Recent advances in managing brain metastasis

MicroRNA-522-3p promotes brain metastasis in non-small cell lung cancer by targeting Tensin 1 and modulating blood-brain barrier permeability

Brain metastases account for more than 50 % of intracranial central nervous system tumors. The blood-brain barrier (BBB) is mainly composed of endothelial cells, which exhibit low endocytosis and high efflux pumps. Although they are connected by continuous tight junctions and serve as a protective insulation, the BBB does not prevent the development of brain metastases from non-small cell lung cancer (NSCLC). Improving understanding on the mechanisms underlying the development of brain metastasis and the differential molecular characteristics relative to the primary tumor are therefore key in the treatment of brain metastases. This study evaluated the differential expression of miR-522-3p in NSCLC and brain metastases using the Gene Expression Omnibus database. NSCLC brain metastasis model was constructed to screen for cell lines that demonstrated high potential for brain metastasis; We also observed differential expression of miRNA-522-3p in the paraffin-embedded specimens of non-small cell lung cancer and brain metastases from our hospital. The molecular biological functions of miRNA-522-3p were verified using 5-ethynyl-2'-deoxyuridine (EdU) proliferation assay and Transwell invasion assays. RNA-seq was employed to identify downstream target proteins, and the dual-luciferase reporter assay confirmed Tensin 1 (TNS1), a protein that links the actin cytoskeleton to the extracellular matrix, as the downstream regulatory target protein. In vitro blood-brain barrier models and co-culture models were constructed to further identify the role of miRNA-522-3p and TNS1; the expression of BBB-related proteins (ZO-1 and OLCN) was also identified. In vivo experiments were performed to verify the effects of miRNA-522-3p on the time and incidence of NSCLC brain metastasis. The results showed significantly high expression in GSE51666; consistent results were obtained in brain metastasis cells and paraffin samples. RNA-seq combined with miRNA target protein prediction demonstrated TNS1 to be directly downstream of miR-522-3p and to be associated with cell proliferation and invasion. By regulating ZO-1 and OCLN expression, mi-522-3p/TNS1 may increase tumor cell penetration through the BBB while decreasing its permeability. In vivo, miR-522-3p was further demonstrated to significantly promote the formation of brain metastases. miR-522-3p/TNS1 can affect BBB permeability and encourage the growth of brain metastases by modifying the BBB TJ proteins. This axis offers new therapeutic targets for the prevention of brain metastasis.

Effect of different optimization parameters in single isocenter multiple brain metastases radiosurgery

PURPOSE

Automated treatment planning for multiple brain metastases differs from traditional planning approaches. It is therefore helpful to understand which parameters for optimization are available and how they affect the plan quality. This study aims to provide a reference for designing multi-metastases treatment plans and to define quality endpoints for benchmarking the technique from a scientific perspective.

METHODS

In all, 20 patients with a total of 183 lesions were retrospectively planned according to four optimization scenarios. Plan quality was evaluated using common plan quality parameters such as conformity index, gradient index and dose to normal tissue. Therefore, different scenarios with combinations of optimization parameters were evaluated, while taking into account dependence on the number of treated lesions as well as influence of different beams.

RESULTS

Different scenarios resulted in minor differences in plan quality. With increasing number of lesions, the number of monitor units increased, so did the dose to healthy tissue and the number of interlesional dose bridging in adjacent metastases. Highly modulated cases resulted in 4-10% higher V10% compared to less complex cases, while monitor units did not increase. Changing the energy to a flattening filter free (FFF) beam resulted in lower local V12Gy (whole brain-PTV) and even though the number of monitor units increased by 13-15%, on average 46% shorter treatment times were achieved.

CONCLUSION

Although no clinically relevant differences in parameters where found, we identified some variation in the dose distributions of the different scenarios. Less complex scenarios generated visually more dose overlap; therefore, a more complex scenario may be preferred although differences in the quality metrics appear minor.

Circular RNAs and the JAK/STAT pathway: New frontiers in cancer therapeutics

Circular RNAs, known as circRNAs, have drawn more attention to cancer biology in the last few years. Novel functions of circRNAs in cancer therapy open promising prospects for personalized medicine. This review focuses on the molecular properties and potential of circRNAs as biomarkers or therapeutic targets in cancer treatment. Unique properties of circular RNAs associated with a circular form provide stability and resilience to RNA exonuclease degradation. Circular RNAs' most important characteristic is that they are involved in the JAK/STAT pathway associated with oncogenesis. Notably, their deregulation has been reported in multiple carcinomas due to involvement in JAK/STAT signaling cascade modulation. Increased knowledge about circRNAs' interaction with the JAK/STAT pathway leads to the emergence of new possibilities for targeted cancer therapy. In addition, since circRNAs demonstrate tissue-relatedness of expression, they may be a reliable biomarker for predicting and diagnosing cancer. With the development of new technologies for targeting circRNAs, novel therapeutics can be produced that offer more personalized cancer treatment options based on the nature of the patient. The present review explores the exciting prospects of circRNAs for transforming cancer treatment into personalized medicine. It describes the current understanding of circRNA biology, its relationship to tumorigenesis, and possible targeting methods.

Spatial transcriptomics of gastric cancer brain metastasis reveals atypical vasculature strategies with supportive immune profiles

Background

Gastric cancer brain metastasis (GCBM) represents a rare but highly aggressive malignancy. Metastatic cancer cells are highly heterogeneous and differentially remodels brain vasculature and immune microenvironments, which affects the treatment effectiveness and patient outcome. This study aimed to investigate the spatial interactions among different cell components, especially the vasculature system and the brain microenvironment of GCBM patients.

Methods

We used digital spatial profiling to examine 140 regions composing tumor, immune, and brain tissues from three GCBM patients. Transcriptomic data with spatial information were analyzed for tissue areas related to different blood recruitment strategies. For validation, independent analysis of patient bulk transcriptomic data and in vivo single-cell transcriptomic data were performed.

Results

Angiogenesis and blood vessel co-option co-existed within the same GCBM lesion. Tumors with high epithelial-mesenchymal transition and an enhanced transcriptomic gene signature composed of CTNNB1, SPARC, VIM, SMAD3, SMAD4, TGFB1, TGFB2, and TGFB3 were more prone to adopt blood vessel co-option than angiogenesis. Enriched macrophage infiltration, angiogenic chemokines, and NAMPT were found in angiogenic areas, while increased T cells, T cell activating cytokines, and reduced NAMPT were found in vessel co-option regions. Spatially, angiogenesis was enriched at the tumor edge, which showed higher DMBT1 expression than the tumor center.

Conclusions

This study mapped the orchestrated spatial characteristics of tumor and immunological compositions that support the conventional and atypical vascularization strategies in GCBM. Our data provided molecular insights for more effective combinations of anti-vascular and immune therapies.

Accurate machine-specific reference and small-field dosimetry for a self-shielded neuro-radiosurgical system

BACKGROUND

The newly available ZAP-X stereotactic radiosurgical system is designed for the treatment of intracranial lesions, with several unique features that include a self-shielding, gyroscopic gantry, wheel collimation, non-orthogonal kV imaging, short source-axis distance, and low-energy megavoltage beam. Systematic characterization of its radiation as well as other properties is imperative to ensure its safe and effective clinical application.

PURPOSE

To accurately determine the radiation output of the ZAP-X with a special focus on the smaller diameter cones and an aim to provide useful recommendations on quantification of small field dosimetry.

METHODS

Six different types of detectors were used to measure relative output factors at field sizes ranging from 4 to 25 mm, including the PTW microSilicon and microdiamond diodes, Exradin W2 plastic scintillator, Exradin A16 and A1SL ionization chambers, and the alanine dosimeter. The 25 mm cone served as the reference field size. Absolute dose was determined with both TG-51-based dosimetry using a calibrated PTW Semiflex ion chamber and measurements using alanine dosimeters.

RESULTS

The average radiation output factors (maximum deviation from the average) measured with the microDiamond, microSilicon, and W2 detectors were: for the 4 mm cone, 0.741 (1.0%); for the 5 mm cone: 0.817 (1.0%); for the 7.5 mm cone: 0.908 (1.0%); for the 10 mm cone: 0.946 (0.4%); for the 12.5 mm cone: 0.964 (0.2%); for the 15 mm cone: 0.976 (0.1%); for the 20 mm cone: 0.990 (0.1%). For field sizes larger than 10 mm, the A1SL and A16 micro-chambers also yielded consistent output factors within 1.5% of those obtained using the microSilicon, microdiamond, and W2 detectors. The absolute dose measurement obtained with alanine was within 1.2%, consistent with combined uncertainties, compared to the PTW Semiflex chamber for the 25 mm reference cone.

CONCLUSION

For field sizes less than 10 mm, the microSilicon diode, microDiamond detector, and W2 scintillator are suitable devices for accurate small field dosimetry of the ZAP-X system. For larger fields, the A1SL and A16 micro-chambers can also be used. Furthermore, alanine dosimetry can be an accurate verification of reference and absolute dose typically measured with ion chambers. Use of multiple suitable detectors and uncertainty analyses were recommended for reliable determination of small field radiation outputs.

Comparative Analysis of Inflammatory Indexes in Lung Cancer Patients With and Without Brain Metastases

Introduction Lung cancer is the leading cause of oncological deaths worldwide. Various combined inflammatory indexes, such as the systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR) have shown associations with pretreatment survival prognosis in patients suffering of lung cancer with or without brain metastases. This study aimed to compare the average values of NLR, PLR, LMR, and SII in healthy patients, patients with lung cancer without any other metastases, and patients with lung cancer and brain metastases. Materials and methods In this prospective study, we have divided the patients into three groups: Group 1 included patients diagnosed with lung cancer and one or more brain metastases of lung cancer origin, Group 2 included patients diagnosed with lung cancer without known metastases, and Group 3 was the control group which included healthy subjects. Preoperative complete blood counts were extracted for all included patients and we calculated the values of SII, NLR, PLR, and LMR for each individual patient in each group. The next step was to calculate the average values of SII, NLR, PLR, and LMR for each group of patients and to identify the differences between groups. Results A total number of 228 patients were enrolled in the study. Group 1 included 67 patients with average values of SII = 2020.98, NLR = 7.25, PLR = 199.46, and LMR = 2.97. Group 2 included 88 patients with average values of SII = 1638.01, NLR = 4.58, PLR = 188.42, and LMR = 3.43. Group 3 included 73 subjects with the following average values of the inflammatory indexes: SII = 577.41, NLR = 2.34, PLR = 117.84, and LMR = 3.56. Conclusion We observed statistically significant differences in SII, NLR, and PLR among the three groups of patients, suggesting their potential role as prognostic markers. Furthermore, our analysis revealed significant correlations between inflammatory markers within lung cancer patients, highlighting their involvement in tumor microenvironment modulation. Our findings demonstrate an escalation in SII, NLR, and PLR values as the disease progresses. These parameters of inflammation and immune status are readily and cost-effectively, and repeatedly assessable in routine clinical practice.

A large open access dataset of brain metastasis 3D segmentations on MRI with clinical and imaging information

Resection and whole brain radiotherapy (WBRT) are standard treatments for brain metastases (BM) but are associated with cognitive side effects. Stereotactic radiosurgery (SRS) uses a targeted approach with less side effects than WBRT. SRS requires precise identification and delineation of BM. While artificial intelligence (AI) algorithms have been developed for this, their clinical adoption is limited due to poor model performance in the clinical setting. The limitations of algorithms are often due to the quality of datasets used for training the AI network. The purpose of this study was to create a large, heterogenous, annotated BM dataset for training and validation of AI models. We present a BM dataset of 200 patients with pretreatment T1, T1 post-contrast, T2, and FLAIR MR images. The dataset includes contrast-enhancing and necrotic 3D segmentations on T1 post-contrast and peritumoral edema 3D segmentations on FLAIR. Our dataset contains 975 contrast-enhancing lesions, many of which are sub centimeter, along with clinical and imaging information. We used a streamlined approach to database-building through a PACS-integrated segmentation workflow.

Assessment of Radiation Dosage to the Hippocampi during Treatment of Multiple Brain Metastases Using Gamma Knife Therapy

Background and Objectives: Brain metastases (BMs) pose significant clinical challenges in systemic cancer patients. They often cause symptoms related to brain compression and are typically managed with multimodal therapies, such as surgery, chemotherapy, whole brain radiotherapy (WBRT), and stereotactic radiosurgery (SRS). With modern oncology treatments prolonging survival, concerns about the neurocognitive side effects of BM treatments are growing. WBRT, though widely used for multiple BMs, has recognized neurocognitive toxicity. SRS, particularly Gamma Knife (GK) therapy, offers a minimally invasive alternative with fewer side effects, suitable for patients with a quantifiable number of metastases and better prognoses. Materials and Methods: A retrospective analysis was conducted on 94 patients with multiple BMs treated exclusively with GK at an academic medical center. Patients with prior WBRT were excluded. This study focused on the mean radiation dose received by the hippocampal area, estimated according to the 'Hippocampal Contouring: A Contouring Atlas for RTOG 0933' guidelines. Results: The precision of GK equipment results in mean doses of radiation that are lower than those suggested by RTOG 0933 and observed in other studies. This precision may help mitigate cognitive dysfunction and other side effects of hippocampal irradiation. Conclusions: GK therapy facilitates the administration of smaller, safer radiation doses to the hippocampi, which is advantageous even for lesions in the temporal lobe. It is feasible to treat multiple metastases, including cases with more than 10, but it is typically reserved for patients with fewer metastases, with an average of 3 in this study. This underlines GK's potential for reducing adverse effects while managing BMs effectively.

The association between graded prognostic assessment and the prognosis of brain metastases after whole brain radiotherapy: a meta-analysis

Introduction

This meta-analysis aims to provide evidence-based medical evidence for formulating rational treatment strategies and evaluating the prognosis of brain metastasis (BM) patients by assessing the effectiveness of the graded prognostic assessment (GPA) model in predicting the survival prognosis of patients with BM after whole-brain radiotherapy (WBRT).

Methods

A comprehensive search was conducted in multiple databases, including the China Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), PubMed, Wanfang database, Cochrane Library, Web of Science, and Embase. Cohort studies that met the inclusion and exclusion criteria were selected. The quality of the included literature was evaluated using the Newcastle-Ottawa Scale, and all statistical analyses were performed with R version 4.2.2. The effect size (ES) was measured by the hazard ratio (HR) of overall survival (OS). The OS rates at 3, 6, 12, and 24 months of patients with BM were compared between those with GPAs of 1.5-2.5, 3.0, and 3.5-4.0 and those with GPAs of 0-1 after WBRT.

Results

A total of 1,797 participants who underwent WBRT were included in this study. The meta-analysis revealed a significant association between GPA and OS rates after WBRT: compared with BM patients with GPA of 0-1, 3-month OS rates after WBRT were significantly higher in BM patients with GPA of 1.5-2.5 (HR = 0.48; 95% CI: 0.40-0.59), GPA of 3 (HR = 0.38; 95% CI: 0.25-0.57), and GPA of 3.5-4 (HR = 0.28; 95% CI: 0.15-0.52); 6-month OS rates after WBRT were significantly higher in BM patients with GPA of 1.5-2.5 (HR = 0.48; 95% CI: 0.41-0.56), GPA of 3 (HR = 0.33; 95% CI: 0.24-0.45), and GPA of 3.5-4 (HR = 0.24; 95% CI: 0.16-0.35); 12-month OS rates after WBRT were significantly higher in BM patients with GPA of 1.5-2.5 (HR = 0.49; 95% CI: 0.41-0.58), GPA of 3 (HR = 0.48; 95% CI: 0.32-0.73), and GPA of 3.5-4 (HR = 0.31; 95% CI: 0.12-0.79); and 24-month OS rates after WBRT were significantly higher in BM patients with GPA of 1.5-2.5 (HR = 0.49; 95% CI: 0.42-0.58), GPA of 3 (HR = 0.49; 95% CI: 0.32-0.74), and GPA of 3.5-4 (HR = 0.38; 95% CI: 0.15-0.94).

Conclusion

BM patients with higher GPAs generally exhibited better prognoses and survival outcomes after WBRT compared to those with lower GPAs.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023422914.

Dissecting patterns and predictors of interhospital transfers for patients with brain metastasis

OBJECTIVE

Interhospital transfers in the acute setting may contribute to high cost, patient inconvenience, and delayed treatment. The authors sought to understand patterns and predictors in the transfer of brain metastasis patients after emergency department (ED) encounter.

METHODS

The authors analyzed 3037 patients with brain metastasis who presented to the ED in Massachusetts and were included in the Healthcare Cost and Utilization Project State Inpatient Database and State Emergency Department Database in 2018 and 2019.

RESULTS

The authors found that 6.9% of brain metastasis patients who presented to the ED were transferred to another facility, either directly or indirectly after admission. The sending EDs were more likely to be nonteaching hospitals without neurosurgery and radiation oncology services (p < 0.01). Transferred patients were more likely to present with neurological symptoms compared to those admitted or discharged (p < 0.01). Among those transferred, approximately 30% did not undergo a significant procedure after transfer and approximately 10% were discharged within 3 days, in addition to not undergoing significant interventions. In total, 74% of transferred patients were sent to a facility significantly farther (> 3 miles) than the nearest facility with neurosurgery and radiation oncology services. Further distance transfers were not associated with improvements in 30-day readmission rate (OR [95% CI] 0.64 [0.30-1.34] for 15-30 miles; OR [95% CI] 0.73 [0.37-1.46] for > 30 miles), 90-day readmission rate (OR [95% CI] 0.50 [0.18-1.28] for 15-30 miles; OR [95% CI] 0.53 [0.18-1.51] for > 30 miles), and length of stay (OR [95% CI] 1.21 days [0.94-1.29] for both 15-30 miles and > 30 miles) compared to close-distance transfers.

CONCLUSIONS

The authors identified a notable proportion of transfers without subsequent significant intervention or appreciable medical management. This may reflect ED physician discomfort with the neurological symptoms of brain metastasis. Many patients were also transferred to hospitals distant from their point of origin and demonstrated no differences in readmission rates and length of stay.

Unexplained Causes of Glioma-Associated Epilepsies: A Review of Theories and an Area for Research

Approximately 30% of glioma patients are able to survive beyond one year postdiagnosis. And this short time is often overshadowed by glioma-associated epilepsy. This condition severely impairs the patient's quality of life and causes great suffering. The genetic, molecular and cellular mechanisms underlying tumour development and epileptogenesis remain incompletely understood, leading to numerous unanswered questions. The various types of gliomas, namely glioblastoma, astrocytoma and oligodendroglioma, demonstrate distinct seizure susceptibility and disease progression patterns. Patterns have been identified in the presence of IDH mutations and epilepsy, with tumour location in cortical regions, particularly the frontal lobe, showing a more frequent association with seizures. Altered expression of TP53, MGMT and VIM is frequently detected in tumour cells from individuals with epilepsy associated with glioma. However, understanding the pathogenesis of these modifications poses a challenge. Moreover, hypoxic effects induced by glioma and associated with the HIF-1a factor may have a significant impact on epileptogenesis, potentially resulting in epileptiform activity within neuronal networks. We additionally hypothesise about how the tumour may affect the functioning of neuronal ion channels and contribute to disruptions in the blood-brain barrier resulting in spontaneous depolarisations.

Deep Learning With an Attention Mechanism for Differentiating the Origin of Brain Metastasis Using MR images

BACKGROUND

Brain metastasis (BM) is a serious neurological complication of cancer of different origins. The value of deep learning (DL) to identify multiple types of primary origins remains unclear.

PURPOSE

To distinguish primary site of BM and identify the best DL models.

STUDY TYPE

Retrospective.

POPULATION

A total of 449 BM derived from 214 patients (49.5% for female, mean age 58 years) (100 from small cell lung cancer [SCLC], 125 from non-small cell lung cancer [NSCLC], 116 from breast cancer [BC], and 108 from gastrointestinal cancer [GIC]) were included.

FIELD STRENGTH/SEQUENCE

A 3-T, T1 turbo spin echo (T1-TSE), T2-TSE, T2FLAIR-TSE, DWI echo-planar imaging (DWI-EPI) and contrast-enhanced T1-TSE (CE T1-TSE).

ASSESSMENT

Lesions were divided into training (n = 285, 153 patients), testing (n = 122, 93 patients), and independent testing cohorts (n = 42, 34 patients). Three-dimensional residual network (3D-ResNet), named 3D ResNet6 and 3D ResNet 18, was proposed for identifying the four origins based on single MRI and combined MRI (T1WI + T2-FLAIR + DWI, CE-T1WI + DWI, CE-T1WI + T2WI + DWI). DL model was used to distinguish lung cancer from non-lung cancer; then SCLC vs. NSCLC for lung cancer classification and BC vs. GIC for non-lung cancer classification was performed. A subjective visual analysis was implemented and compared with DL models. Gradient-weighted class activation mapping (Grad-CAM) was used to visualize the model by heatmaps.

STATISTICAL TESTS

The area under the receiver operating characteristics curve (AUC) assess each classification performance.

RESULTS

3D ResNet18 with Grad-CAM and AIC showed better performance than 3DResNet6, 3DResNet18 and the radiologist for distinguishing lung cancer from non-lung cancer, SCLC from NSCLC, and BC from GIC. For single MRI sequence, T1WI, DWI, and CE-T1WI performed best for lung cancer vs. non-lung cancer, SCLC vs. NSCLC, and BC vs. GIC classifications. The AUC ranged from 0.675 to 0.876 and from 0.684 to 0.800 regarding the testing and independent testing datasets, respectively. For combined MRI sequences, the combination of CE-T1WI + T2WI + DWI performed better for BC vs. GIC (AUCs of 0.788 and 0.848 on testing and independent testing datasets, respectively), while the combined MRI approach (T1WI + T2-FLAIR + DWI, CE-T1WI + DWI) could not achieve higher AUCs for lung cancer vs. non-lung cancer, SCLC vs. NSCLC. Grad-CAM helped for model visualization by heatmaps that focused on tumor regions.

DATA CONCLUSION

DL models may help to distinguish the origins of BM based on MRI data.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

LITT for biopsy proven radiation necrosis: A qualitative systematic review

INTRODUCTION

With the widespread use of stereotactic radiosurgery (SRS), post-radiation treatment effects (PTREs) are increasing in prevalence. Radiation necrosis (RN) is a serious PTRE which carries a poor prognosis. Since 2012, laser interstitial thermal therapy (LITT) has been used to treat RN. However, reviews have attempting to generalise the efficacy of LITT against biopsy-proven RN are limited. In this systematic review, patient demographic characteristics and post-LITT clinical outcomes are characterised.

METHODS

A systematic literature search was conducted in four major databases for cohort studies and case reports published between 2012 and 2022, following the PRISMA 2020 checklist. Data was extracted and descriptively analysed. Quality of reporting was assessed using the PROCESS criteria and reporting bias was evaluated using the ROBINS-I scoring system.

RESULTS

Eleven studies met our inclusion criteria, with an overall moderate risk of reporting bias being observed. Mean pre-LITT target lesion volume was 6.75 cm3, and was independent of gender, time since SRS, age and number of interventions prior to LITT.

DISCUSSION AND CONCLUSION

LITT is a versatile treatment option which may be used to treat a vast range of patients with refractory biopsy-proven RN. However, neurosurgeons should exercise caution when selecting patients for LITT due to insufficient data on the treatment's efficacy against biopsy-proven RN. This warrants further studies to unequivocally determine the safety and clinical outcomes.

Opportunities and Alternatives of Modern Radiation Oncology and Surgery for the Management of Resectable Brain Metastases

Postsurgical radiotherapy (RT) has been early proven to prevent local tumor recurrence, initially performed with whole brain RT (WBRT). Subsequent to disadvantageous cognitive sequalae for the patient and the broad distribution of modern linear accelerators, focal irradiation of the tumor has omitted WBRT in most cases. In many studies, the effectiveness of local RT of the resection cavity, either as single-fraction stereotactic radiosurgery (SRS) or hypo-fractionated stereotactic RT (hFSRT), has been demonstrated to be effective and safe. However, whereas prospective high-level incidence is still lacking on which dose and fractionation scheme is the best choice for the patient, further ablative techniques have come into play. Neoadjuvant SRS (N-SRS) prior to resection combines straightforward target delineation with an accelerated post-surgical phase, allowing an earlier start of systemic treatment or rehabilitation as indicated. In addition, low-energy intraoperative RT (IORT) on the surgical bed has been introduced as another alternative to external beam RT, offering sterilization of the cavity surface with steep dose gradients towards the healthy brain. This consensus paper summarizes current local treatment strategies for resectable brain metastases regarding available data and patient-centered decision-making.

The Brain Pre-Metastatic Niche: Biological and Technical Advancements

Metastasis, particularly brain metastasis, continues to puzzle researchers to this day, and exploring its molecular basis promises to break ground in developing new strategies for combatting this deadly cancer. In recent years, the research focus has shifted toward the earliest steps in the formation of metastasis. In this regard, significant progress has been achieved in understanding how the primary tumor affects distant organ sites before the arrival of tumor cells. The term pre-metastatic niche was introduced for this concept and encompasses all influences on sites of future metastases, ranging from immunological modulation and ECM remodeling to the softening of the blood-brain barrier. The mechanisms governing the spread of metastasis to the brain remain elusive. However, we begin to understand these processes by looking at the earliest steps in the formation of metastasis. This review aims to present recent findings on the brain pre-metastatic niche and to discuss existing and emerging methods to further explore the field. We begin by giving an overview of the pre-metastatic and metastatic niches in general before focusing on their manifestations in the brain. To conclude, we reflect on the methods usually employed in this field of research and discuss novel approaches in imaging and sequencing.

Preoperative Prognostic Index for Patients with Brain Metastases-A Population-Based Multi-Centre Study

BACKGROUND

Brain metastases (BM) are common in cancer patients and are associated with high morbidity and mortality. Surgery is an option, but the optimal selection of patients for surgery is challenging and controversial. Current prognostication tools are not ideal for preoperative prognostication. By using a reference population (derivation data set) and two external populations (validation data set) of patients who underwent surgery for BM, we aimed to create and validate a preoperative prognostic index.

METHODS

The derivation data set consists of 590 patients who underwent surgery for BM (2011-2018) at Oslo University Hospital. We identified variables associated with survival and created a preoperative prognostic index with four prognostic groups, which was validated on patients who underwent surgery for BM at Karolinska University Hospital and St. Olavs University Hospital during the same time period. To reduce over-fitting, we adjusted the index in accordance with our findings.

RESULTS

438 patients were included in the validation data set. The preoperative prognostic index correctly divided patients into four true prognostic groups. The two prognostic groups with the poorest survival outcomes overlapped, and these were merged to create the adjusted preoperative prognostic index.

CONCLUSION

We created a prognostic index for patients with BM that predicts overall survival preoperatively. This index might be valuable in supporting informed choice when considering surgery for BM.

The Management of Oligometastatic Disease in Colorectal Cancer: Present Strategies and Future Perspectives

Oligometastatic disease has been described as an intermediate clinical state between localized cancer and systemically metastasized disease. Recent clinical studies have shown prolonged survival when aggressive locoregional approaches are added to systemic therapies in patients with oligometastases. The aim of this review is to outline the newest options to treat oligometastatic colorectal cancer (CRC), also considering its molecular patterns. We present an overview of the available local treatment strategies, including surgical procedures, stereotactic body radiation therapy (SBRT), thermal ablation, as well as trans-arterial chemoembolization (TACE) and selective internal radiotherapy (SIRT). Moreover, since imaging methods provide crucial information for the early diagnosis and management of oligometastatic CRC, we discuss the role of modern radiologic techniques in selecting patients that are amenable to potentially curative locoregional treatments.

Stratified assessment of an FDA-cleared deep learning algorithm for automated detection and contouring of metastatic brain tumors in stereotactic radiosurgery

PURPOSE

Artificial intelligence-based tools can be leveraged to improve detection and segmentation of brain metastases for stereotactic radiosurgery (SRS). VBrain by Vysioneer Inc. is a deep learning algorithm with recent FDA clearance to assist in brain tumor contouring. We aimed to assess the performance of this tool by various demographic and clinical characteristics among patients with brain metastases treated with SRS.

MATERIALS AND METHODS

We randomly selected 100 patients with brain metastases who underwent initial SRS on the CyberKnife from 2017 to 2020 at a single institution. Cases with resection cavities were excluded from the analysis. Computed tomography (CT) and axial T1-weighted post-contrast magnetic resonance (MR) image data were extracted for each patient and uploaded to VBrain. A brain metastasis was considered "detected" when the VBrain- "predicted" contours overlapped with the corresponding physician contours ("ground-truth" contours). We evaluated performance of VBrain against ground-truth contours using the following metrics: lesion-wise Dice similarity coefficient (DSC), lesion-wise average Hausdorff distance (AVD), false positive count (FP), and lesion-wise sensitivity (%). Kruskal-Wallis tests were performed to assess the relationships between patient characteristics including sex, race, primary histology, age, and size and number of brain metastases, and performance metrics such as DSC, AVD, FP, and sensitivity.

RESULTS

We analyzed 100 patients with 435 intact brain metastases treated with SRS. Our cohort consisted of patients with a median number of 2 brain metastases (range: 1 to 52), median age of 69 (range: 19 to 91), and 50% male and 50% female patients. The primary site breakdown was 56% lung, 10% melanoma, 9% breast, 8% gynecological, 5% renal, 4% gastrointestinal, 2% sarcoma, and 6% other, while the race breakdown was 60% White, 18% Asian, 3% Black/African American, 2% Native Hawaiian or other Pacific Islander, and 17% other/unknown/not reported. The median tumor size was 0.112 c.c. (range: 0.010-26.475 c.c.). We found mean lesion-wise DSC to be 0.723, mean lesion-wise AVD to be 7.34% of lesion size (0.704 mm), mean FP count to be 0.72 tumors per case, and lesion-wise sensitivity to be 89.30% for all lesions. Moreover, mean sensitivity was found to be 99.07%, 97.59%, and 96.23% for lesions with diameter equal to and greater than 10 mm, 7.5 mm, and 5 mm, respectively. No other significant differences in performance metrics were observed across demographic or clinical characteristic groups.

CONCLUSION

In this study, a commercial deep learning algorithm showed promising results in segmenting brain metastases, with 96.23% sensitivity for metastases with diameters of 5 mm or higher. As the software is an assistive AI, future work of VBrain integration into the clinical workflow can provide further clinical and research insights.

OptImal Gamma kNife lIghTnIng sOlutioN (IGNITION) score to characterize the solution space of the Gamma Knife FIP optimizer for stereotactic radiosurgery

OBJECTIVES

The objective of this study is to evaluate the user-defined optimization settings in the Fast Inverse Planning (FIP) optimizer in Leksell GammaPlan® and determine the parameters that result in the best stereotactic radiosurgery (SRS) plan quality for brain metastases, benign tumors, and arteriovenous malformations (AVMs).

METHODS

Thirty patients with metastases and 30 with benign lesions-vestibular schwannoma, AVMs, pituitary adenoma, and meningioma-treated with SRS were evaluated. Each target was planned by varying the low dose (LD) and beam-on-time (BOT) penalties in increments of 0.1, from 0 to 1. The following plan quality metrics were recorded for each plan: Paddick conformity index (PCI), gradient index (GI), BOT, and maximum organ-at-risk (OAR) doses. A novel objective score matrix was calculated for each target using a linearly weighted combination of the aforementioned metrics. A histogram of optimal solutions containing the five best scores was extracted.

RESULTS

A total of 7260 plans were analyzed with 121 plans per patient for the range of LD/BOT penalties. The ranges of PCI, GI, and BOT across all metastatic lesions were 0.58-0.97, 2.1-3.8, and 8.8-238 min, respectively, and were 0.13-0.97, 2.1-3.8, and 8.8-238 min, respectively, for benign lesions. The objective score matrix showed unique optimal solutions for metastatic lesions and benign lesions. Additionally, the plan metrics of the optimal solutions were significantly improved compared to the clinical plans for metastatic lesions with equivalent metrics for all other cases.

CONCLUSION

In this study, FIP optimizer was evaluated to determine the optimal solution space to maximize PCI and minimize GI, BOT and OAR doses simultaneously for single metastatic/benign/non-neoplastic targets. The optimal solution chart was determined using a novel objective score which provides novice and expert planners a roadmap to generate the most optimal plans efficiently using FIP.

Effects of whole-brain radiation therapy on the blood-brain barrier in immunocompetent and immunocompromised mouse models

BACKGROUND

Approximately 20% of all cancer patients will develop brain metastases in their lifespan. The standard of care for patients with multiple brain metastases is whole-brain radiation therapy, which disrupts the blood-brain barrier. Previous studies have shown inflammatory mediators play a role in the radiation-mediated increase in permeability. Our goal was to determine if differential permeability post-radiation occurs between immunocompetent and immunocompromised mice.

METHODS

We utilized a commissioned preclinical irradiator to irradiate brains of C57Bl/6J wild-type and athymic nude mice. Acute (3-24 h) effects on blood-brain barrier integrity were evaluated with our in-situ brain perfusion technique and quantitative fluorescent and phosphorescent microscopy. The presence of inflammatory mediators in the brain and serum was determined with a proinflammatory cytokine panel.

RESULTS

Blood-brain barrier integrity and efflux transporter activity were altered in the immunocompetent mice 12 h following irradiation without similar observations in the immunocompromised mice. We observed increased TNF-α concentrations in the serum of wild-type mice immediately post-radiation and nude mice 12 h post-radiation. The brain concentration of CXCL1 was also increased in both mouse strains at the 12-h time point.

CONCLUSIONS

The immune response plays a role in the magnitude of blood-brain barrier disruption following irradiation in a time- and size-dependent manner.

Dosimetric Parameters in Hypofractionated Stereotactic Radiotherapy for Brain Metastases: Do Flattening Filter-Free Beams Bring Benefits? A Preliminary Study

PURPOSE

This study aimed to compare the dosimetric results of flattening filter-free (FFF) vs. flattened (FF) treatment plans for fractionated stereotactic radiotherapy (fSRT), with the goal to highlight potential advantages of FFF beams.

METHODS

A group of 18 patients with brain metastases treated with fSRT (30 Gy delivered in 5 fractions) were included. The dosimetric parameters evaluated were: (1) physical dosimetric parameters (number of monitor units (MUs), conformity index (CI), dose gradient index (DGI), beam on time (BOT)); (2) clinical dosimetric parameters pertaining to target volume (PTV) and organs at risk (OARs). Two treatment plans were performed for all patients: one used 6 MV FFF beams and the other used 6 MV flattened beams.

RESULTS

A slight increase in MUs was observed for the FFF mode (+23.3 MUs). The CI showed a difference of -2.7% for the FF plans (p = 0.28), correlated with a poorer coverage of the PTV. DGI values reported in terms of PTV are in line with international recommendations and showed a +1.9% difference for FFF plans. An average BOT of 90.3 s was reported for FFF plans, which was 2.3 times shorter than that required for FF plans delivery (p ≤ 0.001). A slight decrease of PTV coverage (-1.26%, p = 0.036) for FF plans can be considered relevant, but no other significant differences were observed between the two optimizations. No statistically significant benefit of using FFF beams to reduce V₂₀ for normal brain could be demonstrated.

CONCLUSION

These dosimetric results encourage the implementation of fSRT with standard flattened beams in centers where FFF linacs are not available.

Circadian rhythms in the blood-brain barrier: impact on neurological disorders and stress responses

Circadian disruption has become more prevalent in society due to the increase in shift work, sleep disruption, blue light exposure, and travel via different time zones. The circadian rhythm is a timed transcription-translation feedback loop with positive regulators, BMAL1 and CLOCK, that interact with negative regulators, CRY and PER, to regulate both the central and peripheral clocks. This review highlights the functions of the circadian rhythm, specifically in the blood-brain barrier (BBB), during both healthy and pathological states. The BBB is a highly selective dynamic interface composed of CNS endothelial cells, astrocytes, pericytes, neurons, and microglia that form the neurovascular unit (NVU). Circadian rhythms modulate BBB integrity through regulating oscillations of tight junction proteins, assisting in functions of the NVU, and modulating transporter functions. Circadian disruptions within the BBB have been observed in stress responses and several neurological disorders, including brain metastasis, epilepsy, Alzheimer's disease, and Parkinson's disease. Further understanding of these interactions may facilitate the development of improved treatment options and preventative measures.

Immune related biomarkers for cancer metastasis to the brain

Brain metastasis accounts for a large number of cancer-related deaths. The host immune system, involved at each step of the metastatic cascade, plays an important role in both the initiation of the brain metastasis and their treatment responses to various modalities, through either local and or systemic effect. However, few reliable immune biomarkers have been identified in predicting the development and the treatment outcome in patients with cancer brain metastasis. Here, we provide a focused perspective of immune related biomarkers for cancer metastasis to the brain and a thorough discussion of the potential utilization of specific biomarkers such as tumor mutation burden (TMB), genetic markers, circulating and tumor-infiltrating immune cells, cytokines, in predicting the brain disease progression and regression after therapeutic intervention. We hope to inspire the field to extend the research and establish practical guidelines for developing and validating immune related biomarkers to provide personalized treatment and improve treatment outcomes in patients with metastatic brain cancers.

Impact of epilepsy and its treatment on brain metastasis from solid tumors: A retrospective study

Introduction

Retrospective observational study on medical records of patients with epilepsy related brain metastases (BM) to evaluate efficacy, safety and possible interaction with cancer treatment of different anti-seizure medications (ASMs) and the risk of seizures.

Materials and methods

We consecutively reviewed all medical records of epilepsy-related BM patients from 2010 to 2020 who were followed for at least one month at the Brain Tumour-related Epilepsy Center of the IRCCS Regina Elena National Cancer Institute Rome, Italy.

Results

We selected 111 cancer patients. Of these, only 42 had at least undergone a second neurological examination. In the whole population, 95 (85.2%) had seizures and 16 patients had no seizures (14.4%). The most frequently first ASM prescribed was LEV (40.5%). We observed a significant correlation between tumor site and probability of having seizures, but not between seizure type and age (>65 or <65 years). Among 42 patients, 26 were administered levetiracetam, followed by oxcarbazepine. Until the last follow-up, 19 never changed the first ASM, maintained the same dosage and remained seizure free. After a median of 7 months, 16 (38.1%) required changes in therapeutic treatment due to inefficacy. At the last follow-up, 24 patients (57.1%) were seizure free. Eighteen patients (42.8%) never achieved freedom from seizures despite had at least 2 therapy changes. Two patients changed ASM due to adverse events and 1 to phenobarbital owing to the interaction with cancer treatment. The mean daily dose of first ASM in all 42 patients was very close to the Defined Daily Dose (DDD).

Conclusion

In BM patients seizure incidence could be underestimated; a team evaluation performed by oncologist and neurologist together, could guarantee an accurate taking care of both oncological illness and epilepsy, in this fragile patient population. More than 50% of our patients respond to monotherapy with new generation ASMs. Furthermore we deemed in patients receiving chemotherapy the choice of ASM should consider possible interactions with antitumor therapies, for this reason newer generation ASMs should be the preferred choice. It is necessary to get close to the DDD before considering an ASM ineffective in seizure control.

Brain metastases: A Society for Neuro-Oncology (SNO) consensus review on current management and future directions

Brain metastases occur commonly in patients with advanced solid malignancies. Yet, less is known about brain metastases than cancer-related entities of similar incidence. Advances in oncologic care have heightened the importance of intracranial management. Here, in this consensus review supported by the Society for Neuro-Oncology (SNO), we review the landscape of brain metastases with particular attention to management approaches and ongoing efforts with potential to shape future paradigms of care. Each coauthor carried an area of expertise within the field of brain metastases and initially composed, edited, or reviewed their specific subsection of interest. After each subsection was accordingly written, multiple drafts of the manuscript were circulated to the entire list of authors for group discussion and feedback. The hope is that the these consensus guidelines will accelerate progress in the understanding and management of patients with brain metastases, and highlight key areas in need of further exploration that will lead to dedicated trials and other research investigations designed to advance the field.

Principles of Lung Cancer Metastasis to Brain

Lung cancer is a disease associated with significant morbidity and mortality on a global setting. This form of cancer commonly gives raise to metastatic lesions the brain, which can further worsen outcomes. In this focused review, we discuss an overview of lung cancers that metastasize to the brain: known risk factors; means of detection and diagnosis; and options for treatment including a comparison between surgical resection, stereotactic radiosurgery, and whole-brain radiation therapy. These interventions are still being assessed by clinical trials and continue to be modified through evidence-based practice.

Correlation Analysis between Retention of Gd-DTPA in the Cystic Area of Brain Metastasis and MRI Signs

Objective

The aim of this study is to investigate gadolinium-diethylenetriaminepentacetate (Gd-DTPA) retention in the cystic area of brain metastasis and its correlation with MRI signs.

Methods

Clinical and MRI data of 76 patients with brain metastasis in the cystic area were collected. The contrast signal intensity (CSI) of the cystic area and edema area in the plain scan, enhanced scan, and plain scan after enhancement within 1 month (hereafter referred to as “enhanced plain scan”) were analyzed to determine whether Gd-DTPA was retained in these areas. The lesions with higher CSI values on the enhanced plain scan were classified as the Gd-DTPA retention group and the remaining lesions as the Gd-DTPA-free group. The two groups were compared to determine significant differences in primary lesion type, tumor size, tumor location, capsule wall thickness and morphology, peritumoral edema, and renal function.

Results

A total of 123 lesions were detected. The CSI of the enhanced plain scan exceeded that of the plain scan and enhanced scan in the cystic area (P < 0.05). There were 54 lesions (43.9%) with Gd-DTPA retention in the cystic area and 69 lesions (56.1%) without Gd-DTPA retention. Significant differences were observed in tumor size and cystic wall thickness between the two groups (P < 0.05), while no significant differences in primary lesion type, cystic wall shape, peritumoral edema, or function were observed.

Conclusion

The retention of Gd-DTPA was found in the cystic area of some brain metastases, which was correlated with tumor size and cystic wall thickness.

Indicators of correct targeting in stereotactic biopsy of intracranial lesions

Background:

Confirmation of whether a stereotactic biopsy was performed in the correct site is usually dependent on the frozen section or on novel tumor-specific markers that are not widely available. Immediate postoperative computed tomography (CT) or magnetic resonance (MR) is routinely performed in our service after biopsy. In this retrospective study, we have carefully analyzed these images in an attempt to determine the presence of markers that indicate appropriate targeting.

Methods:

Medical records and neuroimages of patients who underwent stereotactic biopsy of intracranial lesions were reviewed. The following variables were assessed: age, sex, anatomopathology, lesion site, complications, diagnostic accuracy, and the presence of image markers.

Results:

Twenty-nine patients were included in this case series. About 96.6% of the biopsies were accurate according to the permanent section. Of the 86.2% of patients with intralesional pneumocephalus on the postoperative images, 51.7% additionally presented petechial hemorrhage. In 13.8% of the cases, no image markers were identified.

Conclusion:

This is the first report of intralesional pneumocephalus and petechial hemorrhage as indicators of appropriate targeting in stereotactic biopsy. In the majority of the cases, an immediate postoperative head CT, which is widely available, can estimate how adequate the targeting is. To use intralesional pneumocephalus/ petechial hemorrhages as not only postoperative but also as intraoperative markers of appropriate targeting, it is advised that the surgical wound should be temporarily closed and dressed after the biopsy so that the patient can undergo a CT/MR scan and be checked for the presence of theses markers before removing the stereotactic frame.

Dedicated isotropic 3-D T1 SPACE sequence imaging for radiosurgery planning improves brain metastases detection and reduces the risk of intracranial relapse

BACKGROUND

Stereotactic radiosurgery (SRS) is increasingly used for brain metastases (BM) patients, but distant intracranial failure (DIF) remains the principal disadvantage of this focal therapeutic approach. The objective of this study was to determine if dedicated SRS imaging would improve lesion detection and reduce DIF.

METHODS

Between 02/2020 and 01/2021, SRS patients at a tertiary care institution underwent dedicated treatment planning MRIs of the brain including MPRAGE and SPACE post-contrast sequences. DIF was calculated using the Kaplan-Meier method; comparisons were made to a historical consecutive cohort treated using MPRAGE alone (02/2019-01/2020).

RESULTS

134 patients underwent 171 SRS courses for 821 BM imaged with both MPRAGE and SPACE (primary cohort). MPRAGE sequence evaluation alone detected 679 lesions. With neuroradiologists evaluating SPACE and MPRAGE, an additional 108 lesions were identified (p<0.001). Upon multidisciplinary review, 34 additional lesions were identified. Compared to the historical cohort (103 patients, 135 SRS courses, 479 BM), the primary cohort had improved median time to DIF (13.5 vs. 5.1 months, p=0.004). The benefit was even more pronounced for patients treated for their first SRS course (18.4 vs. 6.3 months, p=0.001). SRS using MPRAGE and SPACE was associated with a 60% reduction in risk of DIF compared to the historical cohort (HR: 0.40; 95%CI: 0.28-0.57, p<0.001).

CONCLUSIONS

Among BM patients treated with SRS, a treatment planning SPACE sequence in addition to MPRAGE substantially improved lesion detection and was associated with a statistically significant and clinically meaningful prolongation in time to DIF, especially for patients undergoing their first SRS course.

Clinical Outcomes and Prognostic Factors of Fractionated Stereotactic Radiosurgery for Brain Metastases ≥20 mm as a Potential Alternative to Surgery

BACKGROUND

This study investigated the outcomes and prognostic factors of fractionated stereotactic radiosurgery (FSRS) for the treatment of brain metastases ≥20 mm, and determined whether FSRS could replace surgery-the primary treatment for large brain metastases.

METHODS

Patients with brain metastases ≥20 mm treated with FSRS were retrospectively examined. Patients who underwent FSRS postoperatively were excluded. Local failure, intracranial failure, and adverse events were evaluated.

RESULTS

Overall, 116 lesions in 105 patients were evaluated. The performance status was 0-1, 2-4, and unknown for 86, 28, and two patients, respectively. The median maximum tumor diameter was 25 mm, and the median prescribed dose was 35 Gy in 3 fractions. The median follow-up period after FSRS was 8 months. The 1-year local failure, intracranial failure, and overall survival rates were 12.5%, 56.6%, and 49.0%, respectively. A maximum dose of ≥135 Gy (biological equivalent dose [α/β = 10 Gy]) and good performance status were independent favorable prognostic factors for local control. Twenty-one (20%) patients were treated with whole-brain radiotherapy after FSRS because of multiple intracranial recurrences, while four (3.4%) patients underwent surgery because of local recurrence.

CONCLUSIONS

FSRS for brain metastases ≥20 mm achieved good local control. Only 3.4% of patients required surgery after FSRS, suggesting that FSRS is a potential alternative to surgery. For FSRS, a higher maximum tumor dose was useful for local control.

Preparation, characterization, and biodistribution of glutathione PEGylated nanoliposomal doxorubicin for brain drug delivery with a post-insertion approach

Objectives

Brain cancer treatments have mainly failed due to their inability to cross the blood-brain barrier. Several studies have confirmed the presence of glutathione (GSH) receptors on BBB's surface, as a result, products like 2B3-101, which contain over 5% pre-inserted GSH PEGylated liposomal doxorubicin, are being tested in clinical trials. Here we conducted the PEGylated nanoliposomal doxorubicin particles that are covalently attached to the glutathione using the post-insertion technique. Compared with the pre-insertion approach, the post-insertion method is notably simpler, faster, and more cost-effective, making it ideal for large-scale pharmaceutical manufacturing.

Materials and Methods

The ligands of the DSPE PEG(2000) Maleimide-GSH were introduced in the amounts of 25, 50, 100, 200, and 400 on the available Caelyx. Following physicochemical evaluations, animal experiments such as biodistribution, fluorescence microscopy, and pharmacokinetics were done.

Results

In comparison with Caelyx, the 200L and 400L treatment arms were the most promising formulations. We showed that nanocarriers containing 40 times fewer GSH micelles than 2B3-101 significantly increased blood-brain barrier penetrance. Due to the expressed GSH receptors on tissues as an endogenous antioxidant, doxorubicin will likely concentrate in the liver, spleen, heart, and lung in comparison with Caelyx, according to other tissue analyses.

Conclusion

The post-insertion technique was found a successful approach with more pharmaceutical aspects for large-scale production. Moreover, further investigations are highly recommended to determine the efficacy of 5% post-inserted GSH targeted nanoliposomes versus 2B3-101 as a similar formulation with a different preparation method.

Low Heart Rate Variability Predicts Poor Overall Survival of Lung Cancer Patients With Brain Metastases

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.

Brain stereotactic radiosurgery using MR-guided online adaptive planning for daily setup variation: An end-to-end test

Online magnetic resonance (MR)‐guided radiotherapy is expected to benefit brain stereotactic radiosurgery (SRS) due to superior soft tissue contrast and capability of daily adaptive planning. The purpose of this study was to investigate daily adaptive plan quality with setup variations and to perform an end‐to‐end test for brain SRS with multiple metastases treated with a 1.5‐Tesla MR‐Linac (MRL). The RTsafe PseudoPatient Prime brain phantom was used with a delineation insert that includes two predefined structures mimicking gadolinium contrast‐enhanced brain lesions. Daily adaptive plans were generated using six preset and six random setup variations. Two adaptive plans per daily MR image were generated using the adapt‐to‐position (ATP) and adapt‐to‐shape (ATS) workflows. An adaptive patient plan was generated on a diagnostic MR image with simulated translational and rotational daily setup variation and was compared with the reference plan. All adaptive plans were compared with the reference plan using the target coverage, Paddick conformity index, gradient index (GI), Brain V12 or V20, optimization time and total monitor units. Target doses were measured as an end‐to‐end test with two ionization chambers inserted into the phantom. With preset translational variations, V12 from the ATS plan was 17% lower than that of the ATP plan. With a larger daily setup variation, GI and V12 of the ATS plan were 10% and 16% lower than those of the ATP plan, respectively. Compared to the ATP plans, the plan quality index of the ATS plans was more consistent with the reference plan, and within 5% in both phantom and patient plans. The differences between the measured and planned target doses were within 1% for both treatment workflows. Treating brain SRS using an MRL is feasible and could achieve satisfactory dosimetric goals. Setup uncertainties could be accounted for using online plan adaptation. The ATS workflow achieved better dosimetric results than the ATP workflow at the cost of longer optimization time.

Multiparametric radiomic tissue signature and machine learning for distinguishing radiation necrosis from tumor progression after stereotactic radiosurgery

Background

Stereotactic radiosurgery (SRS) may cause radiation necrosis (RN) that is difficult to distinguish from tumor progression (TP) by conventional MRI. We hypothesize that MRI-based multiparametric radiomics (mpRad) and machine learning (ML) can differentiate TP from RN in a multi-institutional cohort.

Methods

Patients with growing brain metastases after SRS at 2 institutions underwent surgery, and RN or TP were confirmed by histopathology. A radiomic tissue signature (RTS) was selected from mpRad, as well as single T₁ post-contrast (T₁c) and T₂ fluid-attenuated inversion recovery (T₂-FLAIR) radiomic features. Feature selection and supervised ML were performed in a randomly selected training cohort (N = 95) and validated in the remaining cases (N = 40) using surgical pathology as the gold standard.

Results

One hundred and thirty-five discrete lesions (37 RN, 98 TP) from 109 patients were included. Radiographic diagnoses by an experienced neuroradiologist were concordant with histopathology in 67% of cases (sensitivity 69%, specificity 59% for TP). Radiomic analysis indicated institutional origin as a significant confounding factor for diagnosis. A random forest model incorporating 1 mpRad, 4 T₁c, and 4 T₂-FLAIR features had an AUC of 0.77 (95% confidence interval [CI]: 0.66–0.88), sensitivity of 67% and specificity of 86% in the training cohort, and AUC of 0.71 (95% CI: 0.51–0.91), sensitivity of 52% and specificity of 90% in the validation cohort.

Conclusions

MRI-based mpRad and ML can distinguish TP from RN with high specificity, which may facilitate the triage of patients with growing brain metastases after SRS for repeat radiation versus surgical intervention.

Treating Metastatic Brain Cancers With Stem Cells

Stem cell therapy may present an effective treatment for metastatic brain cancer and glioblastoma. Here we posit the critical role of a leaky blood-brain barrier (BBB) as a key element for the development of brain metastases, specifically melanoma. By reviewing the immunological and inflammatory responses associated with BBB damage secondary to tumoral activity, we identify the involvement of this pathological process in the growth and formation of metastatic brain cancers. Likewise, we evaluate the hypothesis of regenerating impaired endothelial cells of the BBB and alleviating the damaged neurovascular unit to attenuate brain metastasis, using the endothelial progenitor cell (EPC) phenotype of bone marrow-derived mesenchymal stem cells. Specifically, there is a need to evaluate the efficacy for stem cell therapy to repair disruptions in the BBB and reduce inflammation in the brain, thereby causing attenuation of metastatic brain cancers. To establish the viability of stem cell therapy for the prevention and treatment of metastatic brain tumors, it is crucial to demonstrate BBB repair through augmentation of vasculogenesis and angiogenesis. BBB disruption is strongly linked to metastatic melanoma, worsens neuroinflammation during metastasis, and negatively influences the prognosis of metastatic brain cancer. Using stem cell therapy to interrupt inflammation secondary to this leaky BBB represents a paradigm-shifting approach for brain cancer treatment. In this review article, we critically assess the advantages and disadvantages of using stem cell therapy for brain metastases and glioblastoma.

Factors associated with unplanned readmissions and costs following resection of brain metastases in the United States

The purpose of this study was to critically analyze the risk of unplanned readmission following resection of brain metastasis and to identify key risk factors to allow for early intervention strategies in high-risk patients. We analyzed data from the Nationwide Readmissions Database (NRD) from 2010–2014, and included patients who underwent craniotomy for brain metastasis, identified using ICD-9-CM diagnosis (198.3) and procedure (01.59) codes. The primary outcome of the study was unplanned 30-day all-cause readmission rate. Secondary outcomes included reasons and costs of readmissions. Hierarchical logistic regression model was used to identify the factors associated with 30-day readmission following craniotomy for brain metastasis. During the study period, 44,846 index hospitalizations occurred for patients who underwent resection of brain metastasis. In this cohort, 17.8% (n = 7,965) had unplanned readmissions within the first 30 days after discharge from the index hospitalization. The readmission rate did not change significantly during the five-year study period (p-trend = 0.286). The median per-patient cost for 30-day unplanned readmission was $11,109 and this amounted to a total of $26.4 million per year, which extrapolates to a national expenditure of $269.6 million. Increasing age, male sex, insurance status, Elixhauser comorbidity index, length of stay, teaching status of the hospital, neurological complications and infectious complications were associated with 30-day readmission following discharge after an index admission for craniotomy for brain metastasis. Unplanned readmission rates after resection of brain metastasis remain high and involve substantial healthcare expenditures. Developing tools and interventions to prevent avoidable readmissions could focus on the high-risk patients as a future strategy to decrease substantial healthcare expense.

A Single-Institution Retrospective Study of Patients Treated With Laser-Interstitial Thermal Therapy for Radiation Necrosis of the Brain

Object Laser-interstitial thermal therapy (LITT) has been proposed as an alternative treatment to surgery for radiation necrosis (RN) in patients treated with stereotactic radiosurgery (SRS) for brain metastases. The present study sought to retrospectively analyze LITT outcomes in patients with RN from SRS. Methods This was a single-institution retrospective study of 30 patients treated from 2011-2018 with pathologically-proven RN after SRS for brain metastases (n=28) or proximally treated extracranial lesions treated with external beam radiotherapy (n=2). Same-day biopsy was performed in all cases. Patients were prospectively followed with Functional Assessment of Cancer Therapy - Brain (FACT-Br), EuroQol-5 Dimension (EQ-5D), Hopkins Verbal Learning Test (HVLT) and clinical history and examination. Adjusted means, standard errors and tests comparing visits to pre-LITT were generated. Kaplan-Meier method was used to estimate time overall survival. Competing risk analysis was used to estimate cumulative incidence of LITT failure. Results In our patient population, median time from radiotherapy to LITT was 13.1 months. Median SRS dose and median LITT treatment target volume were 20 Gy (IQR 18-22) and 3.5 cc (IQR 2.2-4.6), respectively. Seventy-seven percent of our patients tapered off steroids within one month. There were only two instances of RN recurrence after LITT, with recurrence defined as recurrence of symptoms after initial improvement. These recurrences occurred at 1.9 and 3.4 months. The three-, six- and nine-month freedom from recurrence rates were 95.7%, 90.9%, and 90.9%. Median survival in our patient population with pathologically confirmed RN treated with LITT was 2.1 years. Regarding the quality of life questionnaires with which some patients were followed as part of different prospective studies, completion rates were 22/30 for FACT-Br, 16/30 for the EQ-5D and 8/30 for HVLT. Quality of life questionnaire results were overall stable from baseline. Mean FACT-Br scores were stable from baseline (17.9, 16.6, 21.4 and 22.8) to three months (18.8, 15.4, 18.4 and 23.4) (p=0.38, 0.53, 0.09 and 0.59). The mean EQ-5D Aggregate score was stable from baseline (7.1) to one month (7.6) (p=0.25). Mean HVLT-R Total Recall was stable from baseline (20.6) to three months (18.4) (p=0.09). There was a statistically significant decrease in mean Karnofsky Performance Scale (KPS) score from baseline (84) to three-month follow-up (75) (p=0.03). Conclusions LITT represents a safe and durably effective treatment option for RN in the brain. Results demonstrate a median survival of 2.1 years from LITT with only two recurrences, both within four months of treatment and salvageable. Patient-reported outcomes showed no severe declines after LITT. Quality of life questionnaires demonstrated stable well-being and functionality from baseline. LITT should be considered for definitive treatment of RN, especially in cases where patients have significant side effects from standards medical therapies such as steroids or if steroids are minimally effective.

Reliability of self-report versus the capacity to consent to treatment instrument to make medical decisions in brain metastasis and other metastatic cancers

OBJECTIVE

To evaluate the ability of persons with metastatic cancer to self-assess their medical decision-making capacity (MDC). To investigate this, we compared an objective measure of MDC with self-ratings and evaluated predictors of agreement.

METHODS

Data were obtained from a cross-sectional study of metastatic cancer patients at a large academic medical center. Across all standards of MDC, sensitivity, specificity, and reliability using Gwet's AC1 statistic were calculated using the objective measure as the gold standard. Logistic regression was used to evaluate predictors of agreement between the measures across all MDC standards.

RESULTS

In those with brain metastases, high sensitivity (greater than 0.7), but low specificity was observed for all standards. Poor reliability was observed across all standards. Higher age resulted in higher odds of disagreement for Standard 3 (appreciation) (OR: 1.07, 95% CI: 1.00, 1.15) and Standard 4 (reasoning) (OR: 1.05, 95% CI: 1.00, 1.10). For Standard 3, chemotherapy use and brain metastases compared to other metastases resulted in higher odds of disagreement (Chemotherapy: OR: 5.62, 95% CI: 1.37, 23.09, Brain Metastases: OR: 5.93, 95% CI: 1.28, 27.55). For Standard 5 (understanding), no predictors were associated with disagreement.

CONCLUSIONS

For less cognitively complex standards (e.g., appreciation), self-report may be more valid and reliable than more cognitively complex standards (e.g., reasoning or understanding). However, overall, MDC self-report in the current sample is suboptimal. Thus, the need for detailed assessment of MDC, especially when patients are older or used chemotherapy, is indicated. Other studies should be conducted to assess MDC agreement longitudinally.

Re-irradiation of multiple brain metastases using CyberKnife stereotactic radiotherapy: Case report

INTRODUCTION

Brain metastasis (BM) is the commonest adult intracranial malignancy and many patients with brain metastases require two course radiotherapy. Re-irradiation is frequently performed in Radiotherapy (RT) departments for multiple brain metastases.

PATIENT CONCERNS

We present a case of a 55-year-old male patient suffering from brain metastases, who had previously received whole-brain radiotherapy (WBRT) and first CyberKnife Stereotactic Radiotherapy (CKSRT) for metastases, presented with a recurrence of metastasis and new lesions in the brain.

DIAGNOSES

An enhanced computed tomography (CT) scan of the brain revealed abnormalities with double-dosing of intravenous contrast that identified >10 lesions scattered in the whole brain.

INTERVENTIONS

Re-irradiation was performed using CKSRT. The patient was treated with 30 Gy in 5 fractions for new lesions and 25 Gy in 5 fractions for lesion that were locally recurrent and close to brainstem lesions.

OUTCOME

The lesions were well-controlled, and the headache of the patient was significantly relieved one month after radiotherapy. The total survival time of the patients was 17 months from the beginning of the Cyberknife treatment.

CONCLUSION

The present case report demonstrates that CyberKnife therapy plays a significant role in the repeated radiotherapy for multiple metastatic brain tumors. CKSRT can be used as a salvage method in recurrent multiple brain metastases.

Impact of KRAS mutation status on the efficacy of immunotherapy in lung cancer brain metastases

Immune checkpoint inhibitors (ICIs) have resulted in improved outcomes in non-small cell lung cancer (NSCLC) patients. However, data demonstrating the efficacy of ICIs in NSCLC brain metastases (NSCLCBM) is limited. We analyzed overall survival (OS) in patients with NSCLCBM treated with ICIs within 90 days of NSCLCBM diagnosis (ICI-90) and compared them to patients who never received ICIs (no-ICI). We reviewed 800 patients with LCBM who were diagnosed between 2010 and 2019 at a major tertiary care institution, 97% of whom received stereotactic radiosurgery (SRS) for local treatment of BM. OS from BM was compared between the ICI-90 and no-ICI groups using the Log-Rank test and Cox proportional-hazards model. Additionally, the impact of KRAS mutational status on the efficacy of ICI was investigated. After accounting for known prognostic factors, ICI-90 in addition to SRS led to significantly improved OS compared to no-ICI (12.5 months vs 9.1, p < 0.001). In the 109 patients who had both a known PD-L1 expression and KRAS status, 80.4% of patients with KRAS mutation had PD-L1 expression vs 61.9% in wild-type KRAS patients (p = 0.04). In patients without a KRAS mutation, there was no difference in OS between the ICI-90 vs no-ICI cohort with a one-year survival of 60.2% vs 54.8% (p = 0.84). However, in patients with a KRAS mutation, ICI-90 led to a one-year survival of 60.4% vs 34.1% (p = 0.004). Patients with NSCLCBM who received ICI-90 had improved OS compared to no-ICI patients. Additionally, this benefit appears to be observed primarily in patients with KRAS mutations that may drive the overall benefit, which should be taken into account in the development of future trials.

Integration of Systemic Therapy and Stereotactic Radiosurgery for Brain Metastases

Simple Summary

In the multi-modal treatment of brain metastasis (BM), the role of systemic therapy has undergone a recent revolution. Due to the development of multiple agents with modest central nervous system penetration of the blood-brain barrier, targeted therapies and immune checkpoint inhibitors are increasingly being utilized alone or in combination with radiation therapy. However, the adoption of sequential or concurrent strategies varies considerably, and treatment strategies employed in clinical practice have rapidly outpaced evidence development. Therefore, this review critically analyzes the data regarding combinatorial approaches for a variety of systemic therapeutics with stereotactic radiosurgery and provides an overview of ongoing clinical trials.

Abstract

Brain metastasis (BM) represents a common complication of cancer, and in the modern era requires multi-modal management approaches and multi-disciplinary care. Traditionally, due to the limited efficacy of cytotoxic chemotherapy, treatment strategies are focused on local treatments alone, such as whole-brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), and resection. However, the increased availability of molecular-based therapies with central nervous system (CNS) penetration now permits the individualized selection of tailored systemic therapies to be used alongside local treatments. Moreover, the introduction of immune checkpoint inhibitors (ICIs), with demonstrated CNS activity has further revolutionized the management of BM patients. The rapid introduction of these cancer therapeutics into clinical practice, however, has led to a significant dearth in the published literature about the optimal timing, sequencing, and combination of these systemic therapies along with SRS. This manuscript reviews the impact of tumor biology and molecular profiles on the management paradigm for BM patients and critically analyzes the current landscape of SRS, with a specific focus on integration with systemic therapy. We also discuss emerging treatment strategies combining SRS and ICIs, the impact of timing and the sequencing of these therapies around SRS, the effect of corticosteroids, and review post-treatment imaging findings, including pseudo-progression and radiation necrosis.

The incidence, risk factors and predictive nomograms for early death of lung cancer with synchronous brain metastasis: a retrospective study in the SEER database

BACKGROUND

The prognosis of lung cancer with synchronous brain metastasis (LCBM) is very poor, and patients often die within a short time. However, little is known about the early mortality and related factors in patients with LCBM.

METHODS

Patients diagnosed with LCBM between 2010 and 2016 were enrolled from the Surveillance, Epidemiology, and End Result (SEER) database. Univariate and multivariate logistic regression analysis were used to identify significant independent prognostic factors, which were used to construct nomograms of overall and cancer-specific early death. Then, the prediction ability of the model was verified by receiver operating characteristic (ROC) curve. At last, the clinical application value of the model was tested through decision curve analysis (DCA).

RESULTS

A total of 29,902 patients with LCBM were enrolled in this study. Among them, 13,275 (44.4%) patients had early death, and 11,425 (38.2%) cases died of lung cancer. The significant independent risk factors for overall and cancer-specific early death included age, race, gender, Gleason grade, histological type, T stage, N stage, bone metastasis, liver metastasis and marital status, which were used to construct the nomogram. The ROC curve demonstrated good predictive ability and clinical application value. The areas under the curve (AUC) of the training group was 0.793 (95% CI: 0.788-0.799) and 0.794 (95% CI: 0.788-0.799), in the model of overall and cancer-specific early death respectively. And the AUC of the validation group were 0.803 (95% CI: 0.788-0.818) and 0.806 (95% CI: 0.791-0.821), respectively. The calibration plots of the model showed that the predicted early death is consistent with the actual value. The DCA analysis indicated a good clinical application value of this model.

CONCLUSIONS

We established a comprehensive nomogram to predict early death in lung cancer patients with synchronous brain metastases. Nomograms may help oncologists develop better treatment strategies, such as clinical trials and hospice care.

Do Multiple Brain Lesions Always Connote Worse Outcomes? Appraisal Evidence from a Tertiary Care Center in Koshi/Purbanchal Province of Nepal

Advances in medicine comprising diverse diagnostic and management modalities call for a bundle approach to improve patient care. This study aimed to present diagnostic patterns in patients with multiple intracranial lesions together with connoted survival implications. We retrospectively reviewed medical files of 85 patients with tumor and non-tumor intracranial lesions. Metastatic brain lesions were identified in 23.5% of patients. Neurological pathogenesis underlay 29.4%, infectious 21.2%, and vascular 14.1% of lesions, with the remaining portion comprising less frequent disorders. A favorable prognosis was predicted in 52/85 (61.2%) of the study population despite a variety of pathologies, which speaks for substantial improvements in outcomes of once hardly manageable or mortal brain disorders, comprising both common and rare conditions. The improvements are to the credit of advances in medical radio-imaging enhancing the diagnostic power which enables a precise stratification of brain pathologies. We emphasize the use of an algorithmic evaluation of patients presenting with multiple brain lesions for differential diagnosis and survival prognostication. There seems to be an ongoing transition from imperfect probabilistic prediction models to precision medicine, which determines advantages in disease management and outcome.

Treatment of Brain Metastases of Non-Small Cell Lung Carcinoma

Lung cancer is one of the most common malignant neoplasms. As a result of the disease's progression, patients may develop metastases to the central nervous system. The prognosis in this location is unfavorable; untreated metastatic lesions may lead to death within one to two months. Existing therapies-neurosurgery and radiation therapy-do not improve the prognosis for every patient. The discovery of Epidermal Growth Factor Receptor (EGFR)-activating mutations and Anaplastic Lymphoma Kinase (ALK) rearrangements in patients with non-small cell lung adenocarcinoma has allowed for the introduction of small-molecule tyrosine kinase inhibitors to the treatment of advanced-stage patients. The Epidermal Growth Factor Receptor (EGFR) is a transmembrane protein with tyrosine kinase-dependent activity. EGFR is present in membranes of all epithelial cells. In physiological conditions, it plays an important role in the process of cell growth and proliferation. Binding the ligand to the EGFR causes its dimerization and the activation of the intracellular signaling cascade. Signal transduction involves the activation of MAPK, AKT, and JNK, resulting in DNA synthesis and cell proliferation. In cancer cells, binding the ligand to the EGFR also leads to its dimerization and transduction of the signal to the cell interior. It has been demonstrated that activating mutations in the gene for EGFR-exon19 (deletion), L858R point mutation in exon 21, and mutation in exon 20 results in cancer cell proliferation. Continuous stimulation of the receptor inhibits apoptosis, stimulates invasion, intensifies angiogenesis, and facilitates the formation of distant metastases. As a consequence, the cancer progresses. These activating gene mutations for the EGFR are present in 10-20% of lung adenocarcinomas. Approximately 3-7% of patients with lung adenocarcinoma have the echinoderm microtubule-associated protein-like 4 (EML4)/ALK fusion gene. The fusion of the two genes EML4 and ALK results in a fusion gene that activates the intracellular signaling pathway, stimulates the proliferation of tumor cells, and inhibits apoptosis. A new group of drugs-small-molecule tyrosine kinase inhibitors-has been developed; the first generation includes gefitinib and erlotinib and the ALK inhibitor crizotinib. These drugs reversibly block the EGFR by stopping the signal transmission to the cell. The second-generation tyrosine kinase inhibitor (TKI) afatinib or ALK inhibitor alectinib block the receptor irreversibly. Clinical trials with TKI in patients with non-small cell lung adenocarcinoma with central nervous system (CNS) metastases have shown prolonged, progression-free survival, a high percentage of objective responses, and improved quality of life. Resistance to treatment with this group of drugs emerging during TKI therapy is the basis for the detection of resistance mutations. The T790M mutation, present in exon 20 of the EGFR gene, is detected in patients treated with first- and second-generation TKI and is overcome by Osimertinib, a third-generation TKI. The I117N resistance mutation in patients with the ALK mutation treated with alectinib is overcome by ceritinib. In this way, sequential therapy ensures the continuity of treatment. In patients with CNS metastases, attempts are made to simultaneously administer radiation therapy and tyrosine kinase inhibitors. Patients with lung adenocarcinoma with CNS metastases, without activating EGFR mutation and without ALK rearrangement, benefit from immunotherapy. This therapeutic option blocks the PD-1 receptor on the surface of T or B lymphocytes or PD-L1 located on cancer cells with an applicable antibody. Based on clinical trials, pembrolizumab and all antibodies are included in the treatment of non-small cell lung carcinoma with CNS metastases.

Multidisciplinary brain metastasis clinic: is it effective and worthwhile?

Background

Management of brain metastasis is a complex multidisciplinary venture. Hence, we started a multidisciplinary brain metastasis clinic for the opinion on difficult brain metastasis cases. This is the review of the impact of this clinic on the treatment decisions.

Methods

The brain metastasis clinic (BMC) was started in April 2018 and meets once a week. Data of patients discussed between 27th April 2018 and 28th June 2019 were included for this analysis. Treatment decision made by clinicians (before sending the patient to the BMC) was compared with the decisions made in BMC. The decisions were broken on a predefined proforma as the intent of treatment (curative or palliative), modalities planned (surgery, radiation, chemotherapy) and type of therapy planned (details of each therapy) in each modality were collected both pre and post BMCs. In addition, compliance of the respective physicians to BMC decision was also calculated. SPSS version 20 was used for analysis. Descriptive statistics were performed.

Results

Ninety-nine patients were discussed in this time period. The median age was 51 (range 17–68) years. The gender distribution was 70 males (70.7%) and 29 females (29.3%). Lung was the predominant site of malignancy (79, 79.8%). Thirty-one patients (31.3%) had EGFR TKI domain activating mutation, while 17 (17.2%) had anaplastic lymphoma kinase (ALK) rearrangement. The treatment plan was changed in 46 patients (46.5%). The intent of treatment was changed from palliative to curative in 5%. Change in the treatment plan with respect to surgery in 9.1%, radiation in 37.4%, chemotherapy in15.2%, targeted therapy in 22.9% and intrathecal in 6.1% patients, respectively. The compliance with the BMC decision in patients in whom it was changed was 84.8% (39, n = 46).

Conclusion

Multidisciplinary management of difficult brain metastasis cases in specialised clinics has a significant impact on treatment decisions.

Critically ill patients with cancer: A clinical perspective

Cancer patients account for 15% of all admissions to intensive care unit (ICU) and 5% will experience a critical illness resulting in ICU admission. Mortality rates have decreased during the last decades because of new anticancer therapies and advanced organ support methods. Since early critical care and organ support is associated with improved survival, timely identification of the onset of clinical signs indicating critical illness is crucial to avoid delaying. This article focused on relevant and current information on epidemiology, diagnosis, and treatment of the main clinical disorders experienced by critically ill cancer patients.

Sphingolipid Metabolism in Glioblastoma and Metastatic Brain Tumors: A Review of Sphingomyelinases and Sphingosine-1-Phosphate

Glioblastoma (GBM) is a primary malignant brain tumor with a dismal prognosis, partially due to our inability to completely remove and kill all GBM cells. Rapid tumor recurrence contributes to a median survival of only 15 months with the current standard of care which includes maximal surgical resection, radiation, and temozolomide (TMZ), a blood-brain barrier (BBB) penetrant chemotherapy. Radiation and TMZ cause sphingomyelinases (SMase) to hydrolyze sphingomyelins to generate ceramides, which induce apoptosis. However, cells can evade apoptosis by converting ceramides to sphingosine-1-phosphate (S1P). S1P has been implicated in a wide range of cancers including GBM. Upregulation of S1P has been linked to the proliferation and invasion of GBM and other cancers that display a propensity for brain metastasis. To mediate their biological effects, SMases and S1P modulate signaling via phospholipase C (PLC) and phospholipase D (PLD). In addition, both SMase and S1P may alter the integrity of the BBB leading to infiltration of tumor-promoting immune populations. SMase activity has been associated with tumor evasion of the immune system, while S1P creates a gradient for trafficking of innate and adaptive immune cells. This review will explore the role of sphingolipid metabolism and pharmacological interventions in GBM and metastatic brain tumors with a focus on SMase and S1P.

A Rare Case of Pancreatoblastoma with Intracranial Seeding

BACKGROUND

Pancreatoblastoma is an extremely rare neoplasm that accounts for 0.5% of all pancreatic exocrine tumors. These rare entities typically manifest in the pediatric population but can rarely occur in adults. Systemic seeding has been described before but intracranial metastasis in adults has yet to be described.

CASE DESCRIPTION

A 28-year-old woman with a history of pancreatoblastoma that had been in remission for 51 months after treatment with cisplatin, doxorubicin (Adriamycin), and etoposide had presented to the emergency room with chronic recurrent headaches. Conservative management of the headaches failed, which led to a diagnostic workup with magnetic resonance imaging of the brain. Magnetic resonance imaging demonstrated a well-circumscribed solitary cerebellar lesion. Metastatic disease was suspected, and the patient underwent suboccipital craniotomy for tumor resection with adjuvant gamma knife radiosurgery.

CONCLUSIONS

Central nervous system seeding of pancreatoblastoma is rare, and the available evidence suggests that the strategy we used could be adequate for treating such occurrences.