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Kübler J, Wester-Ebbinghaus M, Wenz F, Stieler F, Bathen B, Mai SK, Wolff R, Hänggi D, Blanck O, Giordano FA. Postoperative stereotactic radiosurgery and hypofractionated radiotherapy for brain metastases using Gamma Knife and CyberKnife: a dual-center analysis. J Neurosurg Sci 2024; 68:22-30. [PMID: 32031357 DOI: 10.23736/s0390-5616.20.04830-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND Postoperative stereotactic radiosurgery (SRS) and hypofractionated stereotactic radiotherapy (hFSRT) to tumor cavities is emerging as a new standard of care after resection of brain metastases. Both Gamma Knife (GK) and CyberKnife (CK) are modalities commonly used for stereotactic radiotherapy, but fractional schemes are not consistent. The objective of this study was to evaluate outcomes in patients receiving postoperative stereotactic radiotherapy of resected brain metastases (BM) using different fractionation schedules and modalities in two large centers. METHODS Patients with newly diagnosed BM who underwent postoperative SRS or hFSRT with either GK or CK at two large cancer centers were retrospectively evaluated. We analyzed local control (LC), regional control (RC) and overall survival (OS). RESULTS From April 14th to May 18th, 2020, 79 patients with 81 resection cavities were treated. Forty-seven patients (59.5%) received GK and 32 patients (40.5%) received CK treatment. Fifty-four cavities (66.7%) were treated with hFSRT and 27 (33.3%) with SRS. The most common hFSRT and SRS scheme was 3x10 Gy and 1x16 Gy, respectively. Median OS was 11.7 months with survival rates of 44.7% at 1 year and 18.5% at 2 years. LC was 83.3% after 1 year. Median time to regional progression was 12.0 months with RC rates of 61.1% at 6 months and 41.0% at 12 months. There was no difference in OS, LC or RC between GK and CK treatments or SRS and hFSRT. CONCLUSIONS Both SRS and hFSRT provide high local control rates in resected BM regardless of the applied modality.
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Affiliation(s)
- Jens Kübler
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Michael Wester-Ebbinghaus
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Florian Stieler
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Bastian Bathen
- Saphir Radiosurgery Center Frankfurt, Frankfurt am Main, Germany
- Department of Radiation Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Sabine K Mai
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Robert Wolff
- Saphir Radiosurgery Center Frankfurt, Frankfurt am Main, Germany
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center Frankfurt, Frankfurt am Main, Germany
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany -
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Yoo KH, Park DJ, Choi JH, Marianayagam NJ, Lim M, Meola A, Chang SD. Optimizing the synergy between stereotactic radiosurgery and immunotherapy for brain metastases. Front Oncol 2023; 13:1223599. [PMID: 37637032 PMCID: PMC10456862 DOI: 10.3389/fonc.2023.1223599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/24/2023] [Indexed: 08/29/2023] Open
Abstract
Solid tumors metastasizing to the brain are a frequent occurrence with an estimated incidence of approximately 30% of all cases. The longstanding conventional standard of care comprises surgical resection and whole-brain radiotherapy (WBRT); however, this approach is associated with limited long-term survival and local control outcomes. Consequently, stereotactic radiosurgery (SRS) has emerged as a potential alternative approach. The primary aim of SRS has been to improve long-term control rates. Nevertheless, rare observations of abscopal or out-of-field effects have sparked interest in the potential to elicit antitumor immunity via the administration of high-dose radiation. The blood-brain barrier (BBB) has traditionally posed a significant challenge to the efficacy of systemic therapy in managing intracranial metastasis. However, recent insights into the immune-brain interface and the development of immunotherapeutic agents have shown promise in preclinical and early-phase clinical trials. Researchers have investigated combining immunotherapy with SRS to enhance treatment outcomes in patients with brain metastasis. The combination approach aims to optimize long-term control and overall survival (OS) outcomes by leveraging the synergistic effects of both therapies. Initial findings have been encouraging in the management of various intracranial metastases, while further studies are required to determine the optimal order of administration, radiation doses, and fractionation regimens that have the potential for the best tumor response. Currently, several clinical trials are underway to assess the safety and efficacy of administering immunotherapeutic agents concurrently or consecutively with SRS. In this review, we conduct a comprehensive analysis of the advantages and drawbacks of integrating immunotherapy into conventional SRS protocols for the treatment of intracranial metastasis.
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Affiliation(s)
| | | | | | | | | | | | - Steven D. Chang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
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3
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Tan XL, Le A, Scherrer E, Tang H, Kiehl N, Han J, Jiang R, Diede SJ, Shui IM. Systematic literature review and meta-analysis of clinical outcomes and prognostic factors for melanoma brain metastases. Front Oncol 2022; 12:1025664. [PMID: 36568199 PMCID: PMC9773194 DOI: 10.3389/fonc.2022.1025664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022] Open
Abstract
Background More than 60% of all stage IV melanoma patients develop brain metastases, while melanoma brain metastases (MBM) is historically difficult to treat with poor prognosis. Objectives To summarize clinical outcomes and prognostic factors in MBM patients. Methods A systematic review with meta-analysis was conducted, and a literature search for relevant studies was performed on November 1, 2020. Weighted average of median overall survival (OS) was calculated by treatments. The random-effects model in conducting meta-analyses was applied. Results A total of 41 observational studies and 12 clinical trials with our clinical outcomes of interest, and 31 observational studies addressing prognostic factors were selected. The most common treatments for MBM were immunotherapy (IO), MAP kinase inhibitor (MAPKi), stereotactic radiosurgery (SRS), SRS+MAPKi, and SRS+IO, with median OS from treatment start of 7.2, 8.6, 7.3, 7.3, and 14.1 months, respectively. Improved OS was observed for IO and SRS with the addition of IO and/or MAPKi, compared to no IO and SRS alone, respectively. Several prognostic factors were found to be significantly associated with OS in MBM. Conclusion This study summarizes pertinent information regarding clinical outcomes and the association between patient characteristics and MBM prognosis.
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Affiliation(s)
- Xiang-Lin Tan
- Merck & Co., Inc., Rahway, NJ, United States,*Correspondence: Xiang-Lin Tan,
| | - Amy Le
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN, United States
| | - Emilie Scherrer
- Merck & Co., Inc., Rahway, NJ, United States,Seagen Inc., Bothell, WA, United States
| | - Huilin Tang
- Integrative Precision Health, LLC, Carmel, IN, United States
| | - Nick Kiehl
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN, United States
| | - Jiali Han
- Integrative Precision Health, LLC, Carmel, IN, United States
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Lucia F, Geier M, Schick U, Bourbonne V. Narrative Review of Synergistics Effects of Combining Immunotherapy and Stereotactic Radiation Therapy. Biomedicines 2022; 10:biomedicines10061414. [PMID: 35740435 PMCID: PMC9219862 DOI: 10.3390/biomedicines10061414] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/02/2022] [Accepted: 06/13/2022] [Indexed: 12/24/2022] Open
Abstract
Stereotactic radiotherapy (SRT) has become an attractive treatment modality in full bloom in recent years by presenting itself as a safe, noninvasive alternative to surgery to control primary or secondary malignancies. Although the focus has been on local tumor control as the therapeutic goal of stereotactic radiotherapy, rare but intriguing observations of abscopal (or out-of-field) effects have highlighted the exciting possibility of activating antitumor immunity using high-dose radiation. Furthermore, immunotherapy has revolutionized the treatment of several types of cancers in recent years. However, resistance to immunotherapy often develops. These observations have led researchers to combine immunotherapy with SRT in an attempt to improve outcomes. The benefits of this combination would come from the stimulation and suppression of various immune pathways. Thus, in this review, we will first discuss the immunomodulation induced by SRT with the promising results of preclinical studies on the changes in the immune balance observed after SRT. Then, we will discuss the opportunities and risks of the combination of SRT and immunotherapy with the preclinical and clinical data available in the literature. Furthermore, we will see that many perspectives are conceivable to potentiate the synergistic effects of this combination with the need for prospective studies to confirm the encouraging data.
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Affiliation(s)
- François Lucia
- Radiation Oncology Department, University Hospital, 29200 Brest, France; (U.S.); (V.B.)
- LaTIM, INSERM, UMR 1101, University of Brest, 29200 Brest, France
- Correspondence:
| | - Margaux Geier
- Medical Oncology Department, University Hospital, 29200 Brest, France;
| | - Ulrike Schick
- Radiation Oncology Department, University Hospital, 29200 Brest, France; (U.S.); (V.B.)
- LaTIM, INSERM, UMR 1101, University of Brest, 29200 Brest, France
| | - Vincent Bourbonne
- Radiation Oncology Department, University Hospital, 29200 Brest, France; (U.S.); (V.B.)
- LaTIM, INSERM, UMR 1101, University of Brest, 29200 Brest, France
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5
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Anvari A, Sasanpour P, Rajabzadeh Kheradmardi M. Radiotherapy and immunotherapy in melanoma brain metastases. Hematol Oncol Stem Cell Ther 2021; 16:1-20. [PMID: 36634277 DOI: 10.1016/j.hemonc.2021.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 10/29/2021] [Accepted: 11/14/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Melanoma brain metastasis (MBM) generally portends a dismal prognosis. Simultaneous use of radiotherapy (RT) and immune checkpoint inhibitor (ICI) therapy demonstrated tremendous promise and emerged as the new standard. This meta-analysis was conducted to evaluate survival outcomes and toxicities of this combination in patients with MBM. Data analyses were performed using Comprehensive Meta-Analysis software (version 2) and IBM SPSS software (version 27). METHODS A systematic literature search of PubMed, EMBASE, and the Cochrane Library (via Wiley) was conducted using PICOS/PRISMA selection protocol and included studies to evaluate survival and safety-associated outcomes of ICI + RT for the treatment of MBM. RESULTS A total 44 studies involving 2498 patients were reviewed. The pooled effect size (ES) for overall survival (OS) to compare the ICI + RT arm and ICI alone arm (HR: 0.693 [0.526-0.913, p = .001]), and compare the ICI + RT arm and brain RT alone (HR: 0.595 [0.489-0.723, p < .001)] indicated better survival outcomes in ICI + RT versus RT alone and ICI alone arms. Comparing central nervous system toxicity in the ICI + RT arm and RT alone arm, the pooled ES Grade ≥ 3 neurologic adverse events (NAEs) risk ratio ([RR] = 1.425; 95% confidence interval [CI]: 0.485-4.183; p = .519) indicated that ICI + RT nonsignificantly increased Grade 3-4 NAEs. Comparing Grade ≥ 3 radiation necrosis in the ICI + RT arm and RT alone arm, the pooled ES RR (RR = 2.73; 95% CI: 0.59-12.59; p = .199) indicated that ICI + RT nonsignificantly increased Grade ≥ 3 radiation necrosis. CONCLUSION Concurrent administration of RT and ICI evinced favorable OS outcomes and acceptable safety profile in MBM patients. Planned prospective trials are required to demonstrate the issue.
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Affiliation(s)
- Amir Anvari
- Department of Radiation Oncology, Imam Hussein Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Pegah Sasanpour
- Department of Radiation Oncology, Imam Ali Hospital, Zahedan University of Medical Science, Zahedan, Iran
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6
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Rodríguez Plá M, Dualde Beltrán D, Ferrer Albiach E. Immune Checkpoints Inhibitors and SRS/SBRT Synergy in Metastatic Non-Small-Cell Lung Cancer and Melanoma: A Systematic Review. Int J Mol Sci 2021; 22:ijms222111621. [PMID: 34769050 PMCID: PMC8584181 DOI: 10.3390/ijms222111621] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/21/2021] [Accepted: 10/23/2021] [Indexed: 12/17/2022] Open
Abstract
Background: Several immunotherapy (IT) agents are FDA approved for treatment of melanoma and non-small-cell lung cancer (NSCLC). The addition of stereotactic radiosurgery (SRS) or stereotactic body radiation therapy (SBRT) to immunotherapy looks promising. A systematic review was conducted to evaluate the possible synergistic effects of immune checkpoints inhibitors (ICIs) and stereotactic radiation therapy in melanoma and NSCLC. Materials and methods: Pubmed databases from January 2010 to December 2020 were reviewed to identify English language studies reporting control of local and abscopal effect of the combination of ICI-SBRT/SRS in metastatic NSCLC and melanoma cancer. The inclusion criteria were followed according to PICO criteria. Results: Thirty-nine articles were included of the 2141 initial results. The reported rates for local control were 16.5–100% and 40–94% in brain and extracerebral metastases, respectively. Distant/abscopal response rates were 1–45% in extracerebral metastases. Abscopal effect could not be evaluated in brain metastases because it was not reported in studies. Treatments were well tolerated with few grade 4 toxicities and no grade 5. Conclusions: The combined treatment of ICI-SBRT/SRS achieves high local control and non-negligible abscopal response in patients with extracerebral metastases, with its benefit in cerebral metastases being more controversial. Clinical trials are needed to better characterize the potential synergism.
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7
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Ge Y, Che X, Gao X, Zhao S, Su J. Combination of radiotherapy and targeted therapy for melanoma brain metastases: a systematic review. Melanoma Res 2021; 31:413-420. [PMID: 34406985 DOI: 10.1097/cmr.0000000000000761] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Radiotherapy is a mainstay of efficient treatment of brain metastases from solid tumors. Immunotherapy has improved the survival of metastatic cancer patients across many tumor types. However, targeted therapy is a feasible alternative for patients unable to continue immunotherapy or with poor outcomes of immunotherapy. The combination of radiotherapy and targeted therapy for the treatment of brain metastases has a strong theoretical underpinning, but data on the efficacy and safety of this combination is still limited. A systematic search of PubMed, Embase, Web of Science and the Cochrane library database was conducted. Eleven studies were included for a total of 316 patients. Median OS was about 6.2-17.8 months from radiotherapy. Weighted survival and local control at 1 and 2 years were correlated (50.1 and 17.8%, 90.7 and 14.7% at 1 and 2 year, respectively). Radiotherapy given before or concurrently to targeted therapy provided the best effect on the outcome. For patients with brain metastases from cutaneous melanoma, the addition of concurrent targeted therapy to brain radiotherapy can increase survival and provide long-term control.
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Affiliation(s)
- Yi Ge
- Department of Dermatology, Xiangya Hospital, Central South University
- Hunan Engineering Research Center of Skin Health and Disease
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Central South University, Changsha, China
| | - Xuanlin Che
- Department of Dermatology, Xiangya Hospital, Central South University
- Hunan Engineering Research Center of Skin Health and Disease
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Central South University, Changsha, China
| | - Xin Gao
- Department of Dermatology, Xiangya Hospital, Central South University
- Hunan Engineering Research Center of Skin Health and Disease
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Central South University, Changsha, China
| | - Shuang Zhao
- Department of Dermatology, Xiangya Hospital, Central South University
- Hunan Engineering Research Center of Skin Health and Disease
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Central South University, Changsha, China
| | - Juan Su
- Department of Dermatology, Xiangya Hospital, Central South University
- Hunan Engineering Research Center of Skin Health and Disease
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Central South University, Changsha, China
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8
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Le Rhun E, Wolpert F, Fialek M, Devos P, Andratschke N, Reyns N, Regli L, Dummer R, Mortier L, Weller M. Response assessment and outcome of combining immunotherapy and radiosurgery for brain metastasis from malignant melanoma. ESMO Open 2021; 5:S2059-7029(20)32647-8. [PMID: 32747372 PMCID: PMC7401999 DOI: 10.1136/esmoopen-2020-000763] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 12/27/2022] Open
Abstract
Background The optimal sequence of stereotactic radiotherapy (SRT) and immune checkpoint inhibition (ICI) and assessment of response in patients with brain metastases from melanoma remain challenging. Methods We reviewed clinical and neuroimaging data of 62 patients with melanoma, including 26 patients with BRAF-mutant tumours, with newly diagnosed brain metastases treated with ICI alone (n=10, group 1), SRT alone or in combination with other systemic therapies (n=20, group 2) or ICI plus SRT (n=32, group 3). Response was assessed retrospectively using response evaluation criteria in solid tumours (RECIST) V.1.1, response assessment in neuro-oncology (RANO) and immunotherapy RANO (iRANO) criteria. MRI follow-up from 43 patients was available for central review. Results Patients treated with ICI alone showed no objective responses and had worse outcome than patients treated with SRT without or with ICI. RECIST, RANO and iRANO criteria were concordant for complete response (CR) and partial response (PR). RANO called progression earlier than RECIST for clinical deterioration without MRI progression in some patients. Progression was called later when using iRANO criteria because of the need for a confirmatory scan. Pseudoprogression was documented in seven patients: three patients in group 2 and four patients in group 3. Radionecrosis was documented in seven patients: two patients in group 2 and five patients in group 3. Regression of non-irradiated lesions was seen neither in two patients treated with SRT alone nor in five patients treated with SRT plus ICI, providing no evidence for rare abscopal effects. Conclusions Pseudoprogression is uncommon with ICI alone, suggesting that growing lesions in such patients should trigger an intervention. Pseudoprogression rates were similar after SRT alone or SRT in combination with ICI. Abscopal effects are rare or do not exist. Response assessment criteria should be considered carefully when designing clinical studies for patients with brain metastases who receive SRT.
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Affiliation(s)
- Emilie Le Rhun
- University of Lille, Inserm, Lille, France.,CHU Lille, Neuro-oncology, General and Stereotaxic Neurosurgery service, Lille, France.,Breast Cancer Department, Oscar Lambret Center, Lille cedex, France.,Department of Neurosurgery & Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse 26, 8091 Zurich, Switzerland
| | - Fabian Wolpert
- Department of Neurosurgery & Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse 26, 8091 Zurich, Switzerland
| | - Maud Fialek
- CHU lille, Service de Dermatologie, Lille, France
| | - Patrick Devos
- Univ. Lille, CHU Lille, METRICS : Évaluation des technologies de santé et des pratiques médicales, Lille, France
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Nicolas Reyns
- CHU Lille, General and Stereotaxic Neurosurgery service, Lille, France
| | - Luca Regli
- Department of Neurosurgery & Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse 26, 8091 Zurich, Switzerland
| | - Reinhard Dummer
- Department of Dermatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Laurent Mortier
- University of Lille, Inserm, CHU Lille, Service de Dermatologie, Lille, France
| | - Michael Weller
- Department of Neurosurgery & Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse 26, 8091 Zurich, Switzerland
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Patel V, Shah J. The current and future aspects of glioblastoma: Immunotherapy a new hope? Eur J Neurosci 2021; 54:5120-5142. [PMID: 34107127 DOI: 10.1111/ejn.15343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/28/2021] [Accepted: 06/03/2021] [Indexed: 12/13/2022]
Abstract
Glioblastoma (GBM) is the most perilous and highly malignant in all the types of brain tumor. Regardless of the treatment, the diagnosis of the patients in GBM is very poor. The average survival rate is only 21 months after multimodal combinational therapies, which include chemotherapy, radiation, and surgery. Due to the intrusive and infiltrative nature of GBM, it requires elective therapy for specific targeting of tumor cells. Tumor vaccine in a form of immunotherapy has potential to address this need. Nanomedicine-based immunotherapies have clutch the trigger of systemic and specific immune response against tumor cells, which might be the approach to eliminating the unrelieved cancer. In this mechanism, combination of immunomodulators with specific target and appropriate strategic vaccines can stifle tumor anti-immune defense system and/or increase the capabilities of the body to move up immunity against the tumor. Here, we explore the different types of immunotherapies and vaccines for brain tumor treatment and their clinical trials, which bring the feasibility of the future of personalized vaccine of nanomedicine-based immunotherapies for the brain tumor. We believe that immunotherapy could result in a significantly more stable reaction in GBM patients.
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Affiliation(s)
- Vimal Patel
- Department of Pharmaceutics, Institute of Pharmacy, Nirma University, Ahmedabad, Gujarat, India
| | - Jigar Shah
- Department of Pharmaceutics, Institute of Pharmacy, Nirma University, Ahmedabad, Gujarat, India
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10
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Rades D, Nguyen T, Blanck O, Schild SE. Survival After Stereotactic Radiosurgery (SRS) or Fractionated Stereotactic Radiotherapy (FSRT) for Cerebral Metastases in the Elderly. In Vivo 2021; 34:1909-1913. [PMID: 32606162 DOI: 10.21873/invivo.11987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/06/2020] [Accepted: 04/08/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND/AIM Stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) have gained popularity especially for treating 1-3 cerebral metastases. Elderly patients benefit from treatment personalisation. A specific survival score was created to facilitate this approach. PATIENTS AND METHODS Ten characteristics were retrospectively analysed for survival in 104 elderly patients with 1-3 cerebral metastases receiving SRS or FSRT alone using a linear accelerator or Cyberknife®. RESULTS On multivariate analysis, better survival was significantly associated with KPS of 90-100 (p=0.049), single lesion (p=0.036), maximum cumulative diameter of all lesions <16 mm (p=0.026) and supratentorial involvement only (p=0.047). Three groups were formed with 12-14 points (n=22), 15-16 points (n=33) and 17-19 points (n=49) with 12-month survival rates of 7%, 34% and 58% (p<0.0001), respectively. Positive predictive values for predicting death ≤12 months and survival ≥12 months were 95% and 54%. CONCLUSION The new score showed very high accuracy in predicting death ≤12 months, but not in predicting survival ≥12 months.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Trang Nguyen
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center Northern Germany, Güstrow, Germany
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, U.S.A
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Amaral T, Kiecker F, Schaefer S, Stege H, Kaehler K, Terheyden P, Gesierich A, Gutzmer R, Haferkamp S, Uttikal J, Berking C, Rafei-Shamsabadi D, Reinhardt L, Meier F, Karoglan A, Posch C, Gambichler T, Pfoehler C, Thoms K, Tietze J, Debus D, Herbst R, Emmert S, Loquai C, Hassel JC, Meiss F, Tueting T, Heinrich V, Eigentler T, Garbe C, Zimmer L. Combined immunotherapy with nivolumab and ipilimumab with and without local therapy in patients with melanoma brain metastasis: a DeCOG* study in 380 patients. J Immunother Cancer 2021; 8:jitc-2019-000333. [PMID: 32221017 PMCID: PMC7206917 DOI: 10.1136/jitc-2019-000333] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2020] [Indexed: 12/29/2022] Open
Abstract
Background Nivolumab combined with ipilimumab have shown activity in melanoma brain metastasis (MBM). However, in most of the clinical trials investigating immunotherapy in this subgroup, patients with symptomatic MBM and/or prior local brain radiotherapy were excluded. We studied the efficacy of nivolumab plus ipilimumab alone or in combination with local therapies regardless of treatment line in patients with asymptomatic and symptomatic MBM. Methods Patients with MBM treated with nivolumab plus ipilimumab in 23 German Skin Cancer Centers between April 2015 and October 2018 were investigated. Overall survival (OS) was evaluated by Kaplan-Meier estimator and univariate and multivariate Cox proportional hazard analyses were performed to determine prognostic factors associated with OS. Results Three hundred and eighty patients were included in this study and 31% had symptomatic MBM (60/193 with data available) at the time of start nivolumab plus ipilimumab. The median follow-up was 18 months and the 2 years and 3 years OS rates were 41% and 30%, respectively. We identified the following independently significant prognostic factors for OS: elevated serum lactate dehydrogenase and protein S100B levels, number of MBM and Eastern Cooperative Oncology Group performance status. In these patients treated with checkpoint inhibition first-line or later, in the subgroup of patients with BRAFV600-mutated melanoma we found no differences in terms of OS when receiving first-line either BRAF and MEK inhibitors or nivolumab plus ipilimumab (p=0.085). In BRAF wild-type patients treated with nivolumab plus ipilimumab in first-line or later there was also no difference in OS (p=0.996). Local therapy with stereotactic radiosurgery or surgery led to an improvement in OS compared with not receiving local therapy (p=0.009), regardless of the timepoint of the local therapy. Receiving combined immunotherapy for MBM in first-line or at a later time point made no difference in terms of OS in this study population (p=0.119). Conclusion Immunotherapy with nivolumab plus ipilimumab, particularly in combination with stereotactic radiosurgery or surgery improves OS in asymptomatic and symptomatic MBM.
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Affiliation(s)
- Teresa Amaral
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University of Tuebingen, Eberhard Karls University of Tuebingen, Tubingen, Germany
| | - Felix Kiecker
- Skin Cancer Center, Department of Dermatology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Sarah Schaefer
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Henner Stege
- Department of Dermatology, University Medical Center Mainz, Mainz, Germany
| | - Katharina Kaehler
- Skin Cancer Center, Department of Dermatology, University Hospital Kiel, Kiel, Germany
| | - Patrick Terheyden
- Skin Cancer Center, Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Anja Gesierich
- Department of Dermatology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ralf Gutzmer
- Skin Cancer Center Hannover, Department of Dermatology, Hannover Medical School, Hannover, Germany
| | | | - Jochen Uttikal
- Skin Cancer Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, Ruprecht-Karl University of Heidelberg, Mannheim, Germany
| | - Carola Berking
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU), Erlangen-Nürnberg, Germany.,Department of Dermatology and Allergy, University Hospital Munich, Ludwig Maximilian University, Munich, Germany
| | - David Rafei-Shamsabadi
- Skin Cancer Center, Department of Dermatology and Venerology, Medical Centre University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lydia Reinhardt
- Skin Cancer Center at the University Cancer Center and National Center for Tumor Diseases Dresden, Department of Dermatology, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Friedegund Meier
- Skin Cancer Center at the University Cancer Center and National Center for Tumor Diseases Dresden, Department of Dermatology, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Ante Karoglan
- Department of Dermatology, University Hospital Magdeburg, Magdeburg, Germany
| | - Christian Posch
- Department of Dermatology and Allergy, Technical University of Munich, School of Medicine, Munich, Germany.,Sigmund Freud Universität Wien, Faculty of Medicine, Wien, Austria
| | - Thilo Gambichler
- Skin Cancer Center, Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
| | - Claudia Pfoehler
- Department of Dermatology, Saarland University Medical School, Homburg/Saar, Germany
| | - Kai Thoms
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, Germany
| | - Julia Tietze
- Department of Dermatology and Allergology, Augsburg Medical Center, Augsburg, Germany
| | - Dirk Debus
- Skin Cancer Center, Department of Dermatology, Paracelsus Medical University, General Hospital Nuremberg, Nuremberg, Germany
| | | | - Steffen Emmert
- Clinic for Dermatology and Venereology, University Medical Center, Rostock, Germany
| | - Carmen Loquai
- Department of Dermatology, University Medical Center Mainz, Mainz, Germany
| | - Jessica C Hassel
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Frank Meiss
- Skin Cancer Center, Department of Dermatology and Venerology, Medical Centre University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Tueting
- Department of Dermatology, University Hospital Magdeburg, Magdeburg, Germany
| | - Vanessa Heinrich
- Clinic of Radiation Oncology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Thomas Eigentler
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University of Tuebingen, Eberhard Karls University of Tuebingen, Tubingen, Germany
| | - Claus Garbe
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University of Tuebingen, Eberhard Karls University of Tuebingen, Tubingen, Germany
| | - Lisa Zimmer
- Department of Dermatology, University Hospital Essen, Essen, Germany
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12
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Rauch M, Tausch D, Stera S, Blanck O, Wolff R, Meissner M, Urban H, Hattingen E. MRI characteristics in treatment for cerebral melanoma metastasis using stereotactic radiosurgery and concomitant checkpoint inhibitors or targeted therapeutics. J Neurooncol 2021; 153:79-87. [PMID: 33761055 PMCID: PMC8131338 DOI: 10.1007/s11060-021-03744-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/18/2021] [Indexed: 11/04/2022]
Abstract
Introduction Combination therapy for melanoma brain metastases (MM) using stereotactic radiosurgery (SRS) and immune checkpoint-inhibition (ICI) or targeted therapy (TT) is currently of high interest. In this collective, time evolution and incidence of imaging findings indicative of pseudoprogression is sparsely researched. We therefore investigated time-course of MRI characteristics in these patients. Methods Data were obtained retrospectively from 27 patients (12 female, 15 male; mean 61 years, total of 169 MMs). Single lesion volumes, total MM burden and edema volumes were analyzed at baseline and follow-up MRIs in 2 months intervals after SRS up to 24 months. The occurrence of intralesional hemorrhages was recorded. Results 17 patients (80 MM) received ICI, 8 (62 MM) TT and 2 (27 MM) ICI + TT concomitantly to SRS. MM-localization was frontal (n = 89), temporal (n = 23), parietal (n = 20), occipital (n = 10), basal ganglia/thalamus/insula (n = 10) and cerebellar (n = 10). A volumetric progression of MM 2–4 months after SRS was observed in combined treatment with ICI (p = 0.028) and ICI + TT (p = 0.043), whereas MMs treated with TT showed an early volumetric regression (p = 0.004). Edema volumes moderately correlated with total MM volumes (r = 0.57; p < 0.0001). Volumetric behavior did not differ significantly over time regarding lesions’ initial sizes or localizations. No significant differences between groups were observed regarding rates of post-SRS intralesional hemorrhages. Conclusion Reversible volumetric increases in terms of pseudoprogression are observed 2–4 months after SRS in patients with MM concomitantly treated with ICI and ICI + TT, rarely after TT. Edema volumes mirror total MM volumes. Medical treatment type does not significantly affect rates of intralesional hemorrhage.
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Affiliation(s)
- Maximilian Rauch
- Institute for Neuroradiology, Johann Wolfgang Goethe-University, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany.
| | - Daniel Tausch
- Institute for Neuroradiology, Johann Wolfgang Goethe-University, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Susanne Stera
- Department of Radiation Oncology, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center, Frankfurt am Main, Germany
| | - Robert Wolff
- Saphir Radiosurgery Center, Frankfurt am Main, Germany
| | - Markus Meissner
- Department of Dermatology, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Hans Urban
- Institute for Neurooncology, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Elke Hattingen
- Institute for Neuroradiology, Johann Wolfgang Goethe-University, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany
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13
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Khan M, Zheng T, Zhao Z, Arooj S, Liao G. Efficacy of BRAF Inhibitors in Combination With Stereotactic Radiosurgery for the Treatment of Melanoma Brain Metastases: A Systematic Review and Meta-Analysis. Front Oncol 2021; 10:586029. [PMID: 33692938 PMCID: PMC7937920 DOI: 10.3389/fonc.2020.586029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/30/2020] [Indexed: 12/30/2022] Open
Abstract
Background BRAF inhibitors have improved the outcome for patients with BRAF mutant metastatic melanoma and have shown intracranial responses in melanoma brain metastases. Stereotactic radiosurgery (SRS) is being used as a local treatment for melanoma brain metastasis (MBM) with better local control and survival. We searched for studies comparing the combination of two treatments with SRS alone to detect any clinical evidence of synergism. Materials and Methods PubMed, EMBASE, Medline, and Cochrane library were searched until May 2020 for studies with desired comparative outcomes. Outcomes of interest that were obtained for meta-analysis included survival as the primary, and local control as the secondary outcome. Results A total of eight studies involving 976 patients with MBM were selected. Survival was significantly improved for patients receiving BRAF inhibitor plus SRS in comparison to SRS alone as assessed from the time of SRS induction (SRS survival: hazard ratio [HR] 0.67 [0.58–0.79], p <0.00001), from the time of brain metastasis diagnosis (BM survival: HR 0.65 [0.54, 0.78], p < 0.00001), or from the time of primary diagnosis (PD survival: HR 0.74 [0.57–0.95], p = 0.02). Dual therapy was also associated with improved local control, indicating an additive effect of the two treatments (HR 0.53 [0.31–0.93], p=0.03). Intracranial hemorrhage was higher in patients receiving BRAF inhibitors plus SRS than in those receiving SRS alone (OR, 3.16 [1.43–6.96], p = 0.004). Conclusions BRAF inhibitors in conjunction with SRS as local treatment appear to be efficacious. Local brain control and survival improved in patients with MBM receiving dual therapy. Safety assessment would need to be elucidated further as the incidence of intracranial hemorrhage was increased.
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Affiliation(s)
- Muhammad Khan
- Department of Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China.,Department of Oncology, First affiliated Hospital of Anhui Medical University, Hefei, China
| | - Tao Zheng
- Department of Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Zhihong Zhao
- Department of Nephrology, Shenzhen People's Hospital, Second Clinical Medicine Centre, Jinan University, Shenzhen, China
| | - Sumbal Arooj
- Department of Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China.,Department of Biochemistry, University of Sialkot, Sialkot, Pakistan
| | - Guixiang Liao
- Department of Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
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14
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Nguyen T, Janssen S, Schild SE, Rades D. A Simple Implement for Assessing the Survival of Elderly Patients With Melanoma Irradiated for Cerebral Metastases. In Vivo 2021; 34:1361-1364. [PMID: 32354931 DOI: 10.21873/invivo.11914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIM Secondary brain lesions occur commonly in patients with advanced melanoma. Despite increasing use of local therapies, many elderly patients qualify for whole-brain radiotherapy (WBRT). For these patients, a survival score was created. PATIENTS AND METHODS Seven characteristics were retrospectively investigated in 35 elderly (≥65 years) patients with melanoma, namely WBRT regimen, age, gender, Karnofsky performance score (KPS), number of brain lesions, non-cerebral metastases and interval from melanoma diagnosis to WBRT. RESULTS Age ≤71 years (p=0.044) and KPS ≥80% (p=0.005) were significantly associated with more favorable survival. Based on these characteristics, patients received 0 (n=13), 1 (n=12) or 2 points (n=10). Two prognostic groups were designed, 0 or 1 point vs. 2 points, with actuarial 6-month survival rates of 12% and 48%, respectively (p=0.002). CONCLUSION This simple implement allows quick estimation of the survival of elderly patients receiving WBRT for cerebral metastases from melanoma.
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Affiliation(s)
- Trang Nguyen
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Stefan Janssen
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany.,Medical Practice for Radiotherapy and Radiation Oncology, Hannover, Germany
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, U.S.A
| | - Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
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15
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Borius PY, Régis J, Carpentier A, Kalamarides M, Valery CA, Latorzeff I. Safety of radiosurgery concurrent with systemic therapy (chemotherapy, targeted therapy, and/or immunotherapy) in brain metastases: a systematic review. Cancer Metastasis Rev 2021; 40:341-354. [PMID: 33392851 DOI: 10.1007/s10555-020-09949-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 12/15/2020] [Indexed: 02/07/2023]
Abstract
Stereotactic radiosurgery (SRS) is a standard option for brain metastases (BM). There is lack of consensus when patients have a systemic treatment, if a washout is necessary. The aim of this review is to analyze the toxicity of SRS when it is concurrent with chemotherapies, immunotherapy, and/or targeted therapies. From Medline and Embase databases, we searched for English literature published up to April 2020 according to the PRISMA guidelines, using for key words the list of the main systemic therapies currently in use And "radiosurgery," "SRS," "GKRS," "Gamma Knife," "toxicity," "ARE," "radiation necrosis," "safety," "brain metastases." Studies reporting safety or toxicity with SRS concurrent with systemic treatment for BM were included. Of 852 abstracts recorded, 77 were included. The main cancers were melanoma, lung, breast, and renal carcinoma. These studies cumulate 6384 patients. The median SRS dose prescription was 20 Gy [12-30] .For some, they compared a concurrent arm with a non-concurrent or a SRS-alone arm. There were no skin toxicities, no clearly increased rate of bleeding, or radiation necrosis with significant clinical impact. SRS combined with systemic therapy appears to be safe, allowing the continuation of treatment when brain SRS is considered.
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Affiliation(s)
- Pierre-Yves Borius
- Neurosurgery Department, Pitié Salpêtrière Sorbonne University Hospital, Paris, France.
| | - Jean Régis
- Aix-Marseille Université, Institut de Neuroscience des Systèmes, Functional Neurosurgery and Radiosurgery Department, Hôpital de la Timone, APHM, Marseille, France
| | - Alexandre Carpentier
- Neurosurgery Department, Pitié Salpêtrière Sorbonne University Hospital, Paris, France
| | - Michel Kalamarides
- Neurosurgery Department, Pitié Salpêtrière Sorbonne University Hospital, Paris, France
| | | | - Igor Latorzeff
- Département de radiothérapie-oncologie, bâtiment Atrium, Clinique Pasteur, 1, rue de la Petite-Vitesse, 31300, Toulouse, France
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16
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Amaral T, Niessner H, Sinnberg T, Thomas I, Meiwes A, Garbe C, Garzarolli M, Rauschenberg R, Eigentler T, Meier F. An open-label, single-arm, phase II trial of buparlisib in patients with melanoma brain metastases not eligible for surgery or radiosurgery-the BUMPER study. Neurooncol Adv 2020; 2:vdaa140. [PMID: 33305271 PMCID: PMC7712798 DOI: 10.1093/noajnl/vdaa140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Patients with melanoma brain metastasis (MBM) still carry a dismal prognosis. Preclinical data originated in xenograft models showed that buparlisib therapy was highly effective in therapy-naïve MBM. Patients and Methods In this open-label, phase II trial, we investigate the safety and efficacy of monotherapy with buparlisib, a PI3K inhibitor, in patients with asymptomatic MBM who were not candidates for local therapy. These patients had also progressed under immunotherapy if BRAF wild-type or under targeted therapy with BRAF/MEK inhibitors if carrying a BRAFV600E/K mutation. The primary endpoint was the intracranial disease control rate assessed by the investigators. The secondary endpoints were overall response rate, duration of response (DOR) of intracranial disease, overall response, progression-free survival (PFS), overall survival (OS), safety, and tolerability of buparlisib. Results A total of 20 patients were screened and 17 patients were treated with buparlisib. Twelve patients had progressed under more than 2 systemic therapy lines and 17 had received at least 1 previous local therapy. There were no intracranial responses. Three patients achieved intracranial stable disease; the median DOR was 117 days. The median PFS was 42 days (95% confidence interval [CI]: 23–61 days) and the median OS was 5.0 months (95% CI: 2.24–7.76 months). No new safety signs were observed. Conclusions Buparlisib was well tolerated but no intracranial responses were observed. These results might be explained in part by the inclusion of only heavily pretreated patients. However, preclinical data strongly support the rationale to explore PI3K inhibitor-based combinations in patients with MBM displaying hyperactivation of the PI3K–AKT pathway.
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Affiliation(s)
- Teresa Amaral
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University of Tuebingen, Tuebingen, Germany.,Health Care Direction, Portuguese Air Force, Lisbon, Portugal
| | - Heike Niessner
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Tobias Sinnberg
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Ioannis Thomas
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Andreas Meiwes
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Claus Garbe
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Marlene Garzarolli
- Skin Cancer Center at the University Cancer Centre and National Center for Tumor Diseases Dresden, Department of Dermatology, University Hospital Carl Gustav Carus at the TU Dresden, Germany.,Department of Dermatology, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Ricarda Rauschenberg
- Skin Cancer Center at the University Cancer Centre and National Center for Tumor Diseases Dresden, Department of Dermatology, University Hospital Carl Gustav Carus at the TU Dresden, Germany.,Department of Dermatology, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Thomas Eigentler
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Friedegund Meier
- Skin Cancer Center at the University Cancer Centre and National Center for Tumor Diseases Dresden, Department of Dermatology, University Hospital Carl Gustav Carus at the TU Dresden, Germany.,Department of Dermatology, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
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17
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Wilhelm ML, Chan MKH, Abel B, Cremers F, Siebert FA, Wurster S, Krug D, Wolff R, Dunst J, Hildebrandt G, Schweikard A, Rades D, Ernst F, Blanck O. Tumor-dose-rate variations during robotic radiosurgery of oligo and multiple brain metastases. Strahlenther Onkol 2020; 197:581-591. [PMID: 32588102 PMCID: PMC8219559 DOI: 10.1007/s00066-020-01652-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 06/02/2020] [Indexed: 12/31/2022]
Abstract
Purpose For step-and-shoot robotic stereotactic radiosurgery (SRS) the dose delivered over time, called local tumor-dose-rate (TDR), may strongly vary during treatment of multiple lesions. The authors sought to evaluate technical parameters influencing TDR and correlate TDR to clinical outcome. Material and methods A total of 23 patients with 162 oligo (1–3) and multiple (>3) brain metastases (OBM/MBM) treated in 33 SRS sessions were retrospectively analyzed. Median PTV were 0.11 cc (0.01–6.36 cc) and 0.50 cc (0.12–3.68 cc) for OBM and MBM, respectively. Prescription dose ranged from 16 to 20 Gy prescribed to the median 70% isodose line. The maximum dose-rate for planning target volume (PTV) percentage p in time span s during treatment (TDRs,p) was calculated for various p and s based on treatment log files and in-house software. Results TDR60min,98% was 0.30 Gy/min (0.23–0.87 Gy/min) for OBM and 0.22 Gy/min (0.12–0.63 Gy/min) for MBM, respectively, and increased by 0.03 Gy/min per prescribed Gy. TDR60min,98% strongly correlated with treatment time (ρ = −0.717, p < 0.001), monitor units (MU) (ρ = −0.767, p < 0.001), number of beams (ρ = −0.755, p < 0.001) and beam directions (ρ = −0.685, p < 0.001) as well as lesions treated per collimator (ρ = −0.708, P < 0.001). Median overall survival (OS) was 20 months and 1‑ and 2‑year local control (LC) was 98.8% and 90.3%, respectively. LC did not correlate with any TDR, but tumor response (partial response [PR] or complete response [CR]) correlated with all TDR in univariate analysis (e.g., TDR60min,98%: hazard ration [HR] = 0.974, confidence interval [CI] = 0.952–0.996, p = 0.019). In multivariate analysis only concomitant targeted therapy or immunotherapy and breast cancer tumor histology remained a significant factor for tumor response. Local grade ≥2 radiation-induced tissue reactions were noted in 26.3% (OBM) and 5.2% (MBM), respectively, mainly influenced by tumor volume (p < 0.001). Conclusions Large TDR variations are noted during MBM-SRS which mainly arise from prolonged treatment times. Clinically, low TDR corresponded with decreased local tumor responses, although the main influencing factor was concomitant medication.
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Affiliation(s)
- Maria-Lisa Wilhelm
- Department of Radiation Oncology, University Medicine Rostock, Rostock, Germany.,Saphir Radiosurgery Center Frankfurt and Northern Germany, Guestrow, Germany
| | - Mark K H Chan
- Department of Radiation Oncology, Karl-Lennert-Krebscentrum Nord, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany.,Strahlenklinik, University Hospital Essen, Hufelandstr. 55, Essen, Germany
| | - Benedikt Abel
- Institute for Robotics and Cognitive Systems, University of Luebeck, Luebeck, Germany
| | - Florian Cremers
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Luebeck, Germany
| | - Frank-Andre Siebert
- Department of Radiation Oncology, Karl-Lennert-Krebscentrum Nord, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany
| | - Stefan Wurster
- Saphir Radiosurgery Center Frankfurt and Northern Germany, Guestrow, Germany.,Department of Radiation Oncology, University Medicine Greifswald, Greifswald, Germany
| | - David Krug
- Saphir Radiosurgery Center Frankfurt and Northern Germany, Guestrow, Germany.,Department of Radiation Oncology, Karl-Lennert-Krebscentrum Nord, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany
| | - Robert Wolff
- Saphir Radiosurgery Center Frankfurt and Northern Germany, Guestrow, Germany.,Department of Neurosurgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, Karl-Lennert-Krebscentrum Nord, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany
| | - Guido Hildebrandt
- Department of Radiation Oncology, University Medicine Rostock, Rostock, Germany
| | - Achim Schweikard
- Institute for Robotics and Cognitive Systems, University of Luebeck, Luebeck, Germany
| | - Dirk Rades
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Luebeck, Germany
| | - Floris Ernst
- Institute for Robotics and Cognitive Systems, University of Luebeck, Luebeck, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center Frankfurt and Northern Germany, Guestrow, Germany. .,Department of Radiation Oncology, Karl-Lennert-Krebscentrum Nord, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany.
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18
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Schaule J, Kroeze SGC, Blanck O, Stera S, Kahl KH, Roeder F, Combs SE, Kaul D, Claes A, Schymalla MM, Adebahr S, Eckert F, Lohaus F, Abbasi-Senger N, Henke G, Szuecs M, Geier M, Sundahl N, Buergy D, Dummer R, Guckenberger M. Predicting survival in melanoma patients treated with concurrent targeted- or immunotherapy and stereotactic radiotherapy : Melanoma brain metastases prognostic score. Radiat Oncol 2020; 15:135. [PMID: 32487100 PMCID: PMC7268472 DOI: 10.1186/s13014-020-01558-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 05/01/2020] [Indexed: 12/14/2022] Open
Abstract
Background Melanoma patients frequently develop brain metastases. The most widely used score to predict survival is the molGPA based on a mixed treatment of stereotactic radiotherapy (SRT) and whole brain radiotherapy (WBRT). In addition, systemic therapy was not considered. We therefore aimed to evaluate the performance of the molGPA score in patients homogeneously treated with SRT and concurrent targeted therapy or immunotherapy (TT/IT). Methods This retrospective analysis is based on an international multicenter database (TOaSTT) of melanoma patients treated with TT/IT and concurrent (≤30 days) SRT for brain metastases between May 2011 and May 2018. Overall survival (OS) was studied using Kaplan-Meier survival curves and log-rank testing. Uni- and multivariate analysis was performed to analyze prognostic factors for OS. Results One hundred ten patients were analyzed. 61, 31 and 8% were treated with IT, TT and with a simultaneous combination, respectively. A median of two brain metastases were treated per patient. After a median follow-up of 8 months, median OS was 8.4 months (0–40 months). The molGPA score was not associated with OS. Instead, cumulative brain metastases volume, timing of metastases (syn- vs. metachronous) and systemic therapy with concurrent IT vs. TT influenced OS significantly. Based on these parameters, the VTS score (volume-timing-systemic therapy) was established that stratified patients into three groups with a median OS of 5.1, 18.9 and 34.5 months, respectively (p = 0.001 and 0.03). Conclusion The molGPA score was not useful for this cohort of melanoma patients undergoing local therapy for brain metastases taking into account systemic TT/IT. For these patients, we propose a prognostic VTS score, which needs to be validated prospectively.
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Affiliation(s)
- Jana Schaule
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland. .,Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany.
| | - Stephanie G C Kroeze
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Oliver Blanck
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany.,University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Susanne Stera
- Department of Radiation Oncology, University Hospital Frankfurt, Frankfurt, Germany
| | - Klaus H Kahl
- Department of Radiation Oncology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Falk Roeder
- Department of Radiation Oncology, University Hospital Munich, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University Munich (TUM), Munich, Germany.,Institute of Radiation Medicine (IRM), Helmholtz Zentrum München (HMGU), Oberschleißheim, Germany.,German Cancer Consortium, Partner Site Munich, Munich, Germany
| | - David Kaul
- Department of Radiation Oncology, Charité-University Hospital Berlin, Berlin, Germany
| | - An Claes
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Markus M Schymalla
- Department of Radiation Oncology, Philipps-University Marburg, Marburg, Germany
| | - Sonja Adebahr
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Breisgau, Germany.,German Cancer Consortium, Partner Site Freiburg, Freiburg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Franziska Eckert
- Department of Radiation Oncology, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Fabian Lohaus
- German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,German Cancer Consortium, Partner Site Dresden, Dresden, Germany
| | | | - Guido Henke
- Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Marcella Szuecs
- Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany
| | - Michael Geier
- Department of Radiation Oncology, Ordensklinikum Linz, Linz, Austria
| | - Nora Sundahl
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Daniel Buergy
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Reinhard Dummer
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
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19
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Mazzola R, Jereczek-Fossa BA, Franceschini D, Tubin S, Filippi AR, Tolia M, Lancia A, Minniti G, Corradini S, Arcangeli S, Scorsetti M, Alongi F. Oligometastasis and local ablation in the era of systemic targeted and immunotherapy. Radiat Oncol 2020; 15:92. [PMID: 32366258 PMCID: PMC7197157 DOI: 10.1186/s13014-020-01544-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/22/2020] [Indexed: 12/13/2022] Open
Abstract
Background During these last years, new agents have dramatically improved the survival of the metastatic patients. Oligometastases represent a continuous field of interest in which the integration of metastases-directed therapy and drugs could further improve the oncologic outcomes. Herein a narrative review is performed regarding the main rationale in combining immunotherapy and target therapies with SBRT looking at the available clinical data in case of oligometastatic NSCLC, Melanoma and Kidney cancer. Material and method Narrative Review regarding retrospective and prospective studies published between January 2009 to November 2019 with at least 20 patients analyzed. Results Concerning the combination between SBRT and Immunotherapy, the correct sequence of remains uncertain, and seems to be drug-dependent. The optimal patients’ selection is crucial to expect substantial benefits to SBRT/Immunotherapy combination and, among several factors. A potential field of interest is represented by the so-called oligoprogressed disease, in which SBRT could improve the long-term efficacy of the existing target therapy. Conclusions A low tumor burden seems to be the most relevant, thus making the oligometastatic disease represent the ideal setting for the use of combination therapies with immunological drugs.
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Affiliation(s)
- Rosario Mazzola
- IRCCS, Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Barbara Alicja Jereczek-Fossa
- Department of Radiation Oncology IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-oncology University of Milan, Milan, Italy
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, Rozzano, Milan, Italy
| | - Slavisa Tubin
- KABEG Klinikum Klagenfurt, Institute of Radiation Oncology, Klagenfurt am Wörthersee, Austria
| | | | - Maria Tolia
- Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larissa, Biopolis, Larisa, Greece
| | - Andrea Lancia
- Radiation Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giuseppe Minniti
- Radiation Oncology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Stefano Arcangeli
- Department of Radiation Oncology, Policlinico S. Gerardo and University of Milan "Bicocca", Milan, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, Rozzano, Milan, Italy
| | - Filippo Alongi
- IRCCS, Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy. .,University of Brescia, Brescia, Italy.
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20
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Rades D, Nguyen T, Schild SE. Elderly Patients With Single Brain Metastasis - Overall Survival After Surgery Plus Whole-Brain Irradiation and a Radiation Boost. In Vivo 2020; 34:1421-1425. [PMID: 32354940 DOI: 10.21873/invivo.11923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Elderly patients with a single brain metastasis likely benefit from personalized treatment protocols. To add to treatment personalization, a survival score was generated for these patients. PATIENTS AND METHODS This retrospective study included 36 elderly patients, each with a single brain metastasis, who received surgery followed by whole-brain irradiation and a radiation boost. Six pre-treatment characteristics were evaluated regarding survival, namely age, gender, Karnofsky performance score (KPS), type of primary tumor, non-cerebral metastasis and interval from diagnosis of the neoplasm until surgery. RESULTS When applying the Cox regression model, KPS (p=0.005) and tumor type (p=0.018) were significant and incorporated in the score. Based on 12-month survival probabilities, three groups of 6-9 (n=5), 10-11 (n=15) and 14-19 points (n=16) were formed, with 12-month survival rates of 0%, 33% and 100%, respectively (p<0.0001). CONCLUSION A survival score was generated specifically for elderly patients with a single brain metastasis that can improve personalization of their treatment.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Trang Nguyen
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, U.S.A
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21
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Eastman BM, Venur VA, Lo SS, Graber JJ. Stereotactic radiosurgery in the treatment of adults with metastatic brain tumors. J Neurosurg Sci 2020; 64:272-286. [PMID: 32270945 DOI: 10.23736/s0390-5616.20.04952-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Brain metastasis is the most common type of intracranial tumor affecting a significant proportion of advanced cancer patients. In recent years, stereotactic radiosurgery (SRS) has become commonly utilized. It has contributed significantly to decreased toxicity, prolonged quality of life and general improvement in outcomes of patients with brain metastases. Frequent imaging and advanced treatment techniques have allowed for the treatment of more patients with large and numerous metastases extending their overall survival. The addition of targeted therapy and immunotherapy to SRS has introduced novel treatment paradigms and has further improved our ability to effectively treat brain lesions. In this review, we examined in detail the available evidence for the use of SRS alone or in combination with surgery and systemic therapies. Given our developing understanding of the importance of primary tumor histology, the use of different treatment strategies for different metastasis is evolving. Combining SRS with immunotherapy and targeted therapy in breast cancer, lung cancer and melanoma as well as the use of preoperative SRS have shown significant promise in recent years and are investigated in multiple ongoing prospective trials. Further research is needed to guide the optimal sequence of therapies and to identify specific patient subgroups that may benefit the most from aggressive, combined treatment approaches.
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Affiliation(s)
- Boryana M Eastman
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Vyshak A Venur
- Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Jerome J Graber
- Department of Neurology and Neurosurgery, Alvord Brain Tumor Center, University of Washington School of Medicine, Seattle, WA, USA -
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22
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Gatterbauer B, Hirschmann D, Eberherr N, Untersteiner H, Cho A, Shaltout A, Göbl P, Fitschek F, Dorfer C, Wolfsberger S, Kasprian G, Höller C, Frischer JM. Toxicity and efficacy of Gamma Knife radiosurgery for brain metastases in melanoma patients treated with immunotherapy or targeted therapy-A retrospective cohort study. Cancer Med 2020; 9:4026-4036. [PMID: 32249551 PMCID: PMC7286469 DOI: 10.1002/cam4.3021] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/28/2020] [Accepted: 03/02/2020] [Indexed: 12/17/2022] Open
Abstract
Background Few safety data of concurrent stereotactic radiosurgery and targeted therapy (TT) or immunotherapy (IT) are available. The aim of the study was to evaluate the outcome of melanoma patients with brain metastases (MBM) after Gamma Knife Radiosurgery (GKRS) in relation to IT/TT. Methods We evaluated 182 MBM patients, who were treated with GKRS in the modern radiosurgical and oncological era. Results The median time between the initial melanoma diagnosis and occurrence of MBM was 2.4 years. The median overall survival time was 5.4 years after melanoma diagnosis. The estimated median survival after the initial diagnosis of MBM was 1.0 year (95% CI = 0.7‐1.2 years). Patients treated with anti‐PD‐1 or a combination of anti‐CTLA‐4/PD‐1 showed a significantly longer survival after first GKRS compared to all other forms of treatment. In addition, patients treated with anti‐PD‐1, anti‐CTLA‐4, or a combination of anti‐CTLA‐4/PD‐1 showed a significantly longer time to new MBM after GKRS1 compared to patients treated with other forms and combinations of the oncological therapy. The occurrence of hemorrhage or radiation reaction/necrosis after GKRS did not show any statistically significant differences in relation to IT/TT. Conclusion In MBM patients, complications after GKRS are not significantly increased if IT/TT treatment is performed at the time of or after radiosurgery. Further, a clear benefit in distant control and survival is seen in MBM patients treated with GKRS and checkpoint inhibitors. Thus, concomitant treatment of MBM with GKRS and IT/TT seems to be a safe and powerful treatment option although further prospective studies should be conducted.
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Affiliation(s)
| | - Dorian Hirschmann
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Nadine Eberherr
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | | | | | - Abdallah Shaltout
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Philipp Göbl
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Fabian Fitschek
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Christian Dorfer
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | | | - Gregor Kasprian
- Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria
| | - Christoph Höller
- Department of Dermatology, Medical University Vienna, Vienna, Austria
| | - Josa M Frischer
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
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23
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Wernicke AG, Polce S, Parashar B. Role of Radiation in the Era of Effective Systemic Therapy for Melanoma. Surg Clin North Am 2020; 100:189-199. [DOI: 10.1016/j.suc.2019.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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24
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van Opijnen MP, Dirven L, Coremans IEM, Taphoorn MJB, Kapiteijn EHW. The impact of current treatment modalities on the outcomes of patients with melanoma brain metastases: A systematic review. Int J Cancer 2019; 146:1479-1489. [PMID: 31583684 PMCID: PMC7004107 DOI: 10.1002/ijc.32696] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/30/2019] [Accepted: 09/11/2019] [Indexed: 12/19/2022]
Abstract
Patients with melanoma brain metastases (MBM) still have a very poor prognosis. Several treatment modalities have been investigated in an attempt to improve the management of MBM. This review aimed to evaluate the impact of current treatments for MBM on patient‐ and tumor‐related outcomes, and to provide treatment recommendations for this patient population. A literature search in the databases PubMed, Embase, Web of Science and Cochrane was conducted up to January 8, 2019. Original articles published since 2010 describing patient‐ and tumor‐related outcomes of adult MBM patients treated with clearly defined systemic therapy were included. Information on basic trial demographics, treatment under investigation and outcomes (overall and progression‐free survival, local and distant control and toxicity) were extracted. We identified 96 eligible articles, comprising 95 studies. A large variety of treatment options for MBM were investigated, either used alone or as combined modality therapy. Combined modality therapy was investigated in 71% of the studies and resulted in increased survival and better distant/local control than monotherapy, especially with targeted therapy or immunotherapy. However, neurotoxic side‐effects also occurred more frequently. Timing appeared to be an important determinant, with the best results when radiotherapy was given before or during systemic therapy. Improved tumor control and prolonged survival can be achieved by combining radiotherapy with immunotherapy or targeted therapy. However, more randomized controlled trials or prospective studies are warranted to generate proper evidence that can be used to change the standard of care for patients with MBM.
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Affiliation(s)
- Mark P van Opijnen
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands.,Department of Radiation Oncology, Leiden University Medical Center, The Netherlands
| | - Ida E M Coremans
- Department of Radiation Oncology, Leiden University Medical Center, The Netherlands
| | - Martin J B Taphoorn
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Ellen H W Kapiteijn
- Leiden University Medical Center, Department of Clinical Oncology, Leiden, The Netherlands
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