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Crouzen JA, Mast ME, Hakstege M, Broekman MLD, Baladi C, Mertens BJA, Nandoe Tewarie RDS, Kerkhof M, Vos MJ, Maas KW, Souwer ETD, Wiggenraad RGJ, van der Voort van Zyp NCMG, Kiderlen M, Petoukhova AL, Zindler JD. External validation of the lung-molGPA to predict survival in patients treated with stereotactic radiotherapy for brain metastases of non-small cell lung cancer. Radiother Oncol 2024; 198:110405. [PMID: 38925263 DOI: 10.1016/j.radonc.2024.110405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 06/14/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND In the era of personalized medicine, individualized prognostic models with tumor characteristics are needed to inform patients about survival. Before clinical use, external validation of such models by an independent group is needed. An updated version of the graded prognostic assessment (GPA) estimates survival in patients with brain metastases (BMs) of non-small cell lung cancer (NSCLC). This is the first external validation of the updated Lung-molGPA in patients treated with stereotactic radiotherapy (SRT) for one or more BMs. MATERIALS AND METHODS Patients treated with SRT for BMs from NSCLC adenocarcinoma were retrospectively included. GPA score was calculated for each patient based on six prognostic factors including age, Karnofsky Performance Status, number of BMs, extracranial metastases, EGFR/ALK status, and PD-L1 expression. Kaplan-Meier analysis evaluated survival probability. Impact of individual prognostic factors on survival was assessed by univariate and multivariate analyses using the Cox proportional hazard model. Predictive performance was evaluated using discrimination (C-statistic) and calibration (Brier test). RESULTS The cohort (n = 241) was divided into four prognostic groups. Overall median survival was 15 months. Predicted and observed median survival were similar between the original and validation cohorts, apart from the most favorable prognostic group. With adequate C-statistics and Brier scores, the Lung-molGPA provided accurate survival predictions. CONCLUSION The Lung-molGPA accurately predicted survival in our European population, except for an overestimation of survival in the small most favorable prognostic group. This prognostic model was externally validated and is therefore useful for counseling of patients with BMs of NSCLC adenocarcinoma.
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Affiliation(s)
- Jeroen A Crouzen
- Department of Radiotherapy, Haaglanden Medical Center, The Hague, The Netherlands
| | - Mirjam E Mast
- Department of Radiotherapy, Haaglanden Medical Center, The Hague, The Netherlands
| | - Martijn Hakstege
- Department of Radiotherapy, Haaglanden Medical Center, The Hague, The Netherlands
| | - Marike L D Broekman
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands; Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Chaouki Baladi
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - Bart J A Mertens
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Melissa Kerkhof
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Maaike J Vos
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands; Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Klaar W Maas
- Department of Pulmonology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Esteban T D Souwer
- Department of Medical Oncology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Ruud G J Wiggenraad
- Department of Radiotherapy, Haaglanden Medical Center, The Hague, The Netherlands
| | | | - Mandy Kiderlen
- Department of Radiotherapy, Haaglanden Medical Center, The Hague, The Netherlands
| | - Anna L Petoukhova
- Department of Medical Physics, Haaglanden Medical Center, The Hague, The Netherlands
| | - Jaap D Zindler
- Department of Radiotherapy, Haaglanden Medical Center, The Hague, The Netherlands; Department of Radiotherapy, HollandPTC, Delft, The Netherlands.
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Toriduka D, Matsuo Y, Hanazawa H, Kishi N, Uto M, Mizowaki T. Validation of the Lung-Mol Graded Prognostic Assessment (GPA) System for the Prognosis of Patients Receiving Radiotherapy for Brain Metastasis From Non-small Cell Lung Cancer. Cureus 2024; 16:e57485. [PMID: 38707125 PMCID: PMC11066373 DOI: 10.7759/cureus.57485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 05/07/2024] Open
Abstract
PURPOSE The Lung-mol graded prognostic assessment (GPA) system predicts the prognosis of patients with brain metastases (BM) from non-small cell lung cancer (NSCLC) separately for adenocarcinoma and non-adenocarcinoma. This study aimed to validate the Lung-molGPA system using a cohort of patients in our institution who received radiotherapy for BM. MATERIALS AND METHODS Three hundred and thirty-nine patients with NSCLC who received their first course of radiotherapy for BM were included in the analysis. Among them, 65 received their second course of radiotherapy for BM. Data on sex, age, Karnofsky performance status (KPS), extracranial metastases (ECM), number of BM, histological type, and gene mutations were collected according to the Lung-molGPA system. We examined the validity of the scores assigned to the factors included in the Lung-molGPA system, separately for adenocarcinoma and non-adenocarcinoma. In addition, we validated the Lung-molGPA system to predict survival during both the first and second courses of radiotherapy. RESULTS The factors in the Lung-molGPA were significantly associated with survival, except for age in non-adenocarcinoma with marginal significance. Regarding discrimination ability, the C-indices were 0.65 and 0.69 for adenocarcinoma and non-adenocarcinoma, respectively, in the first course of radiotherapy for BM, while those in the second course were 0.62 and 0.74, respectively. Survival prediction by Lung-molGPA was almost consistent with actual survival in the first course of radiotherapy, except for the score of 0-1.0 in both histologies and 2.5-3.0 in non-adenocarcinoma. In the second course of radiotherapy, median survival could be predicted for some patients with adenocarcinoma. CONCLUSIONS Our study confirms the validity of Lung-molGPA for the estimation of median survival based on patient characteristics at the time of initiation of radiotherapy for patients in the first course of radiotherapy and shows that it may be applicable to patients with adenocarcinoma in the second course of radiotherapy.
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Affiliation(s)
- Daichi Toriduka
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, Kyoto, JPN
| | - Yukinori Matsuo
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, Kyoto, JPN
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Osakasayama, JPN
| | - Hideki Hanazawa
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, Kyoto, JPN
| | - Noriko Kishi
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, Kyoto, JPN
| | - Megumi Uto
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, Kyoto, JPN
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, Kyoto, JPN
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Zerdes I, Kamali C, Koulouris A, Elsayed M, Schnorbach J, Christopoulos P, Tsakonas G. Validation of the ALK-Brain Prognostic Index for patients with ALK-rearranged lung cancer and brain metastases. ESMO Open 2023; 8:102069. [PMID: 37988952 PMCID: PMC10774967 DOI: 10.1016/j.esmoop.2023.102069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/28/2023] [Accepted: 10/21/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Brain metastases (BMs) are a key challenge in the management of anaplastic lymphoma kinase-rearranged non-small-cell lung cancer (ALK+ NSCLC), but prognostic scores are complicated or rely on data before the era of tyrosine kinase inhibitors (TKIs). This study aimed to validate the novel ALK-Brain Prognostic Index (ALK-BPI), which was originally proposed based on 44 TKI-treated ALK+ NSCLC patients from Karolinska University Hospital, using an external clinical cohort. PATIENTS AND METHODS TKI-treated ALK+ NSCLC patients with BM from Heidelberg (n = 82, cohort 1) were retrospectively analyzed alone and together with the original Karolinska cohort (n = 126, cohort 2). Cox regression models were used to determine the association of clinical variables and scores with overall survival (OS) after BM diagnosis (BM-related OS). RESULTS Both cohorts showed a similar median age (58 years), roughly balanced sex distributions (52%-56% females), and Eastern Cooperative Oncology Group performance status (PS) 0-2 for most patients (87%-92%) at the time of BM development, which were present already at initial diagnosis in 36%-38% of the patients. Most patients had received next-generation ALK inhibitors (54%-63%), while 55%-56% of patients did not receive any radiotherapy. The ALK-BPI identified poor-risk patients (i.e. featuring ≥ 2/3 risk factors: PS > 2, male sex, development of BM after initial diagnosis) with a significantly shorter BM-related OS than other patients in both cohorts: 32/82 in cohort 1 with 21.3 versus 62.2 months in median [hazard ratio (HR) = 2.5, P < 0.001]; 59/126 in cohort 2 with 23.1 versus 67.2 months in median (HR = 2.6, P < 0.001). The five-parameter Lung-molGPA score did not achieve statistical significance and/or clear prognostic separation in all four groups, while the Disease-Specific Graded Prognostic Assessment score did not show consistent results. CONCLUSIONS The ALK-BPI is a reliable tool for easy prognostic dichotomization of TKI-treated ALK+ NSCLC patients with BM in daily clinical practice, without the complexity of previous models.
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Affiliation(s)
- I Zerdes
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden; Thoracic Oncology Center, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - C Kamali
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden; Thoracic Oncology Center, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden.
| | - A Koulouris
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden; Thoracic Oncology Center, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - M Elsayed
- Department of Thoracic Oncology, Thoraxklinik, Heidelberg University Hospital, Heidelberg, Germany; Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research (DZL) Heidelberg, Germany
| | - J Schnorbach
- Department of Thoracic Oncology, Thoraxklinik, Heidelberg University Hospital, Heidelberg, Germany; Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research (DZL) Heidelberg, Germany
| | - P Christopoulos
- Department of Thoracic Oncology, Thoraxklinik, Heidelberg University Hospital, Heidelberg, Germany; Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research (DZL) Heidelberg, Germany
| | - G Tsakonas
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden; Thoracic Oncology Center, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
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Ribeiro LM, Bomtempo FF, Rocha RB, Telles JPM, Neto EB, Figueiredo EG. Development and adaptations of the Graded Prognostic Assessment (GPA) scale: a systematic review. Clin Exp Metastasis 2023; 40:445-463. [PMID: 37819546 DOI: 10.1007/s10585-023-10237-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023]
Abstract
The Graded Prognostic Assessment (GPA) score has the best accuracy among prognostic scales for patients with brain metastases (BM). A wide range of GPA-derived scales have been established to different types of primary tumor BM. However, there is a high variability between them, and their characteristics have not been described altogether yet. We aim to summarize the features of the existent GPA-derived scales and to compare their predictor factors and their uses in clinical setting. Medline was searched from inception until January 2023 to identify studies related to the development, update, or validation of GPA. The initial search yielded 1,083 results. 16 original studies and 16 validation studies were included, comprising a total of 33,348 patients. 13 different scales were assessed, including: GPA, Diagnosis-Specific GPA, Extracranial Score, Lung-molGPA, Updated Renal GPA, Updated Gastrointestinal GPA, Modified Breast GPA, Integrated Melanoma GPA, Melanoma Mol GPA, Sarcoma GPA, Hepatocellular Carcinoma GPA, Colorectal Cancer GPA, and Uterine Cancer GPA. The most prevalent prognostic predictors were age, Karnofsky Performance Status, number of BM, and presence or absence of extracranial metastases. Treatment modalities consisted of whole brain radiation therapy, stereotactic radiosurgery, surgery, cranial radiotherapy, gamma knife radiosurgery, and BRAF inhibitor therapy. Median survival rates with no treatment and with a specific treatment ranged from 6.1 weeks to 33 months and from 3.1 to 21 months, respectively. Original GPA and GPA-derived scales are valid prognostic tools, but with heterogeneous survival results when compared to each other. More studies are needed to improve scientific evidence of these scales.
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Affiliation(s)
| | | | | | | | - Eliseu Becco Neto
- Division of Neurosurgery, University of São Paulo, São Paulo, Brazil
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Higaki H, Nishioka K, Otsuka M, Nishikawa N, Shido M, Minatogawa H, Nishikawa Y, Takashina R, Hashimoto T, Katoh N, Taguchi H, Kinoshita R, Yasuda K, Mori T, Uchinami Y, Koizumi F, Fujita Y, Takahashi S, Hattori T, Nishiyama N, Aoyama H. Brain metastases in Japanese NSCLC patients: prognostic assessment and the use of osimertinib and immune checkpoint inhibitors-retrospective study. Radiat Oncol 2023; 18:25. [PMID: 36750899 PMCID: PMC9903535 DOI: 10.1186/s13014-023-02218-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 01/31/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND The Graded Prognostic Assessment for lung cancer using molecular markers (Lung-molGPA) has not been validated for use with Japanese non-small cell lung cancer (NSCLC) patients with brain metastasis (BM) and the factors impacting survival need to be assessed. METHODS We retrospectively analyzed 294 NSCLC patients who were newly diagnosed with BM between 2013 and 2020 and had received radiotherapy for BM initially at the Hokkaido Cancer Center. We evaluated the effect on the prognosis of Lung-molGPA items, the expression of PD-L1 (classified as high, low, and no expression), and the treatment history. The main outcome was the survival measured from the day of the diagnosis of BM, and log-rank tests were performed to evaluate the results. RESULTS The median overall survival (OS) times for adenocarcinoma by groups of GPA scores (0‒1.0, 1.5‒2.0, 2.5‒3.0, and 3.5‒4.0) were 5.5, 14.8, 28.3, and 39.0 months (p < 0.0001), respectively. The median survival times for non-adenocarcinoma by groups of GPA scores (0‒1.0, 1.5‒2.0, and 2.5‒3.0) were 3.2, 11.0, and 16.0 months (p = 0.0011), respectively. In adenocarcinoma patients with gene mutations, osimertinib significantly improved the outcome (median OS: 34.2 and 17.6 months with and without osimertinib, respectively (p = 0.0164)). There was no significant difference in the OS between patients who were initially treated with tyrosine-kinase inhibitor for BM and those who initially received radiotherapy (p = 0.5337). In patients tested for PD-L1 expression, the median survival times after the diagnosis of BM were 5.6, 22.5, and 9.3 months for the high-, low- and no-expression groups (p = 0.2198), respectively. Also, in patients with high PD-L1 expressions, those with ICI had survival (median OS, 8.6 months) than those without (median OS, 3.6 months). CONCLUSIONS We confirmed that Lung-molGPA successfully classified Japanese NSCLC patients with BM by the prognosis. Osimertinib prolonged survival of EGFR-positive NSCLC patients with BM, and ICI was effective in patients with high PD-L1 expressions.
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Affiliation(s)
- Hajime Higaki
- grid.39158.360000 0001 2173 7691Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15-Jo Nishi 7-Chome, Kita-Ku, Sapporo, Hokkaido 060-8638 Japan
| | - Kentaro Nishioka
- grid.39158.360000 0001 2173 7691Global Center for Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido Japan
| | - Manami Otsuka
- grid.39158.360000 0001 2173 7691Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15-Jo Nishi 7-Chome, Kita-Ku, Sapporo, Hokkaido 060-8638 Japan ,grid.415270.5Department of Radiation Therapy, Hokkaido Cancer Center, Sapporo, Japan
| | - Noboru Nishikawa
- grid.412167.70000 0004 0378 6088Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Japan
| | - Motoyasu Shido
- grid.39158.360000 0001 2173 7691Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15-Jo Nishi 7-Chome, Kita-Ku, Sapporo, Hokkaido 060-8638 Japan
| | - Hideki Minatogawa
- grid.415270.5Department of Radiation Therapy, Hokkaido Cancer Center, Sapporo, Japan
| | - Yukiko Nishikawa
- grid.415270.5Department of Radiation Therapy, Hokkaido Cancer Center, Sapporo, Japan
| | - Rikiya Takashina
- grid.415270.5Department of Radiation Therapy, Hokkaido Cancer Center, Sapporo, Japan
| | - Takayuki Hashimoto
- grid.39158.360000 0001 2173 7691Global Center for Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido Japan
| | - Norio Katoh
- grid.39158.360000 0001 2173 7691Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15-Jo Nishi 7-Chome, Kita-Ku, Sapporo, Hokkaido 060-8638 Japan
| | - Hiroshi Taguchi
- grid.412167.70000 0004 0378 6088Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Japan
| | - Rumiko Kinoshita
- grid.412167.70000 0004 0378 6088Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Japan
| | - Koichi Yasuda
- grid.412167.70000 0004 0378 6088Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Japan
| | - Takashi Mori
- grid.412167.70000 0004 0378 6088Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Japan
| | - Yusuke Uchinami
- grid.39158.360000 0001 2173 7691Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15-Jo Nishi 7-Chome, Kita-Ku, Sapporo, Hokkaido 060-8638 Japan
| | - Fuki Koizumi
- grid.39158.360000 0001 2173 7691Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15-Jo Nishi 7-Chome, Kita-Ku, Sapporo, Hokkaido 060-8638 Japan
| | - Yoshihiro Fujita
- grid.39158.360000 0001 2173 7691Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15-Jo Nishi 7-Chome, Kita-Ku, Sapporo, Hokkaido 060-8638 Japan
| | - Shuhei Takahashi
- grid.39158.360000 0001 2173 7691Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15-Jo Nishi 7-Chome, Kita-Ku, Sapporo, Hokkaido 060-8638 Japan
| | - Takahiro Hattori
- grid.39158.360000 0001 2173 7691Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15-Jo Nishi 7-Chome, Kita-Ku, Sapporo, Hokkaido 060-8638 Japan
| | - Noriaki Nishiyama
- grid.415270.5Department of Radiation Therapy, Hokkaido Cancer Center, Sapporo, Japan
| | - Hidefumi Aoyama
- Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15-Jo Nishi 7-Chome, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan.
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External Validation of the Graded Prognostic Assessment in Patients with Brain Metastases from Small Cell Lung Cancer. Curr Oncol 2022; 29:7181-7188. [PMID: 36290842 PMCID: PMC9600349 DOI: 10.3390/curroncol29100565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Recently, graded prognostic assessment (GPA) for small cell lung cancer (SCLC) patients with brain metastases has been developed. This includes age, performance status, number of brain metastases and presence of extracranial metastases. The aim of the present study was to validate this four-tiered prognostic score in a European cohort of patients. METHODS The retrospective validation study included 180 patients from two centers in Germany and Norway. RESULTS Median survival from radiological diagnosis of brain metastases was 7 months. The GPA point sum as continuous variable (0-4 points) was significantly associated with survival (p < 0.001). However, no significant survival difference was observed between patients in the two strata with better survival (3.5-4 and 2.5-3 points, respectively). Long-term survival in the poor prognosis group (0-1 points) was better than expected. CONCLUSION This study supports the prognostic impact of all four parameters contributing to the GPA. The original way of grouping the parameters and breaking the final strata did not give optimal results in this cohort. Therefore, additional validation databases from different countries should be created and evaluated.
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Zhang M, Tong J, Ma W, Luo C, Liu H, Jiang Y, Qin L, Wang X, Yuan L, Zhang J, Peng F, Chen Y, Li W, Jiang Y. Predictors of Lung Adenocarcinoma With Leptomeningeal Metastases: A 2022 Targeted-Therapy-Assisted molGPA Model. Front Oncol 2022; 12:903851. [PMID: 35795063 PMCID: PMC9252592 DOI: 10.3389/fonc.2022.903851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/17/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To explore prognostic indicators of lung adenocarcinoma with leptomeningeal metastases (LM) and provide an updated graded prognostic assessment model integrated with molecular alterations (molGPA). Methods A cohort of 162 patients was enrolled from 202 patients with lung adenocarcinoma and LM. By randomly splitting data into the training (80%) and validation (20%) sets, the Cox regression and random survival forest methods were used on the training set to identify statistically significant variables and construct a prognostic model. The C-index of the model was calculated and compared with that of previous molGPA models. Results The Cox regression and random forest models both identified four variables, which included KPS, LANO neurological assessment, TKI therapy line, and controlled primary tumor, as statistically significant predictors. A novel targeted-therapy-assisted molGPA model (2022) using the above four prognostic factors was developed to predict LM of lung adenocarcinoma. The C-indices of this prognostic model in the training and validation sets were higher than those of the lung-molGPA (2017) and molGPA (2019) models. Conclusions The 2022 molGPA model, a substantial update of previous molGPA models with better prediction performance, may be useful in clinical decision making and stratification of future clinical trials.
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Affiliation(s)
- Milan Zhang
- Department of Neurology, Henan Joint International Research Laboratory of Accurate Diagnosis, Treatment, Research and Development, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiayi Tong
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Weifeng Ma
- Department of Neurology, Henan Joint International Research Laboratory of Accurate Diagnosis, Treatment, Research and Development, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Chongliang Luo
- Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St Louis, MO, United States
| | - Huiqin Liu
- Department of Neurology, Henan Joint International Research Laboratory of Accurate Diagnosis, Treatment, Research and Development, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Yushu Jiang
- Department of Neurology, Henan Joint International Research Laboratory of Accurate Diagnosis, Treatment, Research and Development, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Lingzhi Qin
- Department of Neurology, Henan Joint International Research Laboratory of Accurate Diagnosis, Treatment, Research and Development, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaojuan Wang
- Department of Neurology, Henan Joint International Research Laboratory of Accurate Diagnosis, Treatment, Research and Development, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Lipin Yuan
- Department of Neurology, Henan Joint International Research Laboratory of Accurate Diagnosis, Treatment, Research and Development, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiewen Zhang
- Department of Neurology, Henan Joint International Research Laboratory of Accurate Diagnosis, Treatment, Research and Development, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yong Chen
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Wei Li
- Department of Neurology, Henan Joint International Research Laboratory of Accurate Diagnosis, Treatment, Research and Development, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Wu S, Li G, Guan W, Zhao H, Wang J, Zhou Y, Zhou Y, Shi B. Low Heart Rate Variability Predicts Poor Overall Survival of Lung Cancer Patients With Brain Metastases. Front Neurosci 2022; 16:839874. [PMID: 35250470 PMCID: PMC8891474 DOI: 10.3389/fnins.2022.839874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/26/2022] [Indexed: 01/04/2023] Open
Abstract
Background The aim of this prospective study was to evaluate the association between heart rate variability (HRV) and overall survival of lung cancer patients with brain metastases (LCBM). Methods Fifty-six LCBM patients were enrolled in this study. Five-minute electrocardiograms were collected before the time to first brain radiotherapy. HRV was analyzed quantitatively by using the time domain parameters, i.e., the standard deviation of all normal-normal intervals (SDNN) and the root mean square of successive differences (RMSSD). Survival time for LCBM patients was defined as from the date of HRV testing to the date of death or the last follow-up. Results In the univariate analysis, SDNN ≤ 13 ms (P = 0.003) and RMSSD ≤ 4.8 ms (P = 0.014) significantly predicted poor survival. Multivariate analysis confirmed that RMSSD ≤ 4.8 ms (P = 0.013, hazard ratio = 3.457, 95% confidence interval = 1.303–9.171) was also an independent negative prognostic factor after adjusting for mean heart rate, Karnofsky performance status, and number of brain metastases in LCBM patients. Conclusion Decreased RMSSD is independently associated with shorter survival time in LCBM patients. HRV might be a novel predictive biomarker for LCBM prognosis.
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Affiliation(s)
- Shuang Wu
- Department of Radiation Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Guangqiao Li
- School of Medical Imaging, Bengbu Medical College, Bengbu, China
- Anhui Key Laboratory of Computational Medicine and Intelligent Health, Bengbu Medical College, Bengbu, China
| | - Weizheng Guan
- School of Medical Imaging, Bengbu Medical College, Bengbu, China
- Anhui Key Laboratory of Computational Medicine and Intelligent Health, Bengbu Medical College, Bengbu, China
| | - Huan Zhao
- School of Medical Imaging, Bengbu Medical College, Bengbu, China
- Anhui Key Laboratory of Computational Medicine and Intelligent Health, Bengbu Medical College, Bengbu, China
| | - Jingfeng Wang
- School of Medical Imaging, Bengbu Medical College, Bengbu, China
- Anhui Key Laboratory of Computational Medicine and Intelligent Health, Bengbu Medical College, Bengbu, China
| | - Yongchun Zhou
- Department of Radiation Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Yufu Zhou
- Department of Radiation Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
- *Correspondence: Yufu Zhou,
| | - Bo Shi
- School of Medical Imaging, Bengbu Medical College, Bengbu, China
- Anhui Key Laboratory of Computational Medicine and Intelligent Health, Bengbu Medical College, Bengbu, China
- Bo Shi,
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9
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Nieder C, Aanes SG, Haukland E. Primary systemic therapy for patients with brain metastases from lung cancer ineligible for targeted agents. J Cancer Res Clin Oncol 2022; 148:3109-3116. [PMID: 35020043 PMCID: PMC9508211 DOI: 10.1007/s00432-022-03919-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 01/04/2022] [Indexed: 11/30/2022]
Abstract
Purpose The purpose of this study was to evaluate overall survival after systemic therapy, largely chemotherapy, in patients with small cell or non-small cell lung cancer and brain metastases. After completion of systemic therapy, some patients received planned brain irradiation, while others were followed. Methods Retrospective cohort study. Results Thirty-eight patients were included (28 small cell, 20 followed with imaging). Six of these 20 patients (30%) received delayed radiotherapy during follow-up. Planned radiotherapy (n = 18, intention-to-treat) was associated with longer survival from diagnosis of brain metastases, median 10.8 versus 6.1 months, p = 0.025. Delayed radiotherapy still resulted in numerically better survival than no radiotherapy at all (median 8.8 versus 5.3 months, not significant). If calculated from the start of delayed radiotherapy, median survival was only 2.7 months. In a multivariable analysis, both Karnofsky performance status ≥ 70 (p = 0.03) and planned radiotherapy (p = 0.05) were associated with better survival. Conclusion In patients ineligible for targeted agents, planned radiotherapy in a modern treatment setting was associated with longer survival compared to no radiotherapy. Timing and type of radiotherapy in such patients should be evaluated in prospective trials to identify patients who might not need planned radiotherapy.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway. .,Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, 9037, Tromsø, Norway.
| | - Siv G Aanes
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway
| | - Ellinor Haukland
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, 9037, Tromsø, Norway.,SHARE-Center for Resilience in Healthcare, Faculty of Health Sciences, Department of Quality and Health Technology, University of Stavanger, 4036, Stavanger, Norway
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10
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Steindl A, Brunner TJ, Heimbach K, Schweighart K, Moser GM, Niziolek HM, Moor E, Kreminger J, Starzer AM, Dieckmann K, Gatterbauer B, Widhalm G, Preusser M, Berghoff AS. Changing characteristics, treatment approaches and survival of patients with brain metastasis: data from six thousand and thirty-one individuals over an observation period of 30 years. Eur J Cancer 2022; 162:170-181. [PMID: 34998049 DOI: 10.1016/j.ejca.2021.12.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/23/2021] [Accepted: 12/04/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND An accurate classification of patients with brain metastases (BMs) is an important foundation to guide individualised treatment decisions and to formulate BM cohorts for modern clinical trials. METHODS Six thousand and thirty-one patients with newly diagnosed BM from different solid tumours treated between 1986 and 2020 were identified from the Vienna Brain Metastasis Registry. RESULTS A rising fraction of patients presented with asymptomatic BM during the observation period (1986-1999: 20.2% vs 2010-2020: 30.6%; p < 0.001). Especially, oncogene-addicted non-small-cell lung cancer (NSCLC) and BRAF (v-Raf murine sarcoma viral oncogene homolog)-positive melanoma had a higher rate of asymptomatic BM presentation compared with wild-type tumours (p < 0.05). Significant changes of initial BM treatment approaches were observed with a decrease of neurosurgical procedures (1986-1999: 30.8% vs 2010-2020: 19.5%) and an increase of radiation treatments (1986-1999: 65.0% vs 2010-2020: 73.3%) and systemic therapies (1986-1999: 1.0% vs 2010-2020: 2.0%; p < 0.001). Median overall survival (OS) was heterogeneous between primary tumour entities but with an overall increase over the decades (median OS 1986-1999: 5 months vs 2010-2020: 7 months; p = 0.001). Survival times were longer in patients with oncogene-addicted NSCLC, BRAF-positive melanoma and hormone receptor-positive breast cancer compared with the other cancer subtypes (p > 0.05). CONCLUSION Our data highlight shifting trends in the symptomatic presentation and in treatment strategies of patients with BM over the last decades. Entity specific aspects and, in particular, the presence of targetable driver mutation impact the clinical presentation and prognosis. Future BM specific trials need to address the modern composition of BM cohorts and the distinct clinical course of patients with targetable driver mutations.
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Affiliation(s)
- Ariane Steindl
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
| | - Tabea J Brunner
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
| | - Kira Heimbach
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
| | - Katharina Schweighart
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
| | - Georg M Moser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
| | - Helena M Niziolek
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
| | - Elisabeth Moor
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
| | - Judith Kreminger
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
| | - Angelika M Starzer
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
| | - Karin Dieckmann
- Department of Radiotherapy, Medical University of Vienna, Austria
| | | | - Georg Widhalm
- Department of Neurosurgery, Medical University of Vienna, Austria
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
| | - Anna S Berghoff
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria.
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11
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Nieder C, Mannsåker B, Yobuta R. Validation of a Graded Prognostic Model in Patients With Brain Metastases Treated With Whole-brain Radiotherapy Instead of Radiosurgery. In Vivo 2021; 35:1569-1572. [PMID: 33910837 DOI: 10.21873/invivo.12412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/04/2021] [Accepted: 02/10/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM The aim of this study was to analyze the survival predictions obtained from a recent graded prognostic model developed and validated in Japan. PATIENTS AND METHODS This was a retrospective single-institution analysis of 249 patients, managed with whole-brain radiotherapy for brain metastases. The sum of scores was calculated as in the Japanese study. The following parameters were included: number of brain metastases, volume of the largest lesion, sex, Karnofsky performance status, primary cancer type, control of primary cancer, and presence of extra-cerebral metastases. RESULTS Median overall survival was 3.0 months (95% CI= 2.6-3.4 months). The median sum of scores was 12, range=0-29. Statistically significant differences were observed between all prognostic strata. CONCLUSION The graded prognostic model is also applicable to patients treated with whole-brain rather than stereotactic radiotherapy.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway; .,Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Bård Mannsåker
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway
| | - Rosalba Yobuta
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway
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12
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Lamba N, Kearney RB, Catalano PJ, Hassett MJ, Wen PY, Haas-Kogan DA, Aizer AA. Population-based estimates of survival among elderly patients with brain metastases. Neuro Oncol 2021; 23:661-676. [PMID: 33068418 DOI: 10.1093/neuonc/noaa233] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Prognostic estimates for patients with brain metastases (BM) stem from younger, healthier patients enrolled in clinical trials or databases from academic centers. We characterized population-level prognosis in elderly patients with BM. METHODS Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified 9882 patients ≥65 years old with BM secondary to lung, breast, skin, kidney, esophageal, colorectal, and ovarian primaries between 2014 and 2016. Survival was assessed by primary site and evaluated with Cox regression. RESULTS In total, 2765 versus 7117 patients were diagnosed with BM at primary cancer diagnosis (synchronous BM, median survival = 2.9 mo) versus thereafter (metachronous BM, median survival = 3.4 mo), respectively. Median survival for all primary sites was ≤4 months, except ovarian cancer (7.5 mo). Patients with non-small-cell lung cancer (NSCLC) receiving epidermal growth factor receptor (EGFR)- or anaplastic lymphoma kinase (ALK)-based therapy for synchronous BM displayed notably better median survival at 12.5 and 20.1 months, respectively, versus 2.8 months exhibited by other patients with NSCLC; survival estimates in melanoma patients based on receipt of BRAF/MEK therapy versus not were 6.7 and 2.8 months, respectively. On multivariable regression, older age, greater comorbidity, and type of managing hospital were associated with poorer survival; female sex, higher median household income, and use of brain-directed stereotactic radiation, neurosurgical resection, or systemic therapy (versus brain-directed non-stereotactic radiation) were associated with improved survival (all P < 0.05). CONCLUSIONS Elderly patients with BM have a poorer prognosis than suggested by prior algorithms. If prognosis is driven by systemic and not intracranial disease, brain-directed therapy with potential for significant toxicity should be utilized cautiously.
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Affiliation(s)
- Nayan Lamba
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rachel Brigell Kearney
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, Massachusetts
| | - Paul J Catalano
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, and Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Michael J Hassett
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ayal A Aizer
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, Massachusetts
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13
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Zhou C, Shan C, Lai M, Zhou Z, Zhen J, Deng G, Li H, Li J, Ren C, Wang J, Lu M, Zhang L, Wu T, Zhu D, Kong FMS, Chen L, Cai L, Wen L. Individualized Nomogram for Predicting Survival in Patients with Brain Metastases After Stereotactic Radiosurgery Utilizing Driver Gene Mutations and Volumetric Surrogates. Front Oncol 2021; 11:659538. [PMID: 34055626 PMCID: PMC8158152 DOI: 10.3389/fonc.2021.659538] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/13/2021] [Indexed: 12/11/2022] Open
Abstract
It is well-known that genomic mutational analysis plays a significant role in patients with NSCLC for personalized treatment. Given the increasing use of stereotactic radiosurgery (SRS) for brain metastases (BM), there is an emerging need for more precise assessment of survival outcomes after SRS. Patients with BM and treated by SRS were eligible in this study. The primary endpoint was overall survival (OS). Cox regression models were used to identify independent prognostic factors. A survival predictive nomogram was developed and evaluated by Concordance-index (C-index), area under the curve (AUC), and calibration curve. From January 2016 to December 2019, a total of 356 BM patients were eligible. The median OS was 17.7 months [95% confidence interval (CI) 15.5–19.9] and the actual OS at 1- and 2-years measured 63.2 and 37.6%, respectively. A nomogram for OS was developed by incorporating four independent prognostic factors: Karnofsky Performance Score, cumulative tumor volume, gene mutation status, and serum lactate dehydrogenase. The nomogram was validated in a separate cohort and demonstrated good calibration and good discriminative ability (C-index = 0.780, AUC = 0.784). The prognostic accuracy of the nomogram (0.792) was considerably enhanced when compared with classical prognostic indices, including the Graded Prognostic Assessment (0.708), recursive partitioning analysis (0.587), and the SRS (0.536). Kaplan–Meier curves showed significant differences in OS among the stratified low-, median- and high-risk groups (P < 0.001). In conclusion, we developed and validated an individualized prognostic nomogram by integrating physiological, volumetric, clinical chemistry, and molecular biological surrogates. Although this nomogram should be validated by independent external study, it has a potential to facilitate more precise risk-stratifications to guide personalized treatment for BM.
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Affiliation(s)
- Cheng Zhou
- Department of Oncology, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Changguo Shan
- Department of Oncology, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Mingyao Lai
- Department of Oncology, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Zhaoming Zhou
- Department of Oncology, Guangdong Sanjiu Brain Hospital, Guangzhou, China.,Department of Radiation Medicine, School of Public Health, Southern Medical University, Guangzhou, China
| | - Junjie Zhen
- Department of Oncology, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Guanhua Deng
- Department of Oncology, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Hainan Li
- Department of Pathology, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Juan Li
- Department of Oncology, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Chen Ren
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jian Wang
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ming Lu
- Department of Neurosurgery, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Liang Zhang
- Department of Neurosurgery, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Taihua Wu
- Department of Neurosurgery, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Dan Zhu
- Department of Neurosurgery, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Feng-Ming Spring Kong
- Department of Clinical Oncology, The University of Hong Kong Shenzhen Hospital, Shenzhen, China
| | - Longhua Chen
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Linbo Cai
- Department of Oncology, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Lei Wen
- Department of Oncology, Guangdong Sanjiu Brain Hospital, Guangzhou, China
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14
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Zhang T, Zhang Y, Zhou L, Deng S, Huang M, Liu Y, Liu Y, Gong Y, Zhu J, Xue J, Bai Y, Ma H, Zhang Y, Yu M, Li Y, Wang Y, Zou B, Zhou X, Xiu W, Na F, Xu Y, Peng F, Wang J, Lu Y. Applicability of the adjusted graded prognostic assessment for lung cancer with brain metastases using molecular markers (Lung-molGPA) in a Chinese cohort: A retrospective study of multiple institutions. Cancer Med 2020; 9:8772-8781. [PMID: 33027555 PMCID: PMC7724493 DOI: 10.1002/cam4.3485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 02/05/2023] Open
Abstract
Background In this era of precision medicine, prognostic heterogeneity is an important feature of patients with non‐small cell lung cancer (NSCLC) with brain metastases (BM). This multi‐institutional study is aimed to verify the applicability of the adjusted Lung‐molGPA model for NSCLC with BM in a Chinese cohort. Methods This retrospective study included 1903 patients at three hospitals in Southwest China. The performance of the Lung‐molGPA model was compared with that of the adjusted DS‐GPA model in terms of estimating the survival of NSCLC with BM. Results The median OS of this patient cohort was 27.0 months, and the adenocarcinoma survived longer than the non‐adenocarcinoma (28.0 months vs 18.7 months, p < 0.001). The adjusted Lung‐molGPA model was more accurate in predicting survival of adenocarcinoma patients than the adjusted DS‐GPA model (C‐index: 0.615 vs 0.571), and it was not suitable for predicting survival of non‐adenocarcinoma patients (p = 0.286, 1.5‐2.0 vs 2.5‐3.0; p = 0.410, 2.5‐3.0 vs 3.5‐4.0). Conclusions The adjusted Lung‐molGPA model is better than the DS‐GPA model in predicting the prognosis of adenocarcinoma patients. However, it failed to estimate the prognosis for non‐adenocarcinoma patients.
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Affiliation(s)
- Tingyou Zhang
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China.,Department of Thoracic Oncology, Zunyi Medical University NO.2 Affiliated Hospital, Zunyi, Guizhou, P.R. China
| | - Yu Zhang
- Department of Oncology, Guizhou Provincial People's Hospital, Guiyang, Guizhou, P.R. China
| | - Lin Zhou
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - Shanshan Deng
- Department of Thoracic Oncology, Zunyi Medical University NO.2 Affiliated Hospital, Zunyi, Guizhou, P.R. China
| | - Meijuan Huang
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - Yuncong Liu
- Department of Oncology, Guizhou Provincial People's Hospital, Guiyang, Guizhou, P.R. China
| | - Yongmei Liu
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - Youlin Gong
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - Jiang Zhu
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - Jianxin Xue
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - Yuju Bai
- Department of Thoracic Oncology, Zunyi Medical University NO.2 Affiliated Hospital, Zunyi, Guizhou, P.R. China
| | - Hu Ma
- Department of Thoracic Oncology, Zunyi Medical University NO.2 Affiliated Hospital, Zunyi, Guizhou, P.R. China
| | - Yan Zhang
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - Min Yu
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - Yanying Li
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - Yongsheng Wang
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - Bingwen Zou
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - Xiaojuan Zhou
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - Weigang Xiu
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - Feifei Na
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - Yong Xu
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - Feng Peng
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - Jin Wang
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
| | - You Lu
- Department of Thoracic Oncology, Cancer Centre, Sichuan University West China Hospital, Chengdu, Sichuan, P.R. China
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15
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Datsenko PV, Gerasimov VA, Belikova AA. [Short-term survival prediction scale in patients with metastatic brain disease caused by lung and breast cancer]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:26-35. [PMID: 32759924 DOI: 10.17116/neiro20208404126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To develop a prognostic scale suitable for distinguishing a group of poor prognosis with low survival prior to deciding on the appropriateness of radiotherapy. MATERIAL AND METHODS We analyzed only those patients with reliably known date of death after previous WBRT to determine objective criteria allowing WBRT abandonment. WBRT was carried out in 100 patients with non-small cell lung cancer (n=49) and breast cancer (n=51) and confirmed metastatic brain disease. All procedures have been conducted at the radiotherapy department of the Herzen Moscow Oncology Research Institute since January 2014. The prescribed dose of 3 Gy was ensured in all patients. Total focal dose of 30 Gy delivered in 10 fractions was achieved in 77 cases, 36 Gy delivered in 12 fractions - in 23 cases. RESULTS Death date was recorded in all patients (n=100) by January 2020. In the electronic SPSS database, death information was digitized for each patient up to 2-24 months, respectively. We identified eight the most significant factors by using of correlation analysis: primary tumor (controlled (0), uncontrolled (1)), number of brain metastases (<17 (0), ≥17 (1)), volume of brain metastases (<48 cm3 (0) ≥48 cm3 (1)), extracranial control (no metastases (0), metastases with positive dynamics after chemotherapy (1), continued growth after chemotherapy (2)), metastatic lesion of liver and lungs, respectively (no (0), yes (1)), functional status (≥ 70% (0), ≤ 60% (1)), carcinomatosis of the meninges (no (0), yes (1)). A simple summation of digital variables for factors 1-8 in each patient resulted a prognostic scale. Low risk of early mortality after WBRT was determined by 0-3 scores, intermediate risk - 4-5 scores, high risk - 6-9 scores. According to univariate analysis (log-rank 0.000), median survival rate varied in these groups: low risk - 15.5 months (11.4-19.7), intermediate risk - 5.26 months (4.6-6.0), high risk - only 1.35 months (0.9-1.8). Only 1 out of 15 high-risk patients (6-9 scores) survived 3 months (3.25 months). Inclusion of all eight factors into multivariate analysis revealed significant impact of only risk group on short-term survival. A 3-month survival in the high-risk group was 20.6 times lower (p=0.002) compared to the low and intermediate risk groups. CONCLUSION High significance of prognostic model and low informative value of each of the included factors emphasize the advisability of determining risk groups for short-term survival according to the suggested scale for each patient scheduled for WBRT. A simple assessment of separate predictors is pointless to decide whether WBRT is necessary.
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Affiliation(s)
- P V Datsenko
- Herzen Moscow Oncology Research Institute, Moscow, Russia
| | - V A Gerasimov
- Herzen Moscow Oncology Research Institute, Moscow, Russia
| | - A A Belikova
- Herzen Moscow Oncology Research Institute, Moscow, Russia
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16
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Tsakonas G, Kamali C, De Petris L, Friesland S, Lewensohn R, Ekman S. ALK-Brain Prognostic Index-Preliminary Study of a Prognostic Tool for Patients with ALK-Rearranged, Non-small Cell Lung Cancer and Brain Metastases. Cancers (Basel) 2020; 12:cancers12071804. [PMID: 32640547 PMCID: PMC7408161 DOI: 10.3390/cancers12071804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/23/2020] [Accepted: 06/29/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Disease-specific Graded Prognostic Assessment (DS-GPA) is the most validated prognostic tool for patients with brain metastasized lung cancer. The Lung-molGPA scoring system was recently introduced for oncogenic-driven brain metastasized lung cancer, but has not yet been validated in cohorts including only ALK-translocated tumors. Methods: We designed a retrospective cohort study consisting of 44 patients with brain metastasized ALK-positive, non-small cell lung cancer (NSCLC) who were treated between January 2009 and November 2019 at Karolinska University Hospital in Stockholm, Sweden. Information about demographics and clinicopathological parameters were collected. Predictors of overall survival (OS) were identified by Cox regression analyses. A bootstrap validation with 1000 samples was performed in order to compare the different prognostic scores. Results: The variables found to independently influence OS in the multivariate analysis, i.e., PS, sex and brain metastases at diagnosis, were used as prognostic variables in our new prognostic index (ALK-BPI). Patients were divided into two prognostic groups. The median OS was 65.7 months for the good prognostic group and 22.7 months for the poor prognostic group (p = 0.0068). In the univariate analysis of the different prognostic scores, ALK-BPI performed better than the others (HR = 3.6; 95% CI: 1.3–9.9). The mean C-statistics of the different prognostic scores were compared to each other, and no significant difference was observed. Conclusion: We propose the ALK-BPI score as a new prognostic tool that can easily be applied for ALK-positive lung cancer patients with brain metastases in daily clinical practice, as it has at least the same prognostic value as Lung-molGPA.
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Affiliation(s)
- Georgios Tsakonas
- Theme Cancer, Medical Unit Head & Neck, Lung and Skin Cancer, Karolinska University Hospital, 17176 Stockholm, Sweden; (C.K.); (L.D.P.); (S.F.); (R.L.); (S.E.)
- Department of Oncology-Pathology, Karolinska Institutet, 17176 Stockholm, Sweden
- Correspondence: ; Tel.: +46-(0)-762129941
| | - Caroline Kamali
- Theme Cancer, Medical Unit Head & Neck, Lung and Skin Cancer, Karolinska University Hospital, 17176 Stockholm, Sweden; (C.K.); (L.D.P.); (S.F.); (R.L.); (S.E.)
- Department of Oncology-Pathology, Karolinska Institutet, 17176 Stockholm, Sweden
| | - Luigi De Petris
- Theme Cancer, Medical Unit Head & Neck, Lung and Skin Cancer, Karolinska University Hospital, 17176 Stockholm, Sweden; (C.K.); (L.D.P.); (S.F.); (R.L.); (S.E.)
- Department of Oncology-Pathology, Karolinska Institutet, 17176 Stockholm, Sweden
| | - Signe Friesland
- Theme Cancer, Medical Unit Head & Neck, Lung and Skin Cancer, Karolinska University Hospital, 17176 Stockholm, Sweden; (C.K.); (L.D.P.); (S.F.); (R.L.); (S.E.)
- Department of Oncology-Pathology, Karolinska Institutet, 17176 Stockholm, Sweden
| | - Rolf Lewensohn
- Theme Cancer, Medical Unit Head & Neck, Lung and Skin Cancer, Karolinska University Hospital, 17176 Stockholm, Sweden; (C.K.); (L.D.P.); (S.F.); (R.L.); (S.E.)
- Department of Oncology-Pathology, Karolinska Institutet, 17176 Stockholm, Sweden
| | - Simon Ekman
- Theme Cancer, Medical Unit Head & Neck, Lung and Skin Cancer, Karolinska University Hospital, 17176 Stockholm, Sweden; (C.K.); (L.D.P.); (S.F.); (R.L.); (S.E.)
- Department of Oncology-Pathology, Karolinska Institutet, 17176 Stockholm, Sweden
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Nieder C, Hintz M, Popp I, Bilger A, Grosu AL. Validation of the graded prognostic assessment for gastrointestinal cancers with brain metastases (GI-GPA). Radiat Oncol 2020; 15:35. [PMID: 32054485 PMCID: PMC7020357 DOI: 10.1186/s13014-020-1484-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/04/2020] [Indexed: 02/06/2023] Open
Abstract
PURPOSE The purpose of this study was to validate a new prognostic model (GI-GPA) originally derived from a multi-center database (USA, Canada, Japan). PATIENTS AND METHODS This retrospective study included 92 German and Norwegian patients treated with individualized approaches, always including brain radiotherapy. Information about age, extracranial spread, number of brain metastases, performance status and other variables was collected. The GI-GPA score was calculated as described by Sperduto et al. RESULTS: Median survival was 4 months. The corresponding figures for the 4 different prognostic strata were 2.3, 4.4, 9.4 and 12.7 months, respectively (p = 0.0001). Patients whose management included surgical resection had longer median survival than those who were treated with other approaches (median 11.9 versus 3.0 months, p = 0.002). Comparable results were seen for additional systemic therapy (median 8.5 versus 3.5 months, p = 0.01). CONCLUSION These results confirm the validity of the GI-GPA in an independent dataset from a different geographical region, despite the fact that overall survival was shorter in all prognostic strata, compared to Sperduto et al. Potential explanations include differences in molecular tumor characteristics and treatment selection, both brain metastases-directed and extracranially. Long-term survival beyond 5 years is possible in a small minority of patients.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway. .,Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, 9037, Tromsø, Norway.
| | - Mandy Hintz
- Department of Radiation Oncology, University Hospital Freiburg, 79106, Freiburg, Germany
| | - Ilinca Popp
- Department of Radiation Oncology, University Hospital Freiburg, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany
| | - Angelika Bilger
- Department of Radiation Oncology, University Hospital Freiburg, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany
| | - Anca L Grosu
- Department of Radiation Oncology, University Hospital Freiburg, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany
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Ha IB, Song JH, Jeong BK, Jeong H, Lee YH, Choi HS, Kang KM. The usefulness of stereotactic radiosurgery for recursive partitioning analysis class II/III lung cancer patients with brain metastases in the modern treatment era. Medicine (Baltimore) 2019; 98:e17390. [PMID: 31577744 PMCID: PMC6783249 DOI: 10.1097/md.0000000000017390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Stereotactic radiosurgery (SRS) is considered the initial treatment for lung cancer patients with small-sized and limited number of brain metastases. The objective of this study was to assess clinical outcomes of SRS treatment using CyberKnife (CK) for recursive partitioning analysis (RPA) class II/III patients with 1 to 3 brain metastases from lung cancer and identify which patients in the high RPA class could benefit from SRS.A total of 48 lung cancer patients who received CK-based SRS for their metastatic brain lesions from 2010 to 2017 were retrospectively analyzed. Radiographic response was evaluated during follow-up period. Overall survival (OS) and intracranial progression-free survival (IPFS) were calculated and prognostic variables associated with OS and IPFS were evaluated.Median follow-up time was 6.6 months. Local control rates at 6 months and 1-year following SRS were 98% and 92%, respectively. The median OS of all patients was 8 months. One-year and 2-year OS rates were 40.8% and 20.9%, respectively. In multivariate analysis, uncontrolled primary disease (P = .01) and Eastern Cooperative Oncology Group performance status of 2 or 3 (P = .001) were independent prognostic factors for inferior OS. These 2 factors were also significantly associated with inferior IPFS. In subgroup analysis according to RPA class, primary disease status was the only prognostic factor, showing statistically significant OS differences in both RPA class II and III (controlled vs uncontrolled: 41.1 vs 12.3 months in RPA class II, P = .03; 26.9 vs 4.1 months in RPA class III, P = .01).Our results indicated that SRS could be an effective treatment option for RPA class II/III patients with brain metastases from lung cancer in the modern treatment era. SRS might be particularly considered for patients with controlled primary disease.
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Affiliation(s)
- In Bong Ha
- Department of Radiation Oncology, Gyeongsang National University School of Medicine, and Gyeongsang National University Hospital, Jinju
| | - Jin Ho Song
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul
| | - Bae Kwon Jeong
- Department of Radiation Oncology, Gyeongsang National University School of Medicine, and Gyeongsang National University Hospital, Jinju
- Institute of Health Science, Gyeongsang National University, Jinju
| | - Hojin Jeong
- Department of Radiation Oncology, Gyeongsang National University School of Medicine, and Gyeongsang National University Hospital, Jinju
- Institute of Health Science, Gyeongsang National University, Jinju
| | - Yun Hee Lee
- Department of Radiation Oncology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul
| | - Hoon Sik Choi
- Department of Radiation Oncology, Gyeongsang National University School of Medicine, and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Ki Mun Kang
- Institute of Health Science, Gyeongsang National University, Jinju
- Department of Radiation Oncology, Gyeongsang National University School of Medicine, and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
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Hsu HS, Hu SL, Chien CR. A Prognostic Score for Brain Metastases of Non-small-cell Lung Cancer in the Era of Precision Medicine. Lung 2019; 197:683. [PMID: 31256234 DOI: 10.1007/s00408-019-00250-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 06/24/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Hua-Shai Hsu
- Hospice Palliative Medicine Unit, China Medical University Hospital, Taichung, Taiwan.,Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan
| | - Sung-Lin Hu
- Department of Family Medicine, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Chun-Ru Chien
- Department of Radiation Oncology, China Medical University Hospital, Taichung, Taiwan. .,Department of Radiation Oncology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan. .,School of Medicine, College of Medicine, China Medical University, North District, No.91 Hsueh-Shih Road, Taichung, 40402, Taiwan.
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20
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Nardone V, Nanni S, Pastina P, Vinciguerra C, Cerase A, Correale P, Guida C, Giordano A, Tini P, Reginelli A, Cappabianca S, Pirtoli L. Role of perilesional edema and tumor volume in the prognosis of non-small cell lung cancer (NSCLC) undergoing radiosurgery (SRS) for brain metastases. Strahlenther Onkol 2019; 195:734-744. [PMID: 31123785 DOI: 10.1007/s00066-019-01475-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/10/2019] [Indexed: 12/25/2022]
Abstract
AIM To assess the role of perilesional edema (PE) in non-small cell lung carcinoma (NSCLC) brain metastases (BM) undergoing radiosurgery (SRS). METHODS This series includes 46 patients with 1-2 BM treated with SRS, selected out of all patients referred for radiotherapy (RT) for BMs over 5 years (2013 to 2017). Both the PE and gross tumor volume (GTV) were contoured on MRI images, and the PE/GTV ratio and PE + GTV value (TV, total volume) were calculated. Our clinical endpoints were brain recurrence free-survival, divided into local brain control (in field, LBC) and distant brain control (out of field, DBC) and overall survival (OS). We analyzed the role of the previously described volumetric parameters and of known clinical prognosticators (disease specific GPA, DS-GPA; chemotherapy, CHT) with Cox regression analyses. RESULTS Only four patients (9%) developed in-field progression, whereas 10 patients (22%) showed new out-of-field BM and thirty-eight patients died in the follow up (83%). In univariate analysis, both volumetric parameters and clinical parameters were correlated with DBC and OS, whereas we did not find any correlation with LBC. In the multivariate analysis of DBC, the significant parameters were PE/GTV ratio (HR 0.302), sex (HR 0.131), and DS-GPA (HR 0.261). The OS multivariate analysis showed that the only significant parameters were DS-GPA (HR 0.478) and TV (HR: 1.038). CONCLUSION Our study, although with the limitations of a monocentric retrospective study analyzing a small cohort of patients, suggests the role of PE/GTV ratio for the development of new BMs. TV also seems to be correlated with OS, together with known clinical prognosticators. These findings, if validated in a larger prospective dataset, could help in selecting patients for the most suitable RT modality (or systemic therapy approach).
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Affiliation(s)
- Valerio Nardone
- Unit of Radiation Oncology, Ospedale del Mare, Viale della Metamorfosi, Naples, Italy.
| | - Sara Nanni
- Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy
| | - Pierpaolo Pastina
- Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy
| | - Claudia Vinciguerra
- Department of Medicine, Surgery and Neurosciences (Clinical Neurology and Neuro-metabolic Disorders), University of Siena, Siena, Italy
| | - Alfonso Cerase
- Unit of Neuro-Radiology, University Hospital of Siena, Siena, Italy
| | - Pierpaolo Correale
- Unit of Medical Oncology, Grand Metropolitan Hospital "Bianchi Melacrino Morelli" Reggio Calabria, Reggio Calabria, Italy
| | - Cesare Guida
- Unit of Radiation Oncology, Ospedale del Mare, Viale della Metamorfosi, Naples, Italy
| | - Antonio Giordano
- Sbarro Health Research Organization, Temple University, Philadelphia, PA, USA.,Department of Biology, College of Science and Technology, Temple University, Philadelphia, PA, USA
| | - Paolo Tini
- Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy.,Sbarro Health Research Organization, Temple University, Philadelphia, PA, USA
| | - Alfonso Reginelli
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Salvatore Cappabianca
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Luigi Pirtoli
- Sbarro Health Research Organization, Temple University, Philadelphia, PA, USA.,Department of Biology, College of Science and Technology, Temple University, Philadelphia, PA, USA
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Nieder C, Yobuta R, Mannsåker B. Patterns of Treatment and Outcome in Patients With 20 or More Brain Metastases. In Vivo 2019; 33:173-176. [PMID: 30587619 DOI: 10.21873/invivo.11455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/12/2018] [Accepted: 11/15/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND/AIM The aim of this study was to analyze the patterns of treatment and outcomes in patients with a large number of brain metastases, arbitrarily defined as 20 or more lesions. These patients are typically excluded from studies of focal brain treatment, e.g., surgery or radiosurgery, and might have a limited prognosis. PATIENTS AND METHODS This was a retrospective single-institution analysis. Overall, 11 patients were identified from a prospectively maintained database. RESULTS Ten patients had received active treatment (9 whole-brain radiotherapy, 7 systemic therapy). Median survival was 5.0 months without long-term survival beyond 13 months. Patients with better performance status had numerically longer survival, however we did not identify baseline parameters with a significant impact on survival. CONCLUSION While long-term survival was not observed in this small study, most patients survived long enough to experience symptomatic improvement from whole-brain radiotherapy. Therefore, we recommend multidisciplinary assessment of the patients' prognosis and systemic treatment options, and initiation of whole-brain radiotherapy if survival is not limited to 1-2 months.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway .,Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Rosalba Yobuta
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway
| | - Bård Mannsåker
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway
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22
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Andratschke N, Kraft J, Nieder C, Tay R, Califano R, Soffietti R, Guckenberger M. Optimal management of brain metastases in oncogenic-driven non-small cell lung cancer (NSCLC). Lung Cancer 2019; 129:63-71. [DOI: 10.1016/j.lungcan.2018.12.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/29/2018] [Accepted: 12/08/2018] [Indexed: 02/07/2023]
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Lewitzki V, Klement RJ, Hess S, Kosmala R, Nieder C, Flentje M. External validation of a prognostic score predicting overall survival for patients with brain metastases based on extracranial factors. Clin Transl Radiat Oncol 2019; 16:15-20. [PMID: 30906886 PMCID: PMC6411583 DOI: 10.1016/j.ctro.2019.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 02/23/2019] [Indexed: 12/25/2022] Open
Abstract
We provide an external validation of the extracranial prognostic score developed by Nieder et al. This extracranial score could effectively define the patients with very short survival. A new combination of extracranial score with DS-GPA-score achieved an even better discrimination
Purpose The aim of our study was an external validation of the extracranial prognostic score predicting survival of patients with brain metastases receiving cranial irradiation on data from a single institution. Materials and methods A retrospective analysis of 524 patients with brain metastases treated with cranial radiotherapy in a single tertiary center was performed. Three predictive scores were calculated and assessed for their ability to discriminate prognostic groups: (i) The Recursive Partitioning Analysis (RPA) score (available for 524 patients); (ii) the Diagnosis-Specific Graded Prognostic Assessment (DS-GPA) score (464 patients); (iii) the extracranial score (EC-S) developed by Nieder et al. which is based on serum albumin, lactate dehydrogenase (LDH) and the number of extracranial organs involved (157 patients). Discrimination of each score was assessed by Gönen & Heller’s concordance probability estimate (CPE). The calibration was checked by comparing median survival estimates of each risk group with the corresponding values of the datasets from which the scores were derived. Finally, a multivariable Cox regression model was built by using the least absolute shrinkage and selection operator on a large number of variables including all three scores. Results With a CPE = 0.626 ± 0.022, the EC-S had the best discriminatory power. The EC-S also appeared to be better calibrated and had the best ability to separate patients with a very poor prognosis: patients with combination of low albumin, elevated LDH and more than 1 extracranial organ with metastatic involvement had a median survival time of only 0.6 months (CI95% 0.1–1.1) and a hazard ratio for death of 6.36 (2.67–15.14) compared to patients with no extracranial metastases and normal levels of albumin and LDH. In the multivariable Cox model serum albumin, LDH, treatment modality, DS-GPA and EC-S were retained as prognostic factors. An ad hoc combination of both DS-GPA and EC-S into a new score was possible for 134 patients and indicated a slightly better discrimination (CPE = 0.636 ± 0.023) than either DS-GPA or EC-S alone. Conclusions This study provides an independent validation of the prognostic EC-S which was the best prognostic model for defining the patients who obviously did not benefit from radiation therapy of brain metastases in terms of overall survival. The combination of the EC-S with the established DS-GPA score resulted in a slight increase in discriminatory ability. The new EC-GPA score needs further validation in larger patient cohorts.
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Affiliation(s)
- Victor Lewitzki
- University of Würzburg, Department of Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Rainer J Klement
- Department of Radiation Oncology, Leopoldina Hospital Schweinfurt, 97422 Schweinfurt, Germany
| | - Sebastian Hess
- University of Würzburg, Department of Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Rebekka Kosmala
- University of Würzburg, Department of Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Carsten Nieder
- Department of Clinical Medicine, Faculty of Health Science, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Oncology and Palliative Medicine, Nordland Hospital Trust, 8092 Bodø, Norway
| | - Michael Flentje
- University of Würzburg, Department of Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
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24
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Nieder C, Guckenberger M, Gaspar LE, Rusthoven CG, De Ruysscher D, Sahgal A, Nguyen T, Grosu AL, Mehta MP. Management of patients with brain metastases from non-small cell lung cancer and adverse prognostic features: multi-national radiation treatment recommendations are heterogeneous. Radiat Oncol 2019; 14:33. [PMID: 30770745 PMCID: PMC6377775 DOI: 10.1186/s13014-019-1237-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/08/2019] [Indexed: 12/25/2022] Open
Abstract
Background Different management options exist for patients with brain metastases from non-small cell lung cancer (NSCLC), patients whose treatment with whole brain radiotherapy (WBRT) has become more controversial over the last decade. It is not trivial to find the optimal balance of over- versus undertreatment in these patients. Several recent trials, including the randomized QUARTZ trial now influence the decision to recommend or withhold WBRT for patients with unfavorable prognosis, and similarly, for favorable prognosis patients, the balance between radiosurgery alone or WBRT has become a nuanced decision. Additionally, the availability of intracranially active targeted agent for some subsets of these patients has added another layer of complexity to the decision-making. Methods A multinational consortium of expert radiation oncologists was established with the aim of compiling treatment recommendations for challenging scenarios, in this case the choice between optimal supportive care (SC), WBRT and other types of radiation therapy (RT). We distributed 17 cases to 7 radiation oncologists who were allowed to involve coworkers to provide their treatment recommendations. The cases differed in extra- and intracranial disease extent, histology, age and other prognostic factors. Expert recommendations were tabulated with the aim of providing guidance. Results Regarding willingness to include the 17 patients in the QUARTZ trial, the rates of trial inclusion were low (range 0/7 to 3/7). Experts not recommending trial inclusion provided their treatment recommendations. These suggestions differed widely for most of the patients. It was not uncommon to see 3 or 4 different recommendations. In general, few (0–2) recommended SC. Some kind of local treatment was suggested by the majority of experts for all 17 patients. Commonly, stereotactic single-fraction radiosurgery (SRS) or stereotactic fractionated radiotherapy (SFRT) were recommended by many experts, also for patients with 5–7 lesions. The highest proportion of recommendations towards WBRT in any patient was 3/7. It was also quite common for patients with multiple metastases of varying size that experts suggested combinations of resection, post-operative SRS/SFRT and SRS/SFRT to intact lesions. Despite recommending active treatment, experts were often willing to include the patients in a hypothetical protocol investigating radiotherapy utilization in the last 30 days of life (assessment of factors predicting early death). Conclusions WBRT was infrequently recommended. Even in patients with adverse prognostic features that raised the experts’ awareness of an increased risk for futile treatment near the end of life, SRS/SFRT were more often recommended than optimal supportive care, unless a patient decided to forego active treatment. Electronic supplementary material The online version of this article (10.1186/s13014-019-1237-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway. .,Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway.
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Laurie E Gaspar
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Dirk De Ruysscher
- Department of Radiation Oncology (MAASTRO Clinic), Maastricht University Medical Center, GROW, Maastricht, The Netherlands
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| | - Timothy Nguyen
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| | - Anca L Grosu
- Department of Radiation Oncology, University Hospital Freiburg, Freiburg, Germany
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA
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The Changing Paradigm of Treatment for Non-Small Cell Lung Cancer Intracranial Metastases. CURRENT PULMONOLOGY REPORTS 2018. [DOI: 10.1007/s13665-018-0215-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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26
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Hartgerink D, van der Heijden B, De Ruysscher D, Postma A, Ackermans L, Hoeben A, Anten M, Lambin P, Terhaag K, Jochems A, Dekker A, Schoenmaekers J, Hendriks L, Zindler J. Stereotactic Radiosurgery in the Management of Patients With Brain Metastases of Non-Small Cell Lung Cancer: Indications, Decision Tools and Future Directions. Front Oncol 2018; 8:154. [PMID: 29868476 PMCID: PMC5954030 DOI: 10.3389/fonc.2018.00154] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/24/2018] [Indexed: 12/18/2022] Open
Abstract
Brain metastases (BM) frequently occur in non-small cell lung cancer (NSCLC) patients. Most patients with BM have a limited life expectancy, measured in months. Selected patients may experience a very long progression-free survival, for example, patients with a targetable driver mutation. Traditionally, whole-brain radiotherapy (WBRT) has been the cornerstone of the treatment, but its indication is a matter of debate. A randomized trial has shown that for patients with a poor prognosis, WBRT does not add quality of life (QoL) nor survival over the best supportive care. In recent decades, stereotactic radiosurgery (SRS) has become an attractive non-invasive treatment for patients with BM. Only the BM is irradiated to an ablative dose, sparing healthy brain tissue. Intracranial recurrence rates decrease when WBRT is administered following SRS or resection but does not improve overall survival and comes at the expense of neurocognitive function and QoL. The downside of SRS compared with WBRT is a risk of radionecrosis (RN) and a higher risk of developing new BM during follow-up. Currently, SRS is an established treatment for patients with a maximum of four BM. Several promising strategies are currently being investigated to further improve the indication and outcome of SRS for patients with BM: the effectivity and safety of SRS in patients with more than four BM, combining SRS with systemic therapy such as targeted agents or immunotherapy, shared decision-making with SRS as a treatment option, and individualized isotoxic dose prescription to mitigate the risk of RN and further enhance local control probability of SRS. This review discusses the current indications of SRS and future directions of treatment for patients with BM of NSCLC with focus on the value of SRS.
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Affiliation(s)
- Dianne Hartgerink
- Department of Radiation Oncology (MAASTRO Clinic), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Britt van der Heijden
- Department of Radiation Oncology (MAASTRO Clinic), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Dirk De Ruysscher
- Department of Radiation Oncology (MAASTRO Clinic), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, Netherlands
- Proton Therapy Department South-East Netherlands (ZON-PTC), Maastricht, Netherlands
| | - Alida Postma
- Department of Radiology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Linda Ackermans
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Ann Hoeben
- Department of Medical Oncology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Monique Anten
- Department of Neurology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO Clinic), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Karin Terhaag
- Department of Radiation Oncology (MAASTRO Clinic), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Arthur Jochems
- Department of Radiation Oncology (MAASTRO Clinic), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Andre Dekker
- Department of Radiation Oncology (MAASTRO Clinic), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, Netherlands
- Proton Therapy Department South-East Netherlands (ZON-PTC), Maastricht, Netherlands
| | - Janna Schoenmaekers
- Department of Pulmonary Diseases, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Lizza Hendriks
- Department of Pulmonary Diseases, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Jaap Zindler
- Department of Radiation Oncology (MAASTRO Clinic), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, Netherlands
- Proton Therapy Department South-East Netherlands (ZON-PTC), Maastricht, Netherlands
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Nieder C, Hintz M, Bilger A, Oehlke O, Grosu AL. Validation of the Graded Prognostic Assessment for Melanoma Using Molecular Markers (Melanoma-molGPA). J Clin Med Res 2018; 10:178-181. [PMID: 29416574 PMCID: PMC5798262 DOI: 10.14740/jocmr3248w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 11/21/2017] [Indexed: 11/29/2022] Open
Abstract
Background It has been suggested to replace the diagnosis-specific graded prognostic assessment (DS-GPA, based on performance status and number of brain metastases) for patients with primary malignant melanoma with the new Melanoma-molGPA. The latter is a more complex assessment, which also includes BRAF mutation status, age and extracranial metastases. To test the performance of the Melanoma-molGPA, we performed a validation study of this new survival prediction tool. Methods A retrospective analysis of patients treated at two different academic institutions was performed. The four-tiered Melanoma-molGPA was calculated as suggested in the original study. Results Median overall survival was 5.4 months (95% confidence interval: 3.1 - 7.7 months). Median survival in the four prognostic classes was 2.1, 7.8, 11.8, and 18.0 months, respectively. The 1-year survival rates were 3%, 25%, 43%, and 80%, respectively. The difference between the Kaplan-Meier curves was significant (P = 0.0001, log-rank test). Conclusions The present survival outcomes support the use of the Melanoma-molGPA. However, survival was better in each of the four groups in the original study. Possible reasons include lead-time bias and different treatment policies.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodo, Norway.,Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromso, 9037 Tromso, Norway
| | - Mandy Hintz
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany
| | - Angelika Bilger
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany
| | - Oliver Oehlke
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Germany
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Nieder C, Kämpe TA. Frequency and Prognostic Impact of Consistently Low Edmonton Symptom Assessment System Score in the Patients Treated with Palliative Radiotherapy. Cureus 2018. [PMID: 29535905 PMCID: PMC5839746 DOI: 10.7759/cureus.2032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introduction Our department's standard work-flow includes assessment of all the patients with the Edmonton Symptom Assessment System (ESAS), a one-sheet questionnaire addressing 11 major symptoms and wellbeing on a numeric scale of zero-10, before the palliative radiotherapy (PRT). Based on previous research, we hypothesized that the patients with minimal or moderate total symptom burden might have better overall survival after the PRT than those with at least one higher symptom score. Methods We performed a retrospective analysis of 94 patients and calculated actuarial survival from the first day of the PRT (Kaplan-Meier method). We identified the patients with the score zero for all ESAS items (no symptoms), at least one item with score one-two (minimal symptoms), and at least one item with the score three (moderate symptoms). Results High proportions of the patients had ESAS scores zero- two for nausea (80%), sadness/depression (65%) and constipation (64%). The mean values were often in the range of two-four. Only one patient reported scores of zero throughout the questionnaire. He was treated for hematuria, a symptom that is not part of the ESAS. Three patients reported scores of zero-two throughout the questionnaire. Except for the performance status zero-one, their baseline characteristics were heterogeneous. Two patients reported scores not exceeding three for all items. These patients had excellent performance status, too. None of the six patients (6%) with relatively low ESAS scores of zero-three received care by the hospital's multidisciplinary palliative team. Only one was using opioid analgesics. The median survival for this small subset of six patients was six months, identical to the result for all the patients with higher symptom burden (p = 0.62). Conclusion The proportion of the patients with ESAS scores zero-three throughout the questionnaire was 6%, which resulted in the limited statistical power for the survival comparisons. The survival outcomes were similar. Before PRT, 94% of the patients reported at least one ESAS item of severity four-10. The symptoms not included in the questionnaire, e.g., hematuria might result in erroneous assignment to the low-symptom-burden group and obscure the prognostic impact of low ESAS symptom burden.
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Affiliation(s)
- Carsten Nieder
- Dept. of Oncology and Palliative Medicine, Nordland Hospital Trust
| | - Thomas A Kämpe
- Dept. of Oncology and Palliative Medicine, Nordland Hospital Trust
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Radiation Therapy in Brain Metastasis of Solid Tumors: A Challenge for the Future. Radiat Oncol 2018. [DOI: 10.1007/978-3-319-52619-5_12-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Bernhardt D, König L, Aufderstrasse S, Krisam J, Hoerner-Rieber J, Adeberg S, Bozorgmehr F, El Shafie R, Lang K, Kappes J, Thomas M, Herth F, Heußel CP, Warth A, Marcrom S, Debus J, Steins M, Rieken S. Generation of a New Disease-specific Prognostic Score for Patients With Brain Metastases From Small-cell Lung Cancer Treated With Whole Brain Radiotherapy (BMS-Score) and Validation of Two Other Indices. Clin Lung Cancer 2017; 19:340-345. [PMID: 29373273 DOI: 10.1016/j.cllc.2017.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/22/2017] [Accepted: 12/08/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Patients with small-cell lung cancer (SCLC) demonstrate an exception in the treatment of brain metastases (BM), because in patients with SCLC whole brain radiotherapy (WBRT) only is the preferred treatment modality. The purpose of this study was to develop a prognostic score for patients with brain metastases from SCLC treated with WBRT. PATIENTS AND METHODS The present study was conducted utilizing a single-institution, previously described, retrospective database of patients with SCLC who were treated with WBRT (n = 221). Univariate and multivariate analyses were performed to generate the "brain metastases from SCLC score" (BMS score) based on favorable prognostic factors: Karnofsky performance status (KPS > 70), extracerebral disease status (stable disease/controlled), and time of appearance of BM (synchronous). Furthermore, the disease-specific graded prognostic assessment score as well as the recursive partitioning analysis (RPA) were performed and compared with the new BMS score by using the log-rank (Mantel-Cox) test. RESULTS BMS score and RPA showed the most significant differences between classes (P < .001). BMS score revealed a mean overall survival (OS) of 2.62 months in group I (0-1 points), 6.61 months in group II (2-3 points), and 12.31 months in group III (4 points). The BMS score also identified the group with the shortest survival (2.62 months in group I), and the numbers of patients in each group were most equally distributed with the BMS score. CONCLUSION The new BMS score was more prognostic than the RPA and disease-specific graded prognostic assessment scores. The BMS score is easy to use and reflects known prognostic factors in contemporary patients with SCLC treated with WBRT. Future studies are necessary to validate these findings.
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Affiliation(s)
- Denise Bernhardt
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany.
| | - Laila König
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Sophie Aufderstrasse
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Johannes Krisam
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Juliane Hoerner-Rieber
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Sebastian Adeberg
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Farastuk Bozorgmehr
- Department of Thoracic Oncology, Thoraxklinik, Heidelberg University, Translational Lung Research Centre Heidelberg (TLRC-H), Heidelberg, Germany; Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Rami El Shafie
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Kristin Lang
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Jutta Kappes
- Department of Pneumology, Thoraxklinik, Heidelberg University, Heidelberg, Germany; Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Michael Thomas
- Department of Thoracic Oncology, Thoraxklinik, Heidelberg University, Translational Lung Research Centre Heidelberg (TLRC-H), Heidelberg, Germany; Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Felix Herth
- Department of Pneumology, Thoraxklinik, Heidelberg University, Heidelberg, Germany; Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Claus Peter Heußel
- Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, Germany; Diagnostic and Interventional Radiology at University of Heidelberg, Heidelberg, Germany
| | - Arne Warth
- Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Institute of Pathology, Heidelberg University, Heidelberg, Germany
| | - Samuel Marcrom
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Jürgen Debus
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Martin Steins
- Department of Thoracic Oncology, Thoraxklinik, Heidelberg University, Translational Lung Research Centre Heidelberg (TLRC-H), Heidelberg, Germany
| | - Stefan Rieken
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
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