Alleviation of brain edema and restoration of functional independence by bevacizumab in brain-metastatic breast cancer: a case report

Effect of low-dose bevacizumab on health-related quality of life in patients with recurrent high-grade glioma: A retrospective clinical study

BACKGROUND

We retrospectively analyzed the effects of low-dose bevacizumab (BEV) combined with temozolomide (TMZ) on health-related quality of life (HRQL) in patients with recurrent high-grade glioma (rHGG).

METHODS

A total of 129 patients with rHGG were included in this study. Patients were divided into a combination group and TMZ group based on the treatment they received. The Quality of Life Questionnaire Core 30 (QLQ-C30) and EORTC Brain Cancer Module (QLQ-BN20) were used to evaluate HRQL in all patients before and after treatment. Categorical variables were compared using the chi-squared test. The data for all continuous variables were first tested for a normal distribution. If the data conformed to a normal distribution, a T test was used for comparison. If the data did not conform to a normal distribution, the rank-sum test was used.

RESULTS

There were differences in PFS and PFS-6 between the BEV + TMZ and TMZ groups (P＜0.05). However, there was no difference in the OS between the two groups (P＞0.05). The BEV + TMZ group performed better than the TMZ group in both the QLQ-C30 and QLQ-BN20. In addition, the KPS score was higher in the BEV + TMZ group than in the TMZ group. Steroid doses given were lower in the BEV + TMZ group than in the TMZ group (P < 0.05).

CONCLUSIONS

Low-dose BEV + TMZ can relieve the clinical symptoms of rHGG patients, reduce their steroid dose, improve HRQL, and prolong PFS, but does not bear any benefit on OS.

Anti-VEGF Therapy Possibly Extends Survival in Patients With Colorectal Brain Metastasis by Protecting Patients From Neurologic Disability

BACKGROUND

Colorectal brain metastases (CBMs) are rare with poor prognosis. There is still no standard systemic treatment for multiple or unresectable CBM. our study aimed to explore the impact of anti-VEGF therapy on overall survival, brain-specific disease control, and neurologic symptom burden in patients with CBM.

METHODS

A total of 65 patients with CBM under treatment were retrospectively enrolled and divided into anti-VEGF based systemic therapy or non-anti-VEGF based therapy. A total of 25 patients who received at least 3 cycles of anti-VEGF agent and 40 patients without anti-VEGF therapy were analyzed by endpoints of overall survival (OS), progression-free survival (PFS), intracranial PFS (iPFS) and neurogenic event-free survival (nEFS). Gene expression in paired primary metastatic colorectal cancer (mCRC), liver, lung and brain metastasis from NCBI data was analyzed using top Gene Ontology (GO) and cBioPortal.

RESULTS

Patients who treated with anti-VEGF therapy had significantly longer OS (19.5 vs. 5.5 months, P = .009), iPFS (14.6 vs. 4.1 months, P < .001) and nEFS (17.6 vs. 4.4 months, P < .001). Patients who received anti-VEGF therapy beyond any disease progression presented with superior OS (19.7 vs. 9.4 months, P = .039). Top GO and cBioPortal analysis revealed a stronger molecular function of angiogenesis in intracranial metastasis.

CONCLUSIONS

Anti-VEGF based systemic therapy showed favorable efficacy that was reflected in longer overall survival, iPFS and NEFS in patients with CBM.

The benefit of bevacizumab therapy in patients with refractory vasogenic edema caused by brain metastasis from lung and colon cancers

Objective

This retrospective study investigated the efficacy of bevacizumab in refractory brain edema caused by brain metastasis from lung cancer and colon cancer.

Methods

A total of 72 patients with refractory brain edema were divided into the lung cancer and colon cancer groups according to their primary tumor. All patients received a single bevacizumab treatment for refractory brain edema. MRI was performed 1 week before the treatment and 4 weeks after the treatment. The edema and tumor volumes were calculated using imaging modalities.

Results

After a single bevacizumab treatment, the refractory brain edema of 61 patients was controlled, and the clinical symptoms of 65 patients were improved. The average edema volume before treatment was 201,708.97 ± 61,426.04 mm³, which has decreased to 116,947.01 ± 43,879.16 mm³ after treatment (P < 0.05). After treatment, the edema index decreased from 25.97 ± 7.15 to 17.32 ± 5.24 (P < 0.05).We found that brain edema was controlled in 40 patients (93.02%) in the lung cancer group and 21 patients (72.41%) in the colon cancer group (P<0.05). In addition, 22 patients (88.00%) in the radiotherapy group achieved edema control, compared to 39 (82.98%) in the non-radiotherapy group (P>0.05). Nine patients experienced hypertension after treatment, two patients exhibited decreased platelet counts, and no hemorrhage cases were observed.

Conclusion

Bevacizumab can significantly alleviate refractory brain edema, and there is a significant difference in the efficacy of bevacizumab on refractory brain edema caused by brain metastasis from lung and colon cancers.

Salvage Treatment for Progressive Brain Metastases in Breast Cancer

Simple Summary

Thirty percent of patients with human epidermal growth factor receptor 2-positive breast cancer and triple-negative breast cancer, and 15% of patients with the remaining subtypes of breast cancer will develop brain metastases. Available treatment methods include surgery and radiotherapy. However, some individuals will experience intracranial progression despite prior local treatment. This situation remains a challenge. In the case of progressing lesions amenable to local therapy, the choice of a treatment method must consider performance status, cancer burden, possible toxicity, and previously applied therapy. Stereotactic radiosurgery or fractionated radiotherapy rather than whole-brain radiotherapy should be used only if feasible. If local therapy is unfeasible, selected patients, especially those with human epidermal growth factor receptor 2-positive breast cancer, may benefit from systemic therapy.

Abstract

Survival of patients with breast cancer has increased in recent years due to the improvement of systemic treatment options. Nevertheless, the occurrence of brain metastases is associated with a poor prognosis. Moreover, most drugs do not penetrate the central nervous system because of the blood–brain barrier. Thus, confirmed intracranial progression after local therapy is especially challenging. The available methods of salvage treatment include surgery, stereotactic radiosurgery (SRS), fractionated stereotactic radiotherapy (FSRT), whole-brain radiotherapy, and systemic therapies. This narrative review discusses possible strategies of salvage treatment for progressive brain metastases in breast cancer. It covers possibilities of repeated local treatment using the same method as applied previously, other methods of local therapy, and options of salvage systemic treatment. Repeated local therapy may provide a significant benefit in intracranial progression-free survival and overall survival. However, it could lead to significant toxicity. Thus, the choice of optimal methods should be carefully discussed within the multidisciplinary tumor board.

Efficacy of bevacizumab in the treatment of refractory brain edema of metastatic tumors from different sources

Aim: This retrospective study investigated bevacizumab in treating refractory brain edema in patients with brain-metastatic tumors from different sources.Methods: From January 2013 to December 2019, 83 patients with brain metastases and refractory brain edema were treated with bevacizumab. They were divided into lung cancer group and breast cancer group. The clinical data, the efficacy, and the side effects of bevacizumab were recorded. Magnetic resonance imaging was performed before and after bevacizumab treatment. The volume of tumor and brain edema were measured respectively.Results: After treatment with bevacizumab, 72 cases of refractory brain edema were significantly relieved. The edema control rate was 93.75% in the lung cancer group and 77.14% in the breast cancer group (P < .05). The brain edema volume was significantly reduced after bevacizumab treatment from 198,286.84 ± 60,564.40 to 114,677.71 ± 42,337.38mm³ (P < .01), and the edema index was reduced from 26.14 ± 7.24 to 17.18 ± 5.14 (P < .01). Hypertension was observed in 14 cases.Conclusion: Bevacizumab could significantly reduce refractory brain edema with a control rate of 86.75%. The efficacy of bevacizumab in the treatment of refractory brain edema caused by lung cancer is better than that of breast cancer.

The relationship between the degree of brain edema regression and changes in cognitive function in patients with recurrent glioma treated with bevacizumab and temozolomide

Background

This retrospective study aims to assess the impacts on cognitive status and quality of life in recurrent high-grade glioma patients treated with temozolomide (TMZ), either alone or in combination with bevacizumab (BEV), and explore the relationship between the brain edema regression, BEV use, and cognitive status.

Methods

A total of 125 patients with recurrent high-grade glioma were enrolled in this study, of which 65 patients were treated with BEV (5-10 mg/kg IV every 2 weeks) plus TMZ (200 mg/m² every 28 days, d1-5), and 60 patients were treated with TMZ (200 mg/m² every 28 days, d1-5) alone. The treatment response was evaluated using the Response Assessment in Neuro-Oncology (RANO) criteria. Tumor-associated edema was evaluated with T2WI magnetic resonance imaging (MRI) and quantitative T2 mapping sequence, and an Edema Regression Index was designed to quantify volumetric changes in edema imaging after every treatment cycle. Cognitive intelligence state and quality of life were evaluated using the Mini-Mental State Examination (MMSE) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (QLQ-C30).

Results

Radiologically, the partial response rate was 78.5% in the BEV + TMZ group and 38.3% in the TMZ group. After the first cycle of treatment, the mean score of the MMSE was 21.1±2.0 and 24.1±1.4 (P<0.001) in the TMZ group and the BEV + TMZ group, respectively. In the functioning domains of the QLQ-C30, scales of physical functioning, emotional functioning and cognitive functioning were 43.0±7.0 vs. 61.7±12.5 (P<0.001), 44.5±8.8 vs. 63.4±6.9 (P<0.001) and 42.4±8.8 vs. 63.7±12.0 (P<0.001) in the TMZ group and the BEV + TMZ group, respectively. In the BEV + TMZ group, a correlation between the Edema Regression Index and improvement in cognitive status and quality of life was observed. Patients with Edema Regression Index scores higher than 50% gained a 25.6% increase in the mean MMSE score from 19.9±1.6 to 25.0±1.1 (P<0.001). In the BEV + TMZ group, physical functioning, emotional functioning, and cognitive functioning increased by 76.8%, 53.1%, and 81.5%, respectively, while scores of nausea/vomiting decreased by 40.3% to 32.1. Patients with no evident edema observed in the pre-BEV MRI scans were given a prolonged four-cycle course of BEV. No significant improvement was observed in the MMSE score and the QLQ score with additional cycles of BEV.

Conclusions

A close relationship was observed between Edema Regression Index and a change in cognitive function in patients treated with BEV and TMZ. Compared with TMZ alone, the combination of TMZ and BEV could improve the cognitive function and quality of life of patients with recurrent high-grade gliomas. The Edema Regression Index could be used as a surrogate imaging biomarker to predict patients who may or may not gain cognitive benefit from the combination therapy of TMZ and BEV, which warrants further prospective clinical studies for validation.

Nintedanib and a bi-specific anti-VEGF/Ang2 nanobody selectively prevent brain metastases of lung adenocarcinoma cells

Brain metastases (BM) are an ever-increasing challenge in oncology, threatening quality of life and survival of many cancer patients. The majority of BM originate from lung adenocarcinoma, and stage III patients have a risk of 40–50% to develop BM in the first years of disease onset. As therapeutic options are limited, prevention of their occurrence is an attractive concept. Here we investigated whether Nintedanib (BIBF 1120), a tyrosine kinase inhibitor (TKI) targeting the VEGF pathway approved for lung adenocarcinoma, and the dual anti-VEGF-A/Ang2 nanobody BI836880 have the potential to prevent BM formation. A mouse model of brain metastasis from lung adenocarcinoma was used in which tumor cells were injected intracardially. Metastases formation occurred inside and outside of the brain and was followed by MRI, IVIS, and immunohistochemistry. BM were reduced in volume and number by both Nintedanib and the dual anti-VEGF-A/Ang2 nanobody, which translated into improved survival. Both compounds were able to normalize cerebral blood vessels at the site of brain metastatic lesions. Extracranial metastases, however, were not reduced, and meningeal metastases only partially. Interestingly, unspecific control IgG also lead to brain vessel normalization and reduction of brain and meningeal metastases. This data indicates a brain-specific group effect of antiangiogenic compounds with respect to metastasis prevention, most likely by preventing an early angiogenic switch. Thus, Nintedanib and BI836880 are promising candidates for future BM preventive study concepts in lung adenocarcinoma patients.

Bevacizumab-based treatment as salvage therapy in patients with recurrent symptomatic brain metastases

Background

Salvage treatment for recurrent brain metastases (BM) of solid cancers is challenging due to the high symptomatic burden and the limited local treatment options.

Methods

Patients with recurrent BM with no option for further local therapies were retrospectively identified from BM databases. Bevacizumab-based treatment was initiated as a salvage treatment. Radiological imaging before and after bevacizumab-based treatment was reevaluated for treatment response using the Response Assessment in Neuro-Oncology (RANO) BM criteria.

Results

Twenty-two patients (36.4% male) with recurrent BM from breast cancer (40.9%), colorectal cancer (31.8%), or lung cancer (27.3%) were identified. Previous BM-directed therapies were radiosurgery in 16/22 (72.7%) patients, whole-brain radiotherapy in 8/22 (36.4%), and neurosurgical resection in 11/22 (50.0%). Time since BM diagnosis to initiation of bevacizumab treatment was 16.5 months. Of 22 patients 14 (63.6%) received concurrent systemic therapies. Neurological symptom improvement could be achieved in 14/22 (63.6%) and stabilization in 6/22 (27.3%) patients, resulting in a clinical benefit in 20/22 (90.9%) patients. Steroids could be reduced or stopped in 15/22 (68.2%) patients. Rate of improvement on T1-weighted imaging was 15/19 (78.9%; median reduction: -26.0% ± 32.9) and 19/20 (95%; median reduction: -36.2% ± 22.2) on T2-weighted FLAIR imaging. According to RANO-BM best response was partial response in 7/19 (36.8%), stable disease in 9/19 (47.3%), and progressive disease in 3/19 (15.7%) patients. Median CNS-specific progression-free survival was 8 months and median overall survival after initiation of bevacizumab treatment was 17 months.

Conclusions

Bevacizumab-based treatment had clinically relevant intracranial activity in the vast majority of patients suffering from recurrent, symptomatic BM. The data supports a prospective clinical trial of bevacizumab as a salvage treatment in BM.

Efficacy and safety of bevacizumab combined with chemotherapy in symptomatic brain metastases from lung adenocarcinoma: a retrospective analysis

Background

Currently, the treatment of symptomatic brain metastases from lung adenocarcinoma has remained difficult. Bevacizumab combined with chemotherapy is one of the standard treatments of lung adenocarcinoma. This study was designed to investigate the efficacy and safety of bevacizumab combined with chemotherapy in symptomatic brain metastases from lung adenocarcinoma that are not suitable for local treatments, and to explore the predictive value of baseline serum vascular endothelial growth factor (VEGF) for the treatment.

Methods

We retrospectively reviewed 14 consecutive patients, between Jan 2015 and Jul 2017, with brain metastases from lung adenocarcinoma who received bevacizumab and chemotherapy to determine efficacy and toxicity. Kaplan-Meier method was used to estimate survival curves, and univariate and multivariate analyses were performed by Cox proportional hazard model. The primary endpoints were objective response rate (ORR) and intracranial ORR (iORR). The secondary endpoints were progression-free survival (PFS), intracranial PFS (iPFS), overall survival (OS) and disease control rate (DCR).

Results

The efficacy of 12 patient was evaluated. Overall ORR was 25% (3/12) and the iORR of brain lesions was 33.3% (4/12). DCR was 75% (9/12). The median OS was 18.3 months, the median PFS was 6.7 months, and the median iPFS was 12 months. After 2 cycles of bevacizumab, 10 patients showed improved symptoms of central nervous system (CNS), and the symptom control rate was 83.3% (10/12). Head MRI showed that edema in the brain was greatly reduced in 6 patients, resulting in the lessened usage of dexamethasone. iPFS was significantly shorter in high VEGF group (3.6 vs. 8.0 m, P=0.02), and multivariate analysis showed a significant correlation between iPFS and serum baseline VEGF level (P=0.023). The most commonly adverse events of bevacizumab included leukopenia [5 (35.7%)], fatigue [3 (21.4%)], thrombocytopenia [3 (21.4%)], anemia [2 (14.3%)], which were mostly degree I and II.

Conclusions

This study showed bevacizumab combined with chemotherapy could effectively control intracranial lesions, relieve symptoms, and improve the quality of life and survival of patients with brain metastases from lung adenocarcinoma. Serum baseline VEGF may be a predictor of efficacy of bevacizumab plus chemotherapy in the treatment of brain metastases from lung adenocarcinoma.

Low-dose bevacizumab as an effective pre-treatment for peri-tumoral brain edema prior to CyberKnife radiosurgery: A case report

A 75-y-old Chinese female patient diagnosed with lung adenocarcinoma with brain metastasis suffered severe nausea and vomiting, and these symptoms were contraindications for CyberKnife treatment. Neither mannitol, nor dexamethasone, relieved the symptoms. However, after the patient received a single dose of bevacizumab (200 mg, 2.9 mg/kg), the patient's symptoms were significantly relieved. The patient subsequently completed a successful CyberKnife treatment. In addition, the patient received an oral treatment of gefitinib. At 15 months post treatment, the patient's brain tumor was controlled. Thus, administration of bevacizumab at a low dose (2.9 mg/kg) may significantly alleviate peri-tumoral brain edema and its symptoms, thereby facilitating radiosurgery treatment.

Anti-angiogenic therapies in brain metastases

Brain metastases are a major challenge in modern oncology, as treatment options upon the diagnosis of symptomatic brain metastases are limited. Neo-angiogenesis was identified as a hallmark of brain metastasis development and inhibition using anti-angiogenic therapy might therefore be an experimental promising preventive as well as therapeutic approach. The current review will summarize the current available data on the efficacy of neo-angiogenic therapies in patients with brain metastases.

Role of the blood-brain barrier in metastatic disease of the central nervous system

Systemic therapy is an important backbone in the multimodal treatment approach of brain metastases. However, the blood-brain barrier or, more correctly, the blood-tumor barrier, as the properties of tumor-associated vessels differ from the physiologic state, potentially limits the passage of systemic drugs. Indeed, several preclinical and clinical investigations showed that the distribution of drugs is very heterogeneous within a given brain metastasis, despite the contrast enhancement in magnetic resonance imaging. Brain metastases may show lower intratumoral concentrations of some drugs as compared to extracranial tumor sites, resulting in mixed responses. Therefore, a more profound understanding of the role of the blood-brain/blood-tumor barrier is needed to effectively formulate clinical trial approaches on systemic therapy options in patients with brain metastases.

Response of brain metastasis from lung cancer patients to an oral nutraceutical product containing silibinin

Despite multimodal treatment approaches, the prognosis of brain metastases (BM) from non-small cell lung cancer (NSCLC) remains poor. Untreated patients with BM have a median survival of about 1 month, with almost all patients dying from neurological causes. We herein present the first report describing the response of BM from NSCLC patients to an oral nutraceutical product containing silibinin, a flavonoid extracted from the seeds of the milk thistle. We present evidence of how the use of the silibinin-based nutraceutical Legasil^® resulted in significant clinical and radiological improvement of BM from NSCLC patients with poor performance status that progressed after whole brain radiotherapy and chemotherapy. The suppressive effects of silibinin on progressive BM, which involved a marked reduction of the peritumoral brain edema, occurred without affecting the primary lung tumor outgrowth in NSCLC patients. Because BM patients have an impaired survival prognosis and are in need for an immediate tumor control, the combination of brain radiotherapy with silibinin-based nutraceuticals might not only alleviate BM edema but also prove local control and time for either classical chemotherapeutics with immunostimulatory effects or new immunotherapeutic agents such as checkpoint blockers to reveal their full therapeutic potential in NSCLC BM patients. New studies aimed to illuminate the mechanistic aspects underlying the regulatory effects of silibinin on the cellular and molecular pathobiology of BM might expedite the entry of new formulations of silibinin into clinical testing for progressive BM from lung cancer patients.

Efficacy and safety of bevacizumab treatment for refractory brain edema: Case report

OBJECTIVE

This retrospective study investigated the efficacy and safety of bevacizumab treatment for refractory brain edema.

METHODS

Between March 2009 and December 2015, bevacizumab was used to treat 59 cases of brain metastatic patients with refractory brain edema. The median dose of bevacizumab was 4.68 mg/kg (range 2.8-6.52 mg/kg). The clinical-pathological data, the efficacy, and the side effects of bevacizumab were recorded. Magnetic resonance imaging (MRI) was performed before and after bevacizumab treatment. Tumor and edema volumes were measured separately.

RESULTS

The clinical symptoms of 50 out of 59 cases (84.74%) improved the day after the bevacizumab treatment, and the edema volumes of 55 (93.22%) cases were reduced after the bevacizumab treatment. The average edema volume was significantly reduced after bevacizumab treatment from 125,583.43 ± 14,093.27 to 71,613.42 ± 9473.42 mm (Mann-Whitney rank test, P < .01), and the average edema index was significantly reduced from 25.66 ± 11.54 to 17.87 ± 6.87 (Mann-Whitney rank test, P < .01). One patient died from a hemorrhage due to a cancerous-ulcer of the maxillary sinus. The main complication observed was hypertension, which was observed in 11 cases (18.6%).

CONCLUSION

The effective rate of bevacizumab for refractory brain edema is 84.74%. Hypertension was the main side effect of the bevacizumab treatment. Bevacizumab is an effective and relatively safe treatment for brain edema.

Prolonged Response and Restoration of Functional Independence with Bevacizumab plus Vinorelbine as Third-Line Treatment for Breast Cancer-Related Leptomeningeal Metastases

Background

Survival of patients with leptomeningeal metastases (LM) and impaired functional status is limited to several months, and rarely does neurological function improve with treatment.

Case Report

A 34-year-old female with hormone-negative and HER2-positive metastatic breast cancer was diagnosed with bulky radiographic LM 45 months after initial diagnosis. She was treated with intra-CSF trastuzumab followed by intra-CSF liposomal cytarabine; however, the cancer progressed 8 months after the diagnosis of LM. At the time of the third LM progression, the patient presented with a cauda equina syndrome and cerebellar impairment resulting in an inability to walk. She was treated with CNS-directed radiotherapy (lumbosacral and cerebellar) and bevacizumab plus vinorelbine. Rapid functional improvement occurred, and the patient regained the ability to walk and independently manage her daily activities. Twelve months later, she presented with rapid progression of the LM resulting in death within several weeks.

Conclusion

In radiographically defined bulky LM, the combination of systemic therapy and CNS-directed radiotherapy likely is more active than intra-CSF therapy only. In lieu of the rapid and significant improvement in neurological function combined with the prolonged response, bevacizumab alone or in combination with chemotherapy and CNS-directed radiotherapy may be considered in select patients with radiographically bulky breast cancer-related LM.