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van der Molen AJ, Quattrocchi CC, Mallio CA, Dekkers IA. Ten years of gadolinium retention and deposition: ESMRMB-GREC looks backward and forward. Eur Radiol 2024; 34:600-611. [PMID: 37804341 PMCID: PMC10791848 DOI: 10.1007/s00330-023-10281-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 07/30/2023] [Accepted: 08/09/2023] [Indexed: 10/09/2023]
Abstract
In 2014, for the first time, visible hyperintensities on unenhanced T1-weighted images in the nucleus dentatus and globus pallidus of the brain were associated with previous Gadolinium-based contrast agent (GBCA) injections and gadolinium deposition in patients with normal renal function. This led to a frenzy of retrospective studies with varying methodologies that the European Society of Magnetic Resonance in Medicine and Biology Gadolinium Research and Educational Committee (ESMRMB-GREC) summarised in 2019. Now, after 10 years, the members of the ESMRMB-GREC look backward and forward and review the current state of knowledge of gadolinium retention and deposition. CLINICAL RELEVANCE STATEMENT: Gadolinium deposition is associated with the use of linear GBCA but no clinical symptoms have been associated with gadolinium deposition. KEY POINTS : • Traces of Gadolinium-based contrast agent-derived gadolinium can be retained in multiple organs for a prolonged time. • Gadolinium deposition is associated with the use of linear Gadolinium-based contrast agents. • No clinical symptoms have been associated with gadolinium deposition.
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Affiliation(s)
- Aart J van der Molen
- Department of Radiology, C-2S, Leiden University Medical Center, Albinusdreef 2, NL-2333 ZA, Leiden, The Netherlands.
| | - Carlo C Quattrocchi
- Centre for Medical Sciences CISMed, University of Trento, 38122, Trento, Italy
| | - Carlo A Mallio
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
- Operative Research Unit of Diagnostic Imaging, Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Ilona A Dekkers
- Department of Radiology, C-2S, Leiden University Medical Center, Albinusdreef 2, NL-2333 ZA, Leiden, The Netherlands
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Cook N, Shelton N, Gibson S, Barnes P, Alinaghi-Zadeh R, Jameson MG. ACPSEM position paper: the safety of magnetic resonance imaging linear accelerators. Phys Eng Sci Med 2023; 46:19-43. [PMID: 36847966 PMCID: PMC10030425 DOI: 10.1007/s13246-023-01224-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 03/01/2023]
Abstract
Magnetic Resonance Imaging linear-accelerator (MRI-linac) equipment has recently been introduced to multiple centres in Australia and New Zealand. MRI equipment creates hazards for staff, patients and others in the MR environment; these hazards must be well understood, and risks managed by a system of environmental controls, written procedures and a trained workforce. While MRI-linac hazards are similar to the diagnostic paradigm, the equipment, workforce and environment are sufficiently different that additional safety guidance is warranted. In 2019 the Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM) formed the Magnetic Resonance Imaging Linear-Accelerator Working Group (MRILWG) to support the safe clinical introduction and optimal use of MR-guided radiation therapy treatment units. This Position Paper is intended to provide safety guidance and education for Medical Physicists and others planning for and working with MRI-linac technology. This document summarises MRI-linac hazards and describes particular effects which arise from the combination of strong magnetic fields with an external radiation treatment beam. This document also provides guidance on safety governance and training, and recommends a system of hazard management tailored to the MRI-linac environment, ancillary equipment, and workforce.
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Affiliation(s)
- Nick Cook
- Christchurch Hospital, Christchurch, New Zealand
| | - Nikki Shelton
- Olivia Newton-John Cancer Wellness and Research Centre, Heidelberg, VIC, Australia
| | | | | | - Reza Alinaghi-Zadeh
- Olivia Newton-John Cancer Wellness and Research Centre, Heidelberg, VIC, Australia
| | - Michael G Jameson
- GenesisCare, Sydney, NSW, Australia.
- University of New South Wales, Sydney, Australia.
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3
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Blethen KE, Sprowls SA, Arsiwala TA, Wolford CP, Panchal DM, Fladeland RA, Glass MJ, Dykstra LP, Kielkowski BN, Blackburn JR, Andrick CJ, Lockman PR. Effects of whole-brain radiation therapy on the blood-brain barrier in immunocompetent and immunocompromised mouse models. Radiat Oncol 2023; 18:22. [PMID: 36732754 PMCID: PMC9896731 DOI: 10.1186/s13014-023-02215-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 01/28/2023] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- K E Blethen
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, 108 Biomedical Drive, Morgantown, WV, 26506, USA
| | - S A Sprowls
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, 108 Biomedical Drive, Morgantown, WV, 26506, USA
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - T A Arsiwala
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, 108 Biomedical Drive, Morgantown, WV, 26506, USA
| | - C P Wolford
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, 108 Biomedical Drive, Morgantown, WV, 26506, USA
| | - D M Panchal
- Department of Chemical and Biomedical Engineering, Benjamin M. Statler College of Engineering and Mineral Resources, West Virginia University, Morgantown, WV, USA
| | - R A Fladeland
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, 108 Biomedical Drive, Morgantown, WV, 26506, USA
| | - M J Glass
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, 108 Biomedical Drive, Morgantown, WV, 26506, USA
- Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - L P Dykstra
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, 108 Biomedical Drive, Morgantown, WV, 26506, USA
| | - B N Kielkowski
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, 108 Biomedical Drive, Morgantown, WV, 26506, USA
| | - J R Blackburn
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, 108 Biomedical Drive, Morgantown, WV, 26506, USA
| | - C J Andrick
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, 108 Biomedical Drive, Morgantown, WV, 26506, USA
| | - P R Lockman
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, 108 Biomedical Drive, Morgantown, WV, 26506, USA.
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Bashir S, Wen L, Zhang P, Ye M, Li Y, Hong W, Zhen J, Lai M, Wang H, Yang Y, Chen X, Luo R, Jia G, Guo Y, Cai L, Xu M. Efficacy and safety of combined immunotherapy and stereotactic radiosurgery in NSCLCBM patients and a novel prognostic nomogram: A real-world study. Front Oncol 2023; 13:1068592. [PMID: 37124533 PMCID: PMC10141675 DOI: 10.3389/fonc.2023.1068592] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 03/29/2023] [Indexed: 05/02/2023] Open
Abstract
Objective To explore the effectiveness of combined immunotherapy (IT) and stereotactic radiosurgery (SRS) and address the gap between evidence-based clinical practice and academic knowledge of optimal timing of IT relative to SRS. In addition, to meet the unmet need for an up-to-date prognostic assessment model in the era of IT. Methods The data of 86 non-small cell lung cancer brain metastasis (NSCLCBM) patients treated with SRS to 268 brain metastases (BMs) were retrospectively extracted from our hospital database. The Kaplan-Meier analysis was employed for overall survival (OS) and a log-rank test for comparison between groups. Cox proportional hazards regression models were used to identify the significant prognostic factors. The prognostic nomogram was established utilizing the rms package of R software. Results IT was found to be associated with improved OS (from BM diagnosis: HR 0.363, 95% CI 0.199 - 0.661, P < 0.001; from SRS: HR 0.472, 95% CI 0.260 - 0.857, P = 0.014). Individuals who received IT in combination with SRS had better OS than those who didn't (from the day of BM diagnosis: 16.8 vs. 8.4 months, P = 0.006; from the day of SRS: 12 vs. 7 months, P = 0.037). Peri-SRS timing of IT administration was a significant prognostic factor for OS (from BM diagnosis: HR 0.132, 95% CI 0.034 - 0.517, P = 0.004; from SRS: HR 0.14, 95% CI 0.044 - 0.450, P = 0.001). Initiating IT after SRS led to superior OS than concurrent or before (from BM diagnosis: 26.5 vs. 14.1 vs. 7.1 months; from SRS: 21.4 vs. 9.9 vs. 4.1 months, respectively). Additionally, we build a nomogram incorporating IT, cumulative intracranial tumor volume (CITV), and recursive partitioning analysis (RPA), demonstrating a remarkable prognosis prediction performance for SRS-treated NSCLCBM patients. Conclusion Peri-SRS IT is a promising approach in treating NSCLCBM, as improved OS was observed without significantly increasing adverse events. Receipt of IT post-SRS was associated with superior OS than those who received IT concurrently or before. Incorporating IT and CITV into the RPA index could augment its prognosis assessment value for SRS-treated NSCLCBM patients, predominantly in the wild-type.
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Affiliation(s)
- Shoaib Bashir
- Oncology Department, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Lei Wen
- Oncology Department, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Ping Zhang
- Oncology Department, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Minting Ye
- Oncology Department, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Yin Li
- Oncology Department, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Weiping Hong
- Oncology Department, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Junjie Zhen
- Oncology Department, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Mingyao Lai
- Oncology Department, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Hui Wang
- Oncology Department, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Yanying Yang
- Oncology Department, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Xingrui Chen
- Oncology Department, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Rishun Luo
- Oncology Department, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Guoxia Jia
- Oncology Department, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yao Guo
- Oncology Department, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Linbo Cai
- Oncology Department, Guangdong Sanjiu Brain Hospital, Guangzhou, China
- *Correspondence: Meng Xu, ; Linbo Cai,
| | - Meng Xu
- Oncology Department, First Affiliated Hospital of Jinan University, Guangzhou, China
- *Correspondence: Meng Xu, ; Linbo Cai,
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Wong KL, Cheng KH, Lam SK, Liu C, Cai J. Review of functional magnetic resonance imaging in the assessment of nasopharyngeal carcinoma treatment response. PRECISION RADIATION ONCOLOGY 2022. [DOI: 10.1002/pro6.1161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Kwun Lam Wong
- Department of Health Technology and Informatics The Hong Kong Polytechnic University Hong Kong SAR People's Republic of China
- Department of Radiotherapy Hong Kong Sanatorium & Hospital HKSH Medical Group Hong Kong SAR People's Republic of China
| | - Ka Hei Cheng
- Department of Health Technology and Informatics The Hong Kong Polytechnic University Hong Kong SAR People's Republic of China
| | - Sai Kit Lam
- Department of Health Technology and Informatics The Hong Kong Polytechnic University Hong Kong SAR People's Republic of China
| | - Chenyang Liu
- Department of Health Technology and Informatics The Hong Kong Polytechnic University Hong Kong SAR People's Republic of China
| | - Jing Cai
- Department of Health Technology and Informatics The Hong Kong Polytechnic University Hong Kong SAR People's Republic of China
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Blood-Brain Barrier Permeability Following Conventional Photon Radiotherapy - A Systematic Review and Meta-Analysis of Clinical and Preclinical Studies. Clin Transl Radiat Oncol 2022; 35:44-55. [PMID: 35601799 PMCID: PMC9117815 DOI: 10.1016/j.ctro.2022.04.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 04/30/2022] [Indexed: 01/16/2023] Open
Abstract
Radiotherapy (RT) is a cornerstone treatment strategy for brain tumours. Besides cytotoxicity, RT can cause disruption of the blood–brain barrier (BBB), resulting in an increased permeability into the surrounding brain parenchyma. Although this effect is generally acknowledged, it remains unclear how and to what extent different radiation schemes affect BBB integrity. The aim of this systematic review and meta-analysis is to investigate the effect of photon RT regimens on BBB permeability, including its reversibility, in clinical and preclinical studies. We systematically reviewed relevant clinical and preclinical literature in PubMed, Embase, and Cochrane search engines. A total of 69 included studies (20 clinical, 49 preclinical) were qualitatively and quantitatively analysed by meta-analysis and evaluated on key determinants of RT-induced BBB permeability in different disease types and RT protocols. Qualitative data synthesis showed that 35% of the included clinical studies reported BBB disruption following RT, whereas 30% were inconclusive. Interestingly, no compelling differences were observed between studies with different calculated biological effective doses based on the fractionation schemes and cumulative doses; however, increased BBB disruption was noted during patient follow-up after treatment. Qualitative analysis of preclinical studies showed RT BBB disruption in 78% of the included studies, which was significantly confirmed by meta-analysis (p < 0.01). Of note, a high risk of bias, publication bias and a high heterogeneity across the studies was observed. This systematic review and meta-analysis sheds light on the impact of RT protocols on BBB integrity and opens the discussion for integrating this factor in the decision-making process of future RT, with better study of its occurrence and influence on concomitant or adjuvant therapies.
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Wang J, Salzillo T, Jiang Y, Mackeyev Y, David Fuller C, Chung C, Choi S, Hughes N, Ding Y, Yang J, Vedam S, Krishnan S. Stability of MRI contrast agents in high-energy radiation of a 1.5T MR-Linac. Radiother Oncol 2021; 161:55-64. [PMID: 34089753 PMCID: PMC8324543 DOI: 10.1016/j.radonc.2021.05.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Gadolinium-based contrast is often used when acquiring MR images for radiation therapy planning for better target delineation. In some situations, patients may still have residual MRI contrast agents in their tissue while being treated with high-energy radiation. This is especially true when MRI contrast agents are administered during adaptive treatment replanning for patients treated on MR-Linac systems. PURPOSE The purpose of this study was to analyze the molecular stability of MRI contrast agents when exposed to high energy photons and the associated secondary electrons in a 1.5T MR-Linac system. This was the first step in assessing the safety of administering MRI contrast agents throughout the course of treatment. MATERIALS AND METHODS Two common MRI contrast agents were irradiated with 7 MV photons to clinical dose levels. The irradiated samples were analyzed using liquid chromatography-high resolution mass spectrometry to detect degradation products or conformational alterations created by irradiation with high energy photons and associated secondary electrons. RESULTS No significant change in chemical composition or displacement of gadolinium ions from their chelates was discovered in samples irradiated with 7 MV photons at relevant clinical doses in a 1.5T MR-Linac. Additionally, no significant correlation between concentrations of irradiated MRI contrast agents and radiation dose was observed. CONCLUSION The chemical composition stability of the irradiated contrast agents is promising for future use throughout the course of patient treatment. However, in vivo studies are needed to confirm that unexpected metabolites are not created in biological milieus.
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Affiliation(s)
- Jihong Wang
- Department of Radiation Physics, MD Anderson Cancer Center, Houston, United States.
| | - Travis Salzillo
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, United States
| | - Yongying Jiang
- The Institute for Applied Cancer Science, MD Anderson Cancer Center, Houston, United States
| | - Yuri Mackeyev
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, United States
| | - Clifton David Fuller
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, United States
| | - Caroline Chung
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, United States
| | - Seungtaek Choi
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, United States
| | - Neil Hughes
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, United States
| | - Yao Ding
- Department of Radiation Physics, MD Anderson Cancer Center, Houston, United States
| | - Jinzhong Yang
- Department of Radiation Physics, MD Anderson Cancer Center, Houston, United States
| | - Sastry Vedam
- Department of Radiation Oncology, University of Maryland, Baltimore, United States
| | - Sunil Krishnan
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, United States
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Ramalho J, Semelka RC, Cruz J, Morais T, Ramalho M. T1 signal intensity in the dentate nucleus after the administration of the macrocyclic gadolinium-based contrast agent gadoterate meglumine: an observational study. RADIOLOGIA 2020; 64:S0033-8338(20)30112-0. [PMID: 33032813 DOI: 10.1016/j.rx.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/26/2020] [Accepted: 07/13/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION AND AIMS Contradictory results have been reported about hyperintensity of the globus pallidus and/or dentate nucleus on unenhanced T1-weighted magnetic resonance (MR) images after exposure to various gadolinium-based contrast agents. This change in signal intensity varies with different gadolinium-based contrast agents. We aimed to determine whether signal intensity in the dentate nucleus is increased in unenhanced T1-weighted images in patients who have undergone multiple studies with the macrocyclic gadolinium-based contrast agent gadoterate meglumine. We thoroughly reviewed the literature to corroborate our results. MATERIALS AND METHODS We included patients who had undergone more than 10 MR studies with gadoterate meglumine. We quantitatively analyzed the signal intensity in unenhanced T1-weighted MR images measured in regions of interest placed in the dentate nucleus and the pons, and we calculated the dentate nucleus-to-pons signal intensity ratios and the differences between the ratio in the first MR study and the last MR study. We used t-tests to evaluate whether the differences between the signal intensity ratios were different from 0. We also analyzed the subgroups of patients who had been administered<15 and ≥15 doses of gadoterate meglumine. We used Pearson correlation to determine the relationships between the differences in the signal intensity ratios and the number of doses of gadoterate meglumine administered. RESULTS The 54 patients (26 men) had received a mean of 13.8±3.47 doses (range, 10-23 doses). The difference in the dentate nucleus-pons signal intensity ratio between the first and last MR study was -0.0275±0.1917 (not significantly different from 0; p=0.2968) in the entire group, -0.0357±0.2204 (not significantly different from 0; p=0.351 in the patients who had received <15 doses (n=34), and -0.0135±0.1332 (not significantly different from 0; p=0.655) in those who had received ≥15 doses (n=20). Differences in signal intensity ratios did not correlate significantly with the accumulated dose of gadoterate meglumine (P=0.9064; ρ=-0.0164 [95%]). CONCLUSIONS Receiving more than 10 doses of gadoterate meglumine was not associated with increased signal intensity in the dentate nucleus.
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Affiliation(s)
- J Ramalho
- Departamento de Neurorradiología, Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | - R C Semelka
- Dr. Richard Semelka. Empresa privada de consultoría
| | - J Cruz
- Departamento de Radiología, Hospital Garcia de Orta, EPE, Almada, Portugal; Departamento de Radiología, Hospital da Luz, Lisboa y Setúbal, Portugal
| | - T Morais
- Departamento de Neurorradiología, Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | - M Ramalho
- Departamento de Radiología, Hospital Garcia de Orta, EPE, Almada, Portugal; Departamento de Radiología, Hospital da Luz, Lisboa y Setúbal, Portugal.
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Challenges in the treatment of breast cancer brain metastases: evidence, unresolved questions, and a practical algorithm. Clin Transl Oncol 2020; 22:1698-1709. [PMID: 32207041 DOI: 10.1007/s12094-020-02333-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/01/2020] [Indexed: 12/24/2022]
Abstract
Breast cancer is the leading cause of brain metastases in women. Large randomized clinical trials that have evaluated local therapies in patients with brain metastases include patients with brain metastases from a variety of cancer types. The incidence of brain metastases in the breast cancer population continues to grow, which is, aside from the rising breast cancer incidence, mainly attributable to improvements in systemic therapies leading to more durable control of extracranial metastatic disease and prolonged survival. The management of breast cancer brain metastases remains challenging, even more so with the continued advancement of local and highly effective systemic therapies. For most patients, a metastases-directed initial approach (i.e., radiation, surgery) represents the most appropriate initial therapy. Treatment should be based on multidisciplinary team discussions and a shared decision with the patients taking into account the risks and benefits of each therapeutic modality with the goal of prolonging survival while maintaining quality of life. In this narrative review, a multidisciplinary group of experts will address challenging questions in the context of current scientific literature and propose a therapeutic algorithm for breast cancer patients with brain metastases.
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Sprowls SA, Arsiwala TA, Bumgarner JR, Shah N, Lateef SS, Kielkowski BN, Lockman PR. Improving CNS Delivery to Brain Metastases by Blood-Tumor Barrier Disruption. Trends Cancer 2019; 5:495-505. [PMID: 31421906 PMCID: PMC6703178 DOI: 10.1016/j.trecan.2019.06.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 06/07/2019] [Accepted: 06/21/2019] [Indexed: 01/13/2023]
Abstract
Brain metastases encompass nearly 80% of all intracranial tumors. A late stage diagnosis confers a poor prognosis, with patients typically surviving less than 2 years. Poor survival can be equated to limited effective treatment modalities. One reason for the failure rates is the presence of the blood-brain barrier (BBB) and blood-tumor barrier (BTB) that limit the access of potentially effective chemotherapeutics to metastatic lesions. Strategies to overcome these barriers include new small molecule entities capable of crossing into the brain parenchyma, novel formulations of existing chemotherapies, and disruptive techniques. Here, we review BBB physiology and BTB pathophysiology. Additionally, we review the limitations of routinely practiced therapies and three current methods being explored for BBB/BTB disruption for improved delivery of chemotherapy to brain tumors.
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Affiliation(s)
- Samuel A. Sprowls
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University HSC, Morgantown, West Virginia 26506
| | - Tasneem A. Arsiwala
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University HSC, Morgantown, West Virginia 26506
| | - Jacob R. Bumgarner
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University HSC, Morgantown, West Virginia 26506
| | - Neal Shah
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University HSC, Morgantown, West Virginia 26506
| | - Sundus S. Lateef
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University HSC, Morgantown, West Virginia 26506
| | - Brooke N. Kielkowski
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University HSC, Morgantown, West Virginia 26506
| | - Paul R. Lockman
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University HSC, Morgantown, West Virginia 26506
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Tang R, Haacke EM, Zhang Y, Wang Q, He N, Chen KM, Yan F. Impact of nasopharyngeal irradiation and gadolinium administration on changes in T 1 signal intensity of the dentate nucleus in nasopharyngeal malignancy patients without intracranial abnormalities. J Magn Reson Imaging 2019; 51:250-259. [PMID: 31124193 DOI: 10.1002/jmri.26800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/13/2019] [Accepted: 05/13/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Irradiation has been found to increase T1 signal intensity (SI) of the dentate nucleus (DN) by accelerating the gadolinium deposition in patients after multiple gadolinium-based contrast agent (GBCA) administrations. Several reports have focused on this phenomenon in patients with brain tumors; however, data in patients receiving irradiation with no intracranial abnormalities (NIAs) are lacking. PURPOSE To explore how nasopharyngeal irradiation affected SI changes on unenhanced T1 -weighted imaging (T1 WI) in the DN in nasopharyngeal malignancy (NPM) patients who presented with NIAs and who had multiple injection doses (IDs) of linear GBCAs. STUDY TYPE Single-center, retrospective, case-control study. POPULATION In all, 132 subjects: 66 NPM patients, 66 matched controls. FIELD STRENGTH/SEQUENCE 1.5T and 3T/T1 WI, T2 WI, and fluid-attenuated inversion recovery (FLAIR). ASSESSMENT Radiation doses (RDs) were calculated by a radiotherapy technician. SIs were measured by a radiologist. The DN-to-cerebellar white matter (CWM) SI ratios and their relative percentage change (Rchange ) were compared. STATISTICAL TESTS Shapiro-Wilk test, paired t-test, independent t-test, Mann-Whitney U-test, Pearson and Spearman correlation. RESULTS DN/CWM b ratios or R change from the NPM group were significantly higher than those from the control group (P < 0.001). No significant difference of DN/CWM a ratios was found between the two groups (P > 0.05). Positive correlations between R change , DN/CWM b ratio, and the number of IDs were found in both the NPM and control groups (P < 0.01). The overall changes of DN/CWM b ratio or R change between NPM and control groups were higher for the higher-IDs subgroup (≥10) than for the lower-IDs subgroup (<10). DATA CONCLUSION Nasopharyngeal irradiation appeared to increase SI in T1 WI in NPM patients with NIAs and repeated GBCA administrations relative to control patients who also underwent GBCA administrations, especially when IDs ≥10. However, no significant association between R change and RDs to the DNs was found. LEVEL OF EVIDENCE 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2020;51:250-259.
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Affiliation(s)
- Rongbiao Tang
- Department of Radiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - E Mark Haacke
- Department of Radiology, Wayne State University, Detroit, Michigan, USA
| | - Yibin Zhang
- Department of Radiation Oncology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Qingrou Wang
- Department of Radiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Naying He
- Department of Radiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Ke-Min Chen
- Department of Radiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Fuhua Yan
- Department of Radiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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Meng Y, Suppiah S, Surendrakumar S, Bigioni L, Lipsman N. Low-Intensity MR-Guided Focused Ultrasound Mediated Disruption of the Blood-Brain Barrier for Intracranial Metastatic Diseases. Front Oncol 2018; 8:338. [PMID: 30211117 PMCID: PMC6121246 DOI: 10.3389/fonc.2018.00338] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 08/03/2018] [Indexed: 12/19/2022] Open
Abstract
Low-intensity MR-guided focused ultrasound in combination with intravenously injected microbubbles is a promising platform for drug delivery to the central nervous system past the blood-brain barrier. The blood-brain barrier is a key bottleneck for cancer therapeutics via limited inter- and intracellular transport. Further, drugs that cross the blood-brain barrier when delivered in a spatially nonspecific way, result in adverse effects on normal brain tissue, or at high concentrations, result in increasing risks to peripheral organs. As such, various anti-cancer drugs that have been developed or to be developed in the future would benefit from a noninvasive, temporary, and repeatable method of targeted opening of the blood-brain barrier to treat metastatic brain diseases. MR-guided focused ultrasound is a potential solution to these design requirements. The safety, feasibility and preliminary efficacy of MRgFUS aided delivery have been demonstrated in various animal models. In this review, we discuss this preclinical evidence, mechanisms of focused ultrasound mediated blood-brain barrier opening, and translational efforts to neuro-oncology patients.
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Affiliation(s)
- Ying Meng
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Suganth Suppiah
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Shanan Surendrakumar
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Luca Bigioni
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
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