Brain metastases in Japanese NSCLC patients: prognostic assessment and the use of osimertinib and immune checkpoint inhibitors-retrospective study

BACKGROUND

The Graded Prognostic Assessment for lung cancer using molecular markers (Lung-molGPA) has not been validated for use with Japanese non-small cell lung cancer (NSCLC) patients with brain metastasis (BM) and the factors impacting survival need to be assessed.

METHODS

We retrospectively analyzed 294 NSCLC patients who were newly diagnosed with BM between 2013 and 2020 and had received radiotherapy for BM initially at the Hokkaido Cancer Center. We evaluated the effect on the prognosis of Lung-molGPA items, the expression of PD-L1 (classified as high, low, and no expression), and the treatment history. The main outcome was the survival measured from the day of the diagnosis of BM, and log-rank tests were performed to evaluate the results.

RESULTS

The median overall survival (OS) times for adenocarcinoma by groups of GPA scores (0‒1.0, 1.5‒2.0, 2.5‒3.0, and 3.5‒4.0) were 5.5, 14.8, 28.3, and 39.0 months (p < 0.0001), respectively. The median survival times for non-adenocarcinoma by groups of GPA scores (0‒1.0, 1.5‒2.0, and 2.5‒3.0) were 3.2, 11.0, and 16.0 months (p = 0.0011), respectively. In adenocarcinoma patients with gene mutations, osimertinib significantly improved the outcome (median OS: 34.2 and 17.6 months with and without osimertinib, respectively (p = 0.0164)). There was no significant difference in the OS between patients who were initially treated with tyrosine-kinase inhibitor for BM and those who initially received radiotherapy (p = 0.5337). In patients tested for PD-L1 expression, the median survival times after the diagnosis of BM were 5.6, 22.5, and 9.3 months for the high-, low- and no-expression groups (p = 0.2198), respectively. Also, in patients with high PD-L1 expressions, those with ICI had survival (median OS, 8.6 months) than those without (median OS, 3.6 months).

CONCLUSIONS

We confirmed that Lung-molGPA successfully classified Japanese NSCLC patients with BM by the prognosis. Osimertinib prolonged survival of EGFR-positive NSCLC patients with BM, and ICI was effective in patients with high PD-L1 expressions.

Analysis of acute-phase toxicities of intensity-modulated proton therapy using a model-based approach in pharyngeal cancer patients

Pharyngeal cancer patients treated with intensity-modulated proton therapy (IMPT) using a model-based approach were retrospectively reviewed, and acute toxicities were analyzed. From June 2016 to March 2019, 15 pharyngeal (7 naso-, 5 oro- and 3 hypo-pharyngeal) cancer patients received IMPT with robust optimization. Simulation plans for IMPT and intensity-modulated X-ray therapy (IMXT) were generated before treatment. We also reviewed 127 pharyngeal cancer patients with IMXT in the same treatment period. In the simulation planning comparison, all of the normal-tissue complication probability values for dysphagia, dysgeusia, tube-feeding dependence and xerostomia were lower for IMPT than for IMXT in the 15 patients. After completing IMPT, 13 patients completed the evaluation, and 12 of these patients had a complete response. The proportions of patients who experienced grade 2 or worse acute toxicities in the IMPT and IMXT cohorts were 21.4 and 56.5% for dysphagia (P < 0.05), 46.7 and 76.3% for dysgeusia (P < 0.05), 73.3 and 62.8% for xerostomia (P = 0.43), 73.3 and 90.6% for mucositis (P = 0.08) and 66.7 and 76.4% for dermatitis (P = 0.42), respectively. Multivariate analysis revealed that IMPT was independently associated with a lower rate of grade 2 or worse dysphagia and dysgeusia. After propensity score matching, 12 pairs of IMPT and IMXT patients were selected. Dysphagia was also statistically lower in IMPT than in IMXT (P < 0.05). IMPT using a model-based approach may have clinical benefits for acute dysphagia.

Long survival of patients with unresectable cervical carcinoma after radiotherapy

We report our experience with radiotherapy for three patients with cervical carcinoma in whom surgery had been downgraded to the performance of exploratory laparotomy only, because of extensive primary tumor or nodal invasion to the surrounding organs and vessels. Tumor invasion to the bladder, side wall invasion or unresectable nodal disease at the time of exploration prevented definitive surgery in our case series. After laparotomy, we carried out radiation therapy consisting of external irradiation to the pelvis and intracavitary irradiation with high dose rate 60Co or low dose rate 137Cs sources. Local and regional control was obtained in all three patients, and there was no locoregional recurrence during > 5 years of follow-up. One patient died of paraaortic lymph node metastases, but she had no pelvic recurrence. Several authors have reported an increased risk of small bowel obstruction in patients who undergo laparotomy before radiotherapy. None of our patients developed small bowel obstruction, although one had anal bleeding which was cured by conservative therapy. Radiotherapy was effective for locoregional control in all three patients with unresectable cervical carcinoma.

Retropharyngeal abscess after radiation therapy and cis-platinum, 5-fluorouracil treatment for nasopharyngeal carcinoma with collagen disease: report of two patients and a review of the literature

Collagen disease are frequently associated with malignant tumors. Recently, radiotherapy combined with chemotherapy has been recommended for improving the efficacy of treatment for nasopharyngeal carcinoma. Two patients with nasopharyngeal carcinoma complicated by collagen diseases (dermatomyositis in one, and Sjögren's syndrome with mixed connective tissue disease in the other) were given radiotherapy combined with chemotherapy consisting of cis-platinum and 5-fluorouracil. Following this combination therapy, both patients developed retropharyngeal abscess and ulceration of the mucosal membrane on the posterior wall of the oropharynx; there was no tumor cell involvement. Because these injuries were more severe than would have been expected from radiotherapy alone, it is recommended that special attention be paid to combination therapy in patients with nasopharyngeal carcinoma complicated by collagen disease.

[A case of Hurthle cell carcinoma in the superior mediastinum]

This is a report for an unusual case of oxyphilic cell adenocarcinoma originating from anterior mediastinum in a 36-year-old male who complained of his neck lymphoadenopathy. 201Tl whole body scanning showed increased uptake of the left supraclavicular and upper mediastinal regions. There was no history of prior operation nor irradiation to the thyroid or neck region. Chest CT scanning also demonstrated the tumor in the superior mediastinum, but the mass has no increased 67Ga uptake. No tumor in the thyroid lobes was apparent on thyroid scintiscanning, ultrasonography and neck CT. The mediastinal tumor resection, the right and left thyroid lobectomy and the neck lymphonodectomy were completed. Serial sectioning of the resected thyroid lobes failed to show any tumorous tissue. The light microscopic features of a Hurthle-cell tumor arising in the mediastinal ectopic thyroid and diagnosed by neck lymph node biopsy were presented. The tumor was clinically malignant, having metastasized to the bone and the neck lymph nodes. Non surgical treatment including radioactive iodine (131I) therapy and combination chemotherapy were disappointing. The patient deteriorated progressively and died 16 months after thyroidectomy. We describe here an unusual case of a papillary growing and thyroglobulin producing tumor in the superior mediastinal region without evidence of a primary thyroid gland tumor.

Availability of 111In-labeled platelet scintigraphy in patients with postinfarction left ventricular aneurysm

Eighteen patients with postinfarction left ventricular aneurysms (LVAs) were examined with Indium-111-labeled autologous platelet scintigraphy to identify intracardiac thrombi and to investigate the effect of antithrombotic agents on thrombogenesity within their LVAs. Left ventriculography (LVG), and two-dimensional echocardiography were also carried out to assess the diagnostic ability of the platelet imaging. Indium-111-platelet scintigraphy for the detection of LVA mural thrombi had a sensitivity of 60% and a specificity of 100%. Four of six patients with false-negative scintigraphic studies had been under antiplatelet therapy. Eight of the nine patients who had showed active platelet deposition on initial examination had not received antiplatelet therapy. Thereafter, five of these nine were treated with tichlopidine (300 mg/day) for 29.8 +/- 5.0 days. On the second platelet study, two had resolution and the other three had interruption of intra-aneurysmal deposition, which remained positive. In only one patient of the three, the third platelet study was performed after warfarin therapy. It took two weeks after beginning the therapy to completely interrupt platelet deposition within the LVA in this patient. ECG gated radionuclide ventriculography and Thallium-201-myocardial scintigraphy were also performed to assess left ventricular wall motion of left ventricular ejection fraction (LVEF) and myocardial blood perfusion. Thallium-201-SPECT showed apical or anteroapical perfusion defects and the radionuclide ventriculography correctly identified all 18 apical and anteroseptal aneurysms which were confirmed by LVG methods. The comparison between the thrombus positive group and the thrombus negative group was carried out on both the LVEF and the period from the last myocardial infarction to the initial platelet scanning study. There were no statistical differences in the LVEF and the interval (34.5 +/- 12.5% vs 37.3 +/- 14.6%, 39.6 +/- 52.6 days vs 89.6 +/- 108.3 days) between the two groups. These results suggest that Indium-111-labeled platelet scintigraphy can be a reliable method for the identification of active left ventricular mural thrombi and a practical method of judging antiplatelet and anticoagulant therapy.

Absence of age effect on plasma haloperidol neuroleptic levels in psychiatric patients

Plasma neuroleptic levels in 41 patients (21 men, 20 women, aged 18 to 74) on haloperidol therapy were examined in relation to their age by means of radioreceptor assay. There was no significant difference among three age groups (below 45 years, 46 to 60 years, over 60 years) in the ratio of the plasma neuroleptic level to daily dose (nM/mg/kg), but a significant difference in the plasma neuroleptic level was found between the average values in parkinsonian (19.1 +/- 8.5 nM, M +/- SD) and nonparkinsonian (5.5 +/- 3.0 nM, M +/- SD) patients. There was, however, no significant difference in the incidence of parkinsonian symptoms between the young (below 60 years) and the old (over 60 years) age groups. These results suggest that in contrast to the previously reported study with chlorpromazine, the plasma neuroleptic level of haloperidol is not altered with aging and that parkinsonian symptoms induced by haloperidol occur simply in a plasma-neuroleptic-level-dependent manner.

Electric convulsive therapy (ECT) increases plasma and red blood cell haloperidol neuroleptic activities

In nine schizophrenic patients (five males and four females) on haloperidol treatment, plasma and red blood cell (RBC) haloperidol neuroleptic activities were measured before and after ECT by radioreceptor assay. Five patients randomly selected from these patients also served as controls on another occasion and neuroleptic activities in plasma and RBC were examined before and after the premedication only. All patients given ECT showed a considerable increase in plasma and RBC haloperidol neuroleptic activities after ECT (% increase in plasma neuroleptic activity, 28-409%; mean + SD, 136 +/- 155%, P less than 0.005, Wilcoxon test; % increase in RBC neuroleptic activity, 11-121%; mean + SD, 59 +/- 40%, P less than 0.005). However, no significant increase was observed for either plasma or RBC haloperidol neuroleptic activity, when patients were examined after premedication only. It was suggested that ECT induced a transient redistribution of haloperidol. It remains to be studied whether this phenomenon is causally related to the previous observation that the combination therapy of ECT and neuroleptics is more effective in the treatment of schizophrenia than ECT alone.