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Lo SN, Hong AM, Haydu LE, Ahmed T, Paton EJ, Steel V, Hruby G, Tran A, Morton RL, Nowak AK, Vardy JL, Drummond KJ, Dhillon HM, Mandel C, Scolyer RA, Middleton MR, Burmeister BH, Thompson JF, Fogarty GB. Whole brain radiotherapy (WBRT) after local treatment of brain metastases in melanoma patients: Statistical Analysis Plan. Trials 2019; 20:477. [PMID: 31382986 PMCID: PMC6683544 DOI: 10.1186/s13063-019-3555-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 07/04/2019] [Indexed: 11/21/2022] Open
Abstract
Background The WBRTMel trial is a multinational, open-label, phase III randomised controlled trial comparing whole brain radiotherapy (WBRT) to observation following local treatment of one to three melanoma brain metastases with surgery and/or stereotactic irradiation. The primary trial endpoint was to determine the effect of adding WBRT to local treatment on distant intracranial control, and the secondary endpoints were neurocognitive function, quality of life (QoL), performance status, overall survival, death from intracranial causes, death from melanoma and cost-effectiveness. Objective The objective of this update is to outline and publish the pre-determined statistical analysis plan (SAP) before the database lock and the start of analysis. Methods The SAP describes basic analysis principles, methods for dealing with a range of commonly encountered data analysis issues and the specific statistical procedures for analysing efficacy and safety outcomes. The SAP was approved after closure of recruitment and before completion of patient follow-up. It outlines the planned primary analyses and a range of subgroup and sensitivity analyses regarding the clinical and QoL outcomes. Health economic outcomes are not included in this plan but will be analysed separately. The SAP will be adhered to for the final data analysis of this trial to avoid analysis bias arising from knowledge of the data. Results The resulting SAP is consistent with best practice and will allow open and transparent reporting. Conclusion We have developed a SAP for the WBRTMel trial which will be followed to ensure high-quality standards of internal validity to minimise analysis bias. Trial registration ANZ Clinical Trials Registry, ACTRN12607000512426. Registered on 9 October 2007. ClinicalTrials.gov, NCT01503827. Registered on 4 January 2012. Trial group reference numbers ANZMTG 01.07, TROG 08.05.
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Affiliation(s)
- Serigne N Lo
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Institute for Research and Medical Consultations (IRMC), Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Angela M Hong
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Mater Hospital, North Sydney, NSW, Australia.,Genesis Care, Mater Radiation Oncology, North Sydney, NSW, Australia
| | - Lauren E Haydu
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,MD Anderson Cancer Center, Houston, TX, USA
| | - Tasnia Ahmed
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
| | - Elizabeth J Paton
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,Australia and New Zealand Melanoma Trials Group, North Sydney, NSW, Australia
| | - Victoria Steel
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,Australia and New Zealand Melanoma Trials Group, North Sydney, NSW, Australia
| | - George Hruby
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,Royal North Shore Hospital, St Leonards, NSW, Australia.,Genesis Care, Sydney, NSW, Australia
| | - Anh Tran
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,NHMRC Clinical Trials Centre, The University of Sydney, Camperdown, NSW, Australia
| | - Rachael L Morton
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,NHMRC Clinical Trials Centre, The University of Sydney, Camperdown, NSW, Australia
| | - Anna K Nowak
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Janette L Vardy
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | | | - Haryana M Dhillon
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | | | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | | | | | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Gerald B Fogarty
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia. .,Mater Hospital, North Sydney, NSW, Australia. .,Genesis Care, Mater Radiation Oncology, North Sydney, NSW, Australia. .,Australia and New Zealand Melanoma Trials Group, North Sydney, NSW, Australia. .,Genesis Care, Sydney, NSW, Australia. .,University of Technology Sydney, Sydney, NSW, Australia. .,St Vincent's Hospital, Sydney, NSW, Australia.
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Fuentes R, Osorio D, Expósito Hernandez J, Simancas‐Racines D, Martinez‐Zapata MJ, Bonfill Cosp X. Surgery versus stereotactic radiotherapy for people with single or solitary brain metastasis. Cochrane Database Syst Rev 2018; 8:CD012086. [PMID: 30125049 PMCID: PMC6513097 DOI: 10.1002/14651858.cd012086.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Brain metastases occur when cancer cells spread from their original site to the brain and are a frequent cause of morbidity and death in people with cancer. They occur in 20% to 40% of people during the course of their disease. Brain metastases are also the most frequent type of brain malignancy. Single and solitary brain metastasis is infrequent and choosing the most appropriate treatment is a clinical challenge. Surgery and stereotactic radiotherapy are two options. For surgery, tumour resection is performed using microsurgical techniques, while in stereotactic radiotherapy, external ionising radiation beams are precisely focused on the brain metastasis. Stereotactic radiotherapy may be given as a single dose, also known as single dose radiosurgery, or in a number of fractions, also known as fractionated stereotactic radiotherapy. There is uncertainty regarding which treatment (surgery or stereotactic radiotherapy) is more effective for people with single or solitary brain metastasis. OBJECTIVES To assess the effectiveness and safety of surgery versus stereotactic radiotherapy for people with single or solitary brain metastasis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, March 2018), MEDLINE and Embase up to 25 March 2018 for relevant studies. We also searched trials databases, grey literature and handsearched relevant literature. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing surgery versus stereotactic radiotherapy, either a single fraction (stereotactic radiosurgery) or multiple fractions (fractionated stereotactic radiotherapy) for treatment of single or solitary brain metastasis. DATA COLLECTION AND ANALYSIS Two review authors screened all references, evaluated the quality of the included studies using the Cochrane tool for assessing risk of bias, and performed data extraction. The primary outcomes were overall survival and adverse events. Secondary outcomes included progression-free survival and quality of life . We analysed overall survival and progression-free survival as hazard ratios (HRs) with 95% confidence intervals (CIs), and analysed adverse events as risk ratios (RRs). For quality of life we used mean difference (MD). MAIN RESULTS Two RCTs including 85 participants met our inclusion criteria. One study included people with single untreated brain metastasis (n = 64), and the other included people with solitary brain metastasis (22 consented to randomisation and 21 were analysed). We identified a third trial reported as completed and pending results this may be included in future updates of this review. The two included studies were prematurely closed due to poor participant accrual. One study compared surgery plus whole brain radiotherapy (WBRT) versus stereotactic radiosurgery alone, and the second study compared surgery plus WBRT versus stereotactic radiosurgery plus WBRT. Meta-analysis was not possible due to clinical heterogeneity between trial interventions. The overall certainty of evidence was low or very low for all outcomes due to high risk of bias and imprecision.We found no difference in overall survival in either of the two comparisons. For the comparison of surgery plus WBRT versus stereotactic radiosurgery alone: HR 0.92, 95% CI 0.48 to 1.77; 64 participants, very low-certainty evidence. We downgraded the certainty of the evidence to very low due to risk of bias and imprecision. For the comparison of surgery plus WBRT versus stereotactic radiosurgery plus WBRT: HR 0.53, 95% CI 0.20 to 1.42; 21 participants, low-certainty evidence. We downgraded the certainty of the evidence to low due to imprecision. Adverse events were reported in both trial groups in the two studies, showing no differences for surgery plus WBRT versus stereotactic radiosurgery alone (RR 0.31, 95% CI 0.07 to 1.44; 64 participants) and for surgery plus WBRT versus stereotactic radiosurgery plus WBRT (RR 0.37, 95% CI 0.05 to 2.98; 21 participants). Most of the adverse events were related to radiation toxicities. We considered the certainty of the evidence from the two comparisons to be very low due to risk of bias and imprecision.There was no difference in progression-free survival in the study comparing surgery plus WBRT versus stereotactic radiosurgery plus WBRT (HR 0.55, 95% CI 0.22 to 1.38; 21 participants, low-certainty evidence). We downgraded the evidence to low certainty due to imprecision. This outcome was not clearly reported for the other comparison. In general, there were no differences in quality of life between the two studies. The study comparing surgery plus WBRT versus stereotactic radiosurgery plus WBRT found no differences after two months using the QLQ-C30 global scale (MD -10.80, 95% CI -44.67 to 23.07; 14 participants, very low-certainty evidence). We downgraded the certainty of evidence to very low due to risk of bias and imprecision. AUTHORS' CONCLUSIONS Currently, there is no definitive evidence regarding the effectiveness and safety of surgery versus stereotactic radiotherapy on overall survival, adverse events, progression-free survival and quality of life in people with single or solitary brain metastasis, and benefits must be decided on a case-by-case basis until well powered and designed trials are available. Given the difficulties in participant accrual, an international multicentred approach should be considered for future studies.
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Affiliation(s)
- Rafel Fuentes
- Institut Català d'OncologiaAvda França, s/nGironaSpain17007
| | - Dimelza Osorio
- Universidad Tecnológica EquinoccialCochrane Ecuador. Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC). Facultad de Ciencias de la Salud Eugenio EspejoQuitoEcuador
| | - José Expósito Hernandez
- Hospital Universitario Virgen de las NievesResearch UnitAvda. Fuerzas Armadas, 4GranadaSpain18014
| | - Daniel Simancas‐Racines
- Universidad Tecnológica EquinoccialCochrane Ecuador. Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC). Facultad de Ciencias de la Salud Eugenio EspejoQuitoEcuador
| | - Maria José Martinez‐Zapata
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 167Pavilion 18BarcelonaCatalunyaSpain08025
| | - Xavier Bonfill Cosp
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 167Pavilion 18BarcelonaCatalunyaSpain08025
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Martinage G, Hong AM, Fay M, Thachil T, Roos D, Williams N, Lo S, Fogarty G. Quality assurance analysis of hippocampal avoidance in a melanoma whole brain radiotherapy randomized trial shows good compliance. Radiat Oncol 2018; 13:132. [PMID: 30029684 PMCID: PMC6053726 DOI: 10.1186/s13014-018-1077-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 07/11/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Melanoma brain metastases (MBM) often cause morbidity and mortality for stage IV melanoma patients. An ongoing randomised phase III trial (NCT01503827 - WBRT-Mel) evaluates the role of adjuvant whole brain radiotherapy (WBRT) following local treatment of MBM. Hippocampal avoidance during WBRT (HA-WBRT) has shown memory and neurocognitive function (NCF) preservation in the RTOG-0933 phase II study. This study assessed the quality assurance of HA-WBRT within the WBRT-Mel trial according to RTOG-0933 study criteria. METHODS Hippocampal avoidance was allowed in approved centres with intensity-modulated radiotherapy capability. Patients treated by HA-WBRT were not randomized within the WBRT arm. The RTOG 0933 contouring Atlas was used to contour hippocampi. In the trial co-ordinating centre, patients were treated with volumetric modulated arc therapy using complementary arcs; similar techniques were used at other sites. Dosimetric data were extracted retrospectively and analysed in accordance with RTOG 0933 study constraints criteria. RESULTS Among the 215 patients accrued to the WBRT-Mel study between April 2009 and September 2017, 107 were randomized to the WBRT arm, 22 were treated by HA-WBRT in 4 centers. Eighteen patients were treated in the same centre. The median age was 65 years. The commonest (91%) HA-WBRT schema was 30 Gy in 10 fractions. Prior to HA-WBRT, 10 patients had been treated by surgery alone, six by radiosurgery alone, four by surgery and radiosurgery and two exclusively by simultaneous integrated boost concurrent to HA-WBRT. Twenty patients were treated with intention to spare both hippocampi and two patients had MBM close to one hippocampus and were treated with intention to spare the contralateral hippocampus. According to RTOG-0933 study criteria, 18 patients (82%) were treated within constraints and four patients (18%) had unacceptable deviation in just one hippocampus. CONCLUSIONS This dosimetric quality assurance study shows good compliance (82%) according to RTOG-0933 study dosimetric constraints. Indeed, all patients respected RTOG hippocampal avoidance constraints on at least one hippocampus. In the futureanalysis of the WBRT-Mel trial, the NCF of patients on the observation arm, WBRT arm and with HA-WBRT arm will be compared.
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Affiliation(s)
- Geoffrey Martinage
- Melanoma Institute Australia, The University of Sydney, NSW, North Sydney, Australia
- Centre Oscar-Lambret, Lille, France
- Mater Hospital, NSW, North Sydney, Australia
| | - Angela M Hong
- Melanoma Institute Australia, The University of Sydney, NSW, North Sydney, Australia
- Mater Hospital, NSW, North Sydney, Australia
- GenesisCare, Radiation Oncology, Mater Hospital, NSW, North Sydney, Australia
- Central Clinical School, The University of Sydney, Camperdown, NSW, Australia
| | - Mike Fay
- School of Medicine and Public Health, University of Newcastle, NSW, Callaghan, Australia
- GenesisCare, Radiation Oncology, NSW, Newcastle, Australia
| | - Thanuja Thachil
- Northern Territory Radiation Oncology, Alan Walker Cancer Care Centre, NT, Darwin, Australia
| | - Daniel Roos
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- University of Adelaide, South Australia, Adelaide, Australia
| | - Narelle Williams
- Australia and New Zealand Melanoma Trials Group, NSW, North Sydney, Australia
| | - Serigne Lo
- Melanoma Institute Australia, The University of Sydney, NSW, North Sydney, Australia
- Central Clinical School, The University of Sydney, Camperdown, NSW, Australia
| | - Gerald Fogarty
- Melanoma Institute Australia, The University of Sydney, NSW, North Sydney, Australia.
- Mater Hospital, NSW, North Sydney, Australia.
- GenesisCare, Radiation Oncology, Mater Hospital, NSW, North Sydney, Australia.
- Central Clinical School, The University of Sydney, Camperdown, NSW, Australia.
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4
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Gupta A, Roberts C, Tysoe F, Goff M, Nobes J, Lester J, Marshall E, Corner C, Wolstenholme V, Kelly C, Wise A, Collins L, Love S, Woodward M, Salisbury A, Middleton MR. RADVAN: a randomised phase 2 trial of WBRT plus vandetanib for melanoma brain metastases - results and lessons learnt. Br J Cancer 2016; 115:1193-1200. [PMID: 27711083 PMCID: PMC5104891 DOI: 10.1038/bjc.2016.318] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 08/13/2016] [Accepted: 09/13/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Brain metastases occur in up to 75% of patients with advanced melanoma. Most are treated with whole-brain radiotherapy (WBRT), with limited effectiveness. Vandetanib, an inhibitor of vascular endothelial growth factor receptor, epidermal growth factor receptor and rearranged during transfection tyrosine kinases, is a potent radiosensitiser in xenograft models. We compared WBRT with WBRT plus vandetanib in the treatment of patients with melanoma brain metastases. METHODS In this double-blind, multi-centre, phase 2 trial patients with melanoma brain metastases were randomised to receive WBRT (30 Gy in 10 fractions) plus 3 weeks of concurrent vandetanib 100 mg once daily or placebo. The primary endpoint was progression-free survival in brain (PFS brain). The main study was preceded by a safety run-in phase to confirm tolerability of the combination. A post-hoc analysis and literature review considered barriers to recruiting patients with melanoma brain metastases to clinical trials. RESULTS Twenty-four patients were recruited, six to the safety phase and 18 to the randomised phase. The study closed early due to poor recruitment. Median PFS brain was 3.3 months (90% confidence interval (CI): 1.6-5.6) in the vandetanib group and 2.5 months (90% CI: 0.2-4.8) in the placebo group (P=0.34). Median overall survival (OS) was 4.6 months (90% CI: 1.6-6.3) and 2.5 months (90% CI: 0.2-7.2), respectively (P=0.54). The most frequent adverse events were fatigue, alopecia, confusion and nausea. The most common barrier to study recruitment was availability of alternative treatments. CONCLUSIONS The combination of WBRT plus vandetanib was well tolerated. Compared with WBRT alone, there was no significant improvement in PFS brain or OS, although we are unable to provide a definitive result due to poor accrual. A review of barriers to trial accrual identified several factors that affect study recruitment in this difficult disease area.
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Affiliation(s)
- Avinash Gupta
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Cancer and Haematology Centre, Churchill Hospital, Old Road, Oxford OX3 7LE, UK
| | - Corran Roberts
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford OX3 7LD, UK
| | - Finn Tysoe
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Cancer and Haematology Centre, Churchill Hospital, Old Road, Oxford OX3 7LE, UK
| | - Matthew Goff
- Oncology Clinical Trials Office, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
| | - Jenny Nobes
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich NR4 7UY, UK
| | - James Lester
- Sheffield Teaching Hospitals NHS Foundation Trust, Weston Park Hospital, Whitham Road, Sheffield S10 2SJ, UK
| | - Ernie Marshall
- Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Wirral CH63 4JY, UK
| | - Carie Corner
- Mount Vernon Cancer Centre, Rickmansworth Road, Northwood, Middlesex HA6 2RN, UK
| | - Virginia Wolstenholme
- Barts Health NHS Trust, St. Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK
| | - Charles Kelly
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - Adelyn Wise
- Oncology Clinical Trials Office, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
| | - Linda Collins
- Oncology Clinical Trials Office, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
| | - Sharon Love
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford OX3 7LD, UK
| | - Martha Woodward
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Cancer and Haematology Centre, Churchill Hospital, Old Road, Oxford OX3 7LE, UK
| | - Amanda Salisbury
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Cancer and Haematology Centre, Churchill Hospital, Old Road, Oxford OX3 7LE, UK
| | - Mark R Middleton
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Cancer and Haematology Centre, Churchill Hospital, Old Road, Oxford OX3 7LE, UK
- Department of Oncology, NIHR Oxford Biomedical Research Centre, Churchill Hospital, Old Road, Oxford OX3 7LE, UK
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Kim MM, Parmar H, Cao Y, Pramanik P, Schipper M, Hayman J, Junck L, Mammoser A, Heth J, Carter CA, Oronsky A, Knox SJ, Caroen S, Oronsky B, Scicinski J, Lawrence TS, Lao CD. Whole Brain Radiotherapy and RRx-001: Two Partial Responses in Radioresistant Melanoma Brain Metastases from a Phase I/II Clinical Trial: A TITE-CRM Phase I/II Clinical Trial. Transl Oncol 2016; 9:108-113. [PMID: 27084426 PMCID: PMC4833892 DOI: 10.1016/j.tranon.2015.12.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 12/22/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND: Kim et al. report two patients with melanoma metastases to the brain that responded to treatment with RRx-001 and whole brain radiotherapy (WBRT) without neurologic or systemic toxicity in the context of a phase I/II clinical trial. RRx-001 is an reactive oxygen and reactive nitrogen species (ROS/RNS)-dependent systemically nontoxic hypoxic cell radiosensitizer with vascular normalizing properties under investigation in patients with various solid tumors including those with brain metastases. SIGNIFICANCE: Metastatic melanoma to the brain is historically associated with poor outcomes and a median survival of 4 to 5 months. WBRT is a mainstay of treatment for patients with multiple brain metastases, but no significant therapeutic advances for these patients have been described in the literature. To date, candidate radiosensitizing agents have failed to demonstrate a survival benefit in patients with brain metastases, and in particular, no agent has demonstrated improved outcome in patients with metastatic melanoma. Kim et al. report two patients with melanoma metastases to the brain that responded to treatment with novel radiosensitizing agent RRx-001 and WBRT without neurologic or systemic toxicity in the context of a phase I/II clinical trial.
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Affiliation(s)
- Michelle M Kim
- University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Hemant Parmar
- University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Yue Cao
- University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Priyanka Pramanik
- University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Matthew Schipper
- University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - James Hayman
- University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Larry Junck
- University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Aaron Mammoser
- University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jason Heth
- University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Corey A Carter
- Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD, 20889, USA
| | - Arnold Oronsky
- InterWest Partners, 2710 Sand Hill Rd #200, Menlo Park, CA, 94025, USA
| | - Susan J Knox
- Stanford University School of Medicine, Radiation Oncology, 875 Blake Wilbur Dr Clinic D, Stanford, CA, 94305, USA
| | - Scott Caroen
- EpicentRx Inc., 800W El Camino Real, Suite 180, Mountain View, CA, 94040, USA
| | - Bryan Oronsky
- EpicentRx Inc., 800W El Camino Real, Suite 180, Mountain View, CA, 94040, USA
| | - Jan Scicinski
- EpicentRx Inc., 800W El Camino Real, Suite 180, Mountain View, CA, 94040, USA
| | - Theodore S Lawrence
- University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Christopher D Lao
- University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
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6
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Chowdhury IH, Ojerholm E, McMillan MT, Miller D, Kolker JD, Kurtz G, Dorsey JF, Nagda SN, Geiger GA, Brem S, O'Rourke DM, Zager EL, Gangadhar T, Schuchter L, Lee JYK, Alonso-Basanta M. Novel risk scores for survival and intracranial failure in patients treated with radiosurgery alone to melanoma brain metastases. Radiat Oncol 2015; 10:248. [PMID: 26626714 PMCID: PMC4666036 DOI: 10.1186/s13014-015-0553-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 11/23/2015] [Indexed: 12/22/2022] Open
Abstract
Purpose Stereotactic radiosurgery (SRS) alone is an increasingly common treatment strategy for brain metastases. However, existing prognostic tools for overall survival (OS) were developed using cohorts of patients treated predominantly with approaches other than SRS alone. Therefore, we devised novel risk scores for OS and distant brain failure (DF) for melanoma brain metastases (MBM) treated with SRS alone. Methods and materials We retrospectively reviewed 86 patients treated with SRS alone for MBM from 2009-2014. OS and DF were estimated using the Kaplan-Meier method. Cox proportional hazards modeling identified clinical risk factors. Risk scores were created based on weighted regression coefficients. OS scores range from 0-10 (0 representing best OS), and DF risk scores range from 0-5 (0 representing lowest risk of DF). Predictive power was evaluated using c-index statistics. Bootstrapping with 200 resamples tested model stability. Results The median OS was 8.1 months from SRS, and 54 (70.1 %) patients had DF at a median of 3.3 months. Risk scores for OS were predicated on performance status, extracranial disease (ED) status, number of lesions, and gender. Median OS for the low-risk group (0-3 points) was not reached. For the moderate-risk (4-6 points) and high-risk (6.5-10) groups, median OS was 7.6 months and 2.4 months, respectively (p < .0001). Scores for DF were predicated on performance status, ED status, and number of lesions. Median time to DF for the low-risk group (0 points) was not reached. For the moderate-risk (1-2 points) and high-risk (3-5 points) groups, time to DF was 4.8 and 2.0 months, respectively (p < .0001). The novel scores were more predictive (c-index = 0.72) than melanoma-specific graded prognostic assessment or RTOG recursive partitioning analysis tools (c-index = 0.66 and 0.57, respectively). Conclusions We devised novel risk scores for MBM treated with SRS alone. These scores have implications for prognosis and treatment strategy selection (SRS versus whole-brain radiotherapy).
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Affiliation(s)
- Imran H Chowdhury
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Boulevard - TRC 2 West, Philadelphia, 19104, PA, USA.
| | - Eric Ojerholm
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Boulevard - TRC 2 West, Philadelphia, 19104, PA, USA.
| | - Matthew T McMillan
- Department of Surgery, University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, 19104, PA, USA.
| | - Denise Miller
- Department of Neurosurgery, University of Pennsylvania, 3400 Spruce Street - 3 Silverstein, Philadelphia, 19104, PA, USA.
| | - James D Kolker
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Boulevard - TRC 2 West, Philadelphia, 19104, PA, USA.
| | - Goldie Kurtz
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Boulevard - TRC 2 West, Philadelphia, 19104, PA, USA.
| | - Jay F Dorsey
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Boulevard - TRC 2 West, Philadelphia, 19104, PA, USA.
| | - Suneel N Nagda
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Boulevard - TRC 2 West, Philadelphia, 19104, PA, USA.
| | - Geoffrey A Geiger
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Boulevard - TRC 2 West, Philadelphia, 19104, PA, USA.
| | - Steven Brem
- Department of Neurosurgery, University of Pennsylvania, 3400 Spruce Street - 3 Silverstein, Philadelphia, 19104, PA, USA.
| | - Donald M O'Rourke
- Department of Neurosurgery, University of Pennsylvania, 3400 Spruce Street - 3 Silverstein, Philadelphia, 19104, PA, USA.
| | - Eric L Zager
- Department of Neurosurgery, University of Pennsylvania, 3400 Spruce Street - 3 Silverstein, Philadelphia, 19104, PA, USA.
| | - Tara Gangadhar
- Department of Medicine, Division of Hematology/Oncology, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, 19104, PA, USA.
| | - Lynn Schuchter
- Department of Medicine, Division of Hematology/Oncology, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, 19104, PA, USA.
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania, 3400 Spruce Street - 3 Silverstein, Philadelphia, 19104, PA, USA.
| | - Michelle Alonso-Basanta
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Boulevard - TRC 2 West, Philadelphia, 19104, PA, USA.
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Goyal S, Silk AW, Tian S, Mehnert J, Danish S, Ranjan S, Kaufman HL. Clinical Management of Multiple Melanoma Brain Metastases: A Systematic Review. JAMA Oncol 2015; 1:668-76. [PMID: 26181286 PMCID: PMC5726801 DOI: 10.1001/jamaoncol.2015.1206] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE The treatment of multiple brain metastases (MBM) from melanoma is controversial and includes surgical resection, stereotactic radiosurgery (SRS), and whole-brain radiation therapy (WBRT). Several new classes of agents have revolutionized the treatment of metastatic melanoma, allowing some subsets of patients to have long-term survival. Given this, management of MBM from melanoma is continually evolving. OBJECTIVE To review the current evidence regarding the treatment of MBM from melanoma. EVIDENCE REVIEW The PubMed database was searched using combinations of search terms and synonyms for melanoma, brain metastases, radiation, chemotherapy, immunotherapy, and targeted therapy published between January 1, 1995, and January 1, 2015. Articles were selected for inclusion on the basis of targeted keyword searches, manual review of bibliographies, and whether the article was a clinical trial, large observational study, or retrospective study focusing on melanoma brain metastases. Of 2243 articles initially identified, 110 were selected for full review. Of these, the most pertinent 73 articles were included. FINDINGS Patients with newly diagnosed MBM can be treated with various modalities, either alone or in combination. Level 1 evidence supports the use of SRS alone, WBRT, and SRS with WBRT. Although the addition of WBRT to SRS improves the overall brain relapse rate, WBRT has no significant impact on overall survival and has detrimental neurocognitive outcomes. Cytotoxic chemotherapy has largely been ineffective; targeted therapies and immunotherapies have been reported to have high response rates and deserve further attention in larger clinical trials. Further studies are needed to fully evaluate the efficacy of these novel regimens in combination with radiation therapy. CONCLUSIONS AND RELEVANCE At this time, the standard management for patients with MBM from melanoma includes SRS, WBRT, or a combination of both. Emerging data exist to support the notion that SRS in combination with targeted therapies or immune therapy may obviate the need for WBRT; prospective studies are required to fully evaluate the efficacy of these novel regimens in combination with radiation therapy.
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Affiliation(s)
- Sharad Goyal
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Ann W. Silk
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Sibo Tian
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Janice Mehnert
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Shabbar Danish
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Sinthu Ranjan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Howard L. Kaufman
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
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Fogarty GB, Hong A, Dolven-Jacobsen K, Reisse CH, Burmeister B, Haydu LH, Dhillon H, Steel V, Shivalingam B, Drummond K, Vardy J, Nowak A, Hruby G, Scolyer RA, Mandel C, Thompson JF. First interim analysis of a randomised trial of whole brain radiotherapy in melanoma brain metastases confirms high data quality. BMC Res Notes 2015; 8:192. [PMID: 25952979 PMCID: PMC4428505 DOI: 10.1186/s13104-015-1153-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 04/27/2015] [Indexed: 11/20/2022] Open
Abstract
Background Brain metastases are a common cause of death in patients with melanoma. The role of adjuvant whole brain radiotherapy (WBRT) following local treatment of intracranial melanoma metastases is controversial. The Australian and New Zealand Melanoma Trials Group (ANZMTG) and the Trans-Tasman Radiation Oncology Group (TROG) are leading the first ever single histology randomised trial investigating this question. The primary endpoint is distant intracranial failure on magnetic resonance imaging (MRI) within twelve months of randomisation. The first planned interim analysis was performed twelve months after randomisation of the 100th patient. The analysis was an opportunity to review completeness of the trial data to date. Methods All data received up to the end of twelve months after randomisation of the 100th patient was reviewed. Results Review of pathology reports confirmed that all 100 patients had stage IV melanoma and were appropriately entered into the study. Of the 47 distant intracranial events, 34 occurred in isolation (i.e. only distant failure was identified), whilst 13 were accompanied by local failure. Data review showed compliance with the protocol mandated MRI schedule and accuracy of intracranial failure reporting was very high. The Quality of Life (QoL) component of the study achieved a 91% completion rate. For the neurocognitive function (NCF) assessments, a high completion rate was maintained throughout the 12 month period. Where assessments were not performed at expected time points, valid reasons were noted. Radiotherapy quality was high. Of 50 patients who received WBRT, 32 were reviewed as per protocol design and there was only one major variation out of 308 data points reviewed (0.3%). There were minimal trial related adverse events (AEs) and no serious adverse events (SAEs). Pre-specified protocol stopping rules were not met. Conclusions The Data Safety Monitoring Committee (DSMC) recommended the trial continue recruitment after reviewing the unblinded data. The data provision and quality to date indicates that a reliable outcome will be obtained when the final analysis is performed. Accrual is ongoing with 156 out of 200 patients randomised to date (26th November 2014).
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Affiliation(s)
- Gerald B Fogarty
- Melanoma Institute Australia, Sydney, Australia. .,Department of Radiation Oncology, St Vincent's General Hospital, Sydney, Australia. .,Genesis Cancer Care, Department of Radiation Oncology, Mater Hospital, Sydney, Australia. .,Trans-Tasman Radiation Oncology Group (TROG), Newcastle, Australia. .,Australia and New Zealand Melanoma Trials Group (ANZMTG), North Sydney, Australia.
| | - Angela Hong
- Melanoma Institute Australia, Sydney, Australia. .,Trans-Tasman Radiation Oncology Group (TROG), Newcastle, Australia. .,Sydney Medical School,
- The University of Sydney, Sydney, Australia.
| | | | - Claudius H Reisse
- Oslo University Hospital HF, The Norwegian Radium Hospital, Oslo, Norway.
| | - Bryan Burmeister
- Trans-Tasman Radiation Oncology Group (TROG), Newcastle, Australia. .,Princess Alexandra Hospital, Brisbane, Australia. .,Australia and New Zealand Melanoma Trials Group (ANZMTG), North Sydney, Australia.
| | | | - Haryana Dhillon
- Centre for Medical Psychology & Evidence-based Decision-making, Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia. .,Psycho-Oncology Co-Operative Research Group (PoCoG), School of Psychology, Faculty of Science, University of Sydney, Sydney, Australia.
| | - Victoria Steel
- Australia and New Zealand Melanoma Trials Group (ANZMTG), North Sydney, Australia.
| | | | - Kate Drummond
- The Royal Melbourne Hospital & University of Melbourne, Parkville, Australia.
| | - Janette Vardy
- Sydney Medical School,
- The University of Sydney, Sydney, Australia. .,Centre for Medical Psychology & Evidence-based Decision-making, Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia. .,Psycho-Oncology Co-Operative Research Group (PoCoG), School of Psychology, Faculty of Science, University of Sydney, Sydney, Australia. .,Concord Repatriation and General Hospital, Concord, Australia.
| | - Anna Nowak
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Australia. .,Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, Australia.
| | - George Hruby
- Sydney Medical School,
- The University of Sydney, Sydney, Australia. .,Royal Prince Alfred Hospital, Sydney, Australia. .,Australia and New Zealand Melanoma Trials Group (ANZMTG), North Sydney, Australia.
| | - Richard A Scolyer
- Melanoma Institute Australia, Sydney, Australia. .,Sydney Medical School,
- The University of Sydney, Sydney, Australia. .,Royal Prince Alfred Hospital, Sydney, Australia.
| | - Catherine Mandel
- Peter MacCallum Cancer Centre East Melbourne & University of Melbourne, Parkville, Australia.
| | - John F Thompson
- Melanoma Institute Australia, Sydney, Australia. .,Sydney Medical School,
- The University of Sydney, Sydney, Australia. .,Royal Prince Alfred Hospital, Sydney, Australia. .,Australia and New Zealand Melanoma Trials Group (ANZMTG), North Sydney, Australia.
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Fogarty GB, Hong A, Thompson JF. Should patients with melanoma brain metastases receive adjuvant whole-brain radiotherapy? Lancet Oncol 2015; 16:e195-6. [DOI: 10.1016/s1470-2045(15)70183-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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