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Vogelbaum MA, Brown PD, Messersmith H, Brastianos PK, Burri S, Cahill D, Dunn IF, Gaspar LE, Gatson NTN, Gondi V, Jordan JT, Lassman AB, Maues J, Mohile N, Redjal N, Stevens G, Sulman E, van den Bent M, Wallace HJ, Weinberg JS, Zadeh G, Schiff D. Treatment for Brain Metastases: ASCO-SNO-ASTRO Guideline. J Clin Oncol 2021; 40:492-516. [PMID: 34932393 DOI: 10.1200/jco.21.02314] [Citation(s) in RCA: 242] [Impact Index Per Article: 80.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To provide guidance to clinicians regarding therapy for patients with brain metastases from solid tumors. METHODS ASCO convened an Expert Panel and conducted a systematic review of the literature. RESULTS Thirty-two randomized trials published in 2008 or later met eligibility criteria and form the primary evidentiary base. RECOMMENDATIONS Surgery is a reasonable option for patients with brain metastases. Patients with large tumors with mass effect are more likely to benefit than those with multiple brain metastases and/or uncontrolled systemic disease. Patients with symptomatic brain metastases should receive local therapy regardless of the systemic therapy used. For patients with asymptomatic brain metastases, local therapy should not be deferred unless deferral is specifically recommended in this guideline. The decision to defer local therapy should be based on a multidisciplinary discussion of the potential benefits and harms that the patient may experience. Several regimens were recommended for non-small-cell lung cancer, breast cancer, and melanoma. For patients with asymptomatic brain metastases and no systemic therapy options, stereotactic radiosurgery (SRS) alone should be offered to patients with one to four unresected brain metastases, excluding small-cell lung carcinoma. SRS alone to the surgical cavity should be offered to patients with one to two resected brain metastases. SRS, whole brain radiation therapy, or their combination are reasonable options for other patients. Memantine and hippocampal avoidance should be offered to patients who receive whole brain radiation therapy and have no hippocampal lesions and 4 months or more expected survival. Patients with asymptomatic brain metastases with either Karnofsky Performance Status ≤ 50 or Karnofsky Performance Status < 70 with no systemic therapy options do not derive benefit from radiation therapy.Additional information is available at www.asco.org/neurooncology-guidelines.
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Affiliation(s)
| | | | | | | | - Stuart Burri
- Levine Cancer Institute at Atrium Health, Charlotte, NC
| | - Dan Cahill
- Massachusetts General Hospital, Boston, MA
| | - Ian F Dunn
- Stephenson Cancer Center at the University of Oklahoma, Oklahoma City, OK
| | - Laurie E Gaspar
- University of Colorado School of Medicine, Aurora, CO.,University of Texas MD Anderson Cancer Center Northern Colorado, Greeley, CO
| | - Na Tosha N Gatson
- Banner MD Anderson Cancer Center, Phoenix, AZ.,Geisinger Neuroscience Institute. Danville, PA
| | - Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville and Proton Center, Warrenville, IL
| | | | | | - Julia Maues
- Georgetown Breast Cancer Advocates, Washington, DC
| | - Nimish Mohile
- University of Rochester Medical Center, Rochester, NY
| | - Navid Redjal
- Capital Health Medical Center - Hopewell Campus, Princeton, NJ
| | | | | | - Martin van den Bent
- Brain Tumor Center at Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | | | | | - David Schiff
- University of Virginia Medical Center, Charlottesville, VA
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2
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Matsumoto K, Tamiya A, Matsuda Y, Taniguchi Y, Atagi S, Kawachi H, Tamiya M, Tanizaki S, Uchida J, Ueno K, Yanase T, Suzuki H, Hirashima T. Impact of docetaxel plus ramucirumab on metastatic site in previously treated patients with non-small cell lung cancer: a multicenter retrospective study. Transl Lung Cancer Res 2021; 10:1642-1652. [PMID: 34012781 PMCID: PMC8107751 DOI: 10.21037/tlcr-20-1263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Docetaxel (DOC) plus ramucirumab (RAM) has been recommended as an optimal therapy for previously treated patients with non-small cell lung cancer (NSCLC). In a clinical setting, there are few reports about DOC plus RAM, therefore its effect on factors such as Eastern Cooperative Oncology Group (ECOG) performance status (PS) and metastatic sites is still unknown. Methods We recruited NSCLC patients who received DOC plus RAM in four medical facilities in Japan from June 2016 to March 2020. We retrospectively investigated the overall response rate (ORR), disease control rate (DCR), and progression-free survival (PFS) of DOC plus RAM and conducted univariate and multivariate analyses using PFS as a dependent factor. Patients were followed up until June 30, 2020. Results A total of 237 patients were consecutively enrolled. For all patients, the ORR, DCR, and median PFS were 25.2%, 63.9%, and 4.5 months, respectively. The ORR and DCR for malignant pleural effusion (MPE), lung metastasis, and liver metastasis were 7.7% and 53.8%, 30.3% and 77.5%, and 48.6% and 71.4%, respectively. In the multivariate analysis, MPE, lung metastasis, and liver metastasis were not prognostic factors for poor PFS. However, ECOG-PS 2 or more [hazard ratio (HR): 1.66, 95% confidence interval (CI): 1.14–2.40, P=0.008] and brain metastasis (HR: 1.71, 95% CI: 1.23–2.37, P=0.001) were significant and independent factors associated with shorter PFS. Conclusions DOC plus RAM could be an optimal therapy for previous treated NSCLC patients with lung and liver metastasis, and furthermore, should be used carefully for patients with poor ECOG-PS or brain metastasis. Keywords Docetaxel and ramucirumab; non-small cell lung cancer (NSCLC); metastatic site; poor performance status
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Affiliation(s)
- Kinnosuke Matsumoto
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Akihiro Tamiya
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Yoshinobu Matsuda
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Yoshihiko Taniguchi
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Shinji Atagi
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Hayato Kawachi
- Department of Respiratory Medicine, Osaka International Cancer Institute, Osaka, Japan
| | - Motohiro Tamiya
- Department of Respiratory Medicine, Osaka International Cancer Institute, Osaka, Japan
| | - Satoshi Tanizaki
- Department of Respiratory Medicine, Osaka General Medical Center, Osaka, Japan
| | - Junji Uchida
- Department of Respiratory Medicine, Osaka General Medical Center, Osaka, Japan
| | - Kiyonobu Ueno
- Department of Respiratory Medicine, Osaka General Medical Center, Osaka, Japan
| | - Takafumi Yanase
- Department of Respiratory Medicine, Osaka Prefectural Medical Center for Respiratory and Allergic Disease, Osaka, Japan
| | - Hidekazu Suzuki
- Department of Respiratory Medicine, Osaka Prefectural Medical Center for Respiratory and Allergic Disease, Osaka, Japan
| | - Tomonori Hirashima
- Department of Respiratory Medicine, Osaka Prefectural Medical Center for Respiratory and Allergic Disease, Osaka, Japan
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3
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Alemany M, Domènech M, Argyriou AA, Vilariño N, Majós C, Naval-Baudin P, Lucas A, Palmero R, Simó M, Nadal E, Bruna J. Perilesional edema in brain metastases as predictive factor of response to systemic therapy in non-small cell lung cancer patients: a preliminary study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:648. [PMID: 33987346 PMCID: PMC8106019 DOI: 10.21037/atm-20-6497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The significance of upfront systemic therapies as an alternative to whole brain radiotherapy (WBRT) for multiple brain metastases (BM) is debatable. Our purpose is to investigate if peritumoral edema could predict the intracranial response to systemic chemotherapy (chemo) in patients with advanced non-squamous non-small cell lung cancer (non-SQ-NSCLC) and synchronous multiple BM. METHODS In this observational cohort study, we evaluated the outcome of 28 patients with multiple BM (≥3) treated with chemo based on cisplatin/carboplatin plus pemetrexed (chemo, group A, n=17) or WBRT plus subsequent chemo (group B, n=11). The intracranial response, assessed by the response assessment neuro-oncology (RANO) BM criteria, was correlated with the degree of BM-associated edema estimated by the maximum diameter ratio among fluid attenuated inversion recovery (FLAIR) and gadolinium-enhanced T1WI (T1Gd) per each BM at the baseline brain magnetic resonance imaging (MRI). RESULTS No differences were observed in baseline characteristics between both groups, except for the number of patients under steroid treatment that was clearly superior in group B (P=0.007). Median OS was similar between groups. Regarding FLAIR/T1Gd ratio (F/Gd), patients treated with chemo alone exhibited significantly higher values (P=0.001) in those who developed intracranial progression disease (PD) (2.80±0.32 mm), compared with those who achieved partial response (PR) (1.30±0.11 mm) or stable disease (SD) (1.35±0.09 mm). In patients treated with WBRT, F/Gd ratio was not predictive of response. CONCLUSIONS Peritumoral edema estimated by F/Gd ratio appears a promising predictive tool to identify oligosymptomatic patients with multiple BM in whom WBRT can be postponed.
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Affiliation(s)
- Montse Alemany
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L’Hospitalet (IDIBELL), Barcelona, Spain
| | - Marta Domènech
- Thoracic Oncology Unit, Catalan Institute of Oncology, L’Hospitalet, Barcelona, Spain
| | - Andreas A. Argyriou
- Department of Neurology, Saint Andrew’s State General Hospital of Patras, Patras, Greece
| | - Noelia Vilariño
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L’Hospitalet (IDIBELL), Barcelona, Spain;,Thoracic Oncology Unit, Catalan Institute of Oncology, L’Hospitalet, Barcelona, Spain
| | - Carles Majós
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L’Hospitalet (IDIBELL), Barcelona, Spain;,Radiology Department ICS-IDI, Hospital Universitari Bellvitge, L’Hospitalet, Barcelona, Spain
| | - Pablo Naval-Baudin
- Radiology Department ICS-IDI, Hospital Universitari Bellvitge, L’Hospitalet, Barcelona, Spain
| | - Anna Lucas
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L’Hospitalet (IDIBELL), Barcelona, Spain
| | - Ramón Palmero
- Thoracic Oncology Unit, Catalan Institute of Oncology, L’Hospitalet, Barcelona, Spain
| | - Marta Simó
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L’Hospitalet (IDIBELL), Barcelona, Spain
| | - Ernest Nadal
- Thoracic Oncology Unit, Catalan Institute of Oncology, L’Hospitalet, Barcelona, Spain
| | - Jordi Bruna
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L’Hospitalet (IDIBELL), Barcelona, Spain
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4
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Le Nha U. Novel Treatment For Non-Small Cell Lung Cancer With Brain Metastases. J Clin Med 2020. [DOI: 10.38103/jcmhch.2020.64.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Brain metastases is common in patients with non-small cell lung cancer (NSCLC) and it is associated with poorer prognosis. Several options to control the secondary brain tumors in the context include chemotherapy, whole-brain radiation, stereotactic surgery, surgery. However, chemotherapy is ineffective to those patients because of poor penetration through the blood-brain barrier. Whole-brain radiation therapy used to be a standard option for brain metastases. However, it potentially damages normal brain tissues and causes neurocognitive decline. Stereotactic radiotherapy has been considered in cases of three or fewer lesions, and the lesions less than 3 cm. In selective cases, surgical removal of brain metastases can be done. These local therapies were accompanied by systemic treatment due to spreading of the cancer. Recently, molecular targeted therapy has opened up a new era in cancer treatment, especially NSCLC with brain metastases. In this review, we discuss brain metastases occurring in NSCLC patients with driver gene mutations with some briefly demonstrated cases.
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5
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Tozuka T, Kitazono S, Sakamoto H, Yoshida H, Amino Y, Uematsu S, Yoshizawa T, Hasegawa T, Ariyasu R, Uchibori K, Yanagitani N, Horai T, Seike M, Gemma A, Nishio M. Poor efficacy of anti-programmed cell death-1/ligand 1 monotherapy for non-small cell lung cancer patients with active brain metastases. Thorac Cancer 2020; 11:2465-2472. [PMID: 32657011 PMCID: PMC7471023 DOI: 10.1111/1759-7714.13557] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/07/2020] [Accepted: 06/11/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The efficacy of anti-programmed cell death-1/ligand 1 antibody monotherapy (anti-PD-1/PD-L1 monotherapy) in patients with active brain metastases (BMs) is not established. Here, we aimed to evaluate the efficacy of anti-PD-1/PD-L1 monotherapy in non-small cell lung cancer (NSCLC) patients with active BMs. METHODS This retrospective study included NSCLC patients treated with second-line or later-line anti-PD-1/PD-L1 monotherapy between December 2015 and August 2019. Patients were classified into those with or without active BMs, including symptomatic BMs requiring systemic steroids and untreated BMs. The progression-free survival (PFS) and overall survival (OS) of the patients with and without active BMs were compared. Intracranial and extracranial tumor responses were evaluated in patients with active BMs. RESULTS We analyzed 197 patients who had received anti-PD-1/PD-L1 monotherapy. Among them, 24 had active BMs. Among those without active BMs, 145 had no BMs and 28 had treated asymptomatic BMs. The PFS and OS of patients with active BMs were significantly shorter than those of patients without active BMs (1.3 vs. 2.7 months; P < 0.001, and 4.5 vs. 16.3 months; P = 0.001 respectively). For patients with active BMs, the intracranial and extracranial response rates were 13.3% and 26.7%, respectively. On multivariate analysis, active BMs, poor performance status (PS), and EGFR/ALK positivity were significant factors associated with shorter PFS. Active BMs and poor PS were significant factors associated with shorter OS. CONCLUSIONS This study suggested that anti-PD-1/PD-L1 monotherapy was not effective for NSCLC patients with active BMs. Further studies on immunotherapy are needed for patients with active BMs. KEY POINTS Significant findings of the study: The present study showed that anti-PD-1/PD-L1 antibody monotherapy was not effective for non-small cell lung cancer patients with active brain metastases. Intracranial and extracranial response rates were 13.3% and 26.7%, respectively. WHAT THIS STUDY ADDS Further studies on immunotherapy are needed for patients with active BMs.
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Affiliation(s)
- Takehiro Tozuka
- Department of Thoracic Medical OncologyThe Cancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
- Department of Pulmonary Medicine and OncologyGraduate School of Medicine, Nippon Medical SchoolTokyoJapan
| | - Satoru Kitazono
- Department of Thoracic Medical OncologyThe Cancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Hiroaki Sakamoto
- Department of Thoracic Medical OncologyThe Cancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Hiroshi Yoshida
- Department of Thoracic Medical OncologyThe Cancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Yoshiaki Amino
- Department of Thoracic Medical OncologyThe Cancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Shinya Uematsu
- Department of Thoracic Medical OncologyThe Cancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Takahiro Yoshizawa
- Department of Thoracic Medical OncologyThe Cancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Tsukasa Hasegawa
- Department of Thoracic Medical OncologyThe Cancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Ryo Ariyasu
- Department of Thoracic Medical OncologyThe Cancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Ken Uchibori
- Department of Thoracic Medical OncologyThe Cancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Noriko Yanagitani
- Department of Thoracic Medical OncologyThe Cancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Takeshi Horai
- Department of Thoracic Medical OncologyThe Cancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Masahiro Seike
- Department of Pulmonary Medicine and OncologyGraduate School of Medicine, Nippon Medical SchoolTokyoJapan
| | - Akihiko Gemma
- Department of Pulmonary Medicine and OncologyGraduate School of Medicine, Nippon Medical SchoolTokyoJapan
| | - Makoto Nishio
- Department of Thoracic Medical OncologyThe Cancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
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6
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Higuchi T, Oshiro H, Zhang Z, Miyake K, Sugisawa N, Katsuya Y, Yamamoto N, Hayashi K, Kimura H, Miwa S, Igarashi K, Zhao M, Bouvet M, Singh SR, Tsuchiya H, Hoffman RM. Osimertinib Regresses an EGFR-Mutant Cisplatinum- Resistant Lung Adenocarcinoma Growing in the Brain in Nude Mice. Transl Oncol 2019; 12:640-645. [PMID: 30807997 PMCID: PMC6393699 DOI: 10.1016/j.tranon.2019.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 01/29/2019] [Indexed: 12/23/2022] Open
Abstract
The goal of the present study was to determine the efficacy of osimertinib (AZD9291), a third-generation epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor for the treatment of aggressive EGFR-mutant non-small cell lung cancer (NSCLC), compared to cisplatinum (CDDP) + pemetrexed (PEM). The NSCLC cell line PC-9 expressing green fluorescence protein (PC-9-GFP) was implanted in the brain of nude mice and was treated with CDDP + PEM or AZD9291. Tumors were observed by non-invasive fluorescence imaging. AZD9291 treatment caused tumor regression in contrast to CDDP + PEM which had only a slight inhibitory effect. These results suggest that AZD9291 is a promising clinical option for NSCLC patients with brain metastasis.
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Affiliation(s)
- Takashi Higuchi
- AntiCancer, Inc., San Diego, CA, USA; Department of Surgery, University of California, San Diego, CA, USA; Department of Orthopedic Surgery, Kanazawa University, Kanazawa, Japan
| | - Hiromichi Oshiro
- AntiCancer, Inc., San Diego, CA, USA; Department of Surgery, University of California, San Diego, CA, USA
| | - Zhiying Zhang
- AntiCancer, Inc., San Diego, CA, USA; Department of Surgery, University of California, San Diego, CA, USA
| | - Kentaro Miyake
- AntiCancer, Inc., San Diego, CA, USA; Department of Surgery, University of California, San Diego, CA, USA
| | - Norihiko Sugisawa
- AntiCancer, Inc., San Diego, CA, USA; Department of Surgery, University of California, San Diego, CA, USA
| | - Yuki Katsuya
- AntiCancer, Inc., San Diego, CA, USA; Department of Surgery, University of California, San Diego, CA, USA
| | - Norio Yamamoto
- Department of Orthopedic Surgery, Kanazawa University, Kanazawa, Japan
| | - Katsuhiro Hayashi
- Department of Orthopedic Surgery, Kanazawa University, Kanazawa, Japan
| | - Hiroaki Kimura
- Department of Orthopedic Surgery, Kanazawa University, Kanazawa, Japan
| | - Shinji Miwa
- Department of Orthopedic Surgery, Kanazawa University, Kanazawa, Japan
| | - Kentaro Igarashi
- Department of Orthopedic Surgery, Kanazawa University, Kanazawa, Japan
| | - Ming Zhao
- AntiCancer, Inc., San Diego, CA, USA
| | - Michael Bouvet
- Department of Surgery, University of California, San Diego, CA, USA.
| | - Shree Ram Singh
- Basic Research Laboratory, National Cancer Institute, Frederick, MD, USA.
| | - Hiroyuki Tsuchiya
- Department of Orthopedic Surgery, Kanazawa University, Kanazawa, Japan.
| | - Robert M Hoffman
- AntiCancer, Inc., San Diego, CA, USA; Department of Surgery, University of California, San Diego, CA, USA.
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7
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Wrona A, Dziadziuszko R, Jassem J. Management of brain metastases in non-small cell lung cancer in the era of tyrosine kinase inhibitors. Cancer Treat Rev 2018; 71:59-67. [DOI: 10.1016/j.ctrv.2018.10.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 10/11/2018] [Accepted: 10/19/2018] [Indexed: 01/16/2023]
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8
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Su PL, Wu YL, Chang WY, Ho CL, Tseng YL, Lai WW, Su WC, Lin CC, Yang SC. Preventing and treating brain metastases with three first-line EGFR-tyrosine kinase inhibitors in patients with EGFR mutation-positive advanced non-small cell lung cancer. Ther Adv Med Oncol 2018; 10:1758835918797589. [PMID: 30263066 PMCID: PMC6156208 DOI: 10.1177/1758835918797589] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 06/22/2018] [Indexed: 12/28/2022] Open
Abstract
Introduction Brain metastases (BM) are common in advanced non-small cell lung cancer (NSCLC), and the prognosis is poor with few therapeutic options. This study evaluated the efficacy of three epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) in preventing and treating BM in patients with EGFR mutation-positive advanced NSCLC. Methods Patients with EGFR mutation-positive advanced NSCLC who visited a tertiary referral center from 1 December 2013 to 30 November 2017 were analyzed retrospectively. They received gefitinib, erlotinib, or afatinib until disease progression, death, or intolerable adverse events. The cumulative incidence of subsequent BM of initial non-BM patients, progression-free survival (PFS), and overall survival (OS) of the BM and non-BM patients were estimated and compared using the Kaplan-Meier and log-rank tests. Results 306 NSCLC patients were enrolled, with 116, 75, and 115 receiving first-line gefitinib, erlotinib, and afatinib, respectively. The afatinib group had a better PFS [12.7 versus 9.8 months; hazard ratio (HR) 0.59, p = 0.001] and OS (39.1 versus 22.0 months; HR 0.64, p = 0.035) than the gefitinib group. Afatinib tended to provide better BM prevention than gefitinib (BM cumulative incidence, HR 0.49; 95% confidence interval 0.34-0.71, p < 0.001) according to a Cox model adjusted for possible confounders. Patients with initial BM had a shorter PFS (p < 0.001) and OS (p = 0.015) than those without initial BM. Among the former, there were no differences in median PFS (p = 0.34) and median OS (p = 0.46) in the three EGFR-TKI groups. Conclusions Our data suggested that, compared with gefitinib, afatinib provided better benefits significantly in terms of PFS and OS. Both had the same effectiveness in preventing subsequent BM.
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Affiliation(s)
- Po-Lan Su
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yi-Lin Wu
- Department of Nursing, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wei-Yuan Chang
- Department of Internal Medicine and Institute of Clinical Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chung-Liang Ho
- Department of Pathology, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yau-Lin Tseng
- Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wu-Wei Lai
- Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wu-Chou Su
- Department of Internal Medicine and Institute of Clinical Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chien-Chung Lin
- Department of Internal Medicine, National Cheng Kung University Hospital, 138 Sheng-Li Road, Tainan 704, Taiwan
| | - Szu-Chun Yang
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
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9
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Turkaj A, Morelli AM, Vavalà T, Novello S. Management of Leptomeningeal Metastases in Non-oncogene Addicted Non-small Cell Lung Cancer. Front Oncol 2018; 8:278. [PMID: 30140655 PMCID: PMC6094962 DOI: 10.3389/fonc.2018.00278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/04/2018] [Indexed: 12/13/2022] Open
Abstract
Brain metastases in non-small cell lung cancer (NSCLC) patients are more often detected due to imaging modalities improvements but also emerge because of improved treatments of the primary tumor which lead to a longer survival. In this context, development of leptomeningeal metastases (LM) is a devastating complication and its prognosis remains poor despite advances in systemic and local approaches. Histology characterization of NSCLC and molecular expression influence LM management. For those with “oncogene addiction,” new generation epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) were developed to strongly penetrate the blood-brain barrier (BBB) with the aim to prevent central nervous system cancer dissemination, eventually impacting on LM appearance and its subsequent management. Systemic chemotherapy, often combined with intrathecal chemotherapy (when possible), was one of common indications for lung cancer patients affected by LM, without driver mutations and a good performance status but currently, with the advent of innovative systemic approaches treatment solutions in this subgroup of patients are rapidly evolving. Whole brain radiation therapy (WBRT) is the conventional treatment for patients with brain metastases. Furthermore, modern radiation techniques, as stereotactic radiotherapy (SRT), improve outcomes in those cases with a limited number of lesions. However, LM represent a minority of CNS metastases and few literature data are available to drive the radiotherapy approach. Considering all relevant progress made in this setting, after a literature review, the aim of this paper is to discuss about recent developments and therapeutic options in LM management of non-oncogene addicted NSCLC.
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Affiliation(s)
- Ana Turkaj
- Department of Oncology, University of Torino, Ospedale San Luigi Gonzaga, Orbassano, Italy
| | - Anna M Morelli
- Department of Oncology, University of Torino, Ospedale San Luigi Gonzaga, Orbassano, Italy
| | - Tiziana Vavalà
- SC of Oncology, ASL CN1, Ospedale Civile di Saluzzo, Saluzzo, Italy
| | - Silvia Novello
- Department of Oncology, University of Torino, Ospedale San Luigi Gonzaga, Orbassano, Italy
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10
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Preusser M, Winkler F, Valiente M, Manegold C, Moyal E, Widhalm G, Tonn JC, Zielinski C. Recent advances in the biology and treatment of brain metastases of non-small cell lung cancer: summary of a multidisciplinary roundtable discussion. ESMO Open 2018; 3:e000262. [PMID: 29387475 PMCID: PMC5786916 DOI: 10.1136/esmoopen-2017-000262] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 11/21/2017] [Accepted: 11/29/2017] [Indexed: 12/21/2022] Open
Abstract
This article is the result of a round table discussion held at the European Lung Cancer Conference (ELCC) in Geneva in May 2017. Its purpose is to explore and discuss the advances in the knowledge about the biology and treatment of brain metastases originating from non-small cell lung cancer. The authors propose a series of recommendations for research and treatment within the discussed context.
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Affiliation(s)
- Matthias Preusser
- Clinical Division of Oncology, Department of Medicine I, Comprehensive Cancer Centre, Medical University Vienna - General Hospital, Vienna, Austria
| | - Frank Winkler
- Neurology Clinic and National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Neuro-oncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Manuel Valiente
- Brain Metastasis Group, Spanish National Cancer Research Centre (CNIO), Madrid, Spain
| | - Christian Manegold
- Medical Faculty Mannheim, University of Heidelberg, Mannheim, Baden-Württemberg, Germany
| | - Elizabeth Moyal
- Radiation Oncology Department, Radiobiology team 11, UMR1037 INSERM, Institut Universitaire du Cancer de Toulouse Oncopole, Centre de Recherche contre le Cancer, Toulouse, France
| | - Georg Widhalm
- Department of Neurosurgery, Medical University of Vienna (MUV), Vienna, Austria.,Department of Neurosurgery, University of California San Francisco (UCSF), San Francisco, USA.,Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna (MUV), Vienna, Austria
| | - Jörg-Christian Tonn
- Department of Neurosurgery, Ludwig-Maximilians University, Munich-Grosshadern, Germany and German Cancer Consortium (DKTK) at the German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - Christoph Zielinski
- Clinical Division of Oncology, Department of Medicine I, Comprehensive Cancer Centre, Medical University Vienna - General Hospital, Vienna, Austria
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11
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Gubens MA, Chuang JC, Akerley W, Langer CJ, Clément-Duchêne C, San Pedro-Salcedo M, Colevas AD, Dragnev K, Socinski MA, Wakelee HA. A pooled analysis of advanced nonsquamous non-small cell lung cancer patients with stable treated brain metastases in two phase II trials receiving bevacizumab and pemetrexed as second-line therapy. J Thorac Dis 2018; 10:219-227. [PMID: 29600052 DOI: 10.21037/jtd.2017.12.30] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Brain metastases are a common complication of advanced non-small cell lung cancer (NSCLC). Patients with brain metastases were excluded from the registration trials of bevacizumab that showed a survival benefit with the use of angiogenesis inhibition. Methods In this study, we pooled data from two separate trials designed to evaluate the risk of central nervous system (CNS) hemorrhage in patients with stable treated brain metastases to look specifically at both the safety and efficacy of bevacizumab and pemetrexed when used as second-line treatment in NSCLC patients with stable treated brain metastases. Results We report acceptable safety and promising efficacy from our analysis. Conclusions Our study adds further evidence of safety of administering pemetrexed and bevacizumab to patients with stable brain metastases. There is increasing roles for systemic therapies to treat stable brain metastases for patients with advanced NSCLC.
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Affiliation(s)
- Matthew A Gubens
- Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Jody C Chuang
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Wallace Akerley
- Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Corey J Langer
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - A Dimitrios Colevas
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Konstantin Dragnev
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | | - Heather A Wakelee
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, USA
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12
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Fernandes AW, Wu B, Turner RM. Brain metastases in non-small cell lung cancer patients on epidermal growth factor receptor tyrosine kinase inhibitors: symptom and economic burden. J Med Econ 2017; 20:1136-1147. [PMID: 28758857 DOI: 10.1080/13696998.2017.1361960] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE This study describes the symptom and economic burden associated with brain metastases (BM) in patients with non-small cell lung cancer (NSCLC) receiving epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (EGFR-TKIs). METHODS This retrospective study included adults with ≥2 medical claims, within 90 days, for lung cancer and ≥1 administration of EGFR-TKIs. Based on ICD-9 codes, patients were stratified into cohorts by type of metastases (BM, other metastases [OM], or no metastases [NM]), and by when the metastasis diagnosis occurred (synchronous or asynchronous). RESULTS The population (synchronous BM [SBM] = 24, synchronous OM [SOM] = 23, asynchronous BM [ASBM] = 15, asynchronous OM [ASOM] = 49, NM = 85) was mostly female (57%), average age 69 years (SD = 11). SBM patients experienced more fatigue and nausea/vomiting compared with SOM and NM patients and more headaches and loss of appetite than NM patients. ASBM was associated with more fatigue, nausea/vomiting, headaches, pain/numbness, altered mental status, and seizures than NM, and more headaches and pain/numbness than ASOM. SBM patients experienced a greater increase in per-member-per-month all-cause total healthcare costs after diagnosis ($20,301) vs SOM ($9,131, p = .001) and NM ($2,493, p = .001). ASBM's cost increase between baseline and follow-up ($7,867) did not differ from ASOM's ($4,947, p = .195); both were larger than NM ($2,493, p = .001 and p = .009, respectively). LIMITATIONS EGFR mutation status was inferred based on EGFR-TKI treatment, not by molecular testing. Patients were from US commercial insurance plans; results may not be generalizable to other populations. CONCLUSIONS Among patients with EGFR-TKI-treated NSCLC, patients with BM experienced more symptoms and, when diagnosed synchronously, had significant increases in total medical costs vs patients with OM and NM. Therapeutic options with central nervous system activity may offer advantages in symptomatology and costs in EGFR-mutated patients with BM.
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Affiliation(s)
| | - Bingcao Wu
- b Janssen Pharmaceuticals, Inc. , Titusville , NJ , USA
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13
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Healy V, O'Halloran P, O'Brien S, Beausang A, Caird J. CNS metastasis secondary to malignant-mixed Müllerian tumor: case report and review of therapeutics. CNS Oncol 2017; 6:315-323. [PMID: 28990810 DOI: 10.2217/cns-2017-0015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
This paper reviews CNS involvement secondary to malignant-mixed Müllerian tumor or uterine carcinosarcoma, a rare aggressive biphasic Müllerian tumor. We report a cerebellar metastasis with epithelial and mesenchymal components, demonstrating heterologous rhabdomyogenic and chondroblastic differentiation. The patient had undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy for palliation of symptomatic chemotherapy-resistant node-positive disease. CNS involvement is rare, and prognostically poor, and suggestively poorer in predominantly sarcomatous metastases. Multimodal therapy is indicated; in solitary metastases, surgical resection or stereotactic radiosurgery is included, followed by whole brain radiotherapy. In unresectable brain metastases, stereotactic radiosurgery and whole brain radiotherapy warrant consideration in up to 2-3 metastases. In multiple metastases, palliative steroid therapy or cranial irradiation may be considered. Combination or platinum-based chemotherapy (i.e., ifosfamide-paclitaxel or carboplatin-paclitaxel) is indicated in all stages, with a role in both disease cure and control-directed management. Targeted therapeutics have thus far not demonstrated significant clinical efficacy.
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Affiliation(s)
- Vincent Healy
- Department of Neurosurgery, National Neurosurgery Centre, Beaumont Hospital, Dublin 11, Ireland
| | - Philip O'Halloran
- Department of Neurosurgery, National Neurosurgery Centre, Beaumont Hospital, Dublin 11, Ireland
| | - Sorca O'Brien
- Department of Gynaecological Oncology, UCD School of Medicine, MMUH, Dublin 7, Ireland
| | - Alan Beausang
- Department of Neuropathology, Beaumont Hospital, Dublin 9, Ireland
| | - John Caird
- Department of Neurosurgery, National Neurosurgery Centre, Beaumont Hospital, Dublin 11, Ireland
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14
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Paradigm shift of therapeutic management of brain metastases in EGFR-mutant non-small cell lung cancer in the era of targeted therapy. Med Oncol 2017; 34:121. [PMID: 28555261 DOI: 10.1007/s12032-017-0978-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 05/09/2017] [Indexed: 12/25/2022]
Abstract
Non-small cell lung cancer (NSCLC) patients with epidermal growth factor receptor (EGFR) mutations commonly present brain metastases (BM) at the time of NSCLC diagnosis or during the clinical course. Conventionally, the prognosis of BM has been extremely poor, but the advent of EGFR-tyrosine kinase inhibitors (TKIs) has drastically improved the prognosis in these patients. Despite the presence of the blood-brain barrier, EGFR-TKIs have dramatic therapeutic effects on both BM and extracranial disease. In addition, recent systemic chemotherapies reportedly play a role in controlling BM. These treatment modalities can potentially replace whole brain radiotherapy (WBRT) to prevent or delay neurocognitive decline. Therefore, how to utilize these treatments is one issue. The other issue is what kind of treatment is best for recurrence after TKI therapy. Recent reports have shown a positive effect of a combination therapy of EGFR-TKI and radiotherapy on BM. Although neurocognitive decline is underscored when WBRT is considered, a survival benefit from WBRT has been proven especially in the potential long survivors with good prognostic index, especially disease-specific graded prognostic index (DS-GPA). In this review, treatment strategy including chemotherapeutic agents and radiotherapy is discussed in terms of risk-benefit balance in conjunction with DS-GPA.
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15
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Inno A, Di Noia V, D'Argento E, Modena A, Gori S. State of the art of chemotherapy for the treatment of central nervous system metastases from non-small cell lung cancer. Transl Lung Cancer Res 2016; 5:599-609. [PMID: 28149755 DOI: 10.21037/tlcr.2016.11.01] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chemotherapy is the mainstay of treatment of advanced non-small cell lung cancer (NSCLC) without molecular drivers. Despite a low penetration of central nervous system (CNS), chemotherapy drugs demonstrated encouraging activity against CNS metastases from NSCLC. Based on the available data, chemotherapy should be considered as an important part of the multidisciplinary treatment of CNS metastases. Particularly, platinum-based regimens represent the most active combinations and pemetrexed is associated with a meaningful clinical benefit for patients with non-squamous histology. How to integrate chemotherapy and radiotherapy for newly diagnosed brain metastases (BMs) is still debated. Although flawed by some limitations, the available evidence suggests a role for upfront chemotherapy for the treatment of NSCLC patients with synchronous, asymptomatic BMs, thus allowing a delay of radiotherapy. Despite the introduction of modern and more effective chemotherapy, however, the prognosis of NSCLC patients with CNS metastases remains poor, especially for those with progressive BMs or leptomeningeal carcinomatosis (LC).
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Affiliation(s)
- Alessandro Inno
- Medical Oncology Unit, Sacro Cuore don Calabria Hospital, Cancer Care Center, Verona, Italy
| | - Vincenzo Di Noia
- Medical Oncology Unit, Policlinico Gemelli Foundation, Catholic University of the Sacred Heart, Rome, Italy
| | - Ettore D'Argento
- Medical Oncology Unit, Policlinico Gemelli Foundation, Catholic University of the Sacred Heart, Rome, Italy
| | - Alessandra Modena
- Medical Oncology Unit, Sacro Cuore don Calabria Hospital, Cancer Care Center, Verona, Italy
| | - Stefania Gori
- Medical Oncology Unit, Sacro Cuore don Calabria Hospital, Cancer Care Center, Verona, Italy
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16
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Buttigliero C, Bertaglia V, Novello S. Anti-angiogenetic therapies for central nervous system metastases from non-small cell lung cancer. Transl Lung Cancer Res 2016; 5:610-627. [PMID: 28149756 DOI: 10.21037/tlcr.2016.09.03] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Central nervous system (CNS) metastases are common in patients with advanced non-small cell lung cancer (NSCLC), occurring in 24% to 44% of patients in the course of their disease and confer significant morbidity and mortality. Systemic therapies have been deemed ineffective in brain metastases (BM) under the hypothesis that the blood-brain barrier (BBB) limits their delivery to the brain. Angiogenesis, which is mainly mediated by vascular endothelial growth factor (VEGF) pathway, is crucial for tumor survival, growth and invasion both in primary and metastatic brain lesions. Two major categories of agents have been developed to target this pathway: antibody-based agents and VEGF receptor tyrosine kinase inhibitors (TKIs). Clinical benefits have been shown with anti-angiogenetic therapies in the treatment of metastatic NSCLC. However, patients with CNS metastases were often excluded from trials with these agents, due to concerns about a potentially greater risk of cerebral haemorrhage and thromboembolic disease. Therefore, the overall efficacy and safety of angiogenetic agents in patients with BM from NSCLC are yet to be clarified. This paper aims to review available data about the efficacy and safety of anti-angiogenetic therapies for CNS metastases in NSCLC patients.
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Affiliation(s)
- Consuelo Buttigliero
- Department of Oncology, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy
| | - Valentina Bertaglia
- Department of Oncology, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy
| | - Silvia Novello
- Department of Oncology, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy
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17
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Stefanou D, Stamatopoulou S, Sakellaropoulou A, Akakios G, Gkiaouraki M, Gkeka D, Prevezanou M, Ardavanis A. Bevacizumab, pemetrexed and carboplatin in first-line treatment of non-small cell lung cancer patients: Focus on patients with brain metastases. Oncol Lett 2016; 12:4635-4642. [PMID: 28101218 DOI: 10.3892/ol.2016.5268] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 04/05/2016] [Indexed: 01/16/2023] Open
Abstract
Data concerning bevacizumab plus pemetrexed plus carboplatin as first-line treatment for patients with non-squamous non-small cell lung cancer (NSCLC) with or without brain metastases (BM) are lacking. The present study analyzed the efficacy and safety of this combination as induction therapy, followed by maintenance therapy with bevacizumab plus pemetrexed in non-squamous NSCLC patients with or without BM. Treatment-naïve patients with advanced non-squamous NSCLC and an Eastern Cooperative Oncology Group performance status score of 0-2 were eligible. Treatment consisted of carboplatin (area under the curve of 5), pemetrexed (500 mg/m2) and bevacizumab (15 mg/kg) every 3 weeks for 6 cycles. Responders and patients with stable disease received maintenance therapy with bevacizumab plus pemetrexed until disease progression, which was evaluated every 3 cycles, or unacceptable toxicity. Kaplan-Meier median progression-free survival (PFS) and overall survival (OS) times were the primary endpoints, and safety was the secondary endpoint. In total, 39 patients, aged 44-78 years (median, 60 years), were treated; 11 (28.2%) of whom presented with BM. The majority of patients (56.4%) completed 6 cycles of induction therapy, and 26 patients continued on to maintenance therapy. The median PFS time was 8.2 months [95% confidence interval (CI), 7.05-9.35] and the median OS time was 14.0 months (95% CI, 8.46-19.54). Median PFS and OS times did not differ significantly between patients with or without BM (log rank (Mantel-Cox): PFS, P=0.748 and OS, P=0.447). The majority of patients (76.9%) did not experience adverse events during treatment. Overall, bevacizumab plus pemetrexed plus carboplatin as induction therapy, followed by bevacizumab plus pemetrexed as maintenance therapy was effective and well tolerated in advanced NSCLC, whether brain metastases were present or not.
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Affiliation(s)
- Dimitra Stefanou
- First Department of Medical Oncology, St. Savas Anticancer Hospital, Athens 115 22, Greece
| | - Sofia Stamatopoulou
- First Department of Medical Oncology, St. Savas Anticancer Hospital, Athens 115 22, Greece
| | | | - Gavriil Akakios
- First Department of Medical Oncology, St. Savas Anticancer Hospital, Athens 115 22, Greece
| | - Marina Gkiaouraki
- First Department of Medical Oncology, St. Savas Anticancer Hospital, Athens 115 22, Greece
| | - Despina Gkeka
- First Department of Medical Oncology, St. Savas Anticancer Hospital, Athens 115 22, Greece
| | - Maria Prevezanou
- First Department of Medical Oncology, St. Savas Anticancer Hospital, Athens 115 22, Greece
| | - Alexandros Ardavanis
- First Department of Medical Oncology, St. Savas Anticancer Hospital, Athens 115 22, Greece
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18
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Khalifa J, Amini A, Popat S, Gaspar LE, Faivre-Finn C. Brain Metastases from NSCLC: Radiation Therapy in the Era of Targeted Therapies. J Thorac Oncol 2016; 11:1627-43. [PMID: 27343440 DOI: 10.1016/j.jtho.2016.06.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/02/2016] [Accepted: 06/09/2016] [Indexed: 02/07/2023]
Abstract
Brain metastases (BMs) will develop in a large proportion of patients with NSCLC throughout the course of their disease. Among patients with NSCLC with oncogenic drivers, mainly EGFR activating mutations and anaplastic lymphoma receptor tyrosine kinase gene (ALK) rearrangements, the presence of BM is a common secondary localization of disease both at the time of diagnosis and at relapse. Because of the limited penetration of a wide range of drugs across the blood-brain barrier, radiotherapy is considered the cornerstone of treatment of BMs. However, evidence of dramatic intracranial response rates has been reported in recent years with targeted therapies such as tyrosine kinase inhibitors and has been supported by new insights into pharmacokinetics to increase rates of tyrosine kinase inhibitors' penetration of the cerebrospinal fluid (CSF). In this context, the combination of brain radiotherapy and targeted therapies seems relevant, and there is a strong radiobiological rationale to harness the radiosentizing effect of the drugs. Nevertheless, to date, there is a paucity of high-level clinical evidence supporting the combination of brain radiotherapy and targeted therapies in patients with NSCLC and BMs, and there are often methodological biases in reported studies, such as the lack of stratification by mutation status. Moreover, among asymptomatic patients not suitable for ablative treatment, this strategy is challenged by the promising results associated with the administration of targeted therapies alone. Herein, we review the biological rationale to combine targeted therapies and brain radiotherapy for patients with NSCLC and BMs, report the clinical data available to date, and discuss future directions to improve outcome in this group of patients.
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Affiliation(s)
- Jonathan Khalifa
- Radiotherapy Related Research, The Christie National Health Service Foundation Trust, Manchester, United Kingdom.
| | - Arya Amini
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Sanjay Popat
- Lung Cancer Unit, Royal Marsden Hospital, London, United Kingdom
| | - Laurie E Gaspar
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Corinne Faivre-Finn
- Radiotherapy Related Research, The Christie National Health Service Foundation Trust, Manchester, United Kingdom; Manchester Academic Health Science Centre, Institute of Cancer Sciences, Manchester Cancer Research Centre, The University of Manchester, Manchester, United Kingdom
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19
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The impact of brain metastasis on quality of life, resource utilization and survival in patients with non-small-cell lung cancer. Cancer Treat Rev 2016; 45:139-62. [DOI: 10.1016/j.ctrv.2016.03.009] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 03/08/2016] [Accepted: 03/09/2016] [Indexed: 01/17/2023]
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20
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Metro G, Chiari R, Ricciuti B, Rebonato A, Lupattelli M, Gori S, Bennati C, Castrioto C, Floridi P, Minotti V, Chiarini P, Crinò L. Pharmacotherapeutic options for treating brain metastases in non-small cell lung cancer. Expert Opin Pharmacother 2015; 16:2601-13. [PMID: 26439599 DOI: 10.1517/14656566.2015.1094056] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Central nervous system (CNS) metastases represent an important cause of morbidity and mortality in non-small cell lung cancer (NSCLC) patients. Local approaches of neurosurgery (usually for single brain lesions), whole brain radiotherapy, and stereotactic radiosurgery are often withheld for the treatment of NSCLC-derived brain metastases (BMs). However, systemic treatment is consistently emerging as an option for patients with asymptomatic BMs, which could allow for delaying cranial radiotherapy at symptomatic/radiological progression. AREAS COVERED Chemotherapy, monoclonal antibodies, tyrosine-kinase inhibitors (TKIs) for molecularly selected NSCLCs, such as epidermal growth factor receptor (EGFR)-mutant and anaplastic lymphoma kinase (ALK)-rearranged diseases, and immune checkpoint inhibitors are all systemic treatments that have shown activity against NSCLC-derived CNS metastases. Among these, EGFR- and ALK-TKIs will be discussed more in detail owing to their superior efficacy in this context. EXPERT OPINION Up-front systemic treatment should be considered for patients with asymptomatic, multiple BMs, as recently acknowledged by the European Society of Medical Oncology guidelines. Nevertheless, it must be emphasized that the best treatment strategy for NSCLC-derived BMs has to be defined within a multidisciplinary team.
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Affiliation(s)
- Giulio Metro
- a 1 Medical Oncology, Santa Maria della Misericordia Hospital, Azienda Ospedaliera di Perugia , Perugia, Italy +39 07 55 78 41 85 ; +39 07 55 78 41 84 ;
| | - Rita Chiari
- a 1 Medical Oncology, Santa Maria della Misericordia Hospital, Azienda Ospedaliera di Perugia , Perugia, Italy +39 07 55 78 41 85 ; +39 07 55 78 41 84 ;
| | - Biagio Ricciuti
- a 1 Medical Oncology, Santa Maria della Misericordia Hospital, Azienda Ospedaliera di Perugia , Perugia, Italy +39 07 55 78 41 85 ; +39 07 55 78 41 84 ;
| | - Alberto Rebonato
- b 2 University of Perugia, Department of Diagnostic Imaging, Santa Maria della Misericordia Hospital , Perugia, Italy
| | - Marco Lupattelli
- c 3 Division of Radiotherapy, Santa Maria della Misericordia Hospital, Azienda Ospedaliera di Perugia , Perugia, Italy
| | - Stefania Gori
- d 4 Medical Oncology, Sacro Cuore-Don Calabria Hospital , Negrar, VR, Italy
| | - Chiara Bennati
- a 1 Medical Oncology, Santa Maria della Misericordia Hospital, Azienda Ospedaliera di Perugia , Perugia, Italy +39 07 55 78 41 85 ; +39 07 55 78 41 84 ;
| | - Corrado Castrioto
- e 5 Division of Neurosurgery, Santa Maria della Misericordia Hospital, Azienda Ospedaliera di Perugia , Perugia, Italy
| | - Piero Floridi
- f 6 Neuroradiology, Santa Maria della Misericordia Hospital, Azienda Ospedaliera di Perugia , Perugia, Italy
| | - Vincenzo Minotti
- a 1 Medical Oncology, Santa Maria della Misericordia Hospital, Azienda Ospedaliera di Perugia , Perugia, Italy +39 07 55 78 41 85 ; +39 07 55 78 41 84 ;
| | - Pietro Chiarini
- f 6 Neuroradiology, Santa Maria della Misericordia Hospital, Azienda Ospedaliera di Perugia , Perugia, Italy
| | - Lucio Crinò
- a 1 Medical Oncology, Santa Maria della Misericordia Hospital, Azienda Ospedaliera di Perugia , Perugia, Italy +39 07 55 78 41 85 ; +39 07 55 78 41 84 ;
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Abstract
Recognition of the vascular endothelial growth factor (VEGF) pathway as a key mediator of angiogenesis has led to the clinical study of several VEGF and VEGF receptor (VEGFR) targeted therapies in non-small-cell lung cancer (NSCLC). These targeted therapies include neutralizing antibodies to VEGF (bevacizumab and aflibercept) and VEGFR-2 (ramucirumab) and tyrosine kinase inhibitors (TKIs) with selectivity for the VEGFRs. Bevacizumab and ramucirumab are associated with survival advantages in the treatment of advanced NSCLC: bevacizumab in the first-line setting in combination with carboplatin/paclitaxel and ramucirumab in combination with docetaxel in the second-line setting. The VEGFR-2 TKIs have been associated with responses and improved progression-free survival in selected NSCLC settings; however, this level of activity has thus far been insufficient to confer significant survival advantages. This review will focus on the current state of VEGF targeted therapies in NSCLC.
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Affiliation(s)
- Liza C. Villaruz
- Lung Cancer Program, University of Pittsburgh Cancer Institute, 5150 Centre Avenue, 5th Floor Cancer Pavilion, Room 567, Pittsburgh, PA 15232, USA
| | - Mark A. Socinski
- Lung Cancer Program, University of Pittsburgh Cancer Institute, 5150 Centre Avenue, 5th Floor Cancer Pavilion, Room 567, Pittsburgh, PA 15232, USA
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Duell T, Kappler S, Knöferl B, Schuster T, Hochhaus J, Morresi-Hauf A, Huber RM, Tufman A, Zietemann V. Prevalence and risk factors of brain metastases in patients with newly diagnosed advanced non-small-cell lung cancer. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.ctrc.2015.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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23
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D'Antonio C, Passaro A, Gori B, Del Signore E, Migliorino MR, Ricciardi S, Fulvi A, de Marinis F. Bone and brain metastasis in lung cancer: recent advances in therapeutic strategies. Ther Adv Med Oncol 2014; 6:101-14. [PMID: 24790650 DOI: 10.1177/1758834014521110] [Citation(s) in RCA: 149] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Bone and brain metastases are a very common secondary localization of disease in patients with lung cancer. The prognosis of these patients is still poor with a median survival of less than 1 year. Current therapeutic approaches include palliative radiotherapy and systemic therapy with chemotherapy and targeted agents. For bone metastasis, zoledronic acid is the most commonly used bisphosphonate to prevent, reduce the incidence and delay the onset of skeletal-related events (SREs). Recently, denosumab, a fully human monoclonal antibody directed against the receptor activator of nuclear factor κB (RANK) ligand inhibiting the maturation of pre-osteoclasts into osteoclasts, showed increased time to SREs and overall survival compared with zoledronic acid. The treatment of brain metastasis is still controversial. Available standard therapeutic options, such as whole brain radiation therapy and systemic chemotherapy, provide a slight improvement in local control, overall survival and symptom relief. More recently, novel target agents such as the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) erlotinib, gefitinib and afatinib have shown activity in patients with brain metastasis. Inter alia, in patients harboring EGFR mutations, the administration of EGFR TKIs is followed by a response rate of 70-80%, and a longer progression-free and overall survival than those obtained with standard chemotherapeutic regimens. This review is focused on the evidence for therapeutic strategies in bone and brain metastases due to lung cancer.
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Affiliation(s)
- Chiara D'Antonio
- 1st Oncological Pulmonary Unit/Department of Medical and Surgical Sciences and Translational Medicine, 'Sapienza' University of Rome, Sant'Andrea Hospital San Camillo, High Specialization Hospital/University of Rome, Sant'Andrea Hospital, Cir. ne Gianicolense 87, 00151, Rome, Italy
| | - Antonio Passaro
- Division of Thoracic Oncology, European Institute of Oncology, Milan, Italy
| | - Bruno Gori
- 1st Oncological Pulmonary Unit, San Camillo, High Specialization Hospital, Rome, Italy
| | - Ester Del Signore
- Division of Thoracic Oncology, European Institute of Oncology, Milan, Italy
| | - Maria Rita Migliorino
- 1st Oncological Pulmonary Unit, San Camillo, High Specialization Hospital, Rome, Italy
| | - Serena Ricciardi
- 1st Oncological Pulmonary Unit, San Camillo, High Specialization Hospital, Rome, Italy
| | - Alberto Fulvi
- 1st Oncological Pulmonary Unit, San Camillo, High Specialization Hospital, Rome, Italy
| | - Filippo de Marinis
- Division of Thoracic Oncology, European Institute of Oncology, Milan, Italy
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Continuous pemetrexed treatment for brain metastasis in non-small cell lung cancer—A report of two cases. Lung Cancer 2013; 80:111-3. [PMID: 23279874 DOI: 10.1016/j.lungcan.2012.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 12/05/2012] [Indexed: 01/05/2023]
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25
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Davis FG, Dolecek TA, McCarthy BJ, Villano JL. Toward determining the lifetime occurrence of metastatic brain tumors estimated from 2007 United States cancer incidence data. Neuro Oncol 2012; 14:1171-7. [PMID: 22898372 PMCID: PMC3424213 DOI: 10.1093/neuonc/nos152] [Citation(s) in RCA: 166] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 06/22/2012] [Indexed: 12/15/2022] Open
Abstract
Few population estimates of brain metastasis in the United States are available, prompting this study. Our objective was to estimate the expected number of metastatic brain tumors that would subsequently develop among incident cancer cases for 1 diagnosis year in the United States. Incidence proportions for primary cancer sites known to develop brain metastasis were applied to United States cancer incidence data for 2007 that were retrieved from accessible data sets through Centers for Disease Control and Prevention (CDC Wonder) and Surveillance, Epidemiology, and End Results (SEER) Program Web sites. Incidence proportions were identified for cancer sites, reflecting 80% of all cancers. It was conservatively estimated that almost 70 000 new brain metastases would occur over the remaining lifetime of individuals who received a diagnosis in 2007 of primary invasive cancer in the United States. That is, 6% of newly diagnosed cases of cancer during 2007 would be expected to develop brain metastasis as a progression of their original cancer diagnosis; the most frequent sites for metastases being lung and bronchus and breast cancers. The estimated numbers of brain metastasis will be expected to be higher among white individuals, female individuals, and older age groups. Changing patterns in the occurrence of primary cancers, trends in populations at risk, effectiveness of treatments on survival, and access to those treatments will influence the extent of brain tumor metastasis at the population level. These findings provide insight on the patterns of brain tumor metastasis and the future burden of this condition in the United States.
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Affiliation(s)
- Faith G Davis
- Department of Public Health Sciences, School of Public Health, University of Alberta, Alberta, Canada.
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Noël-Savina E, Descourt R, Le Fur E, Robinet G. Traitement des métastases cérébrales des CBNPC. ONCOLOGIE 2012. [DOI: 10.1007/s10269-012-2157-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Phase II Study of Sunitinib in Patients with Non-small Cell Lung Cancer and Irradiated Brain Metastases. J Thorac Oncol 2011; 6:1260-6. [DOI: 10.1097/jto.0b013e318219a973] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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