1
|
Collette C, Willhelm G, Del Bene VA, Aita SL, Marotta D, Myers T, Anderson J, Gammon M, Gerstenecker A, Nabors LB, Fiveash J, Triebel KL. Cognitive Dysfunction in Non-CNS Metastatic Cancer: Comparing Brain Metastasis, Non-CNS Metastasis, and Healthy Controls. Cancer Invest 2024:1-11. [PMID: 39007916 DOI: 10.1080/07357907.2024.2371368] [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: 11/10/2022] [Accepted: 06/19/2024] [Indexed: 07/16/2024]
Abstract
Limited research has compared cognition of people with non-central nervous system metastatic cancer (NCM) vs. metastatic brain cancer (BM). This prospective cross-sectional study was comprised 37 healthy controls (HC), 40 NCM, and 61 BM completing 10 neuropsychological tests. The NCM performed below HCs on processing speed and executive functioning tasks, while the BM group demonstrated lower performance across tests. Tasks of processing speed, verbal fluency, and verbal memory differentiated the clinical groups (BM < NCM). Nearly 20% of the NCM group was impaired on at least three neuropsychological tests whereas approximately 40% of the BM group demonstrated the same level of impairment.
Collapse
Affiliation(s)
- Christopher Collette
- Department of Neurology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Gabrielle Willhelm
- Department of Neurology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Victor A Del Bene
- Department of Neurology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Stephen L Aita
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Department of Mental Health, VA Maine Healthcare System, Augusta, Maine, USA
| | - Dario Marotta
- Department of Neurology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Terina Myers
- Department of Neurology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Joseph Anderson
- Department of Neurology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Meredith Gammon
- Department of Neurology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Adam Gerstenecker
- Department of Neurology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - L Burt Nabors
- Department of Neurology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
- Department of Radiation Oncology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - John Fiveash
- Department of Radiation Oncology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
- O'Neal Comprehensive Cancer Center, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Kristen L Triebel
- Department of Neurology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
- Department of Radiation Oncology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| |
Collapse
|
2
|
Hu F, Zheng XH, Li T, She HL, Zhang SF. Brain Perfusion Abnormalities after Radiotherapy Measured by 3-Dimensional Arterial Spin Labeling MRI and Correlations with Cognitive Impairment. Radiat Res 2022; 197:324-331. [PMID: 35104874 DOI: 10.1667/rade-21-00143.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 12/10/2021] [Indexed: 11/03/2022]
Abstract
The purpose of this study was to use a 3-dimensional arterial spin labeling (3D ASL) magnetic resonance (MR) method to measure cerebral blood flow (CBF) before and after radiotherapy, and correlate changes with time after receiving radiotherapy and cognitive function. Patients with nasopharyngeal carcinoma receiving radiotherapy at our institution were recruited for the study. Participants were divided into three groups: Pre-radiotherapy control (PC) group, acute reaction period (ARP) group, and delayed reaction period (DRP)group. Thirty-four patients were included in the study. Compared with the PC group, the ARP group exhibited significantly decreased perfusion in the left anterior cingulate cortex (ACC) and right putamen, and increased perfusion in the right cerebellum (Crus 1), right inferior occipital gyrus, left lingual gyrus, left precuneus, and left calcarine gyrus. in the DRP group, increased perfusion was noted in the right cerebellum (Crus 1) and decreased perfusion in the left superior frontal gyrus. CBF differences were observed in several brain areas in the DRP group as compared to the ARP group (P < 0.001). Total Montreal Cognitive Assessment score, and subdomain language and delayed memory recall scores were significantly lower in the ARP and DRP groups than in the PC group (P < 0.05). Data suggest that ASL allows for non-invasive detection of radiation-induced whole-brain CBF changes, which is transient, dynamic and complicated and may be a factor contributing to cognitive impairment induced by radiotherapy for nasopharyngeal carcinoma.
Collapse
Affiliation(s)
- Fang Hu
- Medical Imaging and Inspection Institute, Xiangnan University, Chenzhou, Hunan Province, P. R. China.,Department of Radiology, the Affiliated Hospital of Xiangnan University, Chenzhou, Hunan Province, China.,Key Laboratory of Medical Imaging and Artifical Intelligence of Hunan Province, Xiangnan University, Chenzhou 423000, China.,Chenzhou Cognitive Degeneration Brain Disease Early Warning Technology Research and Development Center, Affiliated Hospital of Xiangnan University, Chenzhou 423000, China
| | - Xin-Hui Zheng
- Medical Imaging and Inspection Institute, Xiangnan University, Chenzhou, Hunan Province, P. R. China
| | - Tao Li
- Medical Imaging and Inspection Institute, Xiangnan University, Chenzhou, Hunan Province, P. R. China.,Department of Radiology, the Affiliated Hospital of Xiangnan University, Chenzhou, Hunan Province, China.,Key Laboratory of Medical Imaging and Artifical Intelligence of Hunan Province, Xiangnan University, Chenzhou 423000, China.,Chenzhou Cognitive Degeneration Brain Disease Early Warning Technology Research and Development Center, Affiliated Hospital of Xiangnan University, Chenzhou 423000, China
| | - Hua-Long She
- Department of Radiology, the Affiliated Hospital of Xiangnan University, Chenzhou, Hunan Province, China.,Key Laboratory of Medical Imaging and Artifical Intelligence of Hunan Province, Xiangnan University, Chenzhou 423000, China.,Chenzhou Cognitive Degeneration Brain Disease Early Warning Technology Research and Development Center, Affiliated Hospital of Xiangnan University, Chenzhou 423000, China
| | - Sheng-Fu Zhang
- Department of Anus and Intestine Surgery, the First People's Hospital of Chenzhou, Chenzhou, Hunan Province, China.,Medical Imaging Center, the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, Guangdong Province, China
| |
Collapse
|
3
|
Cognition: development of a cognitive testing battery on the iPad for the evaluation of patients with brain Mets. Acta Neurol Belg 2022; 122:145-152. [PMID: 34302640 DOI: 10.1007/s13760-021-01744-9] [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: 02/26/2021] [Accepted: 07/02/2021] [Indexed: 10/20/2022]
Abstract
To make assessment of neurocognitive decline in patients with brain metastases more reliable and feasible, Brainlab AG developed an application 'Cognition' for the iPad by gamifying validated paper and pencil tests. This study aims at validating the computerized tests. We assessed reliability and comparability of 'Cognition' with similar well-established paper and pencil tests in two consecutive sessions per participant. The electronic tests used the same assignments with different stimuli than the paper and pencil tests. Domains involved are learning and memory, attention and processing speed, verbal fluency and executive functions. In total 5 employees and 25 cancer patients without disease in the CNS participated, of whom 24 completed both sessions. Reliability was found satisfying for the domains learning and memory (p = 0.08; p = 0.612; p = 0.4445) and verbal fluency (p = 0.064). A learning effect showed for attention and processing speed (p = 0.001) while executive functioning showed a significant decline, possibly due to radiotherapy-related fatigue (p = 0.013). Concerning comparability between electronic and paper results, a significant correlation was found for attention and processing speed (p = 0.000), for verbal fluency (p = 0.03), for executive functions (p = 0.000), but not for learning and memory (p = 0.41; p = 0.25). Overall 'Cognition' showed moderate comparability, probably caused by the consecution of tests during sessions and the unfamiliarity with electronic test in older patients. After improving its functionality, the application needs to be validated in patients with brain metastases before it can detect cognitive decline and possible early radiation toxicity or relapses.
Collapse
|
4
|
Mitchell D, Kwon HJ, Kubica PA, Huff WX, O’Regan R, Dey M. Brain metastases: An update on the multi-disciplinary approach of clinical management. Neurochirurgie 2022; 68:69-85. [PMID: 33864773 PMCID: PMC8514593 DOI: 10.1016/j.neuchi.2021.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/16/2021] [Accepted: 04/03/2021] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Brain metastasis (BM) is the most common malignant intracranial neoplasm in adults with over 100,000 new cases annually in the United States and outnumbering primary brain tumors 10:1. OBSERVATIONS The incidence of BM in adult cancer patients ranges from 10-40%, and is increasing with improved surveillance, effective systemic therapy, and an aging population. The overall prognosis of cancer patients is largely dependent on the presence or absence of brain metastasis, and therefore, a timely and accurate diagnosis is crucial for improving long-term outcomes, especially in the current era of significantly improved systemic therapy for many common cancers. BM should be suspected in any cancer patient who develops new neurological deficits or behavioral abnormalities. Gadolinium enhanced MRI is the preferred imaging technique and BM must be distinguished from other pathologies. Large, symptomatic lesion(s) in patients with good functional status are best treated with surgery and stereotactic radiosurgery (SRS). Due to neurocognitive side effects and improved overall survival of cancer patients, whole brain radiotherapy (WBRT) is reserved as salvage therapy for patients with multiple lesions or as palliation. Newer approaches including multi-lesion stereotactic surgery, targeted therapy, and immunotherapy are also being investigated to improve outcomes while preserving quality of life. CONCLUSION With the significant advancements in the systemic treatment for cancer patients, addressing BM effectively is critical for overall survival. In addition to patient's performance status, therapeutic approach should be based on the type of primary tumor and associated molecular profile as well as the size, number, and location of metastatic lesion(s).
Collapse
Affiliation(s)
- D Mitchell
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - HJ Kwon
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - PA Kubica
- Department of Neurosurgery, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA
| | - WX Huff
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - R O’Regan
- Department of Medicine/Hematology Oncology, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA
| | - M Dey
- Department of Neurosurgery, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA,Correspondence Should Be Addressed To: Mahua Dey, MD, University of Wisconsin School of Medicine & Public Health, 600 Highland Ave, Madison, WI 53792; Tel: 317-274-2601;
| |
Collapse
|
5
|
Winther RR, Hjermstad MJ, Skovlund E, Aass N, Helseth E, Kaasa S, Yri OE, Vik-Mo EO. Surgery for brain metastases-impact of the extent of resection. Acta Neurochir (Wien) 2022; 164:2773-2780. [PMID: 35080651 PMCID: PMC9519668 DOI: 10.1007/s00701-021-05104-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 12/23/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Surgical resection of brain metastases improves symptoms and survival in selected patients. The benefit of gross total resection is disputed, as most patients are believed to succumb from their non-CNS tumor burden. We investigated the association between overall survival and residual tumor after surgery for single brain metastases. METHODS We reviewed adults who underwent surgery for a single brain metastasis at a regional referral center (2011-2018). Gross total resection was defined as no visible residual tumor on cerebral MRI 12-48 h postoperatively. RESULTS We included 373 patients. The most common primary tumors were lung cancer (36%) and melanoma (24%). We identified gross total resection in 238 patients (64%). Median overall survival was 11.0 months, 8.0 (6.2-9.8) months for patients with subtotal resection and 13.0 (9.7-16.3) months for patients with gross total resection. In a multivariate regression analysis including preoperative prognostic factors, gross total resection was associated with longer overall survival (HR: 0.66, p = 0.003). Postoperative radiotherapy administered within 6 weeks did not significantly alter the hazard ratio estimates for grade of resection. CONCLUSIONS Our study suggests improved survival with gross total resection compared to subtotal resection. The importance of extent of resection in surgery for brain metastases should not be discarded.
Collapse
Affiliation(s)
- Rebecca Rootwelt Winther
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Marianne Jensen Hjermstad
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Eva Skovlund
- Norwegian University of Science and Technology, Trondheim, Norway
| | - Nina Aass
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway ,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Eirik Helseth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway ,Department of Neurosurgery, OUH, Oslo, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway ,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Olav Erich Yri
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Einar Osland Vik-Mo
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway ,Department of Neurosurgery, OUH, Oslo, Norway
| |
Collapse
|
6
|
Winther RR, Vik-Mo EO, Yri OE, Aass N, Kaasa S, Skovlund E, Helseth E, Hjermstad MJ. Surgery for brain metastases - real-world prognostic factors' association with survival. Acta Oncol 2021; 60:1161-1168. [PMID: 34032547 DOI: 10.1080/0284186x.2021.1930150] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Surgical resection of brain metastases (BM) improves overall survival (OS) in selected patients. Selecting those patients likely to benefit from surgery is challenging. The Graded Prognostic Assessment (GPA) and the diagnosis-specific Graded Prognostic Assessment (ds-GPA) were developed to predict survival in patients with BM, but not specifically to guide patient selection for surgery. Our aim was to evaluate the feasibility of preoperative GPA/ds-GPA scores and assess variables associated with OS. METHODS We retrospectively reviewed first-time surgical resection of BM from solid tumors at a Norwegian regional referral center from 2011 to 2018. RESULTS Of 590 patients, 51% were female and median age was 63 years. Median OS was 10.3 months and 74 patients (13%) died within three months after surgery. Preoperatively tumor origin was unknown in 20% of patients. A GPA score could be calculated for 92% of the patients preoperatively, but could not correctly predict survival. A ds-GPA score could be calculated for 46% of patients. Multivariable regression analysis revealed shorter OS in patients with higher age, worse functioning status, colorectal primary cancer compared to lung cancer, presence of extracranial metastases, and more than four BM. Patients with preoperative progressive extracranial disease or synchronous BM had shorter OS compared to patients with stable extracranial disease. CONCLUSION Ds-GPA could be calculated in less than half of patients preoperatively and GPA poorly identified patients which had minimal benefit of surgery. Including status of extracranial disease improve prognostication and therefore selection to surgery for brain metastases.
Collapse
Affiliation(s)
- Rebecca Rootwelt Winther
- Deparment of Oncology, Regional Advisory Unit for Palliative Care, Oslo University Hospital (OUH), Oslo, Norway
- Department of Oncology, European Palliative Care Research Centre (PRC), Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Einar Osland Vik-Mo
- Department of Neurosurgery, OUH, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Nina Aass
- Deparment of Oncology, Regional Advisory Unit for Palliative Care, Oslo University Hospital (OUH), Oslo, Norway
- Department of Oncology, European Palliative Care Research Centre (PRC), Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Oncology, OUH, Norway, Oslo (OEY, NA, SK)
| | - Stein Kaasa
- Deparment of Oncology, Regional Advisory Unit for Palliative Care, Oslo University Hospital (OUH), Oslo, Norway
- Department of Oncology, European Palliative Care Research Centre (PRC), Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Oncology, OUH, Norway, Oslo (OEY, NA, SK)
| | - Eva Skovlund
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
| | - Eirik Helseth
- Department of Neurosurgery, OUH, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Marianne Jensen Hjermstad
- Deparment of Oncology, Regional Advisory Unit for Palliative Care, Oslo University Hospital (OUH), Oslo, Norway
- Department of Oncology, European Palliative Care Research Centre (PRC), Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
7
|
Milano MT, Chiang VLS, Soltys SG, Wang TJC, Lo SS, Brackett A, Nagpal S, Chao S, Garg AK, Jabbari S, Halasz LM, Gephart MH, Knisely JPS, Sahgal A, Chang EL. Executive summary from American Radium Society's appropriate use criteria on neurocognition after stereotactic radiosurgery for multiple brain metastases. Neuro Oncol 2021; 22:1728-1741. [PMID: 32780818 DOI: 10.1093/neuonc/noaa192] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The American Radium Society (ARS) Appropriate Use Criteria brain malignancies panel systematically reviewed (PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses]) published literature on neurocognitive outcomes after stereotactic radiosurgery (SRS) for patients with multiple brain metastases (BM) to generate consensus guidelines. METHODS The panel developed 4 key questions (KQs) to guide systematic review. From 11 614 original articles, 12 were selected. The panel developed model cases addressing KQs and potentially controversial scenarios not addressed in the systematic review (which might inform future ARS projects). Based upon quality of evidence, the panel confidentially voted on treatment options using a 9-point scale of appropriateness. RESULTS The panel agreed that SRS alone is usually appropriate for those with good performance status and 2-10 asymptomatic BM, and usually not appropriate for >20 BM. For 11-15 and 16-20 BM there was (between 2 case variants) agreement that SRS alone may be appropriate or disagreement on the appropriateness of SRS alone. There was no scenario (among 6 case variants) in which conventional whole-brain radiotherapy (WBRT) was considered usually appropriate by most panelists. There were several areas of disagreement, including: hippocampal sparing WBRT for 2-4 asymptomatic BM; WBRT for resected BM amenable to SRS; fractionated versus single-fraction SRS for resected BM, larger targets, and/or brainstem metastases; optimal treatment (WBRT, hippocampal sparing WBRT, SRS alone to all or select lesions) for patients with progressive extracranial disease, poor performance status, and no systemic options. CONCLUSIONS For patients with 2-10 BM, SRS alone is an appropriate treatment option for well-selected patients with good performance status. Future study is needed for those scenarios in which there was disagreement among panelists.
Collapse
Affiliation(s)
- Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, NY
| | - Veronica L S Chiang
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, CT
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, CT
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Alexandria Brackett
- Cushing/Whitney Medical Library, Yale School of Medicine, Yale University, New Haven, CT
| | - Seema Nagpal
- Department of Neurology, Stanford University School of Medicine, Stanford, CT
| | - Samuel Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Amit K Garg
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Albuquerque, NM
| | - Siavash Jabbari
- Laurel Amtower Cancer Institute and Neuro-oncology Center, Sharp Healthcare, San Diego, CA
| | - Lia M Halasz
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | | | - Jonathan P S Knisely
- Department of Radiation Oncology, Weill Cornell Medicine, Cornell University, New York, NY
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
| | - Eric L Chang
- Department of Radiation Oncology, Keck School of Medicine of University of Southern California, Los Angeles, CA
| |
Collapse
|
8
|
Systematic Evaluation of Neurotoxicity in Children and Young Adults Undergoing CD22 Chimeric Antigen Receptor T-Cell Therapy. J Immunother 2019; 41:350-358. [PMID: 30048343 DOI: 10.1097/cji.0000000000000241] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Neurotoxicity associated with CAR-T cell therapy can be life-threatening. With rapid development of CAR-T therapies, a systematic method is needed to identify and monitor symptoms of neurotoxicity, elucidate potential etiologies, and compare toxicity across trials. This paper presents a systematic evaluation developed and used to prospectively assess neurotoxicity in our phase I anti-CD22 CAR-T-cell trial and describes the symptoms of neurotoxicity identified using this methodology. Central nervous system (CNS) studies included routine lumbar punctures performed for disease evaluation pretherapy and posttherapy and a baseline brain MRI. Brief cognitive evaluations, assessing 4 domains (attention, working memory, cognitive flexibility, and processing speed), were administered preinfusion and postinfusion. A newly developed CAR-T-specific neurological symptom checklist (NSC) was completed by caregivers at 3 designated time-points. Serial serum cytokine levels were compared with neurotoxicity symptoms and severity. The majority of the first 22 consecutively treated subjects (ages, 7-30) demonstrated stable or improved cognitive test scores following therapy and no irreversible neurotoxicity, despite CAR-T-related antileukemic response, cytokine release syndrome, and trafficking of CAR-T cells to the CSF. The NSC allowed us to document the type and timing of symptoms and explore the etiology of neurotoxicity associated with CD22 CAR-T therapy. Cytokine profiling demonstrated that more concerning symptoms of neurotoxicity, such as hallucination and disorientation, were significantly associated with higher serum cytokine levels, supporting the hypothesis of inflammation-driven neurotoxicity. Systematic assessments of neurotoxicity were feasible in acutely ill children and young adults and served to characterize and monitor the symptoms associated with CAR-T therapy. We recommend these evaluations be incorporated into future immunotherapy protocols.
Collapse
|
9
|
Reygagne E, Du Boisgueheneuc F, Berger A, Ingrand P. Examining the Inter Hemispheric Transfer Time Test: A new computerized cognitive test to incorporate into therapeutic strategy for patients with brain metastases? A pilot study. Clin Transl Radiat Oncol 2019; 16:48-54. [PMID: 30993219 PMCID: PMC6449743 DOI: 10.1016/j.ctro.2018.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/17/2018] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To evaluate the computerized Inter Hemispheric Transfer Time Test (IHTTT), a cognitive test designed for the detection of information processing speed impairment in patients undergoing stereotactic radiation therapy for brain metastases. METHODS Inclusion criteria: age ≥18 years, brain metastases treated by stereotactic radiotherapy (SRT) with dose schedule: 33 Gy in 3 fractions, solid tumour, ≥70 Karnofsky Performance Status, Mini-Mental State Evaluation (MMSE) ≥ 24, no history of stroke brain injury. Twenty-nine patients were recruited from June 2014 to April 2015. All recruited patients were administered Frontal Assessment Battery at Bedside (FAB), IHTTT and QLQ-C30 quality of life questionnaire before SRT, at one-month, six-month and one-year follow-up. The primary endpoint was Interhemispheric Transfer Index (IHTI). Secondary endpoints included Interhemispheric Transfer Time (IHTT), MMSE, FAB, and quality of life. RESULTS A significant evolution of cognitive function over time was assessed by the IHTTT: IHTT = 720 ± 27 ms at baseline, 728 ± 20 at one month, 736 ± 36 at 6 months, 799 ± 111 at one-year follow-up (p = 0.0010); IHTI = 13.1 ± 31.4, 11.5 ± 24.3, 50.6 ± 57.9, 91.0 ± 59.4 (p < 0.0001). There was also a significant evolution over time for MMSE (p = 0.014) but neither for FAB score nor the quality of life scores. IHTI was strongly related to progression-free survival (p = 0.0091). CONCLUSION Our results suggest that IHTTT is able to detect the evolution of cognitive function over time. IHTTT could be an interesting sensitive cognitive test to include in evaluation of patients with brain metastases irradiated by SRT.
Collapse
Affiliation(s)
| | | | | | - Pierre Ingrand
- INSERM CIC 1402, CHU, Poitiers, France
- Epidemiology and Biostatistics, Poitou-Charentes Cancer Registry, University of Poitiers, France
| |
Collapse
|
10
|
Smart D. Radiation Toxicity in the Central Nervous System: Mechanisms and Strategies for Injury Reduction. Semin Radiat Oncol 2018; 27:332-339. [PMID: 28865516 DOI: 10.1016/j.semradonc.2017.04.006] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The potential for radiation-induced toxicities in the brain produces significant anxiety, both among patients receiving radiation therapy and those radiation oncologists providing treatment. These concerns often play a significant role in the medical decision-making process for most patients with diseases in which radiotherapy may be a treatment consideration. Although the precise mechanisms of neurotoxicity and neurodegeneration after ionizing radiation exposure continue to be poorly understood from a biological perspective, there is an increasing body of scientific and clinical literature that is producing a better understanding of how radiation causes brain injury; factors that determine whether toxicities occur; and potential preventative, treatment, and mitigation strategies for patients at high risk or with symptoms of injury. This review will focus primarily on injuries and biological processes described in mature brain.
Collapse
Affiliation(s)
- DeeDee Smart
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD.
| |
Collapse
|
11
|
Wefel JS, Parsons MW, Gondi V, Brown PD. Neurocognitive aspects of brain metastasis. HANDBOOK OF CLINICAL NEUROLOGY 2018; 149:155-165. [PMID: 29307352 DOI: 10.1016/b978-0-12-811161-1.00012-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Brain metastases are common, occurring in approximately 20% of cancer patients. One of the biggest concerns for these patients and their families is neurocognitive decline. Neurocognitive issues in this patient population are complex and many patients have neurocognitive impairment due to systemic therapies even before they develop brain metastases. The development of brain metastases as well as the treatment of these tumors can cause decline in neurocognitive function. Diffuse treatments such as whole-brain radiotherapy are more frequently associated with neurocognitive decline than focal interventions such as radiosurgery, surgical resection, and implantable chemotherapy wafers. For patients with brain metastases treatment decisions require a multidisciplinary approach, balancing many factors including the neurocognitive impact of treatment and the disease process itself. Finally, to continue to advance the field there needs to be continued utilization, both off and on clinical trial, of performance-based clinical outcome assessments (i.e., neurocognitive tests) to objectively assess and measure the neurocognitive outcomes of these patients.
Collapse
Affiliation(s)
- Jeffrey S Wefel
- Section of Neuropsychology, Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Michael W Parsons
- Section of Neuropsychology, Burkhardt Brain Tumor Center, Cleveland Clinic, Cleveland, OH, United States
| | - Vinai Gondi
- Brain and Spine Tumor Center, Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Chicago Proton Center, Warrenville, IL, United States
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
12
|
Reygagne E, Du Boisgueheneuc F, Berger A. Métastases cérébrales : rôle des traitements focaux (chirurgie et radiothérapie) et leur impact cognitif. Bull Cancer 2017; 104:344-355. [DOI: 10.1016/j.bulcan.2016.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 12/07/2016] [Accepted: 12/13/2016] [Indexed: 01/25/2023]
|
13
|
Hoffermann M, Bruckmann L, Mahdy Ali K, Zaar K, Avian A, von Campe G. Pre- and postoperative neurocognitive deficits in brain tumor patients assessed by a computer based screening test. J Clin Neurosci 2017; 36:31-36. [DOI: 10.1016/j.jocn.2016.10.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 10/15/2016] [Indexed: 10/20/2022]
|
14
|
Saria MG, Courchesne N, Evangelista L, Carter J, MacManus DA, Gorman MK, Nyamathi AM, Phillips LR, Piccioni D, Kesari S, Maliski S. Cognitive dysfunction in patients with brain metastases: influences on caregiver resilience and coping. Support Care Cancer 2016; 25:1247-1256. [PMID: 27921222 PMCID: PMC10187463 DOI: 10.1007/s00520-016-3517-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 11/28/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Neurologic deficits that may be manifested as cognitive impairment contribute to the challenges faced by caregivers of patients with brain metastases. To better address their needs, we examined how caregivers respond to these challenges and explore the relationship between the patient's cognitive impairment and caregiver resilience and coping. METHODS We conducted a descriptive, cross-sectional study using self-reported data from 56 caregivers of patients with brain metastases. Study participants from a comprehensive cancer center were asked to complete a series of instruments that measured their perception of the patient's cognitive dysfunction (revised memory and behavior problems checklist, RMBC), their own personal resilience (Resilience Scale, RS), and their utilization of a broad range of coping responses (COPE inventory and Emotional-Approach Coping scale). RESULTS Caregivers reported that memory-related problems occurred more frequently in the patients they cared for compared to depression and disruptive behavior (mean scores 3.52 vs 2.34 vs. 1.32, respectively). Coping strategies most frequently used by caregivers were acceptance (3.28), planning (3.08), and positive reinterpretation and growth (2.95). Most caregivers scored moderate to high on the RS (77%). The coping strategy acceptance correlated significantly with the memory and disruptive behavior subscales of the RMBC. CONCLUSIONS Given the protective effect of problem-focused coping and the high rate of caregivers utilizing less effective coping strategies in instances of worsening cognitive dysfunction, healthcare professionals need to systematically assess the coping strategies of caregivers and deliver a more personalized approach to enhance effective coping among caregivers of patients with brain metastases.
Collapse
Affiliation(s)
- Marlon Garzo Saria
- School of Nursing, University of California, Los Angeles, Factor Bldg., 700 Tiverton Ave, Los Angeles, CA, 90095, USA. .,John Wayne Cancer Institute and Pacific Neuroscience Institute at Providence Saint John's Health Center, 2200 Santa Monica Boulevard, Santa Monica, CA, 90404, USA.
| | - Natasia Courchesne
- Moores Cancer Center, University of California San Diego, 3855 Health Sciences Drive, La Jolla, CA, 92093, USA
| | - Lorraine Evangelista
- Nursing Science, University of California, Irvine, 299E Berk Hall, Irvine, CA, 92697-3959, USA
| | - Joshua Carter
- Quintiles, 10 Waterview Boulevard, Parsippany, NJ, 07054, USA
| | - Daniel A MacManus
- Moores Cancer Center, University of California San Diego, 3855 Health Sciences Drive, La Jolla, CA, 92093, USA
| | - Mary Kay Gorman
- Moores Cancer Center, University of California San Diego, 3855 Health Sciences Drive, La Jolla, CA, 92093, USA
| | - Adeline M Nyamathi
- School of Nursing, University of California, Los Angeles, Factor Bldg., 700 Tiverton Ave, Los Angeles, CA, 90095, USA
| | - Linda R Phillips
- School of Nursing, University of California, Los Angeles, Factor Bldg., 700 Tiverton Ave, Los Angeles, CA, 90095, USA
| | - David Piccioni
- School of Medicine, University of California San Diego, 3855 Health Sciences Drive, La Jolla, CA, 92093, USA
| | - Santosh Kesari
- John Wayne Cancer Institute and Pacific Neuroscience Institute at Providence Saint John's Health Center, 2200 Santa Monica Boulevard, Santa Monica, CA, 90404, USA
| | - Sally Maliski
- School of Nursing, University of California, Los Angeles, Factor Bldg., 700 Tiverton Ave, Los Angeles, CA, 90095, USA.,School of Nursing, University of Kansas Medical Center, Mail Stop 2029, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
| |
Collapse
|
15
|
Chen Y, Yang J, Li X, Hao D, Wu X, Yang Y, He C, Wang W, Wang J. First-line epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor alone or with whole-brain radiotherapy for brain metastases in patients with EGFR-mutated lung adenocarcinoma. Cancer Sci 2016; 107:1800-1805. [PMID: 27627582 PMCID: PMC5198957 DOI: 10.1111/cas.13079] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 09/06/2016] [Accepted: 09/12/2016] [Indexed: 01/27/2023] Open
Abstract
We proposed to compare the outcomes of first-line epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) alone with EGFR-TKI plus whole-brain radiotherapy (WBRT) for the treatment of brain metastases (BM) in patients with EGFR-mutated lung adenocarcinoma. A total of 1665 patients were screened from 2008 to 2014, and 132 were enrolled in our study. Among the 132 patients, 72 (54.5%) harbored a deletion in exon 19, 97 (73.5%) showed multiple intracranial lesions, and 67 (50.8%) had asymptomatic BM. Seventy-nine patients (59.8%) were treated with EGFR-TKI alone, 53 with concomitant WBRT. The intracranial objective response rate was significantly higher in the EGFR-TKI plus WBRT treatment group (67.9%) compared with the EGFR-TKI alone group (39.2%) (P = 0.001). After a median follow-up of 36.2 months, 62.1% of patients were still alive. The median intracranial TTP was 24.7 months (95% CI, 19.5-29.9) in patients who received WBRT, which was significantly longer than in those who received EGFR-TKI alone, with the median intracranial TTP of 18.2 months (95% CI, 12.5-23.9) (P = 0.004). There was no significant difference in overall survival between WBRT and EGFR-TKI alone groups, (median, 48.0 vs 41.1 months; P = 0.740). The overall survival is significantly prolonged in patients who had an intracranial TTP exceeding 22 months compared to those who developed intracranial progression <22 months after treatment, (median, 58.0 vs 28.0 months; P = 0.001). For EGFR-mutated lung adenocarcinoma patients with BM, treatment with concomitant WBRT achieved a higher response rate of BM and significant improvement in intracranial progression-free survival compared with EGFR-TKI alone.
Collapse
Affiliation(s)
- Yongshun Chen
- Department of Clinical Oncology, Hubei General Hospital, Renmin Hospital of Wuhan University, Wuhan, China.,Department of Radiation Oncology, Henan Cancer Hospital, Zhengzhou University Affiliated Cancer Hospital, Zhengzhou, China
| | - Jing Yang
- Department of Radiation Oncology, Angang General Hospital, Anyang, China
| | - Xue Li
- Department of Radiation Oncology, Henan Cancer Hospital, Zhengzhou University Affiliated Cancer Hospital, Zhengzhou, China
| | - Daxuan Hao
- Department of Radiation Oncology, Henan Cancer Hospital, Zhengzhou University Affiliated Cancer Hospital, Zhengzhou, China
| | - Xiaoyuan Wu
- Department of Radiation Oncology, Henan Cancer Hospital, Zhengzhou University Affiliated Cancer Hospital, Zhengzhou, China
| | - Yuanyuan Yang
- Department of Radiation Oncology, Henan Cancer Hospital, Zhengzhou University Affiliated Cancer Hospital, Zhengzhou, China
| | - Chunyu He
- Department of Radiation Oncology, Henan Cancer Hospital, Zhengzhou University Affiliated Cancer Hospital, Zhengzhou, China
| | - Wen Wang
- Department of Radiation Oncology, Henan Cancer Hospital, Zhengzhou University Affiliated Cancer Hospital, Zhengzhou, China
| | - Jianhua Wang
- Department of Radiation Oncology, Henan Cancer Hospital, Zhengzhou University Affiliated Cancer Hospital, Zhengzhou, China
| |
Collapse
|
16
|
Abstract
Radiotherapy (RT) has proven to be an effective therapeutic tool in treatment of a wide variety of brain tumors; however, it has a negative impact on quality of life and neurocognitive function. Cognitive dysfunction associated with both the disease and adverse effects of RT is one of the most concerning complication among long-term survivors. The effects of RT to brain can be divided into acute, early delayed, and late delayed. It is, however, the late delayed effects of RT that lead to severe neurological consequences such as minor-to-severe cognitive deficits due to irreversible focal or diffuse necrosis of brain parenchyma. In this review, we discuss current and emerging data regarding the relationship between RT and neurocognitive outcomes, and therapeutic strategies to prevent/treat postradiation neurocognitive deficits.
Collapse
|
17
|
Triebel KL, Gerstenecker A, Meneses K, Fiveash JB, Meyers CA, Cutter G, Marson DC, Martin RC, Eakin A, Watts O, Nabors LB. Capacity of patients with brain metastases to make treatment decisions. Psychooncology 2015; 24:1448-55. [PMID: 25613039 PMCID: PMC4512930 DOI: 10.1002/pon.3753] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 11/21/2014] [Accepted: 12/18/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to investigate medical decision-making capacity (MDC) in patients with brain metastases. METHODS Participants were 41 adults with brain metastases with Karnofsky Performance Status scores of ≥70 who were recruited from an academic medical center and 41 demographically matched controls recruited from the community. We evaluated MDC using the Capacity to Consent to Treatment Instrument and its four clinically relevant consent standards (expressing a treatment choice, appreciation, reasoning, and understanding). Capacity impairment ratings (no impairment, mild/moderate impairment, and severe impairment) on the consent standards were also assigned to each participant with brain metastasis using cutoff scores derived statistically from the performance of the control group. RESULTS The brain metastasis patient group performed significantly below controls on consent standards of understanding and reasoning. Capacity compromise was defined as performance ≤1.5 standard deviations below the control group mean. Using this definition, approximately 60% of the participants with brain metastases demonstrated capacity compromise on at least one MDC standard. CONCLUSION When defining capacity compromise as performance ≤1.5 standard deviation below the control group mean, over half of patients with brain metastases have reduced capacity to make treatment decisions. This impairment is demonstrated shortly after initial diagnosis of brain metastases and highlights the importance of routine clinical assessment of MDC following diagnosis of brain metastasis. These results also indicate a need for the development and investigation of interventions to support or improve MDC in this patient population.
Collapse
Affiliation(s)
- Kristen L. Triebel
- Department of Neurology, UAB, Birmingham, AL
- Comprehensive Cancer Center, UAB, Birmingham, AL
| | | | - Karen Meneses
- Comprehensive Cancer Center, UAB, Birmingham, AL
- School of Nursing, UAB, Birmingham, AL
| | - John B. Fiveash
- Comprehensive Cancer Center, UAB, Birmingham, AL
- Department of Radiation Oncology, UAB, Birmingham, AL
| | - Christina A. Meyers
- Department of Neuro-Oncology, M.D. Anderson Cancer Center, Houston, TX (retired)
| | - Gary Cutter
- Department of Biostatistics, School of Public Health, UAB, Birmingham, AL
| | | | | | | | - Olivia Watts
- Department of Psychology, Boston University, Boston, MA
| | - Louis B. Nabors
- Department of Neurology, UAB, Birmingham, AL
- Comprehensive Cancer Center, UAB, Birmingham, AL
| |
Collapse
|
18
|
Gerstenecker A, Nabors LB, Meneses K, Fiveash JB, Marson DC, Cutter G, Martin RC, Meyers CA, Triebel KL. Cognition in patients with newly diagnosed brain metastasis: profiles and implications. J Neurooncol 2014; 120:179-85. [PMID: 25035099 PMCID: PMC4295820 DOI: 10.1007/s11060-014-1543-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 07/06/2014] [Indexed: 10/25/2022]
Abstract
Cognitive impairment is a common symptom in patients with brain metastasis, and significant cognitive dysfunction is prevalent in a majority of patients who are still able to engage in basic self-care activities. In the current study, the neurocognitive performance of 32 patients with brain metastasis and 32 demographically-matched controls was examined using a battery of standardized neuropsychological tests, with the goal of comprehensively examining the cognitive functioning of newly diagnosed brain metastasis patients. The cognition of all patients was assessed within 1 week of beginning treatment for brain metastasis. Results indicated impairments in verbal memory, attention, executive functioning, and language in relation to healthy controls. Performance in relation to appropriate normative groups was also examined. Overall, cognitive deficits were prevalent and memory was the most common impairment. Given that cognitive dysfunction was present in this cohort of patients with largely minimal functional impairment, these results have implications for patients, caregivers and health care providers treating patients with brain metastasis.
Collapse
|
19
|
McDuff SGR, Taich ZJ, Lawson JD, Sanghvi P, Wong ET, Barker FG, Hochberg FH, Loeffler JS, Warnke PC, Murphy KT, Mundt AJ, Carter BS, McDonald CR, Chen CC. Neurocognitive assessment following whole brain radiation therapy and radiosurgery for patients with cerebral metastases. J Neurol Neurosurg Psychiatry 2013; 84:1384-91. [PMID: 23715918 DOI: 10.1136/jnnp-2013-305166] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The treatment of metastatic brain lesions remains a central challenge in oncology. Because most chemotherapeutic agents do not effectively cross the blood-brain barrier, it is widely accepted that radiation remains the primary modality of treatment. The mode by which radiation should be delivered has, however, become a source of intense controversy in recent years. The controversy involves whether patients with a limited number of brain metastases should undergo whole brain radiation therapy (WBRT) or stereotactic radiosurgery (SRS) delivered only to the radiographically visible tumours. Survival is comparable for patients treated with either modality. Instead, the controversy involves the neurocognitive function (NCF) of radiating cerebrum that appeared radiographically normal relative to effects of the growth from micro-metastatic foci. A fundamental question in this debate involves quantifying the effect of WBRT in patients with cerebral metastasis. To disentangle the effects of WBRT on neurocognition from the effects inherent to the underlying disease, we analysed the results from randomised controlled studies of prophylactic cranial irradiation in oncology patients as well as studies where patients with limited cerebral metastasis were randomised to SRS versus SRS+WBRT. In aggregate, these results suggest deleterious effects of WBRT in select neurocognitive domains. However, there are insufficient data to resolve the controversy of upfront WBRT versus SRS in the management of patients with limited cerebral metastases.
Collapse
Affiliation(s)
- Susan G R McDuff
- Center for Theoretical and Applied Neuro-Oncology, University of California, , La Jolla, California, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Taillia H, Bompaire F, Jacob J, Noël G. [Cognitive evaluation during brain radiotherapy in adults: a simple assessment is possible]. Cancer Radiother 2013; 17:413-8. [PMID: 24007953 DOI: 10.1016/j.canrad.2013.07.139] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 07/10/2013] [Indexed: 10/26/2022]
Abstract
Brain irradiation can be used for the treatment of cancers in different protocols: focal radiotherapy, whole brain radiotherapy, with or without additive dose on the tumour. Different modalities (conformational, stereotactic radiosurgery) can be used for curative or prophylactic treatment. Brain radiotherapy leads to cognitive deterioration with subcortical profile. This cognitive deterioration can be associated to radiation-induced leukoencephalopathy on brain MRI. Taking into account radiation induced cognitive troubles is becoming more important with the prolonged survival allowed by treatment improvement. Concerning low-grade gliomas, radiation-induced cognitive troubles appear about 6 years after treatment and occur earlier when the fraction dose is important. Primitive cerebral lymphoma treatment can induce cognitive troubles in 25 to 30% surviving patients. These deficits are more frequent in elderly patients, leading to radiotherapy delay in those patients. Patients treated for brain metastasis often have cognitive impairment before radiotherapy (until 66%), this pretreatment impairment is related to global survival. The use of conformational radiation therapy, particularly with hippocampal sparing is conceptually interesting but has not proved its efficiency for cognitive preservation in clinical trials yet. Stereotactic radiation therapy could be an interesting compromise between metastatic tumoral volume reduction and cognitive preservation. Taking care of radiotherapy induced cognitive troubles is a challenge. Before considering its treatment and prevention, we need to elaborate a way of detecting them using a reliable and easy way. CSCT, a computerized test whose execution needs 90 seconds, could be used before treatment and during the clinical follow-up by the patient's oncologist or radiotherapist. If the patient's performance reduces, he can be oriented to a neurologist in order to perform fuller evaluation of its cognitive capacities and be treated if necessary.
Collapse
Affiliation(s)
- H Taillia
- Service de neurologie, hôpital d'instruction des armées, 74, boulevard de Port-Royal, 75005 Paris, France.
| | | | | | | |
Collapse
|
21
|
Métastases cérébrales intracrâniennes : signes cliniques et évaluations cognitives. Bull Cancer 2013; 100:83-8. [DOI: 10.1684/bdc.2012.1686] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
|
22
|
Cognition et radiothérapie dans les métastases cérébrales : un nouveau paradigme à définir. Bull Cancer 2013; 100:69-74. [DOI: 10.1684/bdc.2012.1682] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
23
|
Fernandez G, Pocinho R, Travancinha C, Netto E, Roldão M. Quality of life and radiotherapy in brain metastasis patients. Rep Pract Oncol Radiother 2012; 17:281-7. [PMID: 24669309 DOI: 10.1016/j.rpor.2012.08.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2011] [Revised: 08/02/2012] [Accepted: 08/10/2012] [Indexed: 11/15/2022] Open
Abstract
AIM The primary objective of this study was to assess whether there was an improvement in QoL for patients with brain metastases after radiotherapy treatments. BACKGROUND Assessment of quality of life (QoL) in brain metastasis patients has become increasingly recognized as an important outcome. MATERIALS AND METHODS Patients treated for brain metastasis in our department during 2010 were included in our prospective study. QoL assessments were conducted at baseline, 1 month, and 3 months after completion of whole-brain radiotherapy (WBRT). Wilcoxon test for multiple comparisons was calculated to detect significant differences in global QoL scores. RESULTS Thirty-nine patients with brain metastases completed the EORTC QLQ-C30/BN-20 questionnaire independently. Median age was 59.9 years (from 37 to 81 years). Our results report differences between the baseline and 3 months in worsening of a global health status (p = 0.034) and cognitive function (p = 0.004), as well as drowsiness (p = 0.001), appetite loss (p = 0.031) and hair loss (p = 0.005). There is a tendency for deterioration of physical function (p = 0.004), communication deficit (p = 0.012), and weakness of legs (p = 0.024), between the baseline and 1 month evaluation. There was no difference in a global cognitive status between different evaluations. Median survival time was 3 months (CI 95% 1.85; 4.15). CONCLUSIONS Our findings indicate a small deterioration for a global QoL status, and large deterioration for cognitive function after radiation treatments, as well as worsening of brain metastasis related symptom items. Further research is necessary to refine treatment selection for patients with brain metastases, since it may at least contribute to the stabilization of their QoL status.
Collapse
Affiliation(s)
- Gonçalo Fernandez
- Radiotherapy Department at Instituto Português de Oncologia de Lisboa - Francisco Gentil, Portugal
| | - Rute Pocinho
- Radiotherapy Department at Instituto Português de Oncologia de Lisboa - Francisco Gentil, Portugal
| | - Catarina Travancinha
- Radiotherapy Department at Instituto Português de Oncologia de Lisboa - Francisco Gentil, Portugal
| | - Eduardo Netto
- Radiotherapy Department at Instituto Português de Oncologia de Lisboa - Francisco Gentil, Portugal
| | - Margarida Roldão
- Radiotherapy Department at Instituto Português de Oncologia de Lisboa - Francisco Gentil, Portugal
| |
Collapse
|
24
|
Greene-Schloesser D, Robbins ME, Peiffer AM, Shaw EG, Wheeler KT, Chan MD. Radiation-induced brain injury: A review. Front Oncol 2012; 2:73. [PMID: 22833841 PMCID: PMC3400082 DOI: 10.3389/fonc.2012.00073] [Citation(s) in RCA: 430] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 06/26/2012] [Indexed: 12/03/2022] Open
Abstract
Approximately 100,000 primary and metastatic brain tumor patients/year in the US survive long enough (>6 months) to experience radiation-induced brain injury. Prior to 1970, the human brain was thought to be highly radioresistant; the acute CNS syndrome occurs after single doses >30 Gy; white matter necrosis occurs at fractionated doses >60 Gy. Although white matter necrosis is uncommon with modern techniques, functional deficits, including progressive impairments in memory, attention, and executive function have become important, because they have profound effects on quality of life. Preclinical studies have provided valuable insights into the pathogenesis of radiation-induced cognitive impairment. Given its central role in memory and neurogenesis, the majority of these studies have focused on the hippocampus. Irradiating pediatric and young adult rodent brains leads to several hippocampal changes including neuroinflammation and a marked reduction in neurogenesis. These data have been interpreted to suggest that shielding the hippocampus will prevent clinical radiation-induced cognitive impairment. However, this interpretation may be overly simplistic. Studies using older rodents, that more closely match the adult human brain tumor population, indicate that, unlike pediatric and young adult rats, older rats fail to show a radiation-induced decrease in neurogenesis or a loss of mature neurons. Nevertheless, older rats still exhibit cognitive impairment. This occurs in the absence of demyelination and/or white matter necrosis similar to what is observed clinically, suggesting that more subtle molecular, cellular and/or microanatomic modifications are involved in this radiation-induced brain injury. Given that radiation-induced cognitive impairment likely reflects damage to both hippocampal- and non-hippocampal-dependent domains, there is a critical need to investigate the microanatomic and functional effects of radiation in various brain regions as well as their integration at clinically relevant doses and schedules. Recently developed techniques in neuroscience and neuroimaging provide not only an opportunity to accomplish this, but they also offer the opportunity to identify new biomarkers and new targets for interventions to prevent or ameliorate these late effects.
Collapse
Affiliation(s)
- Dana Greene-Schloesser
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | | | | | | | | |
Collapse
|
25
|
Wang HZ, Qiu SJ, Lv XF, Wang YY, Liang Y, Xiong WF, Ouyang ZB. Diffusion tensor imaging and 1H-MRS study on radiation-induced brain injury after nasopharyngeal carcinoma radiotherapy. Clin Radiol 2011; 67:340-5. [PMID: 22119296 DOI: 10.1016/j.crad.2011.09.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 09/17/2011] [Accepted: 09/27/2011] [Indexed: 11/20/2022]
Abstract
AIM To investigate the metabolic characteristics of the temporal lobes following radiation therapy for nasopharyngeal carcinoma using diffusion tensor imaging (DTI) and proton magnetic resonance spectroscopy ((1)H-MRS). MATERIALS AND METHODS DTI and (1)H-MRS were performed in 48 patients after radiotherapy for nasopharyngeal carcinoma and in 24 healthy, age-matched controls. All patients and controls had normal findings on conventional MRI. Apparent diffusion coefficient (ADC), fractional anisotropy (FA), three eigenvalues λ1, λ2, λ3, N-acetylaspartic acid (NAA)/choline (Cho), NAA/creatinine (Cr), and Cho/Cr were measured in both temporal lobes. Patients were divided into three groups according to time after completion of radiotherapy: group 1, less than 6 months; group 2, 6-12 months; group 3, more than 12 months. Mean values for each parameter were compared using one-way analysis of variance (ANOVA). RESULTS Mean FA in group 1 was significantly lower compared to group 3 and the control group (p < 0.05). Group-wise comparisons of apparent diffusion coefficient (ADC) values among all the groups were not significantly different. Eigenvalue λ1 was significantly lower in groups 1 and 3 compared to the control group (p < 0.05). NAA/Cho and NAA/Cr were significantly lower in each group compared to the control group (p < 0.01 for both). The decrease in NAA/Cho was greatest in group 1. There were no significant between-group differences regarding Cho/Cr. CONCLUSION A combination of DTI and (1)H-MRS can be used to detect radiation-induced brain injury, in patients treated for nasopharyngeal carcinoma.
Collapse
Affiliation(s)
- H-Z Wang
- Department of Medical Imaging Center, Nan Fang Hospital, Southern Medical University, Guangzhou 510515, China
| | | | | | | | | | | | | |
Collapse
|
26
|
Olson RA, Iverson GL, Carolan H, Parkinson M, Brooks BL, McKenzie M. Prospective comparison of two cognitive screening tests: diagnostic accuracy and correlation with community integration and quality of life. J Neurooncol 2011; 105:337-44. [PMID: 21520004 DOI: 10.1007/s11060-011-0595-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 04/18/2011] [Indexed: 01/13/2023]
Abstract
Cognitive screening tests are frequently used in brain tumor clinics. The Mini Mental State Examination (MMSE) is the most commonly used, and the Montreal Cognitive Assessment (MoCA) is an alternative. This study compares the diagnostic accuracy of both screening tests. Fifty-eight patients with brain tumors were prospectively accrued and administered the MMSE and MoCA, 67% of who completed a comprehensive neuropsychological evaluation as a gold standard comparison. Quality of life and community integration were measured with the Functional Assessment of Cancer Therapy-Brain (FACT-Br) and Community Integration Questionnaire (CIQ), respectively. At the pre-defined cut-off scores, the MoCA had superior sensitivity (61.9% vs. 19.0%, P < 0.005) and the MMSE had superior specificity (94.4% vs. 55.6%, P < 0.017). The areas under the ROC curve for the MMSE (0.615, standard error = 0.091) and MoCA (0.606, standard error = 0.092) were poor, indicating that at no single cut-off score is either test both sensitive and specific. Neither the MMSE (ρ = 0.12; P < 0.444) nor MoCA (ρ = 0.24; P < 0.108) were significantly correlated with the FACT-Br. The MoCA was modestly correlated with the CIQ (ρ = 0.35; P < 0.017), but the MMSE was not (ρ = 0.14; P < 0.359). The MMSE has extremely poor sensitivity. Using this test in clinical practice, research, and clinical trials will result in failing to detect cognitive impairment in a substantial percentage of patients. The MoCA has superior sensitivity, and is better correlated with self reported measures of community integration, and therefore should be preferentially chosen in practice and clinical trials.
Collapse
Affiliation(s)
- Robert A Olson
- BC Cancer Agency, Centre for North, Prince George, BC, Canada.
| | | | | | | | | | | |
Collapse
|
27
|
Witgert ME, Meyers CA. Neurocognitive and Quality of Life Measures in Patients with Metastatic Brain Disease. Neurosurg Clin N Am 2011; 22:79-85, vii. [DOI: 10.1016/j.nec.2010.08.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
28
|
Current treatment strategies for brain metastasis and complications from therapeutic techniques: a review of current literature. Am J Clin Oncol 2010; 33:398-407. [PMID: 19675447 DOI: 10.1097/coc.0b013e318194f744] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Each year approximately 170,000 patients are diagnosed with brain metastasis in the United States, making this the most common intracranial tumor in adults. Historically, treatment strategies focused on the use of whole brain radiation therapy (WBRT) for palliation, yielding a median survival time of only 3 to 6 months. The possible effect of WBRT on cognitive function has generated much concern and debate regarding the use of this modality. Thus, the use of WBRT alone, or in conjunction with other treatment modalities should take into account both risks and benefits, to ensure the best patient outcome with regard to disease state and functional status. The advent of technologies permitting local dose-escalation have clearly increased local control rates, and in select patients, even survival, thereby, further intensifying the debate regarding the use of WBRT. Here, we review the use of WBRT, radiosurgery, and resection for the treatment of brain metastases. Further, we will review the use of radiation sensitizers and blood-brain barrier penetrating cytotoxics such as temozolomide. Finally, we will discuss current treatment strategies for possibly maintaining and improving cognitive function for these patients.
Collapse
|
29
|
Abstract
OBJECTIVE Two prospective studies in patient with brain tumours were performed comparing the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). The first assessed their feasibility and the second compared their diagnostic accuracy against a four-hour neuropsychological assessment (NPA). The introduction of the NPA decreased accrual and retention rates. We were therefore concerned regarding potential selection bias. METHODS Ninety-two patients were prospectively accrued and subsequently divided into three categories: a) no NPA required b) withdrew consent to NPA c) completed NPA. In order to quantify any potential bias introduced by the NPA, patient demographics and cognitive test scores were compared between the three groups. RESULTS There were significant differences in age (p < 0.001), education (p = 0.034), dexamethasone use (p = 0.002), MMSE (p = 0.005), and MoCA scores (p < 0.001) across the different study groups. Furthermore, with increasing involvement of the NPA, patients' cognitive scores and educational status increased, while their age, dexamethasone use, and opioid use all decreased. Individuals who completed the NPA had higher MoCA scores than individuals who were not asked to complete the NPA (24.7 vs. 20.5; p < 0.001). In addition, this relationship held when restricting the analyses to individuals with brain metastases (p < 0.001). CONCLUSIONS In this study, the lengthy NPA chosen introduced a statistically and clinically significant source of selection bias. These results highlight the importance of selecting brief and well tolerated assessments when possible. However, researchers are challenged by weighing the improved selection bias associated with brief assessments at the cost of reduced diagnostic accuracy.
Collapse
|
30
|
Chang EL, Wefel JS, Hess KR, Allen PK, Lang FF, Kornguth DG, Arbuckle RB, Swint JM, Shiu AS, Maor MH, Meyers CA. Neurocognition in patients with brain metastases treated with radiosurgery or radiosurgery plus whole-brain irradiation: a randomised controlled trial. Lancet Oncol 2009; 10:1037-44. [DOI: 10.1016/s1470-2045(09)70263-3] [Citation(s) in RCA: 1724] [Impact Index Per Article: 114.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
31
|
Abstract
Detecting a new area of contrast enhancement in or in the vicinity of a previously treated brain tumor always causes concern for both the patient and the physician. The question that immediately arises is whether this new lesion is recurrent tumor or a treatment effect. The differentiation of recurrent tumor or progressive tumor from radiation injury after radiation therapy is often a radiologic dilemma regardless the technique used, CT or MR imaging. The purpose of this article was to review the utility of one of the newer MR imaging techniques, MR spectroscopy, to distinguish recurrent tumor from radiation necrosis or radiation injury.
Collapse
Affiliation(s)
- P C Sundgren
- Division of Neuroradiology, Department of Radiology, University of Michigan Health Systems, 1500 E Medical Center Drive, Ann Arbor, MI 48109, USA.
| |
Collapse
|
32
|
Lageman SK, Cerhan JH, Locke DEC, Anderson SK, Wu W, Brown PD. Comparing neuropsychological tasks to optimize brief cognitive batteries for brain tumor clinical trials. J Neurooncol 2009; 96:271-6. [PMID: 19618121 DOI: 10.1007/s11060-009-9960-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Accepted: 07/06/2009] [Indexed: 10/20/2022]
Abstract
Neuropsychological tests are increasingly being used as outcome measures in clinical trials of brain tumor therapies. This study informs development of brief neurocognitive batteries for clinical trials by identifying cognitive tasks that detect effects on a group level in a mixed brain tumor population. This is a retrospective study of brain tumor patients who completed a standardized battery sampling multiple cognitive domains using twelve subtests with widely-used task formats (the Repeatable Battery for the Assessment of Neuropsychological Status). Sixty-eight patients with brain tumors were studied (60% high-grade glioma). Forty patients (58.8%) were impaired (>2 standard deviations below published means) on at least one subtest. A combination of four subtests (Figure Copy, Coding, List Recognition, and Story Recall) captured 90% of the impaired subgroup. These results suggest visuoconstruction, processing speed, and verbal memory measures may be the most important domains to assess when evaluating cognitive change in brain tumor clinical trials.
Collapse
Affiliation(s)
- Sarah K Lageman
- Department of Rehabilitation Medicine, Emory University, 1441 Clifton Road NE, Suite 150, Atlanta, GA 30322, USA.
| | | | | | | | | | | |
Collapse
|
33
|
Sundgren PC, Nagesh V, Elias A, Tsien C, Junck L, Gomez Hassan DM, Lawrence TS, Chenevert TL, Rogers L, McKeever P, Cao Y. Metabolic alterations: a biomarker for radiation-induced normal brain injury-an MR spectroscopy study. J Magn Reson Imaging 2009; 29:291-7. [PMID: 19161192 DOI: 10.1002/jmri.21657] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To assess if interval changes in metabolic status in normal cerebral tissue after radiation therapy (RT) can be detected by 2D CSI (chemical shift imaging) proton spectroscopy. MATERIALS AND METHODS Eleven patients with primary brain tumors undergoing cranial radiation therapy (RT) were included. 2D-CSI MRS was performed before, during, and after the course of RT with the following parameters: TE/TR 144/1500 ms, field of view (FOV) 24, thickness 10 mm, matrix 16 x 16. The metabolic ratios choline/creatine (Cho/Cr), N-acetylaspartate (NAA)/Cr, and NAA/Cho in normal brain tissue were calculated. RESULTS NAA/Cr and Cho/Cr were significantly decreased at week 3 during RT and at 1 month and 6 months after RT compared to values prior to RT (P < 0.01). The NAA/Cr ratio decreased by -0.19 +/- 0.05 (mean +/- standard error [SE]) at week 3 of RT, -0.14 +/- 0.06 at the last week of RT, -0.14 +/- 0.05 at 1 month after RT, and -0.30 +/- 0.08 at 6 months after RT compared to the pre-RT value of 1.43 +/- 0.04. The Cho/Cr ratio decreased by -0.27 +/- 0.05 at week 3 of RT, -0.11 +/- 0.05 at the last week of RT, -0.26 +/- 0.05 at 1 month after RT and -0.25 +/- 0.07 at 6 months after RT from the pre-RT value of 1.29 +/- 0.03. Changes in Cho/Cr were correlated with the interaction of the radiation dose and dose-volume at week 3 of RT, during the last week of RT (P < 0.005), and at 1 month after RT (P = 0.017). CONCLUSION The results of this study suggest that MRS can detect early metabolic changes in normal irradiated brain tissue.
Collapse
Affiliation(s)
- P C Sundgren
- Department of Radiology, University of Michigan University Health Systems, Ann Arbor, Michigan 48109, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Baschnagel A, Wolters PL, Camphausen K. Neuropsychological testing and biomarkers in the management of brain metastases. Radiat Oncol 2008; 3:26. [PMID: 18798997 PMCID: PMC2556333 DOI: 10.1186/1748-717x-3-26] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Accepted: 09/17/2008] [Indexed: 11/10/2022] Open
Abstract
Prognosis for patients with brain metastasis remains poor. Whole brain radiation therapy is the conventional treatment option; it can improve neurological symptoms, prevent and improve tumor associated neurocognitive decline, and prevents death from neurologic causes. In addition to whole brain radiation therapy, stereotactic radiosurgery, neurosurgery and chemotherapy also are used in the management of brain metastases. Radiosensitizers are now currently being investigated as potential treatment options. All of these treatment modalities carry a risk of central nervous system (CNS) toxicity that can lead to neurocognitive impairment in long term survivors. Neuropsychological testing and biomarkers are potential ways of measuring and better understanding CNS toxicity. These tools may help optimize current therapies and develop new treatments for these patients. This article will review the current management of brain metastases, summarize the data on the CNS effects associated with brain metastases and whole brain radiation therapy in these patients, discuss the use of neuropsychological tests as outcome measures in clinical trials evaluating treatments for brain metastases, and give an overview of the potential of biomarker development in brain metastases research.
Collapse
Affiliation(s)
- Andrew Baschnagel
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, 9000 Rockville Pike, Building 10-CRC, Room B2-3561, Bethesda, Maryland, 20892, USA.
| | | | | |
Collapse
|
35
|
Prospective assessment of activities of daily living using modified Barthel's Index in children and young adults with low-grade gliomas treated with stereotactic conformal radiotherapy. J Neurooncol 2008; 90:321-8. [PMID: 18704269 DOI: 10.1007/s11060-008-9666-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2008] [Accepted: 07/24/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE To report prospective evaluations of activities of daily living (ADL) in young patients with low-grade gliomas treated with stereotactic conformal radiotherapy (SCRT). MATERIALS AND METHODS Between April 2001 and February 2008, 38 children and young adults (age 5-25 years, median 12.5 years) with low-grade gliomas with residual/progressive disease and treated with SCRT were accrued in a prospective protocol. Patients underwent baseline and follow-up ADL assessments by the modified Barthel's battery, which comprises domains of personal hygiene, bathing self, feeding, toilet, stair climbing, dressing, bowel control, bladder control, ambulation, and chair-bed transfer. RESULT The patient population consisted of 38 patients (male 29, female 9) with a diagnosis of residual or progressive low-grade glioma (pilocytic astrocytoma in 27, fibrillary astrocytoma in 5, ependymoma in 4, and oligodendroglioma and pleomorphic xanthoastrocytoma in 1 each). Three patients were visually handicapped. Mean of total modified Barthel's ADL score (Barthel' Index, BI) at baseline before staring SCRT was 94.5 (standard deviation 14.8, range 45-100). At 2-year and 3-year follow-up, mean BI was 97.1 and 99, respectively. At baseline pre-radiotherapy assessment, patients with impaired visual function and with low performance status (Karnofsky performance score, KPS < 70) had significantly lower BI than those with normal vision (P <or= 0.001) and with good performance status (P = 0.001). On follow-up, maximum improvement in individual BI was seen in the ambulation-related domain in patients with impaired visual function (P = 0.027), low KPS (P = 0.015), and age less than 13 years (P = 0.103). The mean pre-radiotherapy baseline BI of three patients, who eventually developed local recurrence, was only 64 (SD 32.1) as compared with a baseline score of 97.18 seen in patients whose tumor remained controlled at follow-up (P <or= 0.001). CONCLUSIONS Young patients with low-grade gliomas after surgical intervention had a lower than normal BI before starting radiotherapy, suggesting a decrease in ADL possibly due to tumor- and surgery-related factors. At 2-year and 3-year follow-up after SCRT, there was no further decrease in mean BI. A significant improvement in BI was seen in visually handicapped patients, patients with poor performance status, and younger patients. Patients who developed tumor recurrence at follow-up had a significantly lower BI at baseline than patients with controlled disease (P <or= 0.001).
Collapse
|
36
|
Li J, Bentzen SM, Li J, Renschler M, Mehta MP. Relationship between neurocognitive function and quality of life after whole-brain radiotherapy in patients with brain metastasis. Int J Radiat Oncol Biol Phys 2008; 71:64-70. [PMID: 18406884 DOI: 10.1016/j.ijrobp.2007.09.059] [Citation(s) in RCA: 208] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Revised: 07/29/2007] [Accepted: 09/08/2007] [Indexed: 11/18/2022]
Abstract
PURPOSE To examine the relationship between neurocognitive function (NCF) and quality of life (QOL) in patients with brain metastases after whole-brain radiotherapy. PATIENTS AND METHODS A total of 208 patients from the whole-brain radiotherapy arm of a Phase III trial (PCI-P120-9801), who underwent regular NCF and QOL (ADL [activities of daily living] and FACT-Br [Functional Assessment of Cancer Therapy-Brain-specific]) testing, were analyzed. Spearman's rank correlation was calculated between NCF and QOL, using each patient's own data, at each time point. To test the hypothesis that NCF declines before QOL changes, the predictive effect of NCF from previous visits on QOL was studied with a linear mixed-effects model. Neurocognitive function or QOL deterioration was defined relative to each patient's own baseline. Lead or lag time, defined as NCF deterioration before or after the date of QOL decline, respectively, was computed. RESULTS At baseline, all NCF tests showed statistically significant correlations with ADL, which became stronger at 4 months. A similar observation was made with FACT-Br. Neurocognitive function scores from previous visits predicted ADL (p < 0.05 for seven of eight tests) or FACT-Br. Scores on all eight NCF tests deteriorated before ADL decline (net lead time 9-153 days); and scores on six of eight NCF tests deteriorated before FACT-Br (net lead time 9-82 days). CONCLUSIONS Neurocognitive function and QOL are correlated. Neurocognitive function scores from previous visits are predictive of QOL. Neurocognitive function deterioration precedes QOL decline. The sequential association between NCF and QOL decline suggests that delaying NCF deterioration is a worthwhile treatment goal in brain metastases patients.
Collapse
Affiliation(s)
- Jing Li
- Department of Human Oncology, University of Wisconsin Comprehensive Cancer Center, Madison, WI 53792, USA
| | | | | | | | | |
Collapse
|
37
|
Feasibility study of the Montreal Cognitive Assessment (MoCA) in patients with brain metastases. Support Care Cancer 2008; 16:1273-8. [PMID: 18335256 DOI: 10.1007/s00520-008-0431-3] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2007] [Accepted: 02/20/2008] [Indexed: 10/22/2022]
Abstract
GOAL OF WORK Detection of cognitive impairment in patients with brain metastases is important for both patient management and clinical trials. The most commonly used cognitive screen, the Mini Mental State Examination (MMSE), though convenient, is not sensitive in these patients. More sensitive tools are less convenient and, therefore, uncommonly used. Therefore, a practical and sensitive tool is needed. The Montreal Cognitive Assessment (MoCA) is a good candidate, shown to be sensitive in detecting mild cognitive impairment in the pre-dementia setting. This study is the first to explore the MoCA in cancer patients and is aimed at determining the feasibility of administering the MoCA in brain tumor patients. The secondary objective is to explore the relationship between MoCA and MMSE scores. PATIENTS AND METHODS Forty patients with brain metastases being treated with whole brain radiotherapy were prospectively accrued from January to May 2007. All patients were administered both the MoCA and MMSE. MAIN RESULTS The MoCA was completed in 10 min in 88% of patients. 92% of all the patients found the MoCA to be only mildly or not at all inconvenient. Eighty percent of the patients were deemed cognitively impaired by the MoCA compared with 30% by the MMSE (p < 0.0001). Of the 28 patients with a normal MMSE, 71% had cognitive impairment according to the MoCA. Overall, 50% of the patients had an abnormal MoCA, yet normal MMSE. CONCLUSION The MoCA was well tolerated and provided additional information over the MMSE, justifying further validation studies of the MoCA in brain tumor patients.
Collapse
|
38
|
Abstract
In general, the development of CNS metastases of breast cancer depends on several prognostic factors, including younger age and a negative hormone receptor status. Also, the presence of a breast cancer 1, early onset (BRCA1) germline mutation and expression of the human epidermal growth factor receptor 2 (Her2/neu) proto-oncogene seem to contribute to an increased rate of development of CNS metastases. The choice of appropriate therapy for brain metastases also depends on prognostic factors, including the age of the patient, the Karnofsky performance score, the number of brain metastases and the presence of systemic disease. Surgery followed by whole brain radiation therapy (WBRT) is generally restricted to ambulant patients with a single brain metastasis without active extracranial disease. In patients who have two to four metastases, stereotactic focal radiotherapy (i.e. radiosurgery) with or without WBRT is usually indicated. In the remainder of patients, WBRT alone provides adequate palliation. Although breast carcinoma is sensitive to chemotherapy, the role of chemotherapy in the treatment of brain metastases is still unclear. Objective responses after cyclophosphamide-based therapies were reported in studies performed in the 1980s. Subgroup analysis of data from a randomised study indicates that survival may improve if WBRT is combined with the radiosensitiser efaproxiral. Interestingly, the Her2/neu antibody trastuzumab, which does not cross the blood-brain barrier, produces systemic responses and enhanced survival, without a clear effect on brain metastases. Breast cancer constitutes the most common solid primary tumour leading to leptomeningeal disease. Clinical symptoms such as cranial nerve dysfunction or a cauda equina syndrome can be treated with local radiotherapy. A randomised study in patients with leptomeningeal disease secondary to breast cancer has revealed that intrathecal chemotherapy is associated with substantially more adverse effects than non-intrathecal treatment, without a clear benefit in terms of response or survival. Intramedullary metastasis is rare but often presents with a rapidly progressive myelopathy. Local radiotherapy may preserve neurological function. Epidural spinal cord metastasis occurs in approximately 4% of patients and can lead to paraplegia. A randomised study has shown that surgical intervention together with local radiotherapy is superior to local radiotherapy alone.
Collapse
Affiliation(s)
- Evert C A Kaal
- Department of Neurology, Medical Center Haaglanden, The Hague, The Netherlands
| | | |
Collapse
|
39
|
Affiliation(s)
- Jing Li
- Department of Human Oncology, University of Wisconsin Comprehensive Cancer Center, Madison, WI
| | - Soren M. Bentzen
- Department of Human Oncology, University of Wisconsin Comprehensive Cancer Center, Madison, WI
| | - Minesh P. Mehta
- Department of Human Oncology, University of Wisconsin Comprehensive Cancer Center, Madison, WI
| | | |
Collapse
|
40
|
Li J, Bentzen SM, Renschler M, Mehta MP. Regression After Whole-Brain Radiation Therapy for Brain Metastases Correlates With Survival and Improved Neurocognitive Function. J Clin Oncol 2007; 25:1260-6. [PMID: 17401015 DOI: 10.1200/jco.2006.09.2536] [Citation(s) in RCA: 229] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Brain metastasis (BM) is a major cause of suffering and health costs in cancer patients. Whole-brain radiation therapy (WBRT) offers tumor shrinking and palliation in many cases, but it has been speculated that these benefits may be outweighed by adverse effects on neurocognitive function (NCF). Patients and Methods Two hundred eight BM patients from the WBRT arm of phase III trial PCI-P120-9801 evaluating motexafin gadolinium were analyzed. NCF, assessed by tests of memory, executive function, and fine motor coordination, was correlated to magnetic resonance imaging–measured BM volume. NCF and survival were compared in 135 patients assessable at 2 months with tumor shrinkage below (poor responders) and above (good responders) the population median (45%). Mean NCF scores and BM volume at 4 and 15 months were compared. Results Good responders experienced a significantly improved survival (unidirectional P = .03). For all tests, the median time to NCF deterioration was longer in good compared with poor responders, with statistical significance seen for Trailmaking B (executive function), and two Pegboard tests (fine motor). In long-term survivors, tumor shrinkage significantly correlated with preservation of executive function and fine motor coordination (r = 0.68 to 0.88). During the early follow-up period, the population mean NCF scores were dominated by patients with progressive disease. A small subset of 15-month survivors had stable or improving scores, and greater mean BM reduction. Conclusion WBRT-induced tumor shrinkage correlates with better survival and NCF preservation. NCF is stable or improved in long-term survivors. Tumor progression adversely affects NCF more than WBRT does, thus making enhancement of radiation response a worthwhile aim in this patient population.
Collapse
Affiliation(s)
- Jing Li
- Department of Human Oncology, University of Wisconsin Comprehensive Cancer Center, Madison, WI 53792, USA
| | | | | | | |
Collapse
|
41
|
Abstract
Brain metastasis is the most common intracranial malignancy in adults. Improvements in modern imaging techniques are detecting previously occult brain metastases, and more effective therapies are extending the survival of patients with invasive cancer who have historically died from extracranial disease before developing brain metastasis. This combination of factors along with increased life expectancy has led to the increased diagnosis of brain metastases. Conventional treatment has been whole brain radiotherapy, which can improve symptoms, but potentially results in neurocognitive deficits. Several strategies to improve the therapeutic ratio are currently under investigation to either enhance the radiation effect, thereby preventing tumor recurrence or progression as well as reducing collateral treatment-related brain injury. In this review article, we discuss new directions in the management of brain metastases, including the role of chemical modifiers, novel systemic agents, and the management and prevention of neurocognitive deficits.
Collapse
Affiliation(s)
- Rakesh R Patel
- Department of Human Oncology, University of Wisconsin, Madison, WI 53792, USA.
| | | |
Collapse
|
42
|
Abstract
As effective treatment interventions have increased survival rates, there has been greater awareness that many brain tumor patients experience cognitive dysfunction despite adequate disease control. Cognitive difficulties often have an impact on quality of life and interfere with the patient's ability to function at premorbid levels; however, the incidence of cognitive dysfunction in brain tumor patients is unknown, because it has not been investigated systematically. Future prospective clinical trials in neuro-oncology should include cognitive outcome measures to increase understanding of the contribution of the tumor and the delayed effects of treatment to cognitive dysfunction.
Collapse
Affiliation(s)
- Denise D Correa
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
| |
Collapse
|
43
|
Khuntia D, Brown P, Li J, Mehta MP. Whole-brain radiotherapy in the management of brain metastasis. J Clin Oncol 2006; 24:1295-304. [PMID: 16525185 DOI: 10.1200/jco.2005.04.6185] [Citation(s) in RCA: 327] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Brain metastases are an important cause of morbidity and mortality, afflicting nearly 170,000 Americans annually. The prognosis for these patients is poor, with median survival times measured in months. In this review article, we present the standard treatment approach of whole-brain radiotherapy and discuss new directions, including the role of chemical modifiers and the management and prevention of neurocognitive deficits.
Collapse
|
44
|
Langer CJ, Mehta MP. Current Management of Brain Metastases, With a Focus on Systemic Options. J Clin Oncol 2005; 23:6207-19. [PMID: 16135488 DOI: 10.1200/jco.2005.03.145] [Citation(s) in RCA: 257] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Brain metastases are an important sequelae of many types of cancer, most commonly lung cancer. Current treatment options include whole-brain radiation therapy (WBRT), surgical resection, stereotactic radiosurgery, and chemotherapy. Corticosteroids and antiepileptic medications are commonly used for palliation of mass effect and seizures, respectively. The overall median survival is only 4 months after WBRT. Combined-modality strategies of WBRT with either chemotherapy or novel anticancer agents are under clinical investigation. Promising results have been obtained with several experimental agents and confirmatory phase III trials are underway. Although improvement in overall survival has not been seen universally, reduction in death due to progression of brain metastases and prolongation of the time to neurologic and neurocognitive progression have been reported in selected series. On the basis of these findings, it might be possible to identify new agents that may enhance the efficacy of WBRT.
Collapse
Affiliation(s)
- Corey J Langer
- Division of Thoracic Oncology, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA 19111, USA.
| | | |
Collapse
|
45
|
Shaffrey ME, Mut M, Asher AL, Burri SH, Chahlavi A, Chang SM, Farace E, Fiveash JB, Lang FF, Lopes MBS, Markert JM, Schiff D, Siomin V, Tatter SB, Vogelbaum MA. Brain metastases. Curr Probl Surg 2004; 41:665-741. [PMID: 15354117 DOI: 10.1067/j.cpsurg.2004.06.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Mark E Shaffrey
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|