Chemotherapy and EGFR tyrosine kinase inhibitors for treatment of brain metastases from non-small-cell lung cancer: survival analysis in 210 patients

A Bayesian meta-analysis on MRI-based radiomics for predicting EGFR mutation in brain metastasis of lung cancer

OBJECTIVES

This study aimed to investigate the diagnostic test accuracy of MRI-based radiomics studies for predicting EGFR mutation in brain metastasis originating from lung cancer.

METHODS

This meta-analysis, conducted following PRISMA guidelines, involved a systematic search in PubMed, Embase, and Web of Science up to November 3, 2024. Eligibility criteria followed the PICO framework, assessing population, intervention, comparison, and outcome. The RQS and QUADAS-2 tools were employed for quality assessment. A Bayesian model determined summary estimates, and statistical analysis was conducted using R and STATA software.

RESULTS

Eleven studies consisting of nine training and ten validation cohorts were included in the meta-analysis. In the training cohorts, MRI-based radiomics showed robust predictive performance for EGFR mutations in brain metastases, with an AUC of 0.90 (95% CI: 0.82-0.93), sensitivity of 0.84 (95% CI: 0.80-0.88), specificity of 0.86 (95% CI: 0.80-0.91), and a diagnostic odds ratio (DOR) of 34.17 (95% CI: 19.16-57.49). Validation cohorts confirmed strong performance, with an AUC of 0.91 (95% CI: 0.69-0.95), sensitivity of 0.79 (95% CI: 0.73-0.84), specificity of 0.88 (95% CI: 0.83-0.93), and a DOR of 31.33 (95% CI: 15.50-58.3). Subgroup analyses revealed notable trends: the T1C + T2WI sequences and 3.0 T scanners showed potential superiority, machine learning-based radiomics and manual segmentation exhibited higher diagnostic accuracy, and PyRadiomics emerged as the preferred feature extraction software.

CONCLUSION

This meta-analysis suggests that MRI-based radiomics holds promise for the non-invasive prediction of EGFR mutations in brain metastases of lung cancer.

Tumor Targeted Polymer Nanoparticles Co-loaded with Docetaxel and siCCAT2 for Combination Therapy of Lung Cancer

Multi-drug resistance (MDR) is the major hindrances toward the successful treatment of malignant lung cancer. The aim of this study was to develop a novel nanoparticle co-loaded with docetaxel (DTX) and si-colon cancer-associated transcript-2 (siCCAT2) (NP-DTX/siCCAT2) for overcoming the DTX-resistant non-small cell lung cancer (NSCLC). The NP-DTX/siCCAT2, developed by DTX-conjugated poly (D,L-lactic-co-glycolic acid) (PLGA) copolymers, has an average size of t 87.26 nm. Further modification of Transferrin (Tf) peptides on the surface of NP-DTX/siCCAT2 did not significantly change the particle size with an average diameter of 96.81 nm. The present study demonstrated that TfNP-DTX/siCCAT2 has excellent tumor targeting ability and resulted in an enhanced anti-tumor effect both in vitro and in vivo experiments. Not unexpectedly, more excellent anti-tumor effect of NP-DTX/siCCAT2 was obtained than the NP-DTX because of that that silencing of CCAT2 levels in lung cancer cells resulted in down-regulated expressions of P-glycoprotein (P-gp) and multidrug-resistance-associated proteins 1 (MRP1). Further investigation revealed that inhibition of CCAT2 expression dramatically increased the activity of miR-204-3p and thereby signally suppressed the IGFBP2/AKT/Bcl2 pathway.

The Tumor Control According to Radiation Dose of Gamma Knife Radiosurgery for Small and Medium-Sized Brain Metastases from Non-Small Cell Lung Cancer

Objective

The effectiveness of gamma knife radiosurgery (GKR) in the treatment of brain metastases is well established. The aim of this study was to evaluate the efficacy and safety of maximizing the radiation dose in GKR and the factors influencing tumor control in cases of small and medium-sized brain metastases from non-small cell lung cancer (NSCLC).

Methods

We analyzed 230 metastatic brain tumors less than 5 mL in volume in 146 patients with NSCLC who underwent GKR. The patients had no previous radiation therapy for brain metastases. The pathologies of the tumors were adenocarcinoma (n=207), squamous cell carcinoma (n=18), and others (n=5). The radiation doses were classified as 18, 20, 22, and 24 Gy, and based on the tumor volume, the tumors were categorized as follows : small-sized (less than 1 mL) and medium-sized (1–3 and 3–5 mL). The progression-free survival (PFS) of the individual 230 tumors and 146 brain metastases was evaluated after GKR depending on the pathology, Eastern Cooperative Oncology Group (ECOG) performance score (PS), tumor volume, radiation dose, and anti-cancer regimens. The radiotoxicity after GKR was also evaluated.

Results

After GKR, the restricted mean PFS of individual 230 tumors at 24 months was 15.6 months (14.0–17.1). In small-sized tumors, as the dose of radiation increased, the tumor control rates tended to increase (p=0.072). In medium-sized tumors, there was no statistically difference in PFS with an increase of radiation dose (p=0.783). On univariate analyses, a statistically significant increase in PFS was associated with adenocarcinomas (p=0.001), tumors with ECOG PS 0 (p=0.005), small-sized tumors (p=0.003), radiation dose of 24 Gy (p=0.014), synchronous lesions (p=0.002), and targeted therapy (p=0.004). On multivariate analyses, an improved PFS was seen with targeted therapy (hazard ratio, 0.356; 95% confidence interval, 0.150–0.842; p=0.019). After GKR, the restricted mean PFS of brain at 24 months was 9.8 months (8.5–11.1) in 146 patients, and the pattern of recurrence was mostly distant within the brain (66.4%). The small and medium-sized tumors treated with GKR showed radiotoxicitiy in five out of 230 tumors (2.2%), which were controlled with medical treatment.

Conclusion

The small-sized tumors were effectively controlled without symptomatic radiation necrosis as the radiation dose was increased up to 24 Gy. The medium-sized tumors showed potential for symptomatic radiation necrosis without signifcant tumor control rate, when greater than 18 Gy. GKR combined targeted therapy improved the tumor control of GKR-treated tumors.

The impact of treatment facility type on the survival of brain metastases patients regardless of the primary cancer type

BACKGROUND

Cancer patients with brain metastases (BMs) require multidisciplinary care, and treatment facility may play a role. This study aimed to investigate the impact of receiving treatment at academic centers on the overall survival (OS) of cancer patients with brain metastases (BMs) regardless of the primary cancer site.

METHODS

This retrospective analysis of the National Cancer Database (NCDB) included patients diagnosed with non-small cell lung cancer, small-cell lung cancer, other types of lung cancer, breast cancer, melanoma, colorectal cancer, and kidney cancer and had brain metastases at the time of diagnosis. The data were extracted from the de-identified file of the NCDB, a joint program of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. The Cox proportional hazard model adjusted for age at diagnosis, race, sex, place of living, income, education, primary tumor type, year of diagnosis, chemotherapy, radiation therapy (RT), and surgery of the primary cancer site was used to determine treatment facility-associated hazard ratios (HR) for survival. Overall survival was the primary outcome, which was analyzed with multivariable Cox proportional hazards regression modeling.

RESULTS

A total of 93,633 patients were analyzed, among whom 31,579/93,633 (34.09%) were treated at academic centers. Based on the log-rank analysis, patients who received treatment at an academic facility had significantly improved OS (median OS: 6.18, CI: 6.05-6.31 vs. 4.57, CI: 4.50-4.63 months; p < 0.001) compared to patients who were treated at non-academic facilities. In the multivariable Cox regression analysis, receiving treatment at an academic facility was associated with significantly improved OS (HR: 0.85, CI: 0.84-0.87; p < 0.001) compared to non-academic facility.

CONCLUSIONS

In this extensive analysis of the NCDB, receiving treatment at academic centers was associated with significantly improved OS compared to treatment at non-academic centers.

Novel Treatment For Non-Small Cell Lung Cancer With Brain Metastases

Brain metastases is common in patients with non-small cell lung cancer (NSCLC) and it is associated with poorer prognosis. Several options to control the secondary brain tumors in the context include chemotherapy, whole-brain radiation, stereotactic surgery, surgery. However, chemotherapy is ineffective to those patients because of poor penetration through the blood-brain barrier. Whole-brain radiation therapy used to be a standard option for brain metastases. However, it potentially damages normal brain tissues and causes neurocognitive decline. Stereotactic radiotherapy has been considered in cases of three or fewer lesions, and the lesions less than 3 cm. In selective cases, surgical removal of brain metastases can be done. These local therapies were accompanied by systemic treatment due to spreading of the cancer. Recently, molecular targeted therapy has opened up a new era in cancer treatment, especially NSCLC with brain metastases. In this review, we discuss brain metastases occurring in NSCLC patients with driver gene mutations with some briefly demonstrated cases.

Association of Immunotherapy With Survival Among Patients With Brain Metastases Whose Cancer Was Managed With Definitive Surgery of the Primary Tumor

IMPORTANCE

Immunotherapy has shown significant control of intracranial metastases in patients with melanoma. However, the association of immunotherapy combined with other cancer treatments and overall survival (OS) of patients with brain metastases, regardless of primary tumor site, is unknown.

OBJECTIVE

To explore the association of immunotherapy with OS in patients with cancer and brain metastases who received definitive surgery of the primary site.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness study included 3112 adult patients in the National Cancer Database from 2010 to 2016 with non-small cell lung cancer, breast cancer, melanoma, colorectal cancer, or kidney cancer and brain metastases at the time of diagnosis and who received definitive surgery of the primary site. Data analysis was conducted from March to April 2020.

EXPOSURES

Treatment groups were stratified as follows: (1) any treatment with or without immunotherapy, (2) chemotherapy with or without immunotherapy, (3) radiotherapy (RT) with or without immunotherapy, and (4) chemoradiation with or without immunotherapy.

MAIN OUTCOMES AND MEASURES

The association of immunotherapy with OS was assessed with Cox proportional hazards regression, adjusted for age at diagnosis, race, sex, place of living, income, education, treatment facility type, primary tumor type, and year of diagnosis.

RESULTS

Of 3112 patients, 1436 (46.14%) were men, 2714 (87.72%) were White individuals, 257 (8.31%) were Black individuals, and 123 (3.98%) belonged to other racial and ethnic groups. The median (range) age at diagnosis was 61 (19-90) years. Overall, 183 (5.88%) received immunotherapy, 318 (10.22%) received chemotherapy alone, 788 (25.32%) received RT alone, and 1393 (44.76%) received chemoradiation alone; 22 (6.47%) received chemotherapy plus immunotherapy, 72 (8.37%) received RT plus immunotherapy, and 76 (5.17%) received chemoradiation plus immunotherapy. In the multivariable analysis, patients who received immunotherapy had significantly improved OS compared with no immunotherapy (hazard ratio, 0.62; 95% CI, 0.51-0.76; P < .001). Treatment with RT plus immunotherapy was associated with significantly improved OS compared with RT alone (hazard ratio, 0.59; 95% CI, 0.42-0.84; P = .003). Chemotherapy plus immunotherapy or chemoradiation plus immunotherapy were not associated with improved OS in the multivariable analysis.

CONCLUSIONS AND RELEVANCE

In this study, the addition of immunotherapy to RT was associated with improved OS compared with radiotherapy alone in patients with brain metastases who received definitive surgery of the primary tumor site.

Radiologic Complete Response In Lung Adenocarcinoma With Symptomatic Brain Metastasis After Systematic Therapy: A Case Study

Patients diagnosed as lung adenocarcinoma with brain metastasis usually result in poor prognosis with limited survival time. Palliative systematic therapy has emerged as the primary choice for non-small cell lung cancer patients with brain metastasis harboring wild-type drive genes. However, the objective response rate and long-term survival for patients treated with this therapy remained unsatisfied. Herein, we present a case with lung adenocarcinoma accompanied with symptomatic brain metastasis who achieved radiologic complete response after receiving combined therapy including stereotactic body radiation therapy, anti-angiogenesis, and chemotherapy. He has achieved a duration of disease-free survival of thirty-six months, and is still in extension.

From Whole-Brain Radiotherapy to Immunotherapy: A Multidisciplinary Approach for Patients with Brain Metastases from NSCLC

Non-small cell lung cancer patients with brain metastases have a multitude of treatment options, but there is currently no international and multidisciplinary consensus concerning their optimal treatment. Local therapies have the principal role, especially in symptomatic patients. Advances in surgery and radiation therapy manage considerable local control. Systemic treatments have shown effect in clinical trials and in real life clinical settings; yet, at present, this is restricted to patients with asymptomatic or stable intracranial lesions. Targeted agents can have a benefit only in patients with EGFR mutations or ALK rearrangement. Immunotherapy has shown impressive results in patients with PD-L1 expression in tumor cells. Its effects can be further enhanced by a synergy with radiotherapy, possibly by increasing the percentage of responders. The present review summarizes the need for more effective systemic treatments, so that the increased intracranial control achieved by local treatments can be translated in an increase in overall survival.

Efficacy and Safety of Radiotherapy Plus EGFR-TKIs in NSCLC Patients with Brain Metastases: A Meta-Analysis of Published Data

Background: The role of radiotherapy (RT) combined with epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) in non-small cell lung cancer (NSCLC) patients with brain metastasis (BM) remains controversial. Therefore, we conducted a meta-analysis to comprehensively evaluate the efficacy and safety of RT plus EGFR-TKIs in those patients. Materials and Methods: Relevant literatures published between 2012 and 2017 were searched. Objective response rate(ORR), disease control rate (DCR), overall survival (OS), intracranial progression-free survival (I-PFS) and adverse events (AEs) were extracted. The combined hazard ratios (HRs) and relative risks (RRs) were calculated using random effects models. Results: Twenty-four studies (2810 patients) were included in the analysis. Overall, RT plus EGFR-TKIs had higher ORR (RR = 1.32, 95%CI: 1.13–1.55), DCR (RR = 1.12, 95%CI: 1.04–1.22), and longer OS (HR = 0.72, 95%CI: 0.59–0.89), I-PFS (HR = 0.64, 95%CI: 0.50–0.82) than monotherapy, although with higher overall AEs (20.2% vs 11.8%, RR = 1.34, 95% CI: 1.11–1.62). Furthermore, subgroup analyses found concurrent RT plus EGFR-TKIs could prolong OS (HR = 0.69, 95%CI: 0.55–0.86) and I-PFS (HR = 0.57, 95%CI: 0.44–0.75). Asian ethnicity and lung adenocarcinoma (LAC) patients predicted a more favorable prognosis (HR = 0.69,95%CI: 0.54–0.88, HR = 0.66, 95%CI: 0.53–0.83, respectively). Conclusion: RT plus EGFR-TKIs had higher response rate, longer OS and I-PFS than monotherapy in NSCLC patients with BM. Asian LAC patients with EGFR mutation had a better prognosis with concurrent treatment. The AEs of RT plus EGFR-TKIs were tolerated.

Medical Treatment Options for Patients with Epidermal Growth Factor Receptor Mutation-Positive Non-Small Cell Lung Cancer Suffering from Brain Metastases and/or Leptomeningeal Disease

Brain metastases and/or leptomeningeal disease (LMD) with associated central nervous system (CNS) metastases are known complications of advanced epidermal growth factor receptor (EGFR) mutation-positive non-small cell lung cancer (NSCLC). It is important, therefore, to assess the activity of EGFR tyrosine kinase inhibitors (TKIs) versus such CNS complications. This review explores the literature reporting the intracranial activity of EGFR TKIs, and finds that there is evidence for varying efficacy of the approved agents, erlotinib, gefitinib, afatinib, and osimertinib in patients with CNS metastases. Other EGFR TKIs in development, such as AZD3759, may have a future role as therapeutic options in this setting. Emerging evidence indicates that the second- and third-generation EGFR TKIs, afatinib and osimertinib, effectively penetrate the blood-brain barrier, and therefore represent viable treatment options for CNS lesions, and can reduce the risk of CNS progression. These agents should therefore be considered as first-line treatment options in patients with EGFR mutation-positive NSCLC who have brain metastases and/or LMD. While there are currently no prospective data comparing the intracranial efficacy of second- and third-generation EGFR TKIs in this setting, CNS activity and protection offered by different EGFR TKIs should be an additional consideration when making decisions about the optimal sequence of treatment with EGFR TKIs in order to maximize survival benefit in individual patients.

Brain metastases in non-small-cell lung cancer: are tyrosine kinase inhibitors and checkpoint inhibitors now viable options?

Significant progress has been made in the treatment of stage iv non-small-cell lung cancer (nsclc); however, the prognosis of patients with brain metastases remains poor. Resection and radiation therapy remain standard options. This issue is an important one because 10% of patients with nsclc have brain metastases at diagnosis, and 25%-40% develop brain metastases during their disease. Standard chemotherapy does not cross the blood-brain barrier. However, there is new hope that tyrosine kinase inhibitors (tkis) used in patients with identified targetable mutations such as mutations of EGFR and rearrangements of ALK could have activity in the central nervous system (cns). Furthermore, immunotherapy is increasingly becoming a standard option for patients with nsclc, and interest about the intracranial activity of those agents is growing. This review presents current data about the cns activity of the available major tkis and immunotherapy agents.

Prognostic value of cancer antigen -125 for lung adenocarcinoma patients with brain metastasis: A random survival forest prognostic model

Using random survival forest, this study was intended to evaluate the prognostic value of serum markers for lung adenocarcinoma patients with brain metastasis (BM), and tried to integrate them into a prognostic model. During 2010 to 2015, the patients were retrieved from two medical centers. Besides the Cox proportional hazards regression, the random survival forest (RSF) were also used to develop prognostic model from the group A (n = 142). In RSF of the group A, the factors, whose minimal depth were greater than the depth threshold or had a negative variable importance (VIMP), were firstly excluded. Subsequently, C-index and Akaike information criterion (AIC) were used to guide us finding models with higher prognostic ability and lower overfitting possibility. These RSF models, together with the Cox, modified-RPA and lung-GPA index were validated and compared, especially in the group B (CAMS, n = 53). Our data indicated that the KSE125 model (KPS, smoking, EGFR-20 (exon 18, 19 and 21) and Ca125) was the best in survival prediction, and performed well in internal and external validation. In conclusions, for lung adenocarcinoma patients with brain metastasis, a validated prognostic nomogram (KPS, smoking, EGFR-20 and Ca125) can more accurately predict 1-year and 2-year survival of the patients.

Tyrosine kinase inhibitors show different anti-brain metastases efficacy in NSCLC: A direct comparative analysis of icotinib, gefitinib, and erlotinib in a nude mouse model

Brain metastasis is an increasing problem in non-small cell lung cancer (NSCLC) patients. Tyrosine kinase inhibitors (TKIs), including gefitinib, erlotinib, and icotinib, are reported to be effective in patients with brain metastases. However, direct comparative studies of the pharmacokinetics and efficacy of these three drugs in treating brain metastases are lacking. In the present investigation, we found that gefitinib penetrated the blood-tumor barrier and was distributed to brain metastases more effectively than erlotinib or icotinib in a nude mouse model. The 1-h ratio of brain metastases to plasma concentration for gefitinib, erlotinib, and icotinib was 9.82±1.03%, 4.83±0.25%, and 2.62±0.21%, respectively. The 2-h ratio of brain metastases to plasma concentration for gefitinib, erlotinib, and icotinib was 15.11±2.00%, 5.73±1.31%, and 2.69±0.31%, respectively. Gefitinib exhibited the strongest antitumor activity (p_{gefitinib vs. erlotinib}=0.005; p_{gefitinib vs. icotinib}=0.002). Notably, erlotinib exhibited a better treatment efficacy than icotinib (p=0.037). Consistently, immunohistochemical data showed that TKIs differentially inhibit the proliferation of metastatical tumor cells. Gefitinib and erlotinib markedly inhibited the proliferation of tumor cells, while there were more ki-67-positive tumor cells in the icotinib group. Additionally, gefitinib inhibited the phosphorylation of EGFR better than the other drugs, whereas pEGFR expression levels in erlotinib groups were lower than levels in the icotinib group (p_{gefitinib vs. erlotinib}=0.995; p_{gefitinib vs. icotinib}=0.028; p_{erlotinib vs. icotinib}=0.042).Altogether, our findings suggest that gefitinib and erlotinib can inhibit the growth of PC-9-luc brain tumors. Gefitinib demonstrated better antitumor activity and penetration rate in brain metastases than erlotinib or icotinib.

[Research Progress of EGFR-TKI Therapy for Patients with Central Nervous System Metastases from Non-small Cell Lung Cancer]

Approximately half of all patients with non-small cell lung cancer (NSCLC) develop central nervous system metastases during the course of their disease which indicate poor prognosis. A part of NSCLC patients demonstrates activating epidermal growth factor receptor gene (EGFR) mutations who represent effectiveness and well tolerance of EGFR-specific tyrosine kinase inhibitors (TKIs) therapy. Although the systemic efficacy of targeted agents is established, the efficacy of central nervous system (CNS) metastases is not as well characterized. In this article, we review recent data on the use of EGFR inhibitors for treatment of patients with NSCLC and CNS metastases.

Pemetrexed/cisplatin as first-line chemotherapy for advanced lung cancer with brain metastases: A case report and literature review

BACKGROUND

Brain metastases (BMs) are a common and serious complication of non-small cell lung cancer (NSCLC). Whole-brain radiotherapy (WBRT), surgery, and molecular targeted therapy are usually used to treat NSCLC with BM. Chemotherapeutic options for BM are limited by tumor resistance, ineffective agents, and the blood-brain barrier. Pemetrexed/cisplatin is the preferred chemotherapy in nonsquamous NSCLC, but the efficacy of this treatment for nonsquamous NSCLC with BM is uncertain.

METHODS

We present a case of nonsquamous NSCLC with asymptomatic BM presenting with irritating cough and right shoulder back pain (unknown sensitizing epidermal growth factor receptor mutations or anaplastic lymphoma kinase).

RESULTS

He benefited from administration of first-line chemotherapy of pemetrexed/cisplatin. Partial remission was achieved in the primary lesion of the lungs and BM lesion. He was further given 3 cycles of pemetrexed monotherapy and WBRT. Complete remission was further achieved in BM lesion.

CONCLUSION

The findings of clinical trials and theoretical studies about the current pemetrexed/cisplatin in the treatment of nonsquamous NSCLC with BM are also summarized to provide a reference for the application of pemetrexed/cisplatin in nonsquamous NSCLC with BM. Whether or not pemetrexed/cisplatin is definitely effective in nonsquamous NSCLC with BM must be proven by subsequent phase III clinical trials.

Evaluation on efficacy and safety of tyrosine kinase inhibitors plus radiotherapy in NSCLC patients with brain metastases

Objective

The study was designed to evaluate the efficacy and safety of tyrosine kinase inhibitors (TKIs) plus radiotherapy in patients with brain metastases (BM) of non-small cell lung cancer.

Methods

Medline PubMed, Google Scholar, Web of Science, Oxford Journals Collection, clinical trials and current controlled trials were searched to identify relevant publications. After screening literature and undertaking quality assessment and data extraction, the meta-analysis was performed using RevMan5.3 software.

Results

Eight controlled trials (980 participants) were included in the study. Compared with radiotherapy without TKIs (non-TKI-group), TKIs plus radiotherapy (TKI-group) had a significant benefit on objective response rate (ORR) (RR = 1.56, 95%CI [1.25,2.03]; P =0.0008), significantly prolonged the time to central nerves system progression (CNS-TTP) (HR =0.58, 95% CI [0.35, 0.96]; P =0.03) and median overall survival (MOS) (HR =0.68, 95% CI [0.47, 0.98]; P =0.04) of NSCLC patients with BM. There was no significant difference in overall severe adverse events (Grade≥3) (RR = 1.49, 95% CI [0.88,2.54]; P = 0.14) between two groups.

Conclusion

This meta-analysis showed TKI-group produced superior response rate when compared with non-TKI-group. TKIs plus radiotherapy significantly prolong the CNS-TTP and MOS of patients without enhancing overall severe adverse events.

Targeted therapy combined with radiotherapy in non-small-cell lung cancer: a review of the Oncologic Group for the Study of Lung Cancer (Spanish Radiation Oncology Society)

In recent years, major advances in our understanding of the molecular biology of lung cancer, together with significant improvements in radiotherapy technologies, have revolutionized the treatment of non-small cell lung cancer (NSCLC). This has led to the development of new therapies that target molecular mutations specific to each tumor type, acting on the cell surface antigens or intracellular signaling pathways, or directly affecting cell survival. At the same time, ablative dose radiotherapy can be delivered safely in the context of metastatic disease. In this article, the GOECP/SEOR (Oncological Group for Study of Lung Cancer/Spanish Society of Radiation Oncology) reviews the role of new targeted therapies used in combination with radiotherapy in patients with locally advanced (stage III) NSCLC and in patients with advanced, metastatic (stage IV) NSCLC.

Radiotherapy plus EGFR TKIs in non-small cell lung cancer patients with brain metastases: an update meta-analysis

Brain metastasis (BM) is the common complication of non‐small cell lung cancer (NSCLC) with a poor prognosis and dismal survival rate. This update meta‐analysis aimed to derive a more precise estimation of radiotherapy plus epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) in NSCLC patients with BM. PubMed, EMBASE, Web of Science, Google Scholar, and Cochrane Library were searched to identify any relevant publications. After screening the literature and undertaking quality assessment and data extraction, the meta‐analysis was performed using STATA Version 12.0. In total, 15 studies involving 1552 participants were included. The results indicated that radiotherapy plus EGFR TKIs was more effective at improving response rate and disease control rate (DCR) (risk ratio (RR) = 1.48, 95% confidence interval [CI]: 1.12–1.96, P = 0.005; RR = 1.29, 95% CI: 1.02–1.60, P = 0.035; respectively) than radiotherapy alone or plus chemotherapy. Moreover, radiotherapy plus EGFR TKIs significantly prolonged the time to central nervous system progression (CNS‐TTP) (HR = 0.56, 95% CI [0.33, 0.80]; P = 0.000) and median overall survival (OS) (HR = 0.58, 95% CI [0.42, 0.74]; P = 0.000) but significantly increased adverse events (any grade) (RR = 1.25, 95% CI [1.01, 1.57]; P = 0.009), especially rash and dry skin. These results suggested that radiotherapy plus EGFR TKIs produced superior response rate and DCR and markedly prolonged the CNS‐TTP and OS of NSCLC patients with BM. However, combined groups had the higher rate of incidence of overall adverse effects, especially rash and dry skin.

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

Background

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

Patients and methods

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

Results

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

Conclusion

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

Efficacy of the irreversible ErbB family blocker afatinib in epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI)-pretreated non-small-cell lung cancer patients with brain metastases or leptomeningeal disease

INTRODUCTION

Afatinib is an effective first-line treatment in patients with epidermal growth factor receptor (EGFR)-mutated non-small-cell lung cancer (NSCLC) and has shown activity in patients progressing on EGFR-tyrosine kinase inhibitors (TKIs). First-line afatinib is also effective in patients with central nervous system (CNS) metastasis. Here we report on outcomes of pretreated NSCLC patients with CNS metastasis who received afatinib within a compassionate use program.

METHODS

Patients with NSCLC progressing after at least one line of chemotherapy and one line of EGFR-TKI treatment received afatinib. Medical history, patient demographics, EGFR mutational status, and adverse events including tumor progression were documented.

RESULTS

From 2010 to 2013, 573 patients were enrolled and 541 treated with afatinib. One hundred patients (66% female; median age, 60 years) had brain metastases and/or leptomeningeal disease with 74% having documented EGFR mutation. Median time to treatment failure for patients with CNS metastasis was 3.6 months, and did not differ from a matched group of 100 patients without CNS metastasis. Thirty-five percent (11 of 31) of evaluable patients had a cerebral response, five (16%) responded exclusively in brain. Response duration (range) was 120 (21-395) days. Sixty-six percent (21 of 32) of patients had cerebral disease control on afatinib. Data from one patient with an impressive response showed an afatinib concentration in the cerebrospinal fluid of nearly 1 nMol.

CONCLUSION

Afatinib appears to penetrate into the CNS with concentrations high enough to have clinical effect on CNS metastases. Afatinib may therefore be an effective treatment for heavily pretreated patients with EGFR-mutated or EGFR-TKI-sensitive NSCLC and CNS metastasis.

[Advances in treatment of brain metastases from primary non-small cell lung cancer]

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Serum CA125 level predicts prognosis in patients with multiple brain metastases from non-small cell lung cancer before and after treatment of whole-brain radiotherapy

This study was to evaluate the effect of serum CA125 level on the prognosis of patients with multiple brain metastases from non-small cell lung cancer before and after treatment of whole-brain radiotherapy. Sixty-six patients with multiple brain metastases from non-small cell lung cancer before and after treatment of radiotherapy were reviewed retrospectively. Radiotherapy was given to the whole brain using opposed 6MV lateral beams with a dose of 30 Gy in 15 fractions in 3 weeks. Elevated CA125 was defined as >35 U/mL. The survival rate was calculated using the Kaplan-Meier method, and the univariate and multivariate analyses were used to identify significant factors associated with prognosis, using a Cox proportional hazards model. During the median (range) follow-up of 1.25 (0.25-2.50) years, 62 patients died from non-small cell lung cancer; the 1-year cancer-specific survival (CSS) rate was 43.08 %. Thirty patients had a high CA125 level before chemoradiotherapy (>35U/mL), and their CSS rate was significantly worse than that in the remaining patients (P = 0.024). Multivariate analysis showed that CA125 level, number of metastases and total tumor volume were independent prognostic indicators for CSS, with a hazard ratio of 1.99, 1.67 and 2.02, respectively. The elevation of CA125 before treatment predicts a poor prognosis in patients with multiple brain metastases from non-small cell lung cancer before and after treatment of whole-brain radiotherapy.

Critical appraisal of the role of gefitinib in the management of locally advanced or metastatic non-small cell lung cancer

Past studies have demonstrated that epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors can significantly improve clinical outcomes in patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) and sensitive EGFR gene mutations. Gefitinib (Iressa(®)), the first oral EGFR tyrosine kinase inhibitor, has been shown to be more effective and better tolerated than chemotherapy either in first-line or second-line treatment for patients with advanced NSCLC harboring sensitive EGFR mutations. Conversely, among patients with wild-type EGFR, gefitinib is inferior to standard chemotherapy in both the first-line and second-line settings. Further, gefitinib is effective in patients with brain metastases because of its low molecular weight and excellent penetration of the blood-brain barrier. In this review, we summarize the current data from clinical trials with gefitinib and appraise its role in the management of locally advanced or metastatic NSCLC.