Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy Oncology Group (RTOG) brain metastases trials

Survival Benefit from Surgical Resection in Lung Cancer Patients with Brain Metastases: a Single-Center, Propensity-Matched Analysis Cohort Study

BACKGROUND

Brain metastases (BMs) are the most serious complication of lung cancer, affecting the prognosis of lung cancer patients, and pose distinct clinical challenges. This study was designed to explore the prognostic factors related to lung cancer BM and the value of surgical resection in BMs from lung cancer.

METHODS

A retrospective analysis was performed on 714 patients with lung cancer BMs screened between January 2010 and January 2018 at the Sun Yat-sen University Cancer Center. A 1:1 propensity score matching analysis was performed to reduce the potential bias between the surgery and the nonsurgery group. In both the raw and the propensity-score matched dataset, univariate and multivariate Cox proportional hazards regression analyses were used to evaluate risk factors for survival.

RESULTS

After matching, 258 patients (129 surgery, 129 no surgery) were analyzed. Multivariate analyses after propensity score matching demonstrated that surgical resection was an independent protective factor for overall survival (OS), and older age, lower Karnofsky Performance Scale (KPS) score, and extracranial metastases were independent risk factors for worse OS. Patients without extracranial metastases, without synchronous BM and with a single BM had a better prognosis.

CONCLUSIONS

The findings showed that surgical resection, age, KPS score, and extracranial metastases are independent prognostic factors for predicting the OS of patients with lung cancer BMs, and surgical resection for brain metastatic lesions could significantly improve the OS. However, only certain groups of patients with BMs can benefit from intracranial lesion resection, such as no extracranial metastases and metachronous metastases.

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

Background

The aim of this prospective study was to evaluate the association between heart rate variability (HRV) and overall survival of lung cancer patients with brain metastases (LCBM).

Methods

Fifty-six LCBM patients were enrolled in this study. Five-minute electrocardiograms were collected before the time to first brain radiotherapy. HRV was analyzed quantitatively by using the time domain parameters, i.e., the standard deviation of all normal-normal intervals (SDNN) and the root mean square of successive differences (RMSSD). Survival time for LCBM patients was defined as from the date of HRV testing to the date of death or the last follow-up.

Results

In the univariate analysis, SDNN ≤ 13 ms (P = 0.003) and RMSSD ≤ 4.8 ms (P = 0.014) significantly predicted poor survival. Multivariate analysis confirmed that RMSSD ≤ 4.8 ms (P = 0.013, hazard ratio = 3.457, 95% confidence interval = 1.303–9.171) was also an independent negative prognostic factor after adjusting for mean heart rate, Karnofsky performance status, and number of brain metastases in LCBM patients.

Conclusion

Decreased RMSSD is independently associated with shorter survival time in LCBM patients. HRV might be a novel predictive biomarker for LCBM prognosis.

Prediction of Gastric Gastrointestinal Stromal Tumors before Operation: A Retrospective Analysis of Gastric Subepithelial Tumors

Gastrointestinal stromal tumors (GISTs), leiomyomas, and schwannomas are the most common gastric subepithelial tumors (GSETs) with similar endoscopic findings. Preoperative prediction of GSETs is difficult. This study analyzed and predicted GSET diagnosis through a retrospective review of 395 patients who underwent surgical resection of GISTs, leiomyomas, and schwannomas measuring 2-10 cm. GSETs were divided by size (group 2-5, >2 and ≤5 cm; group 5-10, >5 and ≤10 cm) for analysis. Demographics, clinical symptoms, and images were analyzed. A recursive partitioning analysis (RPA) was used to identify optimal classifications for specific GSET diagnoses. GIST patients were relatively older than other patients. Both groups had higher proportions of UGI bleeding, lower hemoglobin (Hb) levels, and a higher ratio of necrosis on their computed tomography (CT) scans. The RPA tree showed that (a) age ≤ 55, Hb ≥ 10.7, and CT necrosis; (b) age ≤ 55 and Hb < 10.7; (c) age >55 and Hb < 12.9; and (d) age >55 and CT hetero-/homogeneity can predict high GIST risk in group 2-5. Positive or negative CT necrosis, with age >55, can predict high GIST risk in group 5-10. GIST patients were older and presented with low Hb levels and tumor necrosis. In RPA, the accuracy reached 85% and 89% in groups 2-5 and 5-10, respectively.

Emerging Biomarkers for Diagnosis, Prevention and Treatment of Brain Metastases-From Biology to Clinical Utility

Primary malignancies of the lung, skin (melanoma), and breast have higher propensity for metastatic spread to the brain. Advances in molecular tumour profiling have aided the development of targeted therapies, stereotactic radiotherapy, and immunotherapy, which have led to some improvement in patient outcomes; however, the overall prognosis remains poor. Continued research to identify new prognostic and predictive biomarkers is necessary to further impact patient outcomes, as this will enable better risk stratification at the point of primary cancer diagnosis, earlier detection of metastatic deposits (for example, through surveillance), and more effective systemic treatments. Brain metastases exhibit considerable inter- and intratumoural heterogeneity-apart from distinct histology, treatment history and other clinical factors, the metastatic brain tumour microenvironment is incredibly variable both in terms of subclonal diversity and cellular composition. This review discusses emerging biomarkers; specifically, the biological context and potential clinical utility of tumour tissue biomarkers, circulating tumour cells, extracellular vesicles, and circulating tumour DNA.

Stereotactic radiosurgery for brain metastases from pelvic gynecological malignancies: oncologic outcomes, validation of prognostic scores, and dosimetric evaluation

INTRODUCTION

Stereotactic radiosurgery is a well-established treatment option in the management of brain metastases. Multiple prognostic scores for prediction of survival following radiotherapy exist, but are not disease-specific or validated for radiosurgery in women with primary pelvic gynecologic malignancies metastatic to the brain. The aim of the present study is to evaluate the feasibility, safety, outcomes, and impact of established prognostic scores.

METHODS

We retrospectively identified 52 patients treated with radiotherapy for brain metastases between 2008 and 2021. Stereotactic radiosurgery was utilized in 31 patients for an overall number of 75 lesions; the remaining 21 patients received whole-brain radiotherapy. Kaplan-Meier survival analysis and the log-rank test were used to calculate and compare survival curves and univariate and multivariate Cox regression to assess the influence of cofactors on recurrence, local control, and prognosis.

RESULTS

With a median follow-up of 10.7 months, overall survival rates post radiosurgery were 65.3%, 51.3%, and 27.7% for 1, 2, and 5 years, respectively, which were significantly higher than post whole-brain radiotherapy (p=0.049). Five local failures (6.7%) were detected, resulting in 1 and 2 year local cerebral control rates of 97.4% and 94.0%, respectively. Univariate factors for prediction of superior overall survival were high performance status (p=0.030) and application of three prognostic scores, especially the Recursive Partitioning Analysis score (p=0.028). Uni- and multivariate analysis revealed that extracranial progression prior to radiosurgery was significant for inferior overall survival (p<0.0001). Radionecrosis was diagnosed in five women (16%); long-term neurotoxicity was significantly worse after whole-brain radiotherapy compared with radiosurgery (p=0.023).

CONCLUSION

Stereotactic radiosurgery for brain metastases from pelvic gynecologic malignancies appears to be safe and well tolerated, achieving promising local cerebral control. Prognostic scores were shown to be transferable and radiosurgery should be recommended as primary intracranial treatment, especially in women with no prior extracranial progression and Recursive Partitioning Analysis class I.

Linac-based stereotactic radiosurgery and fractionated stereotactic radiotherapy with a micro-multileaf collimator for brain metastasis in the primary motor cortex

This study aimed to assess the clinical outcomes of linear accelerators (linac)-based, stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (fSRT) with a micro-multileaf collimator for brain metastasis in the primary motor cortex (BMPMC). Thirty-five consecutive patients with BMPMC who were treated by linac-based SRS or fSRT between January 2012 and March 2020 were analyzed. BMPMC was defined as a tumor located in the precentral gyrus on gadolinium-enhanced magnetic resonance imaging (MRI) and T2-weghted imaging (T2WI). In total, 35 patients with 37 metastases were analyzed. The median follow-up time was 13 (range: 1-97) months. The tumor volume was 0.05-26.5 (median: 0.62) cm3. All patients were treated with SRS or fSRT using 35 Gy with 7 Gy per fraction daily. The median survival time (MST) was 16.9 months. The pretreatment KPS and RPA class significantly differed in terms of MST on the log-rank tests. Seven symptomatic patients had hemiparesis before SRS or fSRT. All symptomatic patients, except one with facial paresis and one who died within 3 months, experienced improvement at a 3 month follow-up. None of the patients presented with persistent radiation injury at the final follow-up. Two patients presented with grade 3 radiation-related central nervous system necrosis, which was assessed using the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. In BMPMC, SRS and fSRT had good tumor control and did not cause serious complications. Therefore, they are suitable treatment options with an acceptable safety profile.

Comparative associations of baseline frailty status and age with postoperative mortality and duration of hospital stay following metastatic brain tumor resection

Metastatic brain tumors are the most common intracranial neoplasms diagnosed in the United States. Although baseline frailty status has been validated as a robust predictor of morbidity and mortality across various surgical disciplines, evidence within cranial neurosurgical oncology is limited. Adult metastatic brain tumor patients treated with resection were identified in the National Inpatient Sample during the period of 2015-2018. Frailty was quantified using the 11-point modified frailty index (mFI-11) and its association with clinical endpoints was evaluated through complex samples multivariable logistic regression and receiver operating characteristic (ROC) curve analyses. Among 13,650 metastatic brain tumor patients identified (mean age 62.8 years), 26.8% (n = 3665) were robust (mFI = 0), 31.4% (n = 4660) were pre-frail (mFI = 1), 23.2% (n = 3165) were frail (mFI = 2), and 15.8% (n = 2160) were severely frail (mFI ≥ 3). On univariable assessment, these cohorts stratified by increasing frailty were significantly associated with postoperative complications (13.6%, 15.9%, 23.9%, 26.4%; p < 0.001), mortality (1.2%, 1.4%, 2.7%, 3.2%; p = 0.028), and extended length of stay (eLOS) (15.7%, 22.5%, 28.9%, 37.7%; p < 0.001). Following multivariable logistic regression analysis, frailty (by mFI-11) was independently associated with postoperative mortality (aOR 1.34, 95% CI 1.08, 1.65) and eLOS (aOR 1.26, 95% CI 1.17, 1.37), while increasing age was not associated with these endpoints. ROC curve analysis demonstrated superior discrimination of frailty (by mFI-11) in comparison with age for both mortality (AUC 0.61 vs. 0.58) and eLOS (AUC 0.61 vs. 0.53). Further statistical assessment through propensity score adjustment and decision tree analysis confirmed and extended the findings of the primary analytical models. Frailty may be a more robust predictor of postoperative outcomes in comparison with age following metastatic brain tumor resection.

Review of the diagnosis and treatment of brain metastases

Brain metastases (BM) occur in at least 10% of cancer patients, and are one of the main causes of cancer-related deaths and significant deterioration in the quality of life of cancer patients due to the neurological deterioration caused by brain compression and tumor invasion. Whole-brain irradiation has been emphasized as the standard treatment for BM. However, recent clinical trials including the JLGK0901 and JCOG0504 trials conducted in Japan have established therapeutic evidence for the use of stereotactic radiosurgery with regular follow-up with magnetic resonance imaging for BM. In addition to surgery and stereotactic radiotherapy, advances in drug therapy for BM, such as tyrosine kinase inhibitors and immune checkpoint inhibitors, are expected. This review describes the history and the recent evidence of the diagnosis and treatment of BM.

Analysis of prognostic factors in patients with brain metastases affecting survival

INTRODUCTION

Brain metastases (BM) are associated with dismal prognosis as they cause significant morbidity and affect the quality of life of patients. Management of BM depends on the following factors: age, patient performance, size and the number of lesions, location of the tumor, comorbidities, primary tumor type, and extracranial disease burden. In the present study, the pattern of occurrence, clinical characteristics, treatment outcome of brain metastases, and factors, tumor characteristics, and treatment that may impact BM patients' overall survival were analyzed.

METHODS

Retrospective analysis of medical records of 116 patients with histologically proven primary site solid tumors with brain metastases was done in the present study. Clinicoradiological and pathological parameters were documented. The relationship between variables and outcome was assessed by univariate analysis using the Cox proportional regression model to reach a significance of p < 0.05, to determine independent predictors of overall survival.

RESULTS

One hundred sixteen patients of BM from various solid malignancies were included. Age ranged from 18 to 81 years (median 53.5). One hundred four patients received WBRT with a dose range of 8-40Gy/1-15fr, 7 received SRS with a dose of 18-24Gy depending on the size of the metastatic lesion, and 2 received SRT 27-33Gy/3fr. At the time of final analysis, 47 patients with BM had expired, 60 were lost to follow-up, and 9 were alive. Median survival was 8.25 (0.5-32.5 months) months. Female gender (χ² = 8.423; p = 0.015), RPA I (χ² = 9.353; p = 0.05), and metachronous BM (χ² = 3.793; p = 0.03) were associated with better survival. Patients with age 41-50 years, adenocarcinoma lung histology, and supratentorial location survived more than 2 years but did not show any statistical significance.

CONCLUSION

Brain metastases portend a very dismal prognosis. Certain clinicoradiological and pathologic factors have been identified to affect survival. More prospective multicentric trials, with a larger sample size, need to be conducted to assess the benefit of radiation in patients with limited life expectancy and identify prognostic and predictive factors for survival.

A multidisciplinary management algorithm for brain metastases

The incidence of brain metastases continues to present a management issue despite the advent of improved systemic control and overall survival. While the management of oligometastatic disease (ie, 1-4 brain metastases) with surgery and radiation has become fairly straightforward in the era of radiosurgery, the management of patients with multiple metastatic brain lesions can be challenging. Here we review the available evidence and provide a multidisciplinary management algorithm for brain metastases that incorporates the latest advances in surgery, radiation therapy, and systemic therapy while taking into account the latest in precision medicine-guided therapies. In particular, we argue that whole-brain radiation therapy can likely be omitted in most patients as up-front therapy.

Radiomics as an emerging tool in the management of brain metastases

Brain metastases (BM) are associated with significant morbidity and mortality in patients with advanced cancer. Despite significant advances in surgical, radiation, and systemic therapy in recent years, the median overall survival of patients with BM is less than 1 year. The acquisition of medical images, such as computed tomography (CT) and magnetic resonance imaging (MRI), is critical for the diagnosis and stratification of patients to appropriate treatments. Radiomic analyses have the potential to improve the standard of care for patients with BM by applying artificial intelligence (AI) with already acquired medical images to predict clinical outcomes and direct the personalized care of BM patients. Herein, we outline the existing literature applying radiomics for the clinical management of BM. This includes predicting patient response to radiotherapy and identifying radiation necrosis, performing virtual biopsies to predict tumor mutation status, and determining the cancer of origin in brain tumors identified via imaging. With further development, radiomics has the potential to aid in BM patient stratification while circumventing the need for invasive tissue sampling, particularly for patients not eligible for surgical resection.

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

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

Modern possibilities of neurosurgical treatment of brain metastases

Despite significant progress in neuroimaging and introduction of new combined treatments for solid tumors, brain metastases are still adverse factor for overall survival. Brain metastases are diagnosed in 8-10% of patients and associated with extremely poor prognosis. These lesions result focal and general cerebral symptoms. Literature review highlights the current principles of surgical treatment of metastatic brain lesions in patients with solid tumors.

Stereotactic Radiosurgery Results for Patients With Brain Metastases From Gastrointestinal Cancer: A Retrospective Cohort Study of 802 Patients With GI-GPA Validity Test

Purpose

The role of stereotactic radiosurgery (SRS) alone for patients with gastrointestinal (GI) cancer has yet to be established based on a large patient series. We analyzed post-SRS treatment results and reappraised whether either the GI graded prognostic assessment (GPA) system or modified-recursive partitioning assessment (M-RPA) system was applicable to our 802 SRS-treated patients with GI cancer with brain metastases.

Methods and Materials

This was an institutional review board approved retrospective cohort study 2 database comprising 802 patients with GI cancer treated with gamma-knife SRS by 2 experienced neurosurgeons during the 1998 to 2018 period. The Kaplan-Meier method was applied to determine post-SRS survival times, and competing risk analyses were used to estimate cumulative incidences of the secondary endpoints.

Results

The median survival time (MST; months) after SRS was 5.7. With the GI GPA system, MSTs were 3.5/6.1/7.7/11.0 in the 4 subgroups, that is, 0 to 1.0/1.5 to 2.0/2.5 to 3.0/3.5 to 4.0, respectively (stratified P < .0001). However, there was no significant MST difference between 2 of the subgroups, GI-GPA 1.5 to 2.0 and 2.5 to 3.0 (P = .073). In contrast, using the M-RPA system, 3 plot lines corresponding to the 3 subgroups showed no overlap and the MST differences between the subgroups with M-RPA were 1 + 2a versus 2b (P < .0001) and 2b versus 2c + 3 (P < .0001). Better Karnofsky performance status score, solitary tumor, well-controlled primary cancer, and the absence of extracerebral metastases were shown by multivariable analysis to be significant predictors of longer survival. The crude and cumulative incidences of neurologic death, neurologic deterioration, local recurrence, salvage whole brain radiation therapy, and SRS-related complications did not differ significantly between the 2 patient groups, with upper and lower GI cancers.

Conclusions

This study clearly demonstrated the usefulness of the GI GPA. Patients with GI GPA 1.5 to 2.0 or better or M-RPA 2b or better are considered to be favorable candidates for treatment with SRS alone.

Targeting brain metastases in breast cancer

Brain metastases (BMs) are an important source of morbidity and mortality in patients with metastatic breast cancer (BC). As survival of patients with advanced BC considerably improved thanks to research advancements and new therapeutic approaches, the apparent incidence of BMs is increasing. Local interventions, in the form of either surgical resection or radiation therapy, remain the mainstay in the management of BMs. Systemic treatments are typically used to complement local strategies to further improve and maintain control of central nervous system (CNS) disease. Although high-level evidence data about the impact of the blood-brain barrier (BBB), as well as the efficacy of anti-cancer agents on BMs and differentials between the systemic compartment and CNS are still scant, our understanding of the activity of systemic treatments with impact on BMs is rapidly evolving. Novel anti-HER2 agents, such as tucatinib, ado-trastuzumab emtansine, trastuzumab deruxtecan and neratinib, have shown intracranial efficacy. Current research efforts are ongoing not only to clarify the activity of existing treatments on the CNS, as well as to develop new drugs and innovative multi-modality approaches. This review will encompass the current treatment landscape of BMs arising from BC, with a focus on recent advancements in the field and investigational approaches.

Radiation therapy for brain metastases

We present the update of the recommendations of the French society for radiation oncology on radiation therapy for the management of brain metastases. It has evolved in recent years and has become more complex. As the life expectancy of patients has increased and retreatments have become more frequent, side effects must be absolutely avoided. Cognitive side effects must in particular be prevented, and the most modern radiation therapy techniques must be used systematically. New prognostic classifications specific to the primary tumour of patients, advances in imaging and radiation therapy technology and new systemic therapeutic strategies, are making treatment more relevant. Stereotactic radiation therapy has supplanted whole-brain radiation therapy both for patients with metastases in place and for those who underwent surgery. Hippocampus protection is possible with intensity-modulated radiation therapy. Its relevance in terms of cognitive functioning should be more clearly demonstrated but the requirement for its use is constantly increasing. New targeted cancer treatment therapies based on the nature of the primitive have complicated the notion of the place and timing of radiation therapy and the discussion during multidisciplinary care meeting to indicate the best sequences is becoming a challenging issue as data on the interaction between treatments remain to be documented. In the end, although aimed at patients in the palliative phase, the management of brain metastases is one of the locations for which technical reflection is the most challenging and treatment become increasingly personalized.

Intraoperative radiotherapy with low-energy x-rays after neurosurgical resection of brain metastases-an Augsburg University Medical Center experience

PURPOSE

External-beam radiotherapy (EBRT) is the predominant method for localized brain radiotherapy (LBRT) after resection of brain metastases (BM). Intraoperative radiotherapy (IORT) with 50-kV x‑rays is an alternative way to focally irradiate the resection cavity after BM surgery, with the option of shortening the overall treatment time and limiting normal tissue irradiation.

METHODS

We retrospectively analyzed the outcomes of all patients who underwent neurosurgical resection of BM and 50-kV x‑ray IORT between 2013 and 2020 at Augsburg University Medical Center.

RESULTS

We identified 40 patients with 44 resected BM treated with 50-kV x‑ray IORT. Median diameter of the resected metastases was 2.8 cm (range 1.5-5.9 cm). Median applied dose was 20 Gy. All patients received standardized follow-up (FU) including 3‑monthly MRI of the brain. Mean FU was 14.4 months, with a median MRI FU for alive patients of 12.2 months. Median overall survival (OS) of all treated patients was 26.4 months (estimated 1‑year OS 61.6%). The observed local control (LC) rate of the resection cavity was 88.6% (estimated 1‑year LC 84.3%). Distant brain control (DC) was 47.5% (estimated 1‑year DC 33.5%). Only 25% of all patients needed WBI in the further course of disease. The observed radionecrosis rate was 2.5%.

CONCLUSION

IORT with 50-kV x‑rays is a safe and appealing way to apply LBRT after neurosurgical resection of BM, with low toxicity and excellent LC. Close MRI FU is paramount to detect distant brain failure (DBF) early.

Clinical Biomarkers for Early Identification of Patients with Intracranial Metastatic Disease

Simple Summary

The development of brain metastases, or intracranial metastatic disease (IMD), is a serious and life-altering complication for many patients with cancer. While there have been substantial advancements in the treatments available for IMD and in our understanding of its pathogenesis, conventional methods remain insufficient to detect IMD at an early stage. In this review, we discuss current research on biomarkers specific to IMD. In particular, we highlight biomarkers that can be easily accessed via the bloodstream or cerebrospinal fluid, including circulating tumor cells and DNA, as well as advanced imaging techniques. The continued development of these assays could enable clinicians to detect IMD prior to the development of IMD-associated symptoms and ultimately improve patient prognosis and survival.

Abstract

Nearly 30% of patients with cancer will develop intracranial metastatic disease (IMD), and more than half of these patients will die within a few months following their diagnosis. In light of the profound effect of IMD on survival and quality of life, there is significant interest in identifying biomarkers that could facilitate the early detection of IMD or identify patients with cancer who are at high IMD risk. In this review, we will highlight early efforts to identify biomarkers of IMD and consider avenues for future investigation.

Modern Radiation Therapy for the Management of Brain Metastases From Non-Small Cell Lung Cancer: Current Approaches and Future Directions

Brain metastases (BMs) represent the most frequent event during the course of Non-Small Cell Lung Cancer (NSCLC) disease. Recent advancements in the diagnostic and therapeutic procedures result in increased incidence and earlier diagnosis of BMs, with an emerging need to optimize the prognosis of these patients through the adoption of tailored treatment solutions. Nowadays a personalized and multidisciplinary approach should rely on several clinical and molecular factors like patient’s performance status, extent and location of brain involvement, extracranial disease control and the presence of any “druggable” molecular target. Radiation therapy (RT), in all its focal (radiosurgery and fractionated stereotactic radiotherapy) or extended (whole brain radiotherapy) declinations, is a cornerstone of BMs management, either alone or combined with surgery and systemic therapies. Our review aims to provide an overview of the many modern RT solutions available for the treatment of BMs from NSCLC in the different clinical scenarios (single lesion, oligo and poly-metastasis, leptomeningeal carcinomatosis). This includes a detailed review of the current standard of care in each setting, with a presentation of the literature data and of the possible technical solutions to offer a “state-of-art” treatment to these patients. In addition to the validated treatment options, we will also discuss the future perspectives on emerging RT technical strategies (e.g., hippocampal avoidance whole brain RT, simultaneous integrated boost, radiosurgery for multiple lesions), and present the innovative and promising findings regarding the combination of novel targeted agents such as tyrosine kinase inhibitors and immune checkpoint inhibitors with brain irradiation.

Survival benefit with resection of brain metastases from renal cell carcinoma in the setting of molecular targeted therapy and/or immune therapy

Patient survival with renal cell carcinoma (RCC) has improved with the use of molecular targeted agents and immunotherapy. Given the potential activity of these agents in treating brain metastases, the role of aggressive local management with surgery and/or radiation may diminish. The aim of this study was to evaluate the role of aggressive local therapy for RCC brain metastasis in the setting of molecular targeted agents and/or checkpoint inhibitor therapy. A retrospective single-center review between 2011-2018 identified patients that developed brain metastasis from RCC. Data analyzed included demographic information, systemic treatments, intracranial interventions, progression free survival and overall survival (OS). Of 1194 patients, 108(9.0%) were diagnosed with brain metastasis from RCC. OS from diagnosis of brain metastasis (OS_BM) was 12.3 months. OS_BM was analyzed based on three treatment groups: systemic therapy (ST) only (2.0 months, n = 23), systemic and radiotherapy (RT + ST) (12.3 months, n = 52), and systemic and radiotherapy plus resection (Surg + RT + ST) (21.7 months, n = 33). Survival benefit was seen with Surg + RT + ST compared to ST (P = 0.001), but not RT + ST (P = 0.081). Progression free survival was significantly prolonged with Surg + RT + ST compared to RT + ST (10.9 vs 5.9 months, respectively, P = 0.04). Variables such as performance status and number of brain metastases at the time of brain metastasis diagnosis did not differ significantly. In the setting of molecular targeted agents and immunotherapy, resection may benefit the appropriate surgical candidate. Prospective clinical trials are necessary to better understand the role of aggressive RCC brain metastasis treatment. Micro Abstract • Renal cell brain metastasis is often excluded from studies and brain metastases effect a large portion of RCC patients. • Retrospective study of 1194 RCC patients, 108 patients had brain metastasis, determination of the role of surgical resection in the setting of recent advances in checkpoint inhibitors. • A benefit was seen in overall survival in patients that had surgical while undergoing radiation therapy and systemic therapies. • In the setting of molecular targeted agents and immunotherapy, resection may benefit the appropriate surgical candidate(s).

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.

Comprehensive ability evaluation and trend analysis of patients with malignant intracranial tumors in the perisurgery period

INTRODUCTION

Prognostic situations differ in patients with malignant intracranial tumors. We focused on the quality of life, ability of daily living, and cognitive function of patients in the perisurgery period and investigated the correlation between them and the prognosis of patients.

MATERIALS AND METHODS

Patients with malignant intracranial tumors admitted to Peking Union Medical College Hospital from May 2018 to August 2020 for surgery were included. The evaluations were performed 6 times in the perisurgery period. The questionnaires for assessment included QLQ-C30, ADL, and so forth.

RESULTS

A total of 165 patients were included (115 glioma and 50 brain metastases). Patients had their worst performance at the 7-day postsurgical assessment (EORTC QLQ-C30, ADL, HAD-D, Frail Scale, MMSE, MoCA, CSHA-FI, and NANO) and recovered at the 1-month postsurgical assessment (p < .05). Patients with left-sided tumors had significantly worse cognitive function than patients with right-sided tumors before surgery and at 7 days, 1 month, and 6 months after surgery (p < .05). The scores of QLQ-C30 and QLQ-BN20 at 1 month, 3 months, 6 months, and 1 year after surgery were used to reflect the prognosis, and the preoperative MoCA, NANO, CCI, CSHA-FI, and HAD score might predict the quality of life and nutrition status after operation.

CONCLUSION

The quality of life and daily living ability of patients with malignant intracranial tumors decreased significantly 7 days after the surgery but recovered 1 month after the surgery. Patients with left hemisphere lesions had a worse cognitive function, while the ADL is associated with short-term prognosis. The comprehensive evaluation of the perisurgical period can indicate the prognosis of patients and further guide clinical decision-making.

Central Nervous System Metastases

The proportion of patients developing central nervous system (CNS) metastasis is increasing. Most are identified once symptomatic. Surgical resection is indicated for solitary or symptomatic brain metastases, separation surgery for compressive radioresistant spinal metastases, and instrumentation for unstable spinal lesions. Surgical biopsies are performed when histological diagnoses are required. Stereotactic radiosurgery is an option for limited small brain metastases and radioresistant spinal metastases. Whole-brain radiotherapy is reserved for extensive brain metastases and leptomeningeal disease with approaches to reduce cognitive side effects. Radiosensitive and inoperable spinal metastases typically receive external beam radiotherapy. Systemic therapy is increasingly being utilized for CNS metastases.

Outcomes and Prognosis of Non-Elderly Patients with Brain Metastases-A Prospective Cohort Incorporating Individualized Assessment of Heart Rate Variability

Outcomes and prognostic factors among patients with brain metastases (BM) have been widely studied, but seldom for the non-elderly. Heart rate variability (HRV) is a physiological phenomenon and has been shown as a survival prognostic factor in cancer patients. This study aimed to evaluate the outcomes and prognosis among non-elderly BM patients with the incorporation of HRV analysis. Forty non-elderly BM patients treated using whole brain radiotherapy (WBRT) were studied from January 2010 prospectively with 5-min electrocardiography (ECG) recordings. Individualized HRV was generated by the ECG, and the time domain HRV index SDNN was chosen for survival analysis. The median overall survival (OS) for the entire group was 6.21 months. Univariate analysis revealed that a KPS < 80 (p = 0.019) and an SDNN < 10 ms (p = 0.007) demonstrated statistical significance for OS; multivariate analysis confirmed that a KPS < 80 (p = 0.004; HR = 3.060, CI = 1.437–6.517) and an SDNN < 10 ms (p = 0.010; HR = 2.664, CI = 1.262–5.624) were independent prognostic factors. Prospective studies for risk stratification among non-elderly BM patients based on our results are warranted to validate our findings.

A new prognostic score for predicting survival in patients treated with robotic stereotactic radiotherapy for brain metastases

The study aimed to analyze potential prognostic factors in patients treated with robotic radiosurgery for brain metastases irrespective of primary tumor location and create a simple prognostic score that can be used without a full diagnostic workup. A retrospective analysis of 142 patients with 1–9 brain metastases treated with stereotactic radiosurgery (1–4 fractions) was performed. Volumes of all lesions were calculated using linear dimensions of the tumors (CC, LR, AP) and 4/3*π*(CC/2)*(LR/2)*(AP/2) formula. Kaplan–Meier method and log-rank test were used to analyze survival. Variables significantly associated with overall survival in univariate analysis were included in Cox multivariate analysis. The validity of the model was tested with the bootstrap method. Variables from the final model were used to construct a new prognostic index by assigning points according to the impact of a specific variable on overall survival. In the multivariate analysis, four factors: Karnofsky Performance Status (p = 0.000068), number of brain metastases (p = 0.019), volume of the largest lesion (p = 0.0037), and presence of extracerebral metastases (p = 0.0017), were independent predictors of survival. Total scores ranged from 0 to 12 points, and patients were divided into four groups based on median survival of each subgroup: 0–1 points—18.8 months, 2–3 points—16.9 months, 4–5 points—5.6 months, and ≥ 6 points—4.9 months (p < 0.001). The new prognostic index is simple to calculate. It has a strong prognostic value in a heterogeneous population of patients with a various number of brain metastases, but its value requires confirmation in another cohort.

Utilizations and outcomes of intra-arterial balloon occlusion at cesarean hysterectomy for placenta accreta spectrum

INTRODUCTION

This study examined national-level trends, characteristics, and perioperative outcomes of women who had intra-arterial balloon occlusion at cesarean hysterectomy for placenta accreta spectrum (PAS).

MATERIAL AND METHODS

This was a population-based retrospective observational study that queried the National Inpatient Sample from October 2015 to December 2018. Study population was women who underwent hysterectomy at cesarean delivery for PAS (n = 6440 in 806 centers). Exposure allocation was the use of intra-arterial balloon occlusion. Main outcome measures were (a) characteristics associated with intra-arterial balloon occlusion use, and (b) perioperative outcome including hemorrhage, blood transfusion, coagulopathy, shock, urinary tract injury, intra-arterial balloon occlusion-related complication (arterial injury, arterial thrombosis, and lower extremities ischemia), and death, assessed in multivariable analysis.

RESULTS

Intra-arterial balloon occlusion was used in 420 (6.5%) women in 64 (7.9%) centers. Utilization of intra-arterial balloon occlusion during cesarean hysterectomy for placenta accreta decreased significantly over time (from 6.3% to 3.1%, p < 0.001), but not in placenta increta (from 12.8% to 9.3%, p = 0.204) or placenta percreta (from 21.3% to 17.5%, p = 0.344). In a multivariable analysis, patient factors (younger age, earlier year, obesity, diabetes mellitus), pregnancy factors (placenta increta/percreta, previous cesarean delivery, placenta previa, and early gestational age), and facility factors (large bed capacity, urban teaching status, and Northeast/West regions) represented the independent characteristics for using the intra-arterial balloon occlusion (all, p < 0.05). In a classification-tree model, the absolute difference in intra-arterial balloon occlusion use among 18 utilization patterns was 48% (range, 0%-48%). In perioperative outcome analysis, women who received intra-arterial balloon occlusion were more likely to have coagulopathy (adjusted odds ratio [aOR] 3.43) and arterial thrombosis (aOR 9.82) in placenta accreta, but less likely to have hemorrhage (aOR 0.25) in placenta increta, and blood transfusion (aOR 0.60) and urinary tract injury (aOR 0.28) in placenta percreta compared with those who did not (all, p < 0.05).

CONCLUSIONS

There is a wide range in the utilization of intra-arterial balloon occlusion at cesarean hysterectomy for PAS based on patient, pregnancy, and facility factors, which implies that there is a lack of universal practice guidelines in this surgical procedure. Whether the use of intra-arterial balloon occlusion in the severe forms of PAS improves surgical outcome merits further investigation.

The Effects of Postoperative Neurological Deficits on Survival in Patients With Single Brain Metastasis

BACKGROUND

The prognosis for brain metastasis is poor, and surgical resection is part of the standard of care for these patients as it has been shown to improve median overall survival. Development of neurological deficits after surgical resection has been associated with worsened outcomes in patients with glioblastoma. The effect of postoperative neurological deficits on survival in patients with single brain metastasis has not been studied to date.

OBJECTIVE

To evaluate the association between postoperative neurological deficits and median overall survival.

METHODS

A single-institution retrospective cohort study was performed on all patients with single brain metastasis undergoing surgical resection by a single neurosurgeon.

RESULTS

A total of 121 patients met the inclusion criteria for this study. Among them 61% of patients presented with a preoperative deficit, and 26% of patients had a new postoperative deficit. However, most postoperative deficits resolved and only 3.3% of patients developed a new permanent postoperative deficit. Median overall survival in patients with a new postoperative deficit was 2.4 mo, whereas mOS in patients without a postoperative deficit was 12.6 mo (P < .0001).

CONCLUSION

This study suggests that a new neurological deficit is associated with worsened outcomes after surgical resection of a single brain metastasis. This finding has potential implications for patient selection and counseling as the patients most likely to benefit from surgical resection are the patients who are most likely to have resolution of a preoperative deficit.

Long-term Overall Survival and Predictors in Anti-PD-1-naive Melanoma Patients With Brain Metastases Treated With Immune Checkpoint Inhibitors in the Real-world Setting: A Multicohort Study

Long-term survival outcomes among melanoma patients with brain metastases treated with immune checkpoint inhibitors are limited. In this retrospective study at 2 centers, metastatic melanoma patients with radiographic evidence of brain metastases who received anti-programmed death-1 (PD-1) monotherapy or nivolumab in combination with ipilimumab between 2014 and 2017 were included. Overall survival (OS) was assessed in diagnosis-specific graded prognostic assessment (ds-GPA) and melanoma-molecular graded prognostic assessment (molGPA) prognostic risk groups. Baseline clinical covariates were used to identify predictors of OS in univariate/multivariable Cox proportional-hazards models. A total of 84 patients (58 monotherapy, 26 combination) were included with a median duration of follow-up of 43.4 months (maximum: 5.1 y). The median OS [95% confidence interval (CI)] was 3.1 months (1.8, 7) for ds-GPA 0-1, 22.1 months [5.4, not reached (NR)] for ds-GPA 2 and NR (24.9, NR) for ds-GPA 3-4 in the monotherapy cohort [hazard ratio (HR) for ds-GPA 3-4 vs. 0-1: 0.13 (95% CI: 0.052, 0.32); 0.29 (95% CI: 0.12, 0.63) for ds-GPA 2 vs. 0-1]. The median OS was 1.1 months (95% CI: 0.3, NR) for ds-GPA 0-1, 11.8 months (95% CI: 2.9, 23.3) for ds-GPA 2 and 24.4 months (95% CI: 3.4, NR) for ds-GPA 3-4 in the combination cohort [HR for 3-4 vs. 0-1: 0.013 (95% CI: 0.0012, 0.14); HR for ds-GPA 2 vs. 0-1: 0.033 (0.0035, 0.31)]. Predictors associated with longer survival included ds-GPA or molGPA>1 (among prognostic indices), neutrophil-to-lymphocyte ratio (<4 vs. ≥4), while high lactate dehydrogenase, neurological symptoms, and leptomeningeal metastases were associated with shorter survival. Baseline ds-GPA/molGPA>1 and neutrophil-to-lymphocyte ratio <4 were strong predictors of long-term survival to anti-PD-1-based immune checkpoint inhibitors in melanoma brain metastases patients previously naive to anti-PD-1 therapy in a real-world clinical setting treated at independent centers.

Pan-cancer evaluation of gene expression and somatic alteration data for cancer prognosis prediction

BACKGROUND

Over the past decades, approaches for diagnosing and treating cancer have seen significant improvement. However, the variability of patient and tumor characteristics has limited progress on methods for prognosis prediction. The development of high-throughput omics technologies now provides multiple approaches for characterizing tumors. Although a large number of published studies have focused on integration of multi-omics data and use of pathway-level models for cancer prognosis prediction, there still exists a gap of knowledge regarding the prognostic landscape across multi-omics data for multiple cancer types using both gene-level and pathway-level predictors.

METHODS

In this study, we systematically evaluated three often available types of omics data (gene expression, copy number variation and somatic point mutation) covering both DNA-level and RNA-level features. We evaluated the landscape of predictive performance of these three omics modalities for 33 cancer types in the TCGA using a Lasso or Group Lasso-penalized Cox model and either gene or pathway level predictors.

RESULTS

We constructed the prognostic landscape using three types of omics data for 33 cancer types on both the gene and pathway levels. Based on this landscape, we found that predictive performance is cancer type dependent and we also highlighted the cancer types and omics modalities that support the most accurate prognostic models. In general, models estimated on gene expression data provide the best predictive performance on either gene or pathway level and adding copy number variation or somatic point mutation data to gene expression data does not improve predictive performance, with some exceptional cohorts including low grade glioma and thyroid cancer. In general, pathway-level models have better interpretative performance, higher stability and smaller model size across multiple cancer types and omics data types relative to gene-level models.

CONCLUSIONS

Based on this landscape and comprehensively comparison, models estimated on gene expression data provide the best predictive performance on either gene or pathway level. Pathway-level models have better interpretative performance, higher stability and smaller model size relative to gene-level models.

Whole-Brain Radiotherapy vs. Localized Radiotherapy after Resection of Brain Metastases in the Era of Targeted Therapy: A Retrospective Study

Simple Summary

The paradigm shift from cytotoxic chemotherapy to molecular targeted therapy dramatically improved the survival and quality of life of cancer patients. In radio-oncological aspects, there also was a paradigm shift from whole-brain radiotherapy to localized radiotherapy including stereotactic radiosurgery. This retrospective study analyzed 124 consecutive patients who had undergone surgical resection of brain metastases. We found targeted therapies to improve overall survival and distant control with decreased incidence of leptomeningeal metastasis. Our data suggest that localized radiotherapy is sufficient after resection of brain metastases when systemic targeted therapy is available.

Abstract

Whether targeted therapy (TT) and radiotherapy impact survival after resection of brain metastases (BM) is unknown. The purpose of this study was to analyze the factors affecting overall survival (OS), local control (LC), distant control (DC), and leptomeningeal metastases (LMM) in patients who had undergone resection of BM. We retrospectively analyzed 124 consecutive patients who had undergone resection of BM between 2004 and 2020. Patient information about age, sex, Karnofsky Performance Scale (KPS), origin of cancer, synchronicity, tumor size, status of primary cancer, use of TT, extent of resection, and postoperative radiotherapy was collected. Radiation therapy was categorized into whole-brain radiotherapy (WBRT), localized radiotherapy (local brain radiotherapy or stereotactic radiosurgery (LBRT/SRS)), and no radiation. We identified factors that affect OS, LC, DC, and LMM. In multivariable analysis, significant factors for OS were higher KPS score (≥90) (HR 0.53, p = 0.011), use of TT (HR 0.43, p = 0.001), controlled primary disease (HR 0.63, p = 0.047), and single BM (HR 0.55, p = 0.016). Significant factors for LC were gross total resection (HR 0.29, p = 0.014) and origin of cancer (p = 0.041). Both WBRT and LBRT/SRS showed superior LC than no radiation (HR 0.32, p = 0.034 and HR 0.38, p = 0.018, respectively). Significant factors for DC were use of TT (HR 0.54, p = 0.022) and single BM (HR 0.47, p = 0.004). Reduced incidence of LMM was associated with use of TT (HR 0.42, p = 0.038), synchronicity (HR 0.25, p = 0.028), and controlled primary cancer (HR 0.44, p = 0.047). TT was associated with prolonged OS, improved DC, and reduced LMM in resected BM patients. WBRT and LBRT/SRS showed similar benefits on LC. Considering the extended survival of cancer patients and the long-term effect of WBRT on cognitive function, LBRT/SRS appears to be a good option after resection of BM.

Identification of Regorafenib Prognostic Index (REP Index) via Recursive Partitioning Analysis in Patients with Advanced Hepatocellular Carcinoma Receiving Systemic Treatment: A Real-World Multi-Institutional Experience

BACKGROUND

The results of the pivotal RESORCE trial led to the approval of the tyrosine kinase inhibitor regorafenib as second-line treatment in advanced hepatocellular carcinoma (HCC) after sorafenib failure. Data about prognostic factors in a second-line HCC setting are scarce.

OBJECTIVE

The aim of the present study was to investigate prognostic factors in a cohort of patients with advanced HCC treated with regorafenib after progressing on sorafenib.

METHODS

We retrieved the data of 259 patients affected by advanced HCC treated with regorafenib as second-line treatment from four different Italian institutions and one South Korean institution and performed a recursive partitioning analysis to build a score system.

RESULTS

At the first-step univariate analysis for overall survival (OS), alkaline phosphatase (ALP) was the most significant parameter and was chosen as the first node in our tree model. In the subpopulation of patients presenting with ALP ≤122 U/L (n=155) at baseline, the most statistically significant split was by progression-free survival (PFS) on previous sorafenib treatment, between patients with a PFS ≥ 6 months (n  =  59) and patients with a PFS < 6 months (n = 96). In the subpopulation of patients with ALP ≤ 122 U/L and PFS to sorafenib ≥ 6 months, the final split was determined between patients with hepatitis B virus (HBV)-related liver disease (n = 22) and patients with no HBV-related liver disease (n = 37). In the subpopulation of patients presenting ALP >122 U/L (n = 104) at baseline, the most statistically significant split was by aspartate aminotransferase (AST) value, between patients with AST ≤ 56 U/L (n = 48) and patients with AST > 56 U/L (n = 56). We built the Regorafenib Prognostic Index (REP index) stratifying the population into "low-risk," "medium-risk," and "high-risk" groups. The difference in median OS between the three risk groups was statistically significant, being 20.8 months (95% confidence interval [CI] 10.0-46.3) in the "low-risk" group, 8.4 months (95% CI 7.2-1435.8) in the "medium-risk" group, and 5.5 months (95% CI 3.5-13.2) in the "high risk" group. The median PFS was 7.7 months (95% CI 3.7-19.3), 2.5 months (95% CI 2.1-28.8), and 2.4 months (95% CI 1.6-9.1) for the "low-risk," "medium-risk," and "high-risk" groups, respectively.

CONCLUSION

The REP index is an independent prognostic factor for OS and PFS in patients with advanced HCC treated with regorafenib.

The Impact of Stereotactic or Whole Brain Radiotherapy on Neurocognitive Functioning in Adult Patients with Brain Metastases: A Systematic Review and Meta-Analysis

Background & Objectives: Radiotherapy is standard treatment for patients with brain metastases (BMs), although it may lead to radiation-induced cognitive impairment. This review explores the impact of whole-brain radiotherapy (WBRT) or stereotactic radiosurgery (SRS) on cognition.

METHODS

The PRISMA guidelines were used to identify articles on PubMed and EmBase reporting on objective assessment of cognition before, and at least once after radiotherapy, in adult patients with nonresected BMs.

RESULTS

Of the 867 records screened, twenty articles (14 unique studies) were included. WBRT lead to decline in cognitive performance, which stabilized or returned to baseline in patients with survival of at least 9-15 months. For SRS, a decline in cognitive performance was sometimes observed shortly after treatment, but the majority of patients returned to or remained at baseline until a year after treatment.

CONCLUSIONS

These findings suggest that after WBRT, patients can experience deterioration over a longer period of time. The cognitive side effects of SRS are transient. Therefore, this review advices to choose SRS as this will result in lowest risks for cognitive adverse side effects, irrespective of predicted survival. In an already cognitively vulnerable patient population with limited survival, this information can be used in communicating risks and aid in making educated decisions.

Surgery for brain metastases - real-world prognostic factors' association with survival

BACKGROUND

Surgical resection of brain metastases (BM) improves overall survival (OS) in selected patients. Selecting those patients likely to benefit from surgery is challenging. The Graded Prognostic Assessment (GPA) and the diagnosis-specific Graded Prognostic Assessment (ds-GPA) were developed to predict survival in patients with BM, but not specifically to guide patient selection for surgery. Our aim was to evaluate the feasibility of preoperative GPA/ds-GPA scores and assess variables associated with OS.

METHODS

We retrospectively reviewed first-time surgical resection of BM from solid tumors at a Norwegian regional referral center from 2011 to 2018.

RESULTS

Of 590 patients, 51% were female and median age was 63 years. Median OS was 10.3 months and 74 patients (13%) died within three months after surgery. Preoperatively tumor origin was unknown in 20% of patients. A GPA score could be calculated for 92% of the patients preoperatively, but could not correctly predict survival. A ds-GPA score could be calculated for 46% of patients. Multivariable regression analysis revealed shorter OS in patients with higher age, worse functioning status, colorectal primary cancer compared to lung cancer, presence of extracranial metastases, and more than four BM. Patients with preoperative progressive extracranial disease or synchronous BM had shorter OS compared to patients with stable extracranial disease.

CONCLUSION

Ds-GPA could be calculated in less than half of patients preoperatively and GPA poorly identified patients which had minimal benefit of surgery. Including status of extracranial disease improve prognostication and therefore selection to surgery for brain metastases.

Epidemiology of brain metastases and leptomeningeal disease

Brain metastases affect a significant percentage of patients with advanced extracranial malignancies. Yet, the incidence of brain metastases remains poorly described, largely due to limitations of population-based registries, a lack of mandated reporting of brain metastases to federal agencies, and historical difficulties with delineation of metastatic involvement of individual organs using claims data. However, in 2016, the Surveillance Epidemiology and End Results (SEER) program released data relating to the presence vs absence of brain metastases at diagnosis of oncologic disease. In 2020, studies demonstrating the viability of utilizing claims data for identifying the presence of brain metastases, date of diagnosis of intracranial involvement, and initial treatment approach for brain metastases were published, facilitating epidemiologic investigations of brain metastases on a population-based level. Accordingly, in this review, we discuss the incidence, clinical presentation, prognosis, and management patterns of patients with brain metastases. Leptomeningeal disease is also discussed. Considerations regarding individual tumor types that commonly metastasize to the brain are provided.

Prognostic value of pretreatment MRI texture features in breast cancer brain metastasis treated with Gamma Knife radiosurgery

BACKGROUND

Gamma Knife radiosurgery (GKS) was recommended for treating patients with breast cancer brain metastasis (BCBM), but predictions of the existing prognostic models for therapeutic responsiveness vary substantially.

PURPOSE

To investigate the prognostic value of pretreatment clinical, MRI radiologic, and texture features in patients with BCBM undergoing GKS.

MATERIAL AND METHODS

The data of 81 BCBMs in 44 patients were retrospectively reviewed. Progressive disease was defined as an increase of at least 20% in the longest diameter of the target lesion or the presence of new intracranial lesions on contrast-enhanced T1-weighted (CE-T1W) imaging. Radiomic features were extracted from pretreatment CE-T1W images, T2-weighted (T2W) images, and ADC maps. Cox proportional hazard analyses were performed to identify independent predictors associated with BCBM-specific progression-free survival (PFS). A nomogram was constructed and its calibration ability was assessed.

RESULTS

The cumulative BCBM-specific PFS was 52.27% at six months and 11.36% at one year, respectively. Age (hazard ratio [HR] 1.04; 95% confidence interval [CI] 1.01-1.06; P = 0.004) and CE-T1W-based kurtosis (HR 0.72; 95% CI 0.57-0.92; P = 0.008) were the independent predictors. The combination of CE-T1W-based kurtosis and age displayed a higher C-index (C-index 0.70; 95% CI 0.63-0.77) than did CE-T1W-based kurtosis (C-index 0.65; 95% CI 0.57-0.73) or age (C-index 0.63; 95% CI 0.56-0.70) alone. The nomogram based on the combinative model provided a better performance over age (P < 0.05). The calibration curves elucidated good agreement between prediction and observation for the probability of 7- and 12-month BCBM-specific PFS.

CONCLUSION

Pretreatment CE-T1W-based kurtosis combined with age could improve prognostic ability in patients with BCBM undergoing GKS.

Surgical resection versus stereotactic radiosurgery on local recurrence and survival for patients with a single brain metastasis: a systematic review and meta-analysis

BACKGROUND

Brain metastases (BM) are the most frequent intracranial tumours in adults. In patients with solitary BM, surgical resection (SR) or stereotactic radiosurgery (SRS) is performed. There is limited evidence comparing one treatment over the other.

OBJECTIVE

To compare SR versus SRS on patients with solitary BMs, regarding local recurrence (LR) and overall survival (OS) conducting a systematic review and meta-analysis.

METHODS

Systematic review of literature following PRISMA guidelines, using the databases of Medline, Clinicaltrials.gov, Embase, Web of Science, Sciencedirect, CINAHL, Wiley Online Library, Springerlink and LILACS. Following study selection based on inclusion and exclusion criteria, data extraction and a critical analysis of the literature was performed according to the GRADE scale. For quantitative analysis, a random effects model was used. Data were synthetized and evaluated on a forest plot and funnel plot.

RESULTS

Two randomized clinical trials, four cohort studies and one case-control studies met our inclusion criteria for the qualitative analysis. None was excluded subsequently. Overall, 614 patients with single metastasis were included. Studies had high heterogeneity. Multiple significant variables affecting the outcome were signalized. Meta-analysis showed no significant differences for survival (HR, 1.10; 95% CI, 0.75-1.45) or LR (HR, 0.81; 95% CI, 0.42-1.20).

CONCLUSIONS

According to current evidence, in patients with a single small metastasis there is no statistically significant difference in OS or LR among the chosen techniques (SR or SRS). Multiple significant co-variables may affect both outcomes. Different outcomes better than OS should be evaluated in further randomized studies.

Roles of Neutrophils in Glioma and Brain Metastases

Neutrophils, which are the most abundant circulating leukocytes in humans, are the first line of defense against bacterial and fungal infections. Recent studies have reported the role and importance of neutrophils in cancers. Glioma and brain metastases are the most common malignant tumors of the brain. The tumor microenvironment (TME) in the brain is complex and unique owing to the brain-blood barrier or brain-tumor barrier, which may prevent drug penetration and decrease the efficacy of immunotherapy. However, there are limited studies on the correlation between brain cancer and neutrophils. This review discusses the origin and functions of neutrophils. Additionally, the current knowledge on the correlation between neutrophil-to-lymphocyte ratio and prognosis of glioma and brain metastases has been summarized. Furthermore, the implications of tumor-associated neutrophil (TAN) phenotypes and the functions of TANs have been discussed. Finally, the potential effects of various treatments on TANs and the ability of neutrophils to function as a nanocarrier of drugs to the brain TME have been summarized. However, further studies are needed to elucidate the complex interactions between neutrophils, other immune cells, and brain tumor cells.

A Prognostic Index for Predicting Survival of Patients Undergoing Radiation Therapy for Spine Metastasis Using Recursive Partitioning Analysis

Background: Physicians' estimate of life expectancy in patients with spine metastasis frequently impacts treatment decisions regarding surgery, radiation techniques, dose, and fractionation. Objective: We aimed to identify predictors of survival and generate a stratification schema that could guide clinical decision making. Materials and Methods: We identified 269 patients who have undergone surgery and/or radiation for spine metastasis from 2002 to 2013 at an academic medical institution in the United States. A univariate survival analysis was carried out using the Kaplan-Meier method. Differences in survival by histology were assessed using the log-rank test. Multivariate analysis was performed using the Cox proportional hazards model, then using the same variables, recursive partitioning analysis (RPA) was conducted to determine risk groups associated with survival. Results: The median overall survival was 4.76 months. Twenty percent, 40%, and 57% of patients died within one, three, and six months of radiation treatment, respectively. RPA analysis resulted in three classes; class I included patients with Karnofsky Performance Status (KPS) ≥80. Class II included patients with KPS <80 and radioresistant or favorable histologies. Class III included all other histologies. Median survival in months was 11.4, 6.3, and 2.0, respectively. Conclusion: We developed a stratification schema predictive of survival in patients with spine metastasis. This RPA classification should be validated in independent patient populations from several institutions and may ultimately identify patients who are good candidates for more complex treatment regimens, such as stereotactic body radiotherapy.

Identification of lenvatinib prognostic index via recursive partitioning analysis in advanced hepatocellular carcinoma

BACKGROUND

After the advent of new treatment options for advanced hepatocellular carcinoma (HCC), the identification of prognostic factors is crucial for the selection of the most appropriate therapy for each patient.

PATIENTS AND METHODS

With the aim to fill this gap, we applied recursive partitioning analysis (RPA) to a cohort of 404 patients treated with lenvatinib.

RESULTS

The application of RPA resulted in a classification based on five variables that originated a new prognostic score, the lenvatinib prognostic index (LEP) index, identifying three groups: low risk [patients with prognostic nutritional index (PNI) >43.3 and previous trans-arterial chemoembolization (TACE)]; medium risk [patients with PNI >43.3 but without previous TACE and patients with PNI <43.3, albumin-bilirubin (ALBI) grade 1 and Barcelona Clinic Liver Cancer stage B (BCLC-B)]; high risk [patients with PNI <43.3 and ALBI grade 2 and patients with PNI <43.3, albumin-bilirubin (ALBI) grade 1 and Barcelona Clinic Liver Cancer stage C (BCLC-C)]. Median overall survival was 29.8 months [95% confidence interval (CI) 22.8-29.8 months] in low risk patients (n = 128), 17.0 months (95% CI 15.0-24.0 months) in medium risk (n = 162) and 8.9 months (95% CI 8.0-10.7 months) in high risk (n = 114); low risk hazard ratio (HR) 1 (reference group), medium risk HR 1.95 (95% CI 1.38-2.74), high risk HR 4.84 (95% CI 3.16-7.43); P < 0.0001. The LEP index was validated in a cohort of 127 Italian patients treated with lenvatinib. While the same classification did not show a prognostic value in a cohort of 311 patients treated with sorafenib, we also show a possible predictive role in favor of lenvatinib in the low risk group.

CONCLUSIONS

LEP index is a promising, easy-to-use tool that may be used to stratify patients undergoing systemic treatment of advanced HCC.

Analysis Survival of Breast Cancer with Brain Metastases Treated with Different Fraction Whole Brain Radiotherapy Concomitant with Capecitabine

Introduction: Breast cancer is the second most frequent cancer worldwide. The main therapeutic modality for breast cancer with brain metastases is radiation. Whole Brain Radiotherapy (WBRT) is a treatment that provides moderate doses of radiotherapy to all brain tissue. Capecitabine was found to be effective for the treatment of breast cancer with metastases and its metabolites can cross the BBB in animal models.   Objective: This study aims to determine the response and survival of breast cancer patient with brain metastases treated with different fractionation WBRT combined with capecitabine administration.   Materials and methods: This is a prospective, randomized-blind cohort analytic study. Subjects were randomized into two groups by giving different fraction of WBRT (Group I WBRT 10x3Gy and Group II WBRT 20x2Gy) concomitant with capecitabine 850-1000mg/m2. OS was calculated from brain metastases diagnosis. Median follow-up was 5.6 months.   Results: A total of 22 breast cancer patients with brain metastases participated in this study. Group I obtained results of 5 (45.5%) out of 11 are responding to therapy and median OS was 4.4 months. Whereas in group II found 11 (100%) out of 11 patients responded to therapy and median OS was 9.4 months. The results of statistical analysis showed that there were significant differences of response between the two groups with p value= 0.012. The differences of survival of each group also statistically significant with p value=0.004   Conclusions: WBRT with 20x2Gy concomitant with Capecitabine gives a better response rate and OS.

Frequency of actionable molecular drivers in lung cancer patients with precocious brain metastases

Brain metastases frequently occur during the course of disease in patients suffering from lung cancer. Occasionally, neurological symptoms caused by brain metastases (BM) might represent the first sign of systemic tumor disease (so called precocious metastases), leading to the detection of the primary lung tumor. The biological basis of precocious BM is largely unknown, and treatment options are not well established for this subgroup of patients. Therefore, we retrospectively analyzed 33 patients (24 non-small cell lung cancer (NSCLC)), 9 small cell lung cancer (SCLC)) presenting with precocious BM focusing on molecular alterations potentially relevant for the tumor's biology and treatment. We found five FGFR1 amplifications (4 adenocarcinoma, 1 SCLC) among 31 analyzed patients (16.1%), eight MET amplifications among 30 analyzed tumors (7 NSCLC, 1 SCLC; 26.7%), three EGFR mutations within 33 patients (all adenocarcinomas, 9.1%), and five KRAS mutations among 32 patients (all adenocarcinomas; 15.6%). No ALK, ROS1 or RET gene rearrangements were detected. Our findings suggest that patients with precocious BM of lung cancer harbor EGFR mutations, MET amplifications or FGFR1 amplifications as potential targeted treatment options.

Socioeconomic Disparities in Non-Small Cell Lung Cancer With Brain Metastases at Presentation: A Population-Based Study

OBJECTIVE/BACKGROUND

The purpose of this study was to characterize the impact of household income disparities in the survival of patients with non-small cell lung cancer (NSCLC) presenting with brain metastasis on a population-based level.

METHODS

This is a population-based cohort study using the Surveillance, Epidemiology, and End Results (SEER) database from 2010-2016 including 15,808 NSCLC patients presenting with brain metastasis.

RESULTS

This study comprises 15,808 adult patients with NSCLC presenting with brain metastases having an age range 64 ± 10 years with 51% male, 76% white, 52% married, 61% insured, and with 85% of lung adenocarcinoma histopathology. The 1-, 2- and 5-year survival rates for living in the lower household income quartile were 21%, 10%, and 3%, respectively, for the second quartile 24%, 10%, and 3%; for the third quartile 28%, 14%, and 4%; and for the top quartile 31%, 17%, and 4%, respectively. Multivariate Cox proportional hazard analysis showed that living in a higher quartile household income county is associated with increased survival (P < 0.0001), hazard ratio 0.87, 95% confidence interval (0.82-0.92).

CONCLUSIONS

This population-based study suggests that living in higher median household income counties is associated with increased survival time and reduced risk of mortality for patients with NSCLC who have brain metastases present at diagnosis, independent of other factors. These findings underscore the importance of ensuring adequate and easy access to care for all patients, irrespective of their economic background.

Whole-brain Radiation Therapy for Intracranial Metastases as Initial or Late Treatment

BACKGROUND/AIM

We examined the difference between whole-brain radiation therapy (WBRT) for intracranial metastases (IM) from lung cancer as an initial and as a late treatment affecting overall survival (OS).

PATIENTS AND METHODS

Thirty-three patients who presented with IM at initial examination who received WBRT as the initial treatment (initial WBRT group) and 47 patients without IM or with asymptomatic IM at initial examination who received WBRT after systemic therapy, between January 2014 and December 2020, were retrospectively analyzed. Patients' OS after WBRT were compared.

RESULTS

Median OS was significantly longer in patients treated with systemic anticancer therapy after WBRT than in patients who were not (176 vs. 47 days, respectively; p<0.001), and systemic anticancer therapy after WBRT was a significant prognostic factor (p<0.001).

CONCLUSION

Treatment with systemic anticancer therapy after WBRT may prolong the survival of patients who present with IM at initial examination.

Frameless Stereotactic Radiosurgery With Linear Accelerator (LINAC)-Based Technology for Brain Metastases: Outcomes Analysis in 141 Patients

Objectives Brain metastases (BM) are the most common intracranial tumors in adults. Surgery and frame-based stereotactic radiosurgery (SRS) are well-described treatment options. Frameless SRS is an emerging BM treatment option offering fewer side effects. The aim of this study was to describe the therapeutic outcomes and toxicity of frameless SRS with linear accelerator (LINAC)-based technology for BM treatment in our institution. Materials and methods We performed a retrospective study including all adult patients treated with frameless SRS with LINAC-based technology for BM between October 2010 and July 2016. Patients were followed routinely with MRI scans at three-month intervals. Primary endpoints were progression-free survival, local control, overall survival, and toxicity related to the treatment. All survival times were computed with the Kaplan-Meier method. All cumulative incidences were computed using competing risk analyses. Results A total of 194 metastatic lesions in 141 patients were treated in a 69-month interval. At the time of analysis, 33 patients were still alive, with a median follow-up time of 25.1 months. The overall median survival was 8.7 months. The median progression-free survival was 5.3 months. Local recurrence as a first event was 25% and 38% at one and two years, respectively, while distant brain recurrence as a first event was 18% and 21%. Death before any brain event occurred in 31% of patients. The cumulative incidence of radiation necrosis as a first brain event was 2% at one and two years. Conclusions The treatment of BM with LINAC-based frameless SRS in our institution had an overall and progression-free survival comparable with the literature for frameless SRS and for conventional frame-based SRS while being less invasive and more comfortable for the patient. In our study, frameless SRS with LINAC technology seems to be safe for BM treatment with minimal rates of radiation necrosis.

Quality-of-life trajectories after stereotactic radiosurgery for brain metastases

OBJECTIVE

Quality of life (QOL) is an important endpoint measure of cancer treatment. The authors' goal was to evaluate QOL trajectories and prognostic value in cancer patients treated with stereotactic radiosurgery (SRS) for brain metastases.

METHODS

Patients who underwent Gamma Knife radiosurgery (GKRS) between January 2016 and November 2019 were prospectively evaluated for QOL using the EQ-5D-3L questionnaire before SRS and at follow-up visits. Only patients who had pre-SRS and at least 1 post-SRS QOL assessment were considered.

RESULTS

Fifty-four cancer patients underwent 109 GKRS procedures. The first post-SRS visit was at a median of 2.59 months (range 0.13-21.08 months), and the last post-SRS visit was at 14.72 months (range 2.52-45.21 months) after SRS. There was no statistically significant change in the EQ-5D index score (p = 0.539) at the first compared with last post-SRS visit. The proportion of patients reporting some problems on the EQ-5D dimension of self-care increased during the course of follow-up from 9% (pre-SRS visit) to 18% (last post-SRS visit; p = 0.03). The proportion of patients reporting problems on the EQ-5D dimensions of mobility, usual activities, pain/discomfort, and anxiety/depression remained stable during the course of follow-up (p ≥ 0.106). After adjusting for clinical variables, a higher recursive partitioning analysis (RPA) class (i.e., worse prognostic category) was independently associated with greater odds for EQ-5D index score deterioration (p = 0.050). Upfront whole-brain radiation therapy predicted deterioration of the EQ-5D self-care (p = 0.03) and usual activities (p = 0.024) dimensions, while a greater number of lesions predicted deterioration of the EQ-5D anxiety/depression dimension (p = 0.008). A lower pre-SRS EQ-5D index was associated with shorter survival independently from clinical and demographic variables (OR 18.956, 95% CI 2.793-128.64; p = 0.003).

CONCLUSIONS

QOL is largely preserved in brain metastasis patients treated with SRS. Higher RPA class, upfront whole-brain radiation therapy, and greater intracranial disease burden are independent predictors of post-SRS QOL deterioration. Worse pre-SRS QOL predicts shorter survival. Assessment of QOL is recommended in brain metastasis patients managed with SRS.

Efficacy and safety of hypofractionated stereotactic radiotherapy for brain metastases using three fractions: A single-centre retrospective study

PURPOSE

Hypofractionated stereotactic radiotherapy (HFSRT) has become a standard of care for patients with a limited number of brain metastases (BM). An increasing number of linear accelerators (LA) are able to accurately perform HFSRT including VersaHD® (Elekta®) LA. The main aim of this study was to report clinical outcomes of BM treated by HFSRT using 3×7.7Gy on 70% isodose line in terms of local control (LC).

PATIENTS AND METHODS

Between November 2016 and October 2018, all patients suffering from histologically-proven primary with one or several newly diagnosed BM treated by HFSRT were retrospectively included and evaluated. Patients who had received prior treatment by neurosurgery or cerebral radiotherapy were excluded.

RESULTS

Among 44 patients, 61 BM were treated. With a median follow-up of 31.9 months, LC rates at 6 and 12 months were 93.2% and 90.9, respectively. Single-BM was independently predictive of LC (P=0.025) and overall survival (P=0.013). Acute toxicity rates were acceptable: 65.9% of patients had grade 1 and 2 and no acute grade 3 toxicity according to the NCI-CTCAE (version 5.0). Regarding delayed toxicity, one case (2.3%) of radionecrosis was confirmed by magnetic resonance spectroscopy.

CONCLUSION

In our single-centre retrospective analysis, BM treatment by HFSRT delivered in three fractions showed a 12-month LC rate of 90.9% without major toxicities, which suggests safety and efficiency of this technique. However, longer-term follow-up and prospective studies are still needed to confirm these results.

Preoperative Radiosurgery for Resected Brain Metastases: The PROPS-BM Multicenter Cohort Study

PURPOSE

Preoperative radiosurgery (SRS) is a feasible alternative to postoperative SRS, with potential benefits in adverse radiation effect (ARE) and leptomeningeal disease (LMD) relapse. However, previous studies are limited by small patient numbers and single-institution designs. Our aim was to evaluate preoperative SRS outcomes and prognostic factors from a large multicenter cohort (Preoperative Radiosurgery for Brain Metastases [PROPS-BM]).

METHODS AND MATERIALS

Patients with brain metastases (BM) from solid cancers who had at least 1 lesion treated with preoperative SRS and underwent a planned resection were included from 5 institutions. SRS to synchronous intact BM was allowed. Radiographic meningeal disease (MD) was categorized as either nodular or classical "sugarcoating" (cLMD).

RESULTS

The cohort included 242 patients with 253 index lesions. Most patients (62.4%) had a single BM, 93.7% underwent gross total resection, and 98.8% were treated with a single fraction to a median dose of 15 Gray to a median gross tumor volume of 9.9 cc. Cavity local recurrence (LR) rates at 1 and 2 years were 15% and 17.9%, respectively. Subtotal resection (STR) was a strong independent predictor of LR (hazard ratio, 9.1; P < .001). One and 2-year rates of MD were 6.1% and 7.6% and of any grade ARE were 4.7% and 6.8% , respectively. The median overall survival (OS) duration was 16.9 months and the 2-year OS rate was 38.4%. The majority of MD was cLMD (13 of 19 patients with MD; 68.4%). Of 242 patients, 10 (4.1%) experienced grade ≥3 postoperative surgical complications.

CONCLUSIONS

To our knowledge, this multicenter study represents the largest cohort treated with preoperative SRS. The favorable outcomes previously demonstrated in single-institution studies, particularly the low rates of MD and ARE, are confirmed in this expanded multicenter analysis, without evidence of an excessive postoperative surgical complication risk. STR, though infrequent, is associated with significantly worse cavity LR. A randomized trial between preoperative and postoperative SRS is warranted and is currently being designed.

Population-based estimates of survival among elderly patients with brain metastases

BACKGROUND

Prognostic estimates for patients with brain metastases (BM) stem from younger, healthier patients enrolled in clinical trials or databases from academic centers. We characterized population-level prognosis in elderly patients with BM.

METHODS

Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified 9882 patients ≥65 years old with BM secondary to lung, breast, skin, kidney, esophageal, colorectal, and ovarian primaries between 2014 and 2016. Survival was assessed by primary site and evaluated with Cox regression.

RESULTS

In total, 2765 versus 7117 patients were diagnosed with BM at primary cancer diagnosis (synchronous BM, median survival = 2.9 mo) versus thereafter (metachronous BM, median survival = 3.4 mo), respectively. Median survival for all primary sites was ≤4 months, except ovarian cancer (7.5 mo). Patients with non-small-cell lung cancer (NSCLC) receiving epidermal growth factor receptor (EGFR)- or anaplastic lymphoma kinase (ALK)-based therapy for synchronous BM displayed notably better median survival at 12.5 and 20.1 months, respectively, versus 2.8 months exhibited by other patients with NSCLC; survival estimates in melanoma patients based on receipt of BRAF/MEK therapy versus not were 6.7 and 2.8 months, respectively. On multivariable regression, older age, greater comorbidity, and type of managing hospital were associated with poorer survival; female sex, higher median household income, and use of brain-directed stereotactic radiation, neurosurgical resection, or systemic therapy (versus brain-directed non-stereotactic radiation) were associated with improved survival (all P < 0.05).

CONCLUSIONS

Elderly patients with BM have a poorer prognosis than suggested by prior algorithms. If prognosis is driven by systemic and not intracranial disease, brain-directed therapy with potential for significant toxicity should be utilized cautiously.