgery (SRS). Patients who undergo surgical resection typically receive WBRT as adjuvant therapy. However, several studies have demonstrated an association between WBRT and neurotoxicity. Thus, clinicians are increasingly delaying WBRT in favor of postoperative use of SRS. In this review, we will discuss the current literature exploring the efficacy and toxicity of postoperative SRS in the treatment of patients with resected brain metastasis.
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Affiliation(s)
- Zain Ahmed
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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41
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Gazzeri R, Nalavenkata S, Teo C. Minimally invasive key-hole approach for the surgical treatment of single and multiple brain metastases. Clin Neurol Neurosurg 2014; 123:117-26. [DOI: 10.1016/j.clineuro.2014.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 05/13/2014] [Accepted: 05/18/2014] [Indexed: 10/25/2022]
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42
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McWilliams RR, Rao RD, Buckner JC, Link MJ, Markovic S, Brown PD. Melanoma-induced brain metastases. Expert Rev Anticancer Ther 2014; 8:743-55. [DOI: 10.1586/14737140.8.5.743] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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43
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Ray S, Dacosta-Byfield S, Ganguli A, Bonthapally V, Teitelbaum A. Comparative analysis of survival, treatment, cost and resource use among patients newly diagnosed with brain metastasis by initial primary cancer. J Neurooncol 2013; 114:117-25. [PMID: 23700325 DOI: 10.1007/s11060-013-1160-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 05/13/2013] [Indexed: 01/13/2023]
Abstract
Brain metastases are a frequent complication of many systemic cancers and portend a poor prognosis. This retrospective analysis of health claims data compared survival, treatment and health care utilization and costs in patients with brain metastasis by primary tumor site. Adult commercial and Medicare Advantage enrollees newly diagnosed with brain metastasis in 01 Jan 2004 through 30 Apr 2010 were identified. Inclusion required at least 2 claims that identified the same primary cancer site prior to diagnosis of brain metastasis and no evidence of primary brain tumors. Health care utilization rates and costs were calculated at the patient level for each month of follow-up. Differences among primary cancer site cohorts were assessed by ANOVA (continuous variables), Chi square test (proportions) and the Poisson distribution (utilization rates). The primary cancer cohorts comprised 1,031 lung cancer, 93 melanoma and 395 female breast cancer patients. During the 6 months prior to brain metastasis diagnosis, 59 % of lung cancer patients had no evidence of lymph node involvement or other metastatic disease compared to 55 and 42 % of melanoma and breast cancer patients (P < 0.001). Survival after brain metastasis diagnosis was less than 3 months for 52, 43 and 39 % for lung cancer, breast cancer and melanoma, respectively (P < 0.001). Melanoma patients had the highest rate of inpatient stays and outpatient visits (P ≤ 0.003). Total monthly all-cause costs were: melanoma, $23,426; breast cancer $19,708; lung cancer, $17,007 (P = 0.003). Health care utilization and costs after brain metastasis diagnosis were substantial and differed by primary tumor site.
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Affiliation(s)
- Saurabh Ray
- Abbott Laboratories, Abbott Park, IL 60064, USA
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44
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Robbins JR, Ryu S, Kalkanis S, Cogan C, Rock J, Movsas B, Kim JH, Rosenblum M. Radiosurgery to the surgical cavity as adjuvant therapy for resected brain metastasis. Neurosurgery 2013; 71:937-43. [PMID: 22806080 DOI: 10.1227/neu.0b013e31826909f2] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The standard treatment of resected brain metastasis is whole-brain radiotherapy (WBRT). To avoid the potential toxicity of WBRT and to improve local control, we have used radiosurgery alone to the surgical cavity. OBJECTIVE To demonstrate the rates of local control, new intracranial metastasis, and overall survival using this treatment scheme without WBRT. METHODS Eighty-five consecutive patients with brain metastasis were treated with surgical resection of at least 1 lesion followed by radiosurgery alone to the surgical cavity and any unresected lesions from August 2000 to March 2011. Sixty-eight percent had gross total resections. After surgery, radiosurgery was delivered to the surgical cavity with a 2- to 3-mm margin. The median marginal radiosurgery dose was 16 Gy, and median target volume was 13.96 cm. Follow-up imaging and clinical examination were obtained every 2 to 3 months. RESULTS Median follow-up time was 11.2 months. Overall local control was 81.2%. The 6-month, 1-year, and 2-year rates of local control were 88.7%, 81.4%, and 75.7%, respectively. Forty-seven patients (55%) developed new intracranial metastases at a median time of 5.6 months. For the entire population, the rate of new metastases was 32.1%, 58.1%, and 62.9% at 6 months, 1 year, and 2 years, respectively. Median overall survival time was 12.1 months. From initial treatment until death or last follow-up, only 30 patients (35%) received WBRT as salvage treatment. CONCLUSION Radiosurgery to the surgical cavity without WBRT achieved excellent local control of resected brain metastasis. Close imaging follow-up allows early intervention for any new metastasis.
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Affiliation(s)
- Jared R Robbins
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, Michigan 48202, USA
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45
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Abstract
The use of surgery in the treatment of brain metastases is controversial. Patients who present certain clinical characteristics may experience prolonged survival with resection compared with radiation therapy. Thus, for patients with a single metastatic lesion in the setting of well-controlled systemic cancer, surgery is highly indicated. Stereotactic radiosurgery (SRS) alone can provide a similar survival advantage, but when used as postoperative adjuvant therapy, patients experience extended survival times. Furthermore, surgery remains the only treatment option for patients with life-threatening neurological symptoms, who require immediate tumor debulking. Treatment of brain metastases requires a careful clinical assessment of individual patients, as different prognostic factors may indicate various modes or combinations of therapy. Since surgery is an effective method for achieving tumor management in particular cases, it remains an important consideration in the treatment algorithm for brain metastases.
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Affiliation(s)
- Kurt Andrew Yaeger
- Department of Neurosurgery, Georgetown University School of Medicine, Washington DC 20007, USA
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46
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Park YH, Kim TH, Jung SY, Kim YE, Bae JM, Kim YJ, Choi JH, Lee NK, Moon SH, Kim SS, Shin KH, Kim JY, Kim DY, Cho KH. Combined primary tumor and extracranial metastasis status as constituent factor of prognostic indices for predicting the overall survival in patients with brain metastases. J Korean Med Sci 2013; 28:205-12. [PMID: 23400308 PMCID: PMC3565131 DOI: 10.3346/jkms.2013.28.2.205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2012] [Accepted: 12/07/2012] [Indexed: 11/20/2022] Open
Abstract
We retrospectively analyzed the prognostic factors on overall survival (OS) in patients with brain metastasis (BM) and evaluated the role of combined primary tumor and extracranial metastasis (ECM) status as a constituent factor for prognostic index. This study involved 897 patients with BMs who underwent radiotherapy between April 2003 and December 2009. Among the clinical parameters, multivariate analysis showed that age, Karnofsky performance status (KPS), combined primary tumor and ECM status, number of BMs, and treatment group were significant prognostic factors for OS (P < 0.05). To compare the discriminatory ability of 5 prognostic indices, i.e., recursive partitioning analysis (RPA), basic score for BMs (BSBM), score index for radiosurgery (SIR), graded prognostic assessment (GPA), and modified GPA including the combined primary tumor and ECM status (mGPA), the Akaike information criteria (AIC) were calculated. The mGPA showed the lowest AIC value, followed by RPA, GPA, SIR, and BSBM, in that order. It is implicated that modified score of pre-existing factors (i.e., age and KPS) and addition of the combined primary tumor and ECM status to the prognostic index can improve its discriminatory ability and the combined primary tumor and ECM status may be useful as one of constituent factors for prognostic index.
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Affiliation(s)
- Young Hee Park
- Research Institute and Hospital, National Cancer Center, Goyang, Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Tae Hyun Kim
- Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sun-Young Jung
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Young-Eun Kim
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Jong-Myon Bae
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Yeon-Joo Kim
- Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Ji Hoon Choi
- Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Nam Kwon Lee
- Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sung Ho Moon
- Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sang Soo Kim
- Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kyung Hwan Shin
- Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Joo-Young Kim
- Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Yong Kim
- Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kwan Ho Cho
- Research Institute and Hospital, National Cancer Center, Goyang, Korea
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Abstract
Purpose The signal transducer and activator of transcription 3 (STAT3) is a key molecular hub of tumorigenesis and immune suppression. The expression of phosphorylated STAT3 (p-STAT3) has been shown to be higher in melanoma metastasis to the central nervous system (CNS) relative to distant metastasis in the rest of the body (systemic). We sought to determine whether the increased expression of p-STAT3 in non-CNS systemic melanoma metastasis is associated with an increased risk of developing CNS metastasis and is a negative prognostic factor for overall survival time. Methods We retrospectively identified 299 patients with stage IV melanoma. In a tissue microarray of systemic non-CNS metastasis specimens from these patients, we used immunohistochemical analysis to measure the percentage of cells with p-STAT3 expression and Kaplan–Meier survival estimates to analyze the association of p-STAT3 expression with median survival time, time to first CNS metastasis, and development of CNS metastasis. Results Lung metastases exhibited the highest level of p-STAT3 expression while spleen lesions had the lowest. The p-STAT3 expression was not associated with an increased risk of developing CNS metastasis or time to CNS metastasis. However, p-STAT3 expression was a negative prognostic factor for overall survival time in patients that did not develop CNS metastasis. Conclusions Stage IV melanoma patients without CNS metastasis treated with p-STAT3 inhibitors in efficacy studies should be stratified based on tumor expression of p-STAT3; however since p-STAT3 expression is not associated with the risk of CNS disease, increased MRI surveillance of the brain is not likely necessary.
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Affiliation(s)
- Toral R Patel
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06520, USA
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Abstract
Multiple options for retreatment are available, which include whole-brain radiation therapy, stereotactic radiosurgery, surgery, chemotherapy, and supportive care. Size, number, timing, location, histology, performance status, and extracranial disease status all need to be carefully considered when choosing a treatment modality. There are no randomized trials examining the retreatment of brain metastases. Repeat whole-brain radiation has been examined in a single-institution experience, showing the potential for clinical responses in selected patients. Local control rates as high as 91% using stereotactic radiosurgery for relapses after whole-brain radiation are reported. Surgery can be indicated in progressive and/or hemorrhagic lesions causing mass effect. The role of chemotherapy in the recurrent setting is limited but some agents may have activity on the basis of experiences on a smaller scale. Supportive care continues to be an important option, especially in those with a poor prognosis. Follow-up for brain metastases patients is discussed, examining the modality, frequency of imaging, and imaging options in differentiating treatment effect from recurrence. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of the current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Lee SH, Lee KC, Choi J, Kim HY, Lee SH, Sung KH, Kim Y. Clinical application of RapidArc volumetric modulated arc therapy as a component in whole brain radiation therapy for poor prognostic, four or more multiple brain metastases. Radiat Oncol J 2012; 30:53-61. [PMID: 22984683 PMCID: PMC3429889 DOI: 10.3857/roj.2012.30.2.53] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 04/30/2012] [Accepted: 05/04/2012] [Indexed: 01/28/2023] Open
Abstract
Purpose To determine feasibility of RapidArc in sequential or simultaneous integrated tumor boost in whole brain radiation therapy (WBRT) for poor prognostic patients with four or more brain metastases. Materials and Methods Nine patients with multiple (≥4) brain metastases were analyzed. Three patients were classified as class II in recursive partitioning analysis and 6 were class III. The class III patients presented with hemiparesis, cognitive deficit, or apraxia. The ratio of tumor to whole brain volume was 0.8-7.9%. Six patients received 2-dimensional bilateral WBRT, (30 Gy/10-12 fractions), followed by sequential RapidArc tumor boost (15-30 Gy/4-10 fractions). Three patients received RapidArc WBRT with simultaneous integrated boost to tumors (48-50 Gy) in 10-20 fractions. Results The median biologically effective dose to metastatic tumors was 68.1 Gy10 and 67.2 Gy10 and the median brain volume irradiated more than 100 Gy3 were 1.9% (24 cm3) and 0.8% (13 cm3) for each group. With less than 3 minutes of treatment time, RapidArc was easily applied to the patients with poor performance status. The follow-up period was 0.3-16.5 months. Tumor responses among the 6 patients who underwent follow-up magnetic resonance imaging were partial and stable in 3 and 3, respectively. Overall survival at 6 and 12 months were 66.7% and 41.7%, respectively. The local progression-free survival at 6 and 12 months were 100% and 62.5%, respectively. Conclusion RapidArc as a component in whole brain radiation therapy for poor prognostic, multiple brain metastases is an effective and safe modality with easy application.
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Affiliation(s)
- Seung Heon Lee
- Department of Radiation Oncology, Gachon University Gil Hospital, Incheon, Korea
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