EGFR mutations in patients with brain metastases from lung cancer: association with the efficacy of gefitinib

Exploring key genes and pathways associated with sex differences in autism spectrum disorder: integrated bioinformatic analysis

Autism spectrum disorder (ASD) is a heterogenous neurodevelopmental disorder marked by functional abnormalities in brain that causes social and linguistic difficulties. The incidence of ASD is more prevalent in males compared to females, but the underlying mechanism, as well as molecular indications for identifying sex-specific differences in ASD symptoms remain unknown. Thus, impacting the development of personalized strategy towards pharmacotherapy of ASD. The current study employs an integrated bioinformatic approach to investigate the genes and pathways uniquely associated with sex specific differences in autistic individuals. Based on microarray dataset (GSE6575) extracted from the gene expression omnibus, the dysregulated genes between the autistic and the neurotypical individuals for both sexes were identified. Gene set enrichment analysis was performed to ascertain biological activities linked to the dysregulated genes. Protein-protein interaction network analysis was carried out to identify hub genes. The identified hub genes were examined to determine their functions and involvement in the associated pathways using Enrichr. Additionally, hub genes were validated from autism-associated databases and the potential small molecules targeting the hub genes were identified. The present study utilized whole blood transcriptomic gene expression analysis data and identified 2211 and 958 differentially expressed unique genes in males and females respectively. The functional enrichment analysis revealed that male hub genes were functionally associated with RNA polymerase II mediated transcriptional regulation whereas female hub genes were involved in intracellular signal transduction and cell migration. The top male hub genes exhibited functional enrichment in tyrosine kinase signalling pathway. The pathway enrichment analysis of male hub genes indicates the enrichment of papillomavirus infection. Female hub genes were enriched in androgen receptor signalling pathway and functionally enriched in focal adhesion specific excision repair. Identified drug like candidates targeting these genes may serve as a potential sex specific therapeutics. Wortmannin for males, 5-Fluorouracil for females had the highest scores. Targeted and sex-specific pharmacotherapies may be created for the management of ASD. The current investigation identifies sex-specific molecular signatures derived from whole blood which may serve as a potential peripheral sex-specific biomarkers for ASD. The study also uncovers the possible pharmacological interventions against the selected genes/pathway, providing support in development of therapeutic strategies to mitigate ASD. However, experimental proofs on biological systems are warranted.

Selecting the Appropriate Radiation Therapy Technique for Extensive Brain Metastases from Tens to Hundreds: Should the Latest Technique Always Be the Best Option?

Brain metastases (BMs) are one of the most common metastatic lesions in adult cancer patients and the most common intracranial neoplasms in adult patients. Especially for multiple BMs, historically, whole-brain radiotherapy (WBRT) has been performed as the mainstay of therapy, which improves neurological symptoms and median survival. However, WBRT could negatively impact the patient's quality of life due to late complications. Owing to these complications, attempts have been made to use the latest radiotherapy (LRT) such as stereotactic radiosurgery (SRS) and intensity-modulated radiotherapy (IMRT) to treat BMs. However, for the extensive BMs (ranging from tens to hundreds), there are currently no prospective studies comparing WBRT with LRT such as IMRT or SRS. For extensive brain metastases, LRT cannot be the best option. Instead, upfront WBRT should be considered given its advantages and disadvantages, rather than LRT. We hope that faster and more reliable LRT for extensive BMs will be applicable for clinical practice without any clinical concerns in the near future.

Long-term progression-free survival in a patient with advanced non-small-cell lung cancer treated with low-dose gefitinib and traditional herbal medicine: A case report

RATIONALE

Gefitinib is a first-line palliative chemotherapy drug used to treat advanced non-small-cell lung cancer (NSCLC) in patients who have an epidermal growth factor receptor (EGFR) mutation. However, approximately two-thirds of NSCLC patients with EGFR-tyrosine kinase inhibitor experience dermatological toxicity. Cutaneous toxicity is usually not life threatening but can necessitate modification or discontinuation of medication in severe cases. In this case, despite a reduction in the dose of gefitinib due to side effects, combined treatment with modified Bojungikki-tang (BJKIT) increased progression-free survival (PFS) in an advanced NSCLC patient.

PATIENT CONCERNS

An 83-year-old Asian woman presented with chief complaints of chronic cough, dyspnea, weight loss, and anorexia.

DIAGNOSES

The patient was diagnosed with stage IV NSCLC (T2aN3M1), adenocarcinoma with metastasis to the lymph node, brain, and bone based on image scan and biopsy. An EGFR deletion was detected in exon 19.

INTERVENTIONS

The patient was treated with gefitinib (250 mg/d) and traditional herbal medicine, modified Bojungikki-tang (BJIKT). However, after 1 year of combination therapy, gefitinib was tapered down to once per week while modified BJIKT was maintained.

OUTCOMES

A partial response was achieved, but after 3 months severe papulopustular skin rashes developed and became aggravated with time. Thus, the gefitinib dose was reduced. However, the PFS has been maintained for approximately 78 months.

LESSONS

Despite the reduction in gefitinib dose due to side effects, the combined treatment of gefitinib and the modified BJIKT has maintained a PFS of over 78 months, indicating that modified BJIKT enhanced the anti-cancer effect of gefitinib in a patient with advanced NSCLC harboring the EFGR mutation, and may have delayed acquired resistance, the main limitation on the efficacy of gefitinib. Further investigations including clinical trials are needed to confirm these effects.

[Mechanism of EGFR Over-expression and Mutations Leading to Biological Characteristics Changes of Human Lung Adenocarcinoma Cells through CXCR4/CXCL12 Signaling Pathway]

BACKGROUND

The epidermal growth factor receptor (EFGR) mutation was closely related to the invasion and metastasis of lung adenocarcinoma and the biological axis of CXCR4/CXCL12 (chemokine receptor 4/chemokine ligand 12) played an important role in the organ-specific metastasis of the tumor. It was a question surrounding whether there is interaction between them in the process of lung adenocarcinoma metastasis. To investigate the potential molecular mechanisms of EGFR over-expression and EFGR-mutations effects on cell proliferation, migration and invasion, we constructed EGFR over-expression and three EFGR-mutant human lung adenocarcinoma H1299 cell sublines.

METHODS

EGFR over-expression and three EFGR-mutant (EGFR-E746-A750del, EGFR-T790M and EGFR-L858R) plasmid were designed and transfected H1299 cells with Lipofectamine 2000. H1299 cells transfected with empty vector were negative control (NC), and H1299 cells without transfection were set as blank control (BC). The effects of EGFR over-expression and mutations on the proliferation, migration and invasion of H1299 cells were detected by cell cloning assay, wound healing assay and Transwell assay. The mRNA and protein expression levels of MMP-2, MMP-9, CXCR4 and CXCL12 were detected by RT-PCR and Western blot.

RESULTS

Compared with negative control group and blank control group, EGFR over-expression and EGFR-E746-A750 deletion have significantly higher colony formation (28±2, 28.33±4.16; respectively) (P<0.05) and the cell migration and invasion ability were significantly increased (P<0.05). RT-PCR and Western blot assay showed that the mRNA and protein expression of MMP-2, MMP-9, CXCR4 and CXCL12 in EGFR over-expression and EGFR-E746-A750 deletion group were remarkably higher than that in negative control and blank control group (P<0.05).

CONCLUSIONS

EGFR over-expression and 19 exon deletion can promote the expression of MMP-2 and MMP-9 by up-regulating CXCR4/CXCL12 signaling pathway, leading to the change of tumor biological characteristics such as higher proliferation, migration and invasion ability.

Clinicopathological and genetic characteristics associated with brain metastases from lung adenocarcinoma and utility as prognostic factors

Brain metastases (BM) are common in patients with lung adenocarcinoma, and represent a significant cause of morbidity in the disease. A more comprehensive understanding of the clinicopathological characteristics that serve as prognostic factors for survival in patients with BM from lung adenocarcinoma may aid in informing treatment strategies for this patient population. In the present study, clinicopathological factors, including EGFR mutation status, were evaluated in 59 patients who were diagnosed with BM from lung adenocarcinoma, and underwent BM resection between January 1985 and December 2014 at Fukuoka University Hospital. The most frequent subtype of BM from lung adenocarcinoma was solid adenocarcinoma (57.6%), followed by papillary adenocarcinoma (22.0%) and acinar adenocarcinoma (18.6%). A total of 14 patients (23.7%) exhibited EGFR mutations, which were significantly associated with female sex (9/14, 64.3%), non-smoker status (8/14, 57.1%), BM in the frontal lobes (9/14, 64.3%) and papillary adenocarcinoma (5/14, 35.7%). Statistical analysis revealed a significant association between non-smoker status and BM in the frontal lobes, and more favorable disease prognosis. The results of the present study suggest that histological and genetic analysis of tissue from BM provides information useful for managing treatment of patients with resectable BM arising from lung adenocarcinoma.

Risk factors and treatments for brain metastasis in patients with adenocarcinoma of the lung: a retrospective analysis of 373 patients

Background

Risk factors and treatments for brain metastasis (BM) in patients with adenocarcinoma have not been fully profiled in previous studies because of the enrolment of patients with tumours of mixed histology. Thus, we specifically addressed the issue in patients with adenocarcinoma.

Methods

Clinical data for 373 patients with pathologically confirmed adenocarcinoma were studied retrospectively. Factors including age (≤60 vs. > 60), gender (male vs. female), stage at diagnosis, T status (T1–2 vs. T3–4), N status (N0–1 vs. N2–3), epidermal growth factor receptor (EGFR) mutation status (wild-type vs. mutant) and smoking status (never vs. current) were analyzed.

Results

In multivariate analysis, age (P = 0.006) and N status (P = 0.041) were independent risk factors for BM. In patients with BM, adding systemic therapy to local therapy improved median post-brain-metastasis survival (mPBMS) (P = 0.02). However, if stratification was conducted according to the recursive partitioning analysis (RPA) classification or graded prognostic assessment (GPA) scoring, only patients in RPA class II (P = 0.020) or with GPA score 1.5-2.5 (P = 0.032) could benefit from local plus systemic therapy. Those who received both pemetrexed and tyrosine kinase inhibitors (TKIs) as systemic therapies had a longer mPBMS than those who received TKIs alone, regardless of whether local therapy was applied. In patients with EGFR-sensitive mutations, TKIs therapy led to a longer mPBMS than conventional chemotherapy (P = 0.002).

Conclusions

Adenocarcinoma patients who were younger than 60 years of age and those with N2–3 disease have a significantly higher risk of BM. The addition of systemic therapy to local therapy can significantly prolong mPBMS, but the survival benefit confined in certain populations. Patients with opportunity to receive both pemetrexed and TKIs had the longest mPBMS.

Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors for Central Nervous System Metastases from Non-Small Cell Lung Cancer

Central nervous system (CNS) metastases are a common complication in patients with epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NSCLC), resulting in a poor prognosis and limited treatment options. Treatment of CNS metastases requires a multidisciplinary approach, and the optimal treatment options and sequence of therapies are yet to be established. Many systemic therapies have poor efficacy in the CNS due to the challenges of crossing the blood-brain barrier (BBB), creating a major unmet need for the development of agents with good BBB-penetrating biopharmaceutical properties. Although the CNS penetration of first- and second-generation EGFR tyrosine kinase inhibitors (TKIs) is generally low, EGFR-TKI treatment has been shown to delay time to CNS progression in patients with CNS metastases from EGFR-mutated disease. However, a major challenge with EGFR-TKI treatment for patients with NSCLC is the development of acquired resistance, which occurs in most patients treated with a first-line EGFR-TKI. Novel EGFR-TKIs, such as osimertinib, have been specifically designed to address the challenges of acquired resistance and poor BBB permeability and have demonstrated efficacy in the CNS. A rational, iterative drug development process to design agents that could penetrate the BBB could prevent morbidity and mortality associated with CNS disease progression. To ensure a consistent approach to evaluating CNS efficacy, special consideration also needs to be given to clinical trial endpoints.

IMPLICATIONS FOR PRACTICE

Historically, treatment options for patients who develop central nervous system (CNS) metastases have been limited and associated with poor outcomes. The development of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) has improved outcomes for patients with EGFR-mutated disease, and emerging data have demonstrated the ability of these drugs to cross the blood-brain barrier and elicit significant intracranial responses. Recent studies have indicated a role for next-generation EGFR-TKIs, such as osimertinib, in the treatment of CNS metastases. In the context of an evolving treatment paradigm, treatment should be individualized to the patient and requires a multidisciplinary approach.

Bevacizumab and gefitinib enhanced whole-brain radiation therapy for brain metastases due to non-small-cell lung cancer

Non-small-cell lung cancer (NSCLC) patients who experience brain metastases are usually associated with poor prognostic outcomes. This retrospective study proposed to assess whether bevacizumab or gefitinib can be used to improve the effectiveness of whole brain radiotherapy (WBRT) in managing patients with brain metastases. A total of 218 NSCLC patients with multiple brain metastases were retrospectively included in this study and were randomly allocated to bevacizumab-gefitinib-WBRT group (n=76), gefitinib-WBRT group (n=77) and WBRT group (n=75). Then, tumor responses were evaluated every 2 months based on Response Evaluation Criteria in Solid Tumors version 1.0. Karnofsky performance status and neurologic examination were documented every 6 months after the treatment. Compared to the standard WBRT, bevacizumab and gefitinib could significantly enhance response rate (RR) and disease control rate (DCR) of WBRT (P<0.001). At the same time, RR and DCR of patients who received bevacizumab-gefitinib-WBRT were higher than those who received gefitinib-WBRT. The overall survival (OS) rates and progression-free survival (PFS) rates also differed significantly among the bevacizumab-gefitinib-WBRT (48.6 and 29.8%), gefitinib-WBRT (36.7 and 29.6%) and WBRT (9.8 and 14.6%) groups (P<0.05). Although bevacizumab-gefitinib-WBRT was slightly more toxic than gefitinib-WBRT, the toxicity was tolerable. As suggested by prolonged PFS and OS status, bevacizumab substantially improved the overall efficacy of WBRT in the management of patients with NSCLC.

Brain metastases from non-small cell lung carcinoma: Changing concepts for improving patients' outcome

The management of Non Small Cell Lung Cancer (NSCLC) brain metastases is challenging, as this frequent complication negatively impacts patients' quality of life, and can be a life-threatening event. Through a review of the literature, we discuss the main therapeutic options and the recent developments that improved (and complicated) the management of NSCLC brain metastases patients. Most current validated approaches are local with exclusive or combined surgery, whole brain radiotherapy (WBRT) and stereotactic radiotherapy (SRT). At the same time, there is a growing role for systemic treatments that might significantly postpone WBRT. Targeted therapies efficacy/toxicity profile remains to be defined but predictive and prognostic molecular factors integration could help to select treatments fully adapted to life expectancy and progression risk.

Downregulation of EGFR in a metastatic brain lesion of EGFR-mutated non-small cell lung cancer using a tyrosine kinase inhibitor: A case report

Brain metastasis is a common complication in patients with cancer, with lung cancer being the most frequent origin of brain metastases. Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) have begun to serve a pivotal role in lung cancer treatment and have been reported to demonstrate anticancer activity against brain metastases by penetrating the blood-brain barrier. The present study reports, to the best of our knowledge, the first case of EGFR-mutated non-small cell lung cancer (NSCLC) brain metastasis that was surgically resected while the lesion was responding to the EGFR-TKI erlotinib. The results of the present study demonstrated that EGFR-mutated NSCLC cells were able to evade the cytotoxic effect of EGFR-TKI by downregulating EGFR expression, without exhibiting the T790M EGFR mutation.

Systemic treatment of non-small cell lung cancer brain metastases

In the systemic treatment of brain metastases from non-small cell lung cancer (BMF-NSCLC) chemo- and targeted therapy are used. Response rates after platinum-based chemotherapy, range from 23% to 45%. Development of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs): gefitinib or erlotinib, was an improvement in treatment of advanced NSCLC patients. EGFR mutations are present in 10-25% of NSCLC (mostly adenocarcinoma), and up to 55% in never-smoking women of East Asian descent. In the non-selected group of patients with BMF-NSCLC, the overall response rates after gefitinib or erlotinib treatment range from 10% to 38%, and the duration of response ranges from 9 to 13.5 months. In the case of present activating EGFR mutation, the response rate after EGRF-TKIs is greater than 50%, and in selected groups (adenocarcinoma, patients of Asian descent, never-smokers, asymptomatic BMF-NSCLC) even 70%. Gefitinib or erlotinib treatment improves survival of BMF-NSCLC patients with EGFR mutation in comparison to cases without the presence of this mutation. There is no data on the activity of the anti-EML4-ALK agent crizotinib. Bevacizumab, recombinant humanised monoclonal antibody anti-VEGF, in the treatment of advanced non-squamous NSCLC patients is a subject of intense research. Data from a clinical trial enrolling patients with pretreated or occult BMF-NSCLC proved that the addition of bevacizumab to various chemotherapy agents or erlotinib is a safe and efficient treatment, associated with a low incidence of CSN haemorrhages. However, the efficacy and safety of bevacizumab used for therapeutic intent, regarding active brain metastases is unknown.

Fractionated stereotactic radiation therapy for brain metastases: a systematic review with tumour control probability modelling

OBJECTIVE

Fractionated stereotactic radiotherapy (FSRT) is a relatively new option for the treatment of brain metastases. We performed a quantitative systematic review to determine if local control (LC) following is affected by FSRT dosing regimen.

METHODS

We reviewed articles describing LC following FSRT for brain metastases. LC data from each study were extracted from actuarial survival curves and aggregated to form a single data set. LC curves were generated using the Kaplan-Meier method. Log-rank testing and Cox proportional hazards modelling were utilized to test for associations between the biologically effective dose (BED) and LC. Tumour control probability modelling was performed to illustrate the relationship between the BED and the likelihood of LC after FSRT.

RESULTS

10 studies (720 metastases) met inclusion criteria. Prescription doses ranged from 18 to 42 Gy, delivered in 3-12 fractions (BED range: 29-100 Gy₁₀). 1- and 2-year actuarial LC rates were 80% and 69%, respectively. Increasing BED was associated with improved LC (HR = 0.77 per increase of 10 Gy₁₀, p = 0.009). Tumour control probability models demonstrated that the BEDs of 40, 50 and 60 Gy₁₀ yield predicted 1-year LC rates of 73%, 78% and 84%, respectively. The BEDs of 40, 50 and 60 Gy₁₀ yield 2-year LC rates of 62%, 69% and 81%, respectively.

CONCLUSION

FSRT provides high rates of LC for patients with brain metastases. We found evidence for a dose-response relationship that should be explored in prospective trials. Advances in knowledge: This review identified a dose-response relationship for LC in patients treated with FSRT for brain metastases.

Blood-brain barrier permeability of gefitinib in patients with brain metastases from non-small-cell lung cancer before and during whole brain radiation therapy

INTRODUCTION

To explore the ability of gefitinib to penetrate blood brain barrier (BBB) during whole brain radiation therapy (WBRT).

PATIENTS AND METHODS

Enrolled in this study were eligible patients who were diagnosed with BM from NSCLC. Gefitinib was given at 250 mg/day for 30 days, then concurrently with WBRT (40 Gy/20 F/4 w), followed by maintenance. Serial CSF and blood samples were collected on 30 day after gefitinib administration, and at the time of 10, 20, 30 and 40 Gy following WBRT. CSF and plasma samples of 13 patients without BM who were treated with gefitinib were collected as control. CSF and plasma gefitinib levels were measured by LC-MS/MS.

RESULTS

Fifteen BM patients completed gefitinib plus WBRT. The CSF-to-plasma ratio of gefitinib in patients with BM was higher than that in patients without BM (1.34% vs. 0.36%, P < 0.001). The CSF-to-plasma ratio of gefitinib increased with the increased dose of WBRT and reached the peak (1.87 ± 0.72%) at 30 Gy, which was significantly higher than that 1.34 ± 0.49% at 0 Gy (P = 0.01). The median time to progression of brain lesions and the median overall survival were 7.07 and 15.4 months, respectively.

CONCLUSION

The BBB permeability of gefitinib increased in accordance with escalated dose of WBRT.

Combined action of EGFR tyrosine kinase inhibitors and whole-brain radiotherapy on EGFR-mutated non-small-cell lung cancer patients with brain metastasis

Background

Lung cancer is the most common type of cancer to spread to the brain (brain metastasis [BM]). This study assessed the effect of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) in combination with whole-brain radiotherapy (WBRT) on EGFR-mutant non-small-cell lung cancer (NSCLC) patients with BM.

Patients and methods

Thirty-nine patients, who had receieved different EGFR TKIs plus 30 Gy WBRT until disease progression, were retrospectively analyzed between 2010 and 2014. Treatment response was evaluated and survival data were collected and analyzed.

Results

Among the 39 patients, 18 had an EGFR exon 19 deletion and 21 had an EGFR exon 21 point mutation. After therapy, 19 (48.7%) patients had complete remission, 12 (30.8%) had partial remission, and eight (20.5%) had stable disease in the intracranial lesions. Besides, there was no single case of complete remission, 21 (53.8%) had partial remission, and 18 (46.2%) had stable disease of the extracranial lesions. The median progression-free survival (PFS) of intracranial lesions and extracranial lesions was 18 and 12 months, respectively. The median overall survival (OS) was 26 months. The univariate analysis showed that graded prognostic assessment (P=0.006) and Karnofsky Performance Scale (P=0.045) were associated with intracranial progression-free survival (iPFS), while recursive partitioning analysis (P=0.049) was associated with OS of patients.

Conclusion

EGFR TKIs plus concomitant WBRT controlled intracranial lesions of lung cancer metastasis and significantly improved OS of patients. Further studies will be needed to confirm whether this combination treatment could be used as a standard therapy for EGFR-mutated NSCLC patients with BM.

Gefitinib for asymptomatic brain metastasis from advanced non-small cell lung cancer: Report of a favourable outcome

Brain metastasis (BM) is common in patients with non-small cell lung cancer (NSCLC). Although epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) have now been included as standard treatment options for NSCLC harboring EGFR-activating mutations, only a few prospective reports demonstrate the efficacy of these agents in a BM setting. We report a case of a patient with advanced NSCLC, in which oral gefitinib documented a significant antitumor effect on parallel progression of extracranial lesion and BM occurred during chemotherapy.

The Efficacy of Postoperative Chemotherapy for Patients with Metastatic Brain Tumors from Non-Small Cell Lung Cancer

BACKGROUND

The purpose of this study is to evaluate the effect of postoperative chemotherapy on recurrence and survival in patients after resection of metastatic brain tumors from non-small cell lung cancers.

METHODS

Patients who went through resection of a single metastatic brain tumor from non-small cell lung cancer from July 2001 to December 2012 were reviewed. Those selected were 77 patients who survived more than 3 months after surgery were selected. Among them, 44 patients received various postoperative systemic chemotherapies, 33 patients received postoperative adjuvant whole brain radiotherapy (WBRT). Local/distant recurrence rate, local/distant recurrence free survival, disease free survival (DFS), and overall survival were compared between the two groups.

RESULTS

Among the 77 patients, there were 19 (24.7%) local recurrences. Local recurrence occurred in 7 (21.2%) of 33 patients in the adjuvant radiotherapy (RT) group and in 12 (27.3%) of the 44 patients in the chemotherapy group (p=0.542). Among the 77 patients, there were 34 (44.1%) distant recurrences. Distant recurrence occurred in 7 (21.2%) of the 33 patients in the adjuvant RT group and in 27 (61.4%) of the 44 patients in the chemotherapy group (p<0.0005). Patients' survival in terms of local recurrence free survival, distant recurrence free survival, DFS, and overall survival was not shown to be statistically different between the two groups before and after adjusting for covariates.

CONCLUSION

There was no significant difference observed between postoperative adjuvant chemotherapy and adjuvant WBRT in terms of patients' survival. Postoperative chemotherapy is more feasible and may be an appropriate option for simultaneous control of both primary and metastatic lesions.

Overexpression of BRCA1 attenuates the sensitivity of PC9 cells to gefitinib

Gefitinib is an orally active antitumor agent which inhibits uncontrolled cell proliferation by interrupting epidermal growth factor receptor (EGFR) signaling pathways. Various in vitro and in vivo studies have revealed that the upregulated expression of breast cancer susceptibility gene 1 (BRCA1) is associated with chemoresistance and reduced survival following chemotherapies. In this study, a gefitinib-highly-sensitive cell line, PC-9, was used to investigate the effect of BRCA1 expression on the sensitivity of PC-9 cells to gefitinib. PC-9 cells were stably transfected with BRCA-1 (HA-tagged). Transfected and untransfected PC-9 cells were treated with gefitinib, phosphorylated γH2AX was examined by western blot to determine the DNA damages. Following the treatment of gefitinib, the inhibition of proliferation of the PC-9 cells, PC-9-pcDNA3.1 cells, and BRCA1-transfected PC-9 cells were determined. Also, a comet assay was performed to determine the DNA damage caused by gefitinib. The treatment of gefitinib for 6 hr, 12 h, and 24 hr significantly increased the cellular expression of phosphorylated γH2AX. With the treatment of gefitinib, the inhibition of proliferation of BRCA-1 overexpressed PC-9 cells was significantly lower than that of the non-transfected PC-9 cells, indicating the overexpression of BRCA1 plays a role in attenuating the sensitivity of PC-9 cells to gefitinib. The comet assay revealed that BRCA1 transfected cells showed a shorter comet tail, indicating the overexpression of BRCA1 attenuated the DNA damages caused by gefitinib. The overexpression of BRCA1 reduced the DNA damages, and enhanced DNA repair mechanisms. Also, gefitinib-mediated inhibition of cell proliferation is attenuated by the expression of BRCA1.

Treatment of Brain Metastases

Brain metastases (BMs) occur in 10% to 20% of adult patients with cancer, and with increased surveillance and improved systemic control, the incidence is likely to grow. Despite multimodal treatment, prognosis remains poor. Current evidence supports use of whole-brain radiation therapy when patients present with multiple BMs. However, its associated cognitive impairment is a major deterrent in patients likely to live longer than 6 months. In patients with oligometastases (one to three metastases) and even some with multiple lesions less than 3 to 4 cm, especially if the primary tumor is considered radiotherapy resistant, stereotactic radiosurgery is recommended; if the BMs are greater than 4 cm, surgical resection with or without postoperative whole-brain radiation therapy should be considered. There is increasing evidence that systemic therapy, including targeted therapy and immunotherapy, is effective against BM and may be an early choice, especially in patients with sensitive primary tumors. In patients with progressive systemic disease, limited treatment options, and poor performance status, best supportive care may be appropriate. Regardless of treatment goals, use of corticosteroids or antiepileptic medications is helpful in symptomatic patients. In this review, we provide a summary of current therapy, as well as developments in the treatment of BM from solid tumors.

Increased survival with the combination of stereotactic radiosurgery and gefitinib for non-small cell lung cancer brain metastasis patients: a nationwide study in Taiwan

PURPOSE

Whole brain irradiation (WBRT) either with or without resection has historically been the treatment for brain metastases from non-small cell lung cancer (NSCLC). The effect of gamma knife (GK) radiosurgery, chemotherapy, or the combination remains incompletely defined. In this study, we assessed the outcome of brain metastases from non-small cell lung cancer treated by WBRT followed by GK, gefitinib, or the combination of GK and gefitinib.

MATERIAL AND METHODS

We retrieved the records of NSCLC patients with brain metastases from the National Health Insurance Research Database (NHIRD) of Taiwan from 2004 to 2010. WBRT either with or without resection was the first line treatment for nearly all patients. The decision to add GK and/or gefitinib treatment was at the discretion of the treating physician and based upon a patient's medical records and imaging data. These patients were classified into four groups including WBRT, WBRT + gefitinib, WBRT + GK, WBRT + gefitinib + GK. These data was evaluated for difference in survival and factors that portended an extended survival from the time of brain metastasis diagnosis.

RESULTS

Of the 60194 patients with newly diagnosed NSCLC, 23874 (39.6 %) developed brain metastases. The distribution of patients for the groups was WBRT for 20241, WBRT + gefitinib for 3379, WBRT + GK for 155, and WBRT+ gefitinib + GK for 99 patients. The median survival for the time of brain metastasis diagnosis for WBRT, WBRT+ gefitinib, WBRT+ GK, WBRT+ gefitinib + GK groups was 0.53, 1.01, 1.46, and 2.25 years, respectively (p < 0.0001). The hazard ratio (95 % CI) for survival was 1, 0.56, 0.43, and 0.40, respectively (p < 0.001). The adjusted hazard ratio (95 % CI) by age, sex and Charlson comorbidity index (CCI) was 1, 0.73, 0.49, and 0.42, respectively (p < 0.001).

CONCLUSION

Patients with brain metastases from NSCLC receiving GK or gefitinib demonstrated extended survival. The improved survival seen with GK and gefitinib suggests a survival benefit in selected patients receiving the combined treatment. Further Phase II study should be conducted to assessment these influence.

LDA-SVM-based EGFR mutation model for NSCLC brain metastases: an observational study

Epidermal growth factor receptor (EGFR) activating mutations are a predictor of tyrosine kinase inhibitor effectiveness in the treatment of non-small-cell lung cancer (NSCLC). The objective of this study is to build a model for predicting the EGFR mutation status of brain metastasis in patients with NSCLC. Observation and model set-up. This study was conducted between January 2003 and December 2011 in 6 medical centers in Southwest China. The study included 31 NSCLC patients with brain metastases. Eligibility requirements were histological proof of NSCLC, as well as sufficient quantity of paraffin-embedded lung and brain metastases specimens for EGFR mutation detection. The linear discriminant analysis (LDA) method was used for analyzing the dimensional reduction of clinical features, and a support vector machine (SVM) algorithm was employed to generate an EGFR mutation model for NSCLC brain metastases. Training-testing-validation (3 : 1 : 1) processes were applied to find the best fit in 12 patients (validation test set) with NSCLC and brain metastases treated with a tyrosine kinase inhibitor and whole-brain radiotherapy. Primary and secondary outcome measures: EGFR mutation analysis in patients with NSCLC and brain metastases and the development of a LDA-SVM-based EGFR mutation model for NSCLC brain metastases patients. EGFR mutation discordance between the primary lung tumor and brain metastases was found in 5 patients. Using LDA, 13 clinical features were transformed into 9 characteristics, and 3 were selected as primary vectors. The EGFR mutation model constructed with SVM algorithms had an accuracy, sensitivity, and specificity for determining the mutation status of brain metastases of 0.879, 0.886, and 0.875, respectively. Furthermore, the replicability of our model was confirmed by testing 100 random combinations of input values. The LDA-SVM-based model developed in this study could predict the EGFR status of brain metastases in this small cohort of patients with NSCLC. Further studies with larger cohorts should be carried out to validate our findings in the clinical setting.

Prognostic factors for brain metastases from non-small cell lung cancer with EGFR mutation: influence of stable extracranial disease and erlotinib therapy

The aim of this study was to explore prognostic factors for non-small cell lung cancer (NSCLC) patients with brain metastases (BM) on the basis of EGFR mutation status. Among 779 consecutive NSCLC patients who underwent EGFR mutation screening, all 197 patients with BM were divided according to the EGFR mutation status. The prognostic factors, including patient characteristics at the time of BM diagnosis, treatment history, and radiologic features, were analyzed. Of 197 patients with BM, 108 had wild-type EGFR and 89 had EGFR mutation. The patients with EGFR mutation presented longer overall survival after BM diagnosis (OS) than those with wild-type EGFR, regardless of whether BM was synchronous or metachronous. For the patients with EGFR mutation, favorable prognostic factors in multivariate analysis were age<65 (p=0.037), good performance status (PS) (p<0.0001), cranial radiotherapy (p=0.020), previous chemotherapy≤1 regimen (p=0.009), stable extracranial disease at BM diagnosis (p=0.022), and erlotinib therapy after BM diagnosis (p=0.0015). On the other hand, favorable prognostic factors for the patients with wild-type EGFR were only good PS (p=0.0037) and cranial radiotherapy (p=0.0005). Among patients treated with erlotinib after BM diagnosis, the patients with exon 19 deletion showed longer OS than those with exon 21 point mutation (p=0.019). The prognostic factors for NSCLC patients with BM were different according to the EGFR mutation status. Particularly in NSCLC patients with EGFR mutation and stable extracranial disease, regular cranial evaluation for detecting asymptomatic BM would lead to good prognosis. In addition, erlotinib therapy would be preferable in NSCLC patients with BM and EGFR mutation, especially those with exon 19 deletion.

Brain metastases in lung adenocarcinoma: impact of EGFR mutation status on incidence and survival

Background

The brain represents a frequent progression site in lung adenocarcinoma. This study was designed to analyse the association between the epidermal growth factor receptor (EGFR) mutation status and the frequency of brain metastases (BM) and survival in routine clinical practice.

Patients and methods

We retrospectively analysed the medical records of 629 patients with adenocarcinoma in Slovenia who were tested for EGFR mutations in order to analyse the cumulative incidence of BM, the time from the diagnosis to the development of BM (TDBM), the time from BM to death (TTD) and the median survival.

Results

Out of 629 patients, 168 (27%) had BM, 90 patients already at the time of diagnosis. Additional 78 patients developed BM after a median interval of 14.3 months; 25.8 months in EGFR positive and 11.8 months in EGFR negative patients, respectively (p = 0.002). EGFR mutations were present in 47 (28%) patients with BM. The curves for cumulative incidence of BM in EGFR positive and negative patients demonstrate a trend for a higher incidence of BM in EGFR mutant patients at diagnosis (19% vs. 13%, p = 0.078), but no difference later during the course of the disease. The patients with BM at diagnosis had a statistically longer TTD (7.3 months) than patients who developed BM later (3.1 months). The TTD in EGFR positive patients with BM at diagnosis was longer than in EGFR negative patients (12.6 vs. 6.8, p = 0.005), while there was no impact of EGFR status on the TTD of patients who developed BM later.

Conclusions

Except for a non-significant increase of frequency of BM at diagnosis in EGFR positive patients, EGFR status had no influence upon the cumulative incidence of BM. EGFR positive patients had a longer time to CNS progression. While EGFR positive patients with BM at diagnosis had a longer survival, EGFR status had no influence on TTD in patients who developed BM later during the course of disease.

Targeted therapy in brain metastasis

PURPOSE OF REVIEW

To review the state of the art and new developments in the field of targeted agents for brain metastases.

RECENT FINDINGS

The huge amount of information on new molecular compounds and the advances in understanding the molecular pathways that mediate brain colonization have led to an increase of interest in preclinical and clinical investigations in the field of brain metastases. Targeted therapies can be employed either on established brain metastases or in a prevention setting. Targeting angiogenesis is an attractive approach. Up to date, large clinical trial datasets have shown that antiangiogenic agents do not increase the risk of bleeding into the brain. Bevacizumab (an anti-VEGF agent) is undergoing investigation in clinical trials on brain metastases from non-small cell lung cancer (NSCLC), breast cancer and melanoma. Sunitinib, a multitarget small molecule tyrosine kinase inhibitor (TKI), is a promising agent in brain metastases from renal cell cancer. The EGFR inhibitors gefitinib and erlotinib have a definite activity in brain metastases from NSCLC with activating EGFR mutations. Regarding HER2-positive breast cancer patients with established brain metastases, lapatinib (small molecule TKI) seems particularly active in association with capecitabine. Lapatinib alone is attractive in the prevention setting. Brain metastases from melanoma with BRAF V600E mutations respond to a specific inhibitor, such as vemurafenib. The immunomodulator ipilimumab is also active on brain metastases from melanoma.

SUMMARY

The use of targeted agents in brain metastases from solid tumors is promising. The setting of prevention will be probably expanded in the next years. Well designed clinical trials with proper endpoints are needed.

Innovative therapeutic strategies in the treatment of brain metastases

Brain metastases (BM) are the most common intracranial tumors and their incidence is increasing. Untreated brain metastases are associated with a poor prognosis and a poor performance status. Metastasis development involves the migration of a cancer cell from the bulk tumor into the surrounding tissue, extravasation from the blood into tissue elsewhere in the body, and formation of a secondary tumor. In the recent past, important results have been obtained in the management of patients affected by BM, using surgery, radiation therapy, or both. Conventional chemotherapies have generally produced disappointing results, possibly due to their limited ability to penetrate the blood-brain barrier. The advent of new technologies has led to the discovery of novel molecules and pathways that have better depicted the metastatic process. Targeted therapies such as bevacizumab, erlotinib, gefitinib, sunitinib and sorafenib, are all licensed and have demonstrated improved survival in patients with metastatic disease. In this review, we will report current data on targeted therapies. A brief review about brain metastatic process will be also presented.

Gefitinib alone or with concomitant whole brain radiotherapy for patients with brain metastasis from non-small-cell lung cancer: a retrospective study

BACKGROUND

Gefitinib, a tyrosine kinase inhibitor (TKI) of epidermal growth factor receptor (EGFR), is used both as a single drug and concurrently with whole brain radiotherapy (WBRT) the standard treatment for brain metastases (BM), and is reported to be effective in a few small studies of patients with BM from non-small-cell lung cancer (NSCLC). However, no study has compared the two treatment modalities. This retrospective analysis was conducted to compare the efficacy of gefitinib alone with gefitinib plus concomitant WBRT in treatment of BM from NSCLC.

METHODS

We retrospectively reviewed 90 patients with BM from NSCLC who received gefitinib alone (250 mg/day, gefitinib group) or with concomitant WBRT (40 Gy/20 f/4 w, gefitinib-WBRT group) between September 2005 and September 2009 at Sun Yat-Sen University Cancer Center. Forty-five patients were in each group.

RESULTS

The objective response rate of BM was significantly higher in gefitinib-WBRT group (64.4%) compared with gefitinib group (26.7%, P<0.001). The disease control rate of BM was 71.1% in gefitinib- WBRT group and 42.2% in gefitinib group (P=0.006). The median time to progression of BM was 10.6 months in gefitinib-WBRT group and 6.57 months in gefitinib group (P<0.001). The median overall survival (OS) of gefitinib-WBRT and gefitinib alone group was 23.40 months and 14.83 months, respectively (HR, 0.432, P=0.002).

CONCLUSION

Gefitinib plus concomitant WBRT had higher response rate of BM and significant improvement in OS compared with gefitinib alone in treatment of BM from NSCLC.

EGFR mutation status in brain metastases of non-small cell lung carcinoma

Brain metastases are a frequent and grave complication of non-small cell lung carcinoma (NSCLC). The prognosis is generally poor, despite standard therapy based on surgery and radiotherapy. A degree of understanding of the molecular basis of tumors has led to the development of targeted agents with promising initial findings for the treatment of NSCLC. EGFR mutations have been identified which are associated with significant sensitivity to EGFR tyrosine kinase inhibitors (TKI) and correlate with improved outcome in patients with NSCLC who are treated with these agents. The adoption of treatment tailored to the genetic make-up of individual tumors could lead to substantial therapeutic improvements, and such targeted therapy might be considered as a therapeutic option for brain metastases in the future. We review current knowledge about EGFR mutation status in the specific context of brain metastasis: its association with the response of brain metastases to TKI, its prevalence in brain metastases, and the correlation between mutation status in metastases as compared to the corresponding primary lung carcinoma.

Cerebrospinal fluid concentrations of gefitinib in patients with lung adenocarcinoma

BACKGROUND

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs), such as gefitinib and erlotinib, have high response and disease control rates in patients with central nervous system (CNS) metastases. However there have been only a few case reports on the penetration of gefitinib into the cerebrospinal fluid (CSF). The aim of this study was to investigate the CSF concentration of gefitinib in Chinese patients with lung adenocarcinomas.

METHODS

From March 2007 to December 2010, 22 patients were sequentially enrolled in this study at Peking Union Medical College Hospital (PUMCH). CSF and plasma samples were collected at the same time from each patient after at least 7 doses of gefitinib. The concentrations of gefitinib in the CSF and plasma were measured by high performance liquid chromatography coupled with tandem mass spectrometry. The clinical factors that may affect gefitinib penetration were analyzed.

RESULTS

The mean plasma and CSF concentrations of gefitinib were 491.8 ± 184.2 ng/mL and 6.2 ± 4.6 ng/mL, respectively, and the mean ratio of CSF-plasma concentration was 1.3% ± 0.7%. There was a good correlation between CSF and plasma gefitinib concentrations (R = 0.556, P = .006). The presence of CNS metastases was associated with increased gefitinib CSF penetration (1.46% vs. 0.95%; P = .042).

CONCLUSIONS

The concentration of gefitinib in CSF was low, and it was significantly related to the plasma gefitinib concentration. Because of the inadequate CNS drug exposure, patients in whom the extracranial lesions were well controlled may benefit from increasing gefitinib dose for the new intracranial lesions.

Brain metastases: what's new with an old problem?

PURPOSE OF REVIEW

To summarize developments in the management of brain metastases over the past decade.

RECENT FINDINGS

A few randomized trials have been published during the past decade examining the use of whole brain radiotherapy (WBRT) and radiosurgery (SRS) boost versus WBRT alone. Other recent trials have been published examining the use of SRS alone versus SRS and WBRT.There continues to be neither a role for the routine use of chemotherapy (excluding patients with metastatic seminoma to brain) nor radiosensitizers in the management of patients with brain metastases.

SUMMARY

The management options for selected patients with brain metastases today include steroids (to treat brain edema), anticonvulsants (to treat seizures), WBRT, surgery (for single brain metastasis) and radiosurgery (SRS), either alone or in combination. Survival, local metastasis control, overall brain control, and neuro-cognitive outcomes should influence management. New therapeutic areas of research for brain metastases include defining the role of conventional and novel chemotherapy and targeted agents, radiation sensitizers, and stem cell-associated therapies either alone or in combination with various forms of radiation, as well as decreasing radiation morbidities, using drugs or technology.

Management of brain metastasis: past lessons, modern management, and future considerations

Brain metastasis is a major challenge for patients, physicians, and the broader health care system, with approximately 170,000 new cases per year. After a diagnosis of brain metastasis, patients have a poor prognosis, but modern management has made significant advances in the past two decades to improve palliative efficacy and patient survival through a multidisciplinary approach. A number of factors must be taken into consideration in the treatment approach, including the number of intracranial lesions, the control of extracranial disease, and the patient's overall health, while weighing the benefits of treatment against the toxicities, both acute and chronic. With quality of life as an emphasis, emerging concepts for modern management of brain metastasis have sought to minimize long-term toxicities. The economic impact of such strategies for patients and the health care system has been demonstrated in some studies, but has not been a consistent area of focus. Each of these strategies, as well as novel therapeutics, has embraced the concept of personalized treatment. This review will discuss the current knowledge of modern multidisciplinary management of brain metastasis and look forward to emerging concepts.

Epidermal growth factor receptor tyrosine kinase inhibitors in the treatment of epidermal growth factor receptor-mutant non-small cell lung cancer metastatic to the brain

Brain metastases are a common and devastating consequence of disease progression in patients with non-small cell lung cancer (NSCLC). The epidermal growth factor receptor (EGFR) inhibitors erlotinib and gefitinib have shown efficacy in patients with NSCLC and brain metastases. The cerebrospinal fluid (CSF) exposure to these drugs is a small fraction of the plasma levels achieved with standard doses, but disruption of the blood-brain barrier in the presence of central nervous system metastases is likely to lead to locally increased drug concentration, and dose escalation to boost CSF exposure has documented clinical efficacy. The use of gefitinib and erlotinib in this setting is reviewed here, including evidence from case reports, case series, and single-arm phase II trials. High response rates in the brain are seen in patients with EGFR mutation, or in populations in which this genotype is expected. By contrast, activity in the context of documented wild-type EGFR in disease metastatic to the brain is not common. These drugs may potentiate the effectiveness of radiotherapy to the brain, and their use may also delay development of disease within the brain.

Near Total Regression of Diffuse Brain Metastases in Adenocarcinoma of the Lung with an EGFR Exon 19 Mutation: A Case Report and Review of the Literature

We report the case of a woman with diffuse brain metastases from lung cancer who experienced total regression of the metastases under gefitinib treatment. The 58-year-old woman was referred to our hospital with a complaint of severe headache. A brain MRI revealed diffuse metastatic lesions in the cerebra and cerebellum. Adenocarcinoma of the lung with multiple brain metastases was diagnosed. The tumor was positive for an epidermal growth factor receptor (EGFR) exon 19 deletion mutation. She was treated with gefitinib 250 mg per day. One year later, the diffuse brain metastases had totally resolved. EGFR-tyrosine kinase inhibitor therapy could be a first-line treatment for patients with advanced adenocarcinoma of the lung with EGFR mutation, especially in those with brain metastases.

EGFR Intron Recombination in Human Gliomas: Inappropriate Diversion of V(D)J Recombination?

The epidermal growth factor receptor (EGFR) is a membrane-bound, 170 kDa, protein tyrosine kinase that plays an important role in tumorigenesis. The EGFR gene, which is composed of over 168 kb of sequence, including a 123-kb first intron, is frequently amplified and rearranged in malignant gliomas leading to the expression of oncogenic deletion (DM) and tandem duplication (TDM) mutants. The most common DM in gliomas is EGFRvIII, which arises from recombination between introns 1 and 7 with deletion of exons 2 through 7 and intervening introns. In addition, some human gliomas express 180- to 190-kDa TDM, which are constitutively active and highly oncogenic. Both DM and TDM arise by recombination of introns that contain sequences with homology to the recombination signal sequence (RSS) heptamers and nonamers present in the V(D)J region of the immunoglobin and T lymphocyte antigen receptor genes. V(D)J RSS have also been identified in certain proto-oncogenes like bcl-2 that are involved in translocations associated with the development of human lymphomas and in other genes such as hypoxanthine-guainine phosphoribosyl transferase (HPRT) in which deletion mutations and intron rearrangements are a common phenomenon. Together with the expression of recombination associated gene (RAG) and nonhomologous end-joining (NHEJ) proteins in gliomas, these observation suggest that aberrant activity of the V(D)J recombinase may be involved in the activation of proto-oncogenes in both liquid and solid tumors.

Brain metastases

Metastatic brain tumors are the most common intracranial neoplasm in adults, affecting up to 10% of adults with cancer in the United States. The risk of developing brain metastases varies by primary cancer type, with lung cancer, breast cancer, and melanoma accounting for the majority. The incidence of brain metastases appears to be rising because of several factors, including an aging population, better treatment of systemic disease, and improved cranial imaging techniques. Therapeutic approaches to brain metastases include surgery, whole brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), and chemotherapy. Many patients are treated with a combination of these, and treatment decisions must take into account clinical prognostic factors in order to maximize survival and neurologic function while avoiding unnecessary treatments. WBRT remains the most widely used treatment for patients with brain metastases. Although many radiation sensitizers have been studied over the years, none has emerged for widespread use. For patients with a limited number of brain metastases and favorable prognostic factors, local therapies such as surgery and SRS improve control rates and may extend survival compared with WBRT alone. SRS can also be used effectively at recurrence in patients with a limited number of lesions. Chemotherapy has traditionally played only a salvage role for brain metastases when all other treatments have failed, but research is likely to increasingly focus on systemic options such as targeted agents and angiogenesis inhibitors, as well as on novel delivery techniques and multidrug resistance pathways specific to brain in order to expand treatment options for this growing population of patients.

[Management of brain metastases from non-small cell lung carcinoma]

INTRODUCTION

In France, approximately 30,000 new patients per year develop brain metastases (BM), most of them resulting from a lung cancer.

STATE OF THE ART

Surgery and radiosurgery of all the BM must be considered when possible. In other cases, whole brain radiotherapy remains the standard of care.

PERSPECTIVES

The role of chemotherapy, poorly investigated so far, should be revisited.

CONCLUSION

This review focused on BM secondary to a non-small cell lung carcinoma.

Therapy and prophylaxis of brain metastases

Metastases of various tumors to the brain account for the majority of brain cancers, and are associated with a poor prognosis. The most common primary sites are lung, breast, skin, kidney and colon; 10-40% of cancer patients develop brain metastases during the course of the disease. The incidence of brain metastasis appears to be rising; reasons may include better therapies for the systemic disease with longer survival of cancer patients but lower efficiency against brain metastases. In this article, we will discuss the conventional treatment with surgery, radiosurgery, radiotherapy and chemotherapy, but also new directions in the management of solid brain metastases. While general therapeutic nihilism should be avoided, it is important to recognize that the number of brain metastases, the extent of the systemic disease and also the tumor type have to be taken into account when choosing individual treatment regimens. Finally, special emphasis will be put on established and future approaches to prevent the disease. We thus aim to provide a framework for treating patients with different presentations of brain metastases, and to highlight important avenues for research.

Investigational therapies for brain metastases

Contrary to the incidence of primary cancers, the incidence of brain metastasis has been increasing. This increase is likely because of the effects of an aging population, improved neuroimaging surveillance, and better control of systemic cancer, allowing time for brain metastasis to occur. Unlike systemic cancers, for which chemotherapy is the mainstay of treatment, the therapeutic strategies available to treat brain metastasis have traditionally been limited to surgical resection, whole brain radiation therapy, or stereotactic radiosurgery, either individually or in combination. It is important to put the treatment in the context of the prognosis for patients with brain metastases.

EGFR mutation status and survival after diagnosis of brain metastasis in nonsmall cell lung cancer

A small subset of patients with nonsmall cell lung cancer (NSCLC) harbors mutations in the epidermal growth factor receptor (EGFR) that predict unique sensitivity to EGFR tyrosine kinase inhibitors (TKIs). The characteristics and behavior of brain metastases (BMs) in these patients have not been well described. The longitudinal records of all NSCLC patients who underwent EGFR mutation screening at our center from August 2004 to November 2008 were reviewed for eligibility, and 93 patients were identified who developed BM during the course of their disease. Survival was estimated using the Kaplan-Meier method and the log-rank test. Multivariable predictors were assessed via the Cox proportional hazards model. Among the 93 patients with BM, 41 (44%) had mutations in EGFR, including 13 exon 19 deletions and 12 L858R mutations. Eighty-three percent of patients with BM were treated initially with whole brain radiation, either alone (53%) or in combination with craniotomy for neurosurgical resection (22%) or stereotactic radiosurgery (8%). Median survival from the time of BM was 11.7 months and was longer for patients with an EGFR mutation (14.5 vs 7.6 months, P = .09). On multivariable analysis, EGFR mutation (HR: 0.50, 95% CI: 0.30-0.82), age (HR: 1.03, 95% CI: 1.00-1.05), and active extracranial disease (HR: 3.30, 95% CI: 1.70-6.41) were independently associated with survival. In NSCLC patients with BM, EGFR mutation status is associated with improved survival, independent of age, functional status, extracranial disease status, and number of BMs.