Survival and intracranial control outcomes of whole-brain radiotherapy (WBRT) alone versus WBRT plus a radiotherapy boost in non-small-cell lung cancer with brain metastases: a single-institution retrospective analysis

Efficacy of Whole-Brain Radiotherapy Plus Simultaneous Integrated Boost (SIB-WBRT) for Lung Cancer Brain Metastases

Objective: To investigate the outcomes of SIB-WBRT in patients with brain metastases and analyze the impact of some factors on prognosis. Materials and Methods: This single-arm retrospective study analyzed patients with brain metastases who were treated with SIB-WBRT at Peking Union Medical College Hospital from September 2015 to December 2021. The primary endpoint was intracranial progression free survival (iPFS). Secondary endpoints included overall survival (OS), intracranial new foci, and tumor control. The Kaplan-Meier method was then used to depict and estimate iPFS, OS, intracranial neoplasia, and tumor control. Finally, the Cox model was used to analyze the association between some relevant factors and outcomes. Results: A total of 107 patients were included and the median iPFS in these patients treated with SIB-WBRT was 13.4 (95% CI: 4.2-22.6) months, with 68.0% (95% CI: 57.4%-78.6%) and 50.8% (95% CI: 38.3%-63.3%) iPFS at 6- and 12-months. The median local control was 37.6 (95% CI: 28.3-46.8) months, with local control rates of 84.3% (95% CI: 80.6%-88.0%) and 73.3% (95% CI: 68.2%-78.4%) at 6- and 12-months. The median time to appearance of new intracranial foci was 17.4 (95% CI: 14.1-20.8) months, and the 6- and 12-month control rates were 74.5% (95% CI: 64.5%-84.5%) and 61.5% (95% CI: 49.0%-74.0%). The number of brain metastases in patients before treatment was significantly associated with iPFS (HR=0.4, 95% CI: 0.2-0.973, P=0.043). Conclusions: The iPFS, local control, and intracranial new foci of patients with brain metastases after treatment with SIB-WBRT were acceptable. In addition, the number of brain metastases in patients before treatment may be associated with iPFS.

Adding simultaneous integrated boost to whole brain radiation therapy improved intracranial tumour control and minimize radiation-induced brain injury risk for the treatment of brain metastases

BACKGROUND

Brain metastases (BMs) are the most frequent intracranial tumours associated with poor clinical outcomes. Radiotherapy is essential in the treatment of these tumours, although the optimal radiation strategy remains controversial. The present study aimed to assess whether whole brain radiation therapy with a simultaneous integrated boost (WBRT + SIB) provides any therapeutic benefit over WBRT alone.

METHODS

We included and retrospectively analysed 82 patients who received WBRT + SIB and 83 who received WBRT alone between January 2012 and June 2021. Intracranial progression-free survival (PFS), local tumour control (LTC), overall survival (OS), and toxicity were compared between the groups.

RESULTS

Compared to WBRT alone, WBRT + SIB improved intracranial LTC and PFS, especially in the lung cancer subgroup. Patients with high graded prognostic assessment score or well-controlled extracranial disease receiving WBRT + SIB had improved intracranial PFS and LTC. Moreover, WBRT + SIB also improved the long-term intracranial tumour control of small cell lung cancer patients. When evaluating toxicity, we found that WBRT + SIB might slightly increase the risk of radiation-induced brain injury, and that the risk increased with increasing dosage. However, low-dose WBRT + SIB had a tolerable radiation-induced brain injury risk, which was lower than that in the high-dose group, while it was comparable to that in the WBRT group.

CONCLUSIONS

WBRT + SIB can be an efficient therapeutic option for patients with BMs, and is associated with improved intracranial LTC and PFS. Furthermore, low-dose WBRT + SIB (biologically effective dose [BED] ≤ 56 Gy) was recommended, based on the acceptable risk of radiation-induced brain injury and satisfactory tumour control.

TRIAL REGISTRATION

Retrospectively registered.

Real-world analysis of different intracranial radiation therapies in non-small cell lung cancer patients with 1–4 brain metastases

Purpose

Stereotactic radiosurgery (SRS) has become a standard approach for the treatment of patients with few metastatic brain lesions. However, the optimal treatment approach for the use radiotherapy in the treatment of non-small cell lung cancer (NSCLC) patients with brain metastases (BMs) remain unclear. This study aimed to compare the survival outcomes and intracranial local control in NSCLC patients with 1–4 BMs who are treated with SRS using linear accelerators (LINAC-SRS), whole-brain radiotherapy (WBRT), or WBRT plus radiotherapy boost (WBRT + RTB).

Materials and methods

We retrospectively analyzed 156 NSCLC patients with 1–4 BMs who received LINAC-SRS, WBRT, and WBRT + RTB. The median overall survival (OS), intracranial progression-free survival (iPFS), and distant brain failure-free survival (DBF-FS) and related prognostic factors were analyzed.

Results

The median follow-up period was 31.6 months. The median OS times in the LINAC-SRS, WBRT, and WBRT + RTB groups were not reached, 33.3 months and 27.9 months, respectively. The difference in survival rate was non-significant (P = 0.909). The 2-year iPFS and DBF-FS rates in the LINAC-SRS, WBRT and WBRT + RTB groups were 51.6% and 37.5%; 42.0% and 50.4%; and 51.1% and 56.1%, respectively. There was no significant difference in 2-year iPFS or DBF-FS among the three groups (P = 0.572 for iPFS, P = 0.628 for DBF-FS). Multivariate analysis showed that the independent adverse prognostic factors for OS, iPFS, and DBF-FS were neurological symptoms, recursive partitioning analysis (RPA) class, and targeted therapy.

Conclusion

LINAC-SRS did not result in significantly superior survival times or intracranial local control compared to WBRT or WBRT + RTB in the treatment of NSCLC patients with 1–4 BMs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-10083-8.

Analysis of Immunotherapy Combined with Radiotherapy in Patients with Brain Metastasis of Driver Gene-Negative Non-Small-Cell Lung Cancer

Purpose. To observe the remission rate and side effects of immunotherapy combined with radiotherapy in patients with brain metastasis of driver gene-negative non-small-cell lung cancer (NSCLC). Methods. 152 patients with NSCLC brain metastasis admitted to our hospital from January 2019 to December 2021 were selected as the research objects. Patients were divided into a single group (85 cases) and a combined group (67 cases) according to treatment methods. The therapeutic effects and side effects of the single group and combined group were compared. In addition, the patients who received immunotherapy combined with radiotherapy were divided into three subgroups: A, B, and C, and the therapeutic effects and side effects of different radiotherapy modes were compared among group A [whole brain radiotherapy (WBRT)], group B (WBRT combined with local radiotherapy) and group C (local radiotherapy). Results. The objective response rate (ORR) and disease control rate (DCR) in the combined group were higher than those in the single group ( $P<0.05$ ). The incidence of reactive capillary hyperplasia and immune-related pneumonia in the combined group were higher than that in the single group ( $P<0.05$ ). There was no significant difference in the incidence of other side effects between the two groups ( $P>0.05$ ). ORR and DCR in group B were higher than those in group A ( $P<0.05$ ). There was no significant difference in the incidence of side effects among the three groups ( $P>0.05$ ). Conclusion. Immunotherapy combined with radiotherapy is effective in patients with brain metastasis of driver gene-negative NSCLC, which can improve the disease control rate without increasing the side effects. In addition, WBRT combined with local push radiotherapy is effective and safe. Clinical Study Registration Number. The Clinical study registration number is K2019086.

Time taken for a primary tumor to metastasize to the brain and the overall survival of patients with brain metastasis: An analysis of outcomes and factors affecting survival

BACKGROUND:

Brain metastasis (BM) is one of the main causes of high morbidity and mortality in cancer patients.

OBJECTIVE:

To evaluate the factors that influenced the survival time of patients with primary cancer and survival time after BM.

METHODS:

Ninety patients with BM diagnosed by magnetic resonance imaging (MRI) were included in the study. We retrospectively analyzed the time to brain metastasis (TTB), overall survival time (OS1) and survival time after BM (OS2). The Kaplan-Meier method and Cox regression analysis were used for survival analyses.

RESULTS:

The median TTB was 12.0 (95% CI: 9.2–14.8 months), the median OS1 was 31.0 (95% CI: 25.8–35.2 months) and the median OS2 was 14.0 (95% CI: 10.9–17.1 months). Surgical excision of the primary tumor was an independent factor for a prolonged TTB (p< 0.000) and prolonged OS1 (p< 0.000). A single intracranial metastatic lesion was an independent protective factor for prolonged OS1 (p= 0.011) and prolonged OS2 (p= 0.050). TTB, OS1 and OS2 were analyzed with Gender (p< 0.000, < 0.000, and = 0.017, respectively).

CONCLUSIONS:

It suggests that TTB can be prolonged by primary tumor resection. Furthermore, women with a prolonged TTB and single intracranial metastasis are associated with high OS. These were helpful for the clinical treatment of BM patients before brain metastasis.

The effect of smoking on survival in lung carcinoma patients with brain metastasis: a systematic review and meta-analysis

The effects of smoking on survival in BM patients have yet to be reviewed and meta-analysed. However, previous studies have shown that smokers had a greater risk of dying from lung cancer compared to non-smokers. This meta-analysis, therefore, aimed to analyse the effects of cigarette smoking on overall survival (OS) and progression-free survival (PFS) in lung cancer BM patients. PubMed, Embase, Web of Science, Cochrane and Google Scholar were searched for comparative studies regarding the effects of smoking on incidence and survival in brain metastases patients up to December 2020. Three independent reviewers extracted overall survival (OS) and progression-free survival data (PFS). Random-effects models were used to pool multivariate-adjusted hazard ratios (HR). Out of 1890 studies, fifteen studies with a total of 2915 patients met our inclusion criteria. Amongst lung carcinoma BM patients, those who were smokers (ever or yes) had a worse overall survival (HR: 1.34, 95% CI 1.13, 1.60, I2: 72.1%, p-heterogeneity < 0.001) than those who were non-smokers (never or no). A subgroup analysis showed the association to remain significant in the ever/never subgroup (HR: 1.34, 95% CI 1.11, 1.63) but not in the yes/no smoking subgroup (HR: 1.30, 95% CI 0.44, 3.88). This difference between the two subgroups was not statistically significant (p = 0.91). Amongst lung carcinoma BM patients, smoking was associated with a worse OS and PFS. Future studies examining BMs should report survival data stratified by uniform smoking status definitions.

Treatment for Brain Metastases: ASCO-SNO-ASTRO Guideline

PURPOSE

To provide guidance to clinicians regarding therapy for patients with brain metastases from solid tumors.

METHODS

ASCO convened an Expert Panel and conducted a systematic review of the literature.

RESULTS

Thirty-two randomized trials published in 2008 or later met eligibility criteria and form the primary evidentiary base.

RECOMMENDATIONS

Surgery is a reasonable option for patients with brain metastases. Patients with large tumors with mass effect are more likely to benefit than those with multiple brain metastases and/or uncontrolled systemic disease. Patients with symptomatic brain metastases should receive local therapy regardless of the systemic therapy used. For patients with asymptomatic brain metastases, local therapy should not be deferred unless deferral is specifically recommended in this guideline. The decision to defer local therapy should be based on a multidisciplinary discussion of the potential benefits and harms that the patient may experience. Several regimens were recommended for non-small-cell lung cancer, breast cancer, and melanoma. For patients with asymptomatic brain metastases and no systemic therapy options, stereotactic radiosurgery (SRS) alone should be offered to patients with one to four unresected brain metastases, excluding small-cell lung carcinoma. SRS alone to the surgical cavity should be offered to patients with one to two resected brain metastases. SRS, whole brain radiation therapy, or their combination are reasonable options for other patients. Memantine and hippocampal avoidance should be offered to patients who receive whole brain radiation therapy and have no hippocampal lesions and 4 months or more expected survival. Patients with asymptomatic brain metastases with either Karnofsky Performance Status ≤ 50 or Karnofsky Performance Status < 70 with no systemic therapy options do not derive benefit from radiation therapy.Additional information is available at www.asco.org/neurooncology-guidelines.

Whole-Brain Radiation Therapy With Simultaneous Integrated Boost Versus Whole-Brain Radiation Therapy Plus Stereotactic Radiosurgery for the Treatment of Brain Metastasis From Lung Cancer

Radiotherapy is one of the most important treatments for brain metastasis (BM). This study aimed to assess whether whole-brain radiation therapy (WBRT) with simultaneous integrated boost (SIB) provided any therapeutic benefit compared to WBRT followed by stereotactic radiosurgery (SRS). Seventy-two consecutive cases of lung cancer with BM treated from January 2014 to June 2020 were analyzed retrospectively. Thirty-seven patients were treated with WBRT (30 Gy in 10 fractions) and SIB (45 Gy in 10 fractions), and 35 patients were treated with WBRT (30 Gy in ten fractions) followed by SRS (16–24 Gy according to the maximum tumor diameter). The primary endpoint was intracranial progression-free survival (PFS). The secondary endpoints were intracranial objective response (partial and complete responses), pattern of intracranial progression, overall survival (OS), and toxicity. The WBRT + SIB group had a significantly longer median intracranial PFS (9.1 vs. 5.9 months, P = 0.001) than the WBRT + SRS group. The intracranial objective response rate was 67.6% and 62.9% in the WBRT + SIB and in WBRT + SRS groups, respectively (P = 0.675). The incidence of progression outside the P-GTV in the WBRT + SIB group was significantly lower than that in the WBRT + SRS group (39.4% vs. 75.0%, P = 0.004). The median OS was 24.3 and 20.3 months in the WBRT + SIB and WBRT + SRS groups, respectively (P = 0.205). There was no significant difference in the incidence of grade 3 or worse adverse reactions between the two groups. Compared to treatment with WBRT + SRS, that with WBRT + SIB for BM appeared to contribute to local control.

Brain metastases from lung cancer with neuropsychiatric symptoms as the first symptoms

Background

To investigate the neuropsychiatric symptoms and their treatment and outcomes in lung cancer patients with brain metastases (BM), with an attempt to achieve early detection and prompt management of these symptoms.

Methods

Ten lung cancer patients (8 males and 2 females) with BMs who were treated in our center from 2013 to 2019 were enrolled in this analysis. Without exception, all 10 patients presented with chief complaints of neuropsychiatric symptoms, and BMs were eventually diagnosed. Appropriate treatments were offered, and all patients were followed up.

Results

Two patients died (case 5 died of sudden massive hemoptysis, and case 6 died after his families refused to receive the invasive treatment). Data on 3- and 5-year survival have been obtained from one patient each. The average follow-up duration was 19.4 months (except that two patients were hospitalized only once, and one patient received the second follow-up visit only 9 days after the first visit).

Conclusions

The possibility of BM from lung cancer should be considered when a lung cancer patient develops neuropsychiatric symptoms, and timely diagnosis treatment should be arranged accordingly.