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Wiegreffe S, Sarria GR, Layer JP, Dejonckheere E, Nour Y, Schmeel FC, Anton Giordano F, Schmeel LC, Popp I, Grosu AL, Gkika E, Stefaan Dejonckheere C. Incidence of hippocampal and perihippocampal brain metastases and impact on hippocampal-avoiding radiotherapy: A systematic review and meta-analysis. Radiother Oncol 2024; 197:110331. [PMID: 38772476 DOI: 10.1016/j.radonc.2024.110331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/25/2024] [Accepted: 05/03/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND AND PURPOSE In patients requiring prophylactic cranial irradiation (PCI) or whole-brain radiotherapy (WBRT) for brain metastases (BMs), hippocampal avoidance (HA) has been shown to preserve neurocognitive function and quality of life. Here, we aim to estimate the incidence of hippocampal and perihippocampal BMs and the subsequent risk of local undertreatment in patients undergoing hippocampal sparing radiotherapy. MATERIALS AND METHODS MEDLINE, Embase, and Scopus were searched with the terms "Hippocampus", "Brain Neoplasms", and related terms. Trials reporting on the incidence of hippocampal and/or perihippocampal BMs or hippocampal failure rate after PCI or WBRT were included. RESULTS Forty records were included, encompassing a total of 5,374 patients with over 32,570 BMs. Most trials employed a 5 mm margin to define the HA zone. In trials reporting on BM incidence, 4.4 % (range 0 - 27 %) and 9.2 % (3 - 41 %) of patients had hippocampal and perihippocampal BMs, respectively. The most common risk factor for hippocampal BMs was the total number of BMs. The reported failure rate within the HA zone after HA-PCI or HA-WBRT was 4.5 % (0 - 13 %), salvageable with radiosurgery in most cases. SCLC histology was not associated with a higher risk of hippocampal failure (OR = 2.49; p = 0.23). In trials comparing with a conventional (non-HA) PCI or WBRT group, HA did not increase the hippocampal failure rate (OR = 1.90; p = 0.17). CONCLUSION The overall incidence of hippocampal and perihippocampal BMs is considerably low, with a subsequent low risk of local undertreatment following HA-PCI or HA-WBRT. In patients without involvement, the hippocampus should be spared to preserve neurocognitive function and quality of life.
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Affiliation(s)
- Shari Wiegreffe
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | | | - Julian Philipp Layer
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; Institute of Experimental Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | - Egon Dejonckheere
- Faculty of Psychology and Educational Sciences, KU Leuven, 3000 Leuven, Belgium; Department of Medical and Clinical Psychology, Tilburg School of Social and Behavioural Sciences, 5037 Tilburg, the Netherlands
| | - Younèss Nour
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | | | - Frank Anton Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, 68167 Mannheim, Germany; DKFZ-Hector Cancer Institute, University Medical Center Mannheim, 68167 Mannheim, Germany
| | | | - Ilinca Popp
- Department of Radiation Oncology, Medical Faculty, University Freiburg, 79106 Freiburg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, Medical Faculty, University Freiburg, 79106 Freiburg, Germany
| | - Eleni Gkika
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany
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Rossi S, Pagliaro A, Michelini A, Navarria P, Clerici E, Franceschini D, Toschi L, Finocchiaro G, Scorsetti M, Santoro A. The Era of Immunotherapy in Small-Cell Lung Cancer: More Shadows Than Light? Cancers (Basel) 2023; 15:5761. [PMID: 38136306 PMCID: PMC10741846 DOI: 10.3390/cancers15245761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/10/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
Small-cell lung cancer is an extremely chemo-sensitive disease; the addition of immunotherapy to chemotherapy has demonstrated a slight clinical benefit in pivotal trials, even with a statistically significant difference in terms of survival outcomes when compared to chemotherapy alone. In this scenario, the role of radiotherapy as a consolidation treatment in thoracic disease or as a prophylactic therapy in the brain should be clarified. In addition, due to the frailty and the poor prognostic characteristics of these patients, the need for predictive biomarkers that could support the use of immunotherapy is crucial. PD-L1 and TMB are not actually considered definitive biomarkers due to the heterogeneity of results in the literature. A new molecular classification of small-cell lung cancer based on the expression of key transcription factors seems to clarify the disease behavior, but the knowledge of this molecular subtype is still insufficient and the application in clinical practice far from reality; this classification could lead to a better understanding of SCLC disease and could provide the right direction for more personalized treatment. The aim of this review is to investigate the current knowledge in this field, evaluating whether there are predictive biomarkers and clinical patient characteristics that could help us to identify those patients who are more likely to respond to immunotherapy.
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Affiliation(s)
- Sabrina Rossi
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.P.); (A.M.); (L.T.); (G.F.); (A.S.)
| | - Arianna Pagliaro
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.P.); (A.M.); (L.T.); (G.F.); (A.S.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy;
| | - Angelica Michelini
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.P.); (A.M.); (L.T.); (G.F.); (A.S.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy;
| | - Pierina Navarria
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (P.N.); (E.C.); (D.F.)
| | - Elena Clerici
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (P.N.); (E.C.); (D.F.)
| | - Davide Franceschini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (P.N.); (E.C.); (D.F.)
| | - Luca Toschi
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.P.); (A.M.); (L.T.); (G.F.); (A.S.)
| | - Giovanna Finocchiaro
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.P.); (A.M.); (L.T.); (G.F.); (A.S.)
| | - Marta Scorsetti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy;
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (P.N.); (E.C.); (D.F.)
| | - Armando Santoro
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.P.); (A.M.); (L.T.); (G.F.); (A.S.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy;
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Rios-Hoyo A, Arriola E. Immunotherapy and brain metastasis in lung cancer: connecting bench side science to the clinic. Front Immunol 2023; 14:1221097. [PMID: 37876939 PMCID: PMC10590916 DOI: 10.3389/fimmu.2023.1221097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/15/2023] [Indexed: 10/26/2023] Open
Abstract
Brain metastases (BMs) are the most common form of intracranial malignant neoplasms in adults, with a profound impact on quality of life and traditionally associated with a dismal prognosis. Lung cancer accounts for approximately 40%-50% of BM across different tumors. The process leading to BMs is complex and includes local invasion, intravasation, tumor cells circulation into the bloodstream, disruption of the blood-brain barrier, extravasation of tumor cells into the brain parenchyma, and interaction with cells of the brain microenvironment, among others. Once the tumor cells have seeded in the brain parenchyma, they encounter different glial cells of the brain, as well as immune cells. The interaction between these cells and tumor cells is complex and is associated with both antitumoral and protumoral effects. To overcome the lethal prognosis associated with BMs, different treatment strategies have been developed, such as immunotherapy with immune checkpoint inhibitors, particularly inhibitors of the PD-1/PD-L1 axis, which have demonstrated to be an effective treatment in both non-small cell lung cancer and small cell lung cancer. These antibodies have shown to be effective in the treatment of BM, alone or in combination with chemotherapy or radiotherapy. However, many unsolved questions remain to be answered, such as the sequencing of immunotherapy and radiotherapy, the optimal management in symptomatic BMs, the role of the addition of anti-CTLA-4 antibodies, and so forth. The complexity in the management of BMs in the era of immunotherapy requires a multidisciplinary approach to adequately treat this devastating event. The aim of this review is to summarize evidence regarding epidemiology of BM, its pathophysiology, current approach to treatment strategies, as well as future perspectives.
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Affiliation(s)
- Alejandro Rios-Hoyo
- Yale Cancer Center, Yale School of Medicine, Yale University, New Haven, CT, United States
| | - Edurne Arriola
- Department of Medical Oncology, Hospital del Mar-CIBERONC (Centro de Investigación Biomédica en Red de Oncología), Barcelona, Spain
- Cancer Research Program, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Barcelona, Spain
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4
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Levis M, Gastino A, De Giorgi G, Mantovani C, Bironzo P, Mangherini L, Ricci AA, Ricardi U, Cassoni P, Bertero L. Modern Stereotactic Radiotherapy for Brain Metastases from Lung Cancer: Current Trends and Future Perspectives Based on Integrated Translational Approaches. Cancers (Basel) 2023; 15:4622. [PMID: 37760591 PMCID: PMC10526239 DOI: 10.3390/cancers15184622] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/01/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Brain metastases (BMs) represent the most frequent metastatic event in the course of lung cancer patients, occurring in approximately 50% of patients with non-small-cell lung cancer (NSCLC) and in up to 70% in patients with small-cell lung cancer (SCLC). Thus far, many advances have been made in the diagnostic and therapeutic procedures, allowing improvements in the prognosis of these patients. The modern approach relies on the integration of several factors, such as accurate histological and molecular profiling, comprehensive assessment of clinical parameters and precise definition of the extent of intracranial and extracranial disease involvement. The combination of these factors is pivotal to guide the multidisciplinary discussion and to offer the most appropriate treatment to these patients based on a personalized approach. Focal radiotherapy (RT), in all its modalities (radiosurgery (SRS), fractionated stereotactic radiotherapy (SRT), adjuvant stereotactic radiotherapy (aSRT)), is the cornerstone of BM management, either alone or in combination with surgery and systemic therapies. We review the modern therapeutic strategies available to treat lung cancer patients with brain involvement. This includes an accurate review of the different technical solutions which can be exploited to provide a "state-of-art" focal RT and also a detailed description of the systemic agents available as effective alternatives to SRS/SRT when a targetable molecular driver is present. In addition to the validated treatment options, we also discuss the future perspective for focal RT, based on emerging clinical reports (e.g., SRS for patients with many BMs from NSCLC or SRS for BMs from SCLC), together with a presentation of innovative and promising findings in translational research and the combination of novel targeted agents with SRS/SRT.
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Affiliation(s)
- Mario Levis
- Radiation Oncology Unit, Department of Oncology, University of Turin, 10126 Turin, Italy; (M.L.); (A.G.); (G.D.G.); (C.M.); (U.R.)
| | - Alessio Gastino
- Radiation Oncology Unit, Department of Oncology, University of Turin, 10126 Turin, Italy; (M.L.); (A.G.); (G.D.G.); (C.M.); (U.R.)
| | - Greta De Giorgi
- Radiation Oncology Unit, Department of Oncology, University of Turin, 10126 Turin, Italy; (M.L.); (A.G.); (G.D.G.); (C.M.); (U.R.)
| | - Cristina Mantovani
- Radiation Oncology Unit, Department of Oncology, University of Turin, 10126 Turin, Italy; (M.L.); (A.G.); (G.D.G.); (C.M.); (U.R.)
| | - Paolo Bironzo
- Oncology Unit, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, 10043 Orbassano, Italy;
| | - Luca Mangherini
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (L.M.); (A.A.R.); (P.C.)
| | - Alessia Andrea Ricci
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (L.M.); (A.A.R.); (P.C.)
| | - Umberto Ricardi
- Radiation Oncology Unit, Department of Oncology, University of Turin, 10126 Turin, Italy; (M.L.); (A.G.); (G.D.G.); (C.M.); (U.R.)
| | - Paola Cassoni
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (L.M.); (A.A.R.); (P.C.)
| | - Luca Bertero
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (L.M.); (A.A.R.); (P.C.)
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Rusthoven CG, Staley AW, Gao D, Yomo S, Bernhardt D, Wandrey N, El Shafie R, Kraemer A, Padilla O, Chiang V, Faramand AM, Palmer JD, Zacharia BE, Wegner RE, Hattangadi-Gluth JA, Levy A, Bernstein K, Mathieu D, Cagney DN, Chan MD, Grills IS, Braunstein S, Lee CC, Sheehan JP, Kluwe C, Patel S, Halasz LM, Andratschke N, Deibert CP, Verma V, Trifiletti DM, Cifarelli CP, Debus J, Combs SE, Sato Y, Higuchi Y, Aoyagi K, Brown PD, Alami V, Niranjan A, Lunsford LD, Kondziolka D, Camidge DR, Kavanagh BD, Robin TP, Serizawa T, Yamamoto M. Comparison of first-line radiosurgery for small-cell and non-small cell lung cancer brain metastases (CROSS-FIRE). J Natl Cancer Inst 2023; 115:926-936. [PMID: 37142267 PMCID: PMC10407696 DOI: 10.1093/jnci/djad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/23/2023] [Accepted: 04/28/2023] [Indexed: 05/06/2023] Open
Abstract
INTRODUCTION Historical reservations regarding stereotactic radiosurgery (SRS) for small-cell lung cancer (SCLC) brain metastases include concerns for short-interval and diffuse central nervous system (CNS) progression, poor prognoses, and increased neurological mortality specific to SCLC histology. We compared SRS outcomes for SCLC and non-small cell lung cancer (NSCLC) where SRS is well established. METHODS Multicenter first-line SRS outcomes for SCLC and NSCLC from 2000 to 2022 were retrospectively collected (n = 892 SCLC, n = 4785 NSCLC). Data from the prospective Japanese Leksell Gamma Knife Society (JLGK0901) clinical trial of first-line SRS were analyzed as a comparison cohort (n = 98 SCLC, n = 814 NSCLC). Overall survival (OS) and CNS progression were analyzed using Cox proportional hazard and Fine-Gray models, respectively, with multivariable adjustment for cofactors including age, sex, performance status, year, extracranial disease status, and brain metastasis number and volume. Mutation-stratified analyses were performed in propensity score-matched retrospective cohorts of epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) positive NSCLC, mutation-negative NSCLC, and SCLC. RESULTS OS was superior for patients with NSCLC compared to SCLC in the retrospective dataset (median OS = 10.5 vs 8.6 months; P < .001) and in the JLGK0901 dataset. Hazard estimates for first CNS progression favoring NSCLC were similar in both datasets but reached statistical significance in the retrospective dataset only (multivariable hazard ratio = 0.82, 95% confidence interval = 0.73 to 0.92, P = .001). In the propensity score-matched cohorts, there were continued OS advantages for NSCLC patients (median OS = 23.7 [EGFR and ALK positive NSCLC] vs 13.6 [mutation-negative NSCLC] vs 10.4 months [SCLC], pairwise P values < 0.001), but no statistically significant differences in CNS progression were observed in the matched cohorts. Neurological mortality and number of lesions at CNS progression were similar for NSCLC and SCLC patients. Leptomeningeal progression was increased in patients with NSCLC compared to SCLC in the retrospective dataset only (multivariable hazard ratio = 1.61, 95% confidence interval = 1.14 to 2.26, P = .007). CONCLUSIONS After SRS, SCLC histology was associated with shorter OS compared to NSCLC. CNS progression occurred earlier in SCLC patients overall but was similar in patients matched on baseline factors. SCLC was not associated with increased neurological mortality, number of lesions at CNS progression, or leptomeningeal progression compared to NSCLC. These findings may better inform clinical expectations and individualized decision making regarding SRS for SCLC patients.
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Affiliation(s)
- Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alyse W Staley
- University of Colorado Cancer Center, Biostatistics Core, Aurora, CO, USA
| | - Dexiang Gao
- University of Colorado Cancer Center, Biostatistics Core, Aurora, CO, USA
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Division of Radiation Oncology, Aizawa Hospital, Matsumoto, Japan
| | - Denise Bernhardt
- Department of Radiation Oncology, Technical University of Munich (TUM), Munich, Germany
| | - Narine Wandrey
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rami El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Radiation Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Anna Kraemer
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Oscar Padilla
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY, USA
| | - Veronica Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Andrew M Faramand
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The James Comprehensive Cancer Center at The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Brad E Zacharia
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | | | - Antonin Levy
- Department of Radiation Oncology, Gustave Roussy, Villejuif, Université Paris Saclay, France
| | - Kenneth Bernstein
- Department of Radiation Oncology, New York University Langone Medical Center, New York, NY, USA
| | - David Mathieu
- Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - Daniel N Cagney
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Steve Braunstein
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Cheng-Chia Lee
- Taipei Veterans General Hospital, Department of Neurosurgery, Neurological Institute, Taipei, Taiwan
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Christien Kluwe
- Department of Radiation Oncology, Vanderbilt University, Nashville, TN, USA
| | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Lia M Halasz
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich (USZ), The University of Zurich, Zurich, Switzerland
| | | | - Vivek Verma
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Jacksonville, Jacksonville, FL, USA
| | | | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), Munich, Germany
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Yoshinori Higuchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kyoko Aoyagi
- Gamma Knife House, Chiba Cerebral and Cardiovascular Center, Chiba, Japan
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Vida Alami
- University of Colorado Cancer Center, Biostatistics Core, Aurora, CO, USA
| | - Ajay Niranjan
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Douglas Kondziolka
- Department of Neurosurgery and Radiation Oncology, New York University Langone Medical Center, New York, NY, USA
| | - D Ross Camidge
- Division of Medical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Brian D Kavanagh
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Tyler P Robin
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Toru Serizawa
- Tokyo Gamma Unit Center, Tsukiji Neurological Clinic, Tokyo, Japan
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6
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Diehl CD, Giordano FA, Grosu AL, Ille S, Kahl KH, Onken J, Rieken S, Sarria GR, Shiban E, Wagner A, Beck J, Brehmer S, Ganslandt O, Hamed M, Meyer B, Münter M, Raabe A, Rohde V, Schaller K, Schilling D, Schneider M, Sperk E, Thomé C, Vajkoczy P, Vatter H, Combs SE. Opportunities and Alternatives of Modern Radiation Oncology and Surgery for the Management of Resectable Brain Metastases. Cancers (Basel) 2023; 15:3670. [PMID: 37509330 PMCID: PMC10377800 DOI: 10.3390/cancers15143670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Postsurgical radiotherapy (RT) has been early proven to prevent local tumor recurrence, initially performed with whole brain RT (WBRT). Subsequent to disadvantageous cognitive sequalae for the patient and the broad distribution of modern linear accelerators, focal irradiation of the tumor has omitted WBRT in most cases. In many studies, the effectiveness of local RT of the resection cavity, either as single-fraction stereotactic radiosurgery (SRS) or hypo-fractionated stereotactic RT (hFSRT), has been demonstrated to be effective and safe. However, whereas prospective high-level incidence is still lacking on which dose and fractionation scheme is the best choice for the patient, further ablative techniques have come into play. Neoadjuvant SRS (N-SRS) prior to resection combines straightforward target delineation with an accelerated post-surgical phase, allowing an earlier start of systemic treatment or rehabilitation as indicated. In addition, low-energy intraoperative RT (IORT) on the surgical bed has been introduced as another alternative to external beam RT, offering sterilization of the cavity surface with steep dose gradients towards the healthy brain. This consensus paper summarizes current local treatment strategies for resectable brain metastases regarding available data and patient-centered decision-making.
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Affiliation(s)
- Christian D Diehl
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 80336 München, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Anca-L Grosu
- Department of Radiation Oncology, University Medical Center, Medical Faculty, 79106 Freiburg, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Klaus-Henning Kahl
- Department of Radiation Oncology, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Julia Onken
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- Berlin Institute of Health, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- German Cancer Consortium (DKTK), Partner Site Berlin, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, 37075 Göttingen, Germany
- Comprehensive Cancer Center Niedersachsen (CCC-N), 37075 Göttingen, Germany
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Arthur Wagner
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Jürgen Beck
- Department of Neurosurgery, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Stefanie Brehmer
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Marc Münter
- Department of Radiation Oncology, Klinikum Stuttgart Katharinenhospital, 70174 Stuttgart, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Veit Rohde
- Department of Neurosurgery, Universitätsmedizin Göttingen, 37075 Göttingen, Germany
| | - Karl Schaller
- Department of Neurosurgery, University of Geneva Medical Center & Faculty of Medicine, 1211 Geneva, Switzerland
| | - Daniela Schilling
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Elena Sperk
- Mannheim Cancer Center, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 80336 München, Germany
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7
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Georgiou LA, Wright JH, Markel TO, Sims PJ. Small-cell lung cancer metastasis to a meningioma: Case report and review of the literature. Radiol Case Rep 2023; 18:1452-1456. [PMID: 36798062 PMCID: PMC9925871 DOI: 10.1016/j.radcr.2023.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 02/04/2023] Open
Abstract
Tumor-to-tumor metastasis is a rare event with meningioma as the recipient tumor accounting for 20% of the reported cases. The most common primary cancers showing this phenomenon are lung and breast cancer. Most lung cancers metastasizing to a meningioma are due to lung adenocarcinoma with the literature containing only 3 prior reports of small-cell lung cancer showing this pattern of spread. Herein, we present the case of a 67-year-old-patient with small-cell lung cancer that developed a metastasis to a meningioma.
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Affiliation(s)
- Loukas A. Georgiou
- Kentucky College of Osteopathic Medicine, 147 Sycamore St., Pikeville, KY 41501, USA
- Corresponding author.
| | - Jeremiah H. Wright
- Department of Radiology, Jackson-Madison County General Hospital, Jackson, TN, USA
| | - Thomas O. Markel
- Department of Radiology, Radia Inc., Legacy Salmon Creek Medical Center, Vancouver, WA, USA
| | - Paul J. Sims
- Department of Pathology, Jackson-Madison County General Hospital, Jackson, TN, USA
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8
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Chu X, Zhu Z. Prophylactic cranial irradiation in small cell lung cancer: an update. Curr Opin Oncol 2023; 35:61-67. [PMID: 36421007 DOI: 10.1097/cco.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The current review presents recent updates in the seminal literature of research on prophylactic cranial irradiation (PCI) in small cell lung cancer (SCLC). RECENT FINDINGS Brain MRI restaging before the administration of PCI reveals a substantial proportion of brain metastasis in baseline brain metastasis free extensive-stage SCLC (ES-SCLC) and limited-stage SCLC (LS-SCLC). Posthoc analyses from the CASPIAN and IMpower133 trials revealed decreases in brain metastasis rates in ES-SCLC treated with chemoimmunotherapy relative to the brain metastasis rates in ES-SCLC treated with chemotherapy alone. A recent meta-analysis of literature published after the landmark 1999 Auperin meta-analysis confirmed the survival benefit of PCI in LS-SCLC patients. A recent study employing PET before and after PCI demonstrated that hippocampal avoidance -PCI (HA-PCI) preserved the metabolic activity of the hippocampi compared with regular PCI. Two phase III trials evaluating neurocognitive functions after HA-PCI versus PCI have yielded conflicting results. Ongoing clinical trials (MAVERICK, PRIMALung, NRG CC003, NCT04535739, NCT04829708 and NCT03514849) regarding PCI versus MRI surveillance and HA-PCI versus PCI were also discussed. SUMMARY Currently, the indications for PCI in SCLC are under question in the modern MRI era. Result from prospective phase III, MRI staged and MRI monitored RCTs are expected to elucidate the role of PCI in LS-SCLC and ES-SCLC. Preliminary results indicated that adding immunotherapy to chemotherapy may reduce brain metastasis rate in SCLC. Further data to this aspect are warranted to determine the role of PCI in the immuno-chemotherapy era. The future direction for PCI should be the comprehensive integration of personalized patient selection, HA-PCI utilization and potential employment of other neurocognitive preservation strategies.
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Affiliation(s)
- Xiao Chu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center
- Department of Oncology, Shanghai Medical College, Fudan University
- Shanghai Clinical Research Center for Radiation Oncology
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Zhengfei Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center
- Department of Oncology, Shanghai Medical College, Fudan University
- Shanghai Clinical Research Center for Radiation Oncology
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
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9
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Diehl CD, Pigorsch SU, Gempt J, Krieg SM, Reitz S, Waltenberger M, Barz M, Meyer HS, Wagner A, Wilkens J, Wiestler B, Zimmer C, Meyer B, Combs SE. Low-Energy X-Ray Intraoperative Radiation Therapy (Lex-IORT) for Resected Brain Metastases: A Single-Institution Experience. Cancers (Basel) 2022; 15:cancers15010014. [PMID: 36612015 PMCID: PMC9817795 DOI: 10.3390/cancers15010014] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Resection followed by local radiation therapy (RT) is the standard of care for symptomatic brain metastases. However, the optimal technique, fractionation scheme and dose are still being debated. Lately, low-energy X-ray intraoperative RT (lex-IORT) has been of increasing interest. METHOD Eighteen consecutive patients undergoing BM resection followed by immediate lex-IORT with 16-30 Gy applied to the spherical applicator were retrospectively analyzed. Demographic, RT-specific, radiographic and clinical data were reviewed to evaluate the effectiveness and safety of IORT for BM. Descriptive statistics and Kaplan-Meyer analysis were applied. RESULTS The mean follow-up time was 10.8 months (range, 0-39 months). The estimated local control (LC), distant brain control (DBC) and overall survival (OS) at 12 months post IORT were 92.9% (95%-CI 79.3-100%), 71.4% (95%-CI 50.2-92.6%) and 58.0% (95%-CI 34.1-81.9%), respectively. Two patients developed radiation necrosis (11.1%) and wound infection (CTCAE grade III); both had additional adjuvant treatment after IORT. For five patients (27.8%), the time to the start or continuation of systemic treatment was ≤15 days and hence shorter than wound healing and adjuvant RT would have required. CONCLUSION In accordance with previous series, this study demonstrates the effectiveness and safety of IORT in the management of brain metastases despite the small cohort and the retrospective characteristic of this analysis.
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Affiliation(s)
- Christian D. Diehl
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany
- Correspondence:
| | - Steffi U. Pigorsch
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- TUM-Neuroimaging Center, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Silvia Reitz
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Maria Waltenberger
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Melanie Barz
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Hanno S. Meyer
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Arthur Wagner
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Jan Wilkens
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Benedikt Wiestler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany
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10
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Aizer AA, Lamba N, Ahluwalia MS, Aldape K, Boire A, Brastianos PK, Brown PD, Camidge DR, Chiang VL, Davies MA, Hu LS, Huang RY, Kaufmann T, Kumthekar P, Lam K, Lee EQ, Lin NU, Mehta M, Parsons M, Reardon DA, Sheehan J, Soffietti R, Tawbi H, Weller M, Wen PY. Brain metastases: A Society for Neuro-Oncology (SNO) consensus review on current management and future directions. Neuro Oncol 2022; 24:1613-1646. [PMID: 35762249 PMCID: PMC9527527 DOI: 10.1093/neuonc/noac118] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Brain metastases occur commonly in patients with advanced solid malignancies. Yet, less is known about brain metastases than cancer-related entities of similar incidence. Advances in oncologic care have heightened the importance of intracranial management. Here, in this consensus review supported by the Society for Neuro-Oncology (SNO), we review the landscape of brain metastases with particular attention to management approaches and ongoing efforts with potential to shape future paradigms of care. Each coauthor carried an area of expertise within the field of brain metastases and initially composed, edited, or reviewed their specific subsection of interest. After each subsection was accordingly written, multiple drafts of the manuscript were circulated to the entire list of authors for group discussion and feedback. The hope is that the these consensus guidelines will accelerate progress in the understanding and management of patients with brain metastases, and highlight key areas in need of further exploration that will lead to dedicated trials and other research investigations designed to advance the field.
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Affiliation(s)
- Ayal A Aizer
- Corresponding Author: Dr. Ayal A. Aizer, MD/MHS, Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA ()
| | | | | | - Kenneth Aldape
- Laboratory of Pathology, National Cancer Institute, Bethesda, Maryland, USA
| | - Adrienne Boire
- Department of Neurology, Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Priscilla K Brastianos
- Departments of Neuro-Oncology and Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - D Ross Camidge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Veronica L Chiang
- Departments of Neurosurgery and Radiation Oncology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael A Davies
- Department of Melanoma Medical Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Leland S Hu
- Department of Radiology, Neuroradiology Division, Mayo Clinic, Phoenix, Arizona, USA
| | - Raymond Y Huang
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | | | - Priya Kumthekar
- Department of Neurology at The Feinberg School of Medicine at Northwestern University and The Malnati Brain Tumor Institute at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois, USA
| | - Keng Lam
- Department of Neurology, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, California, USA
| | - Eudocia Q Lee
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Minesh Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida, USA
| | - Michael Parsons
- Departments of Oncology and Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David A Reardon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Riccardo Soffietti
- Division of Neuro-Oncology, Department of Neuroscience Rita Levi Montalcini, University of Turin, Turin, Italy
| | - Hussein Tawbi
- Department of Melanoma Medical Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Patrick Y Wen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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11
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Liu J, Wu D, Shen B, Chen M, Zhou X, Zhang P, Qiu G, Ji Y, Du X, Yang Y. Serum lactate dehydrogenase predicts brain metastasis and survival in limited-stage small cell lung cancer patients treated with thoracic radiotherapy and prophylactic cranial irradiation. Strahlenther Onkol 2022; 198:1094-1104. [PMID: 35857072 DOI: 10.1007/s00066-022-01977-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Small cell lung cancer (SCLC) is characterized by a high risk of brain metastasis and poor survival. This study aims to assess the prognostic role of lactate dehydrogenase (LDH) in limited-stage small cell lung cancer (LS-SCLC) treated with thoracic radiotherapy (TRT) and prophylactic cranial irradiation (PCI). METHODS This study retrospectively evaluated 197 consecutive patients who underwent TRT and PCI for LS-SCLC between November 2005 and October 2017. Both pretreatment and maximal serum LDH levels (mLDH) during treatment were checked, and an increased LDH level was defined as more than 240 IU/ml. Clinical factors were tested for associations with intracranial progression-free survival (IPFS) and overall survival (OS) after PCI. The Kaplan-Meier method was used to calculate survival rates, and multivariate Cox regression analyses were carried out to identify variables associated with survival. RESULTS Of the total patients, 28 had higher pretreatment LDH levels and mLDH levels were increased in 95 patients during treatment. In patients in the normal and elevated mLDH groups, the 1‑, 2‑, and 5‑year IPFS rates were 96.7% vs. 90.1%, 91.7% vs. 73.8%, and 87.8% vs. 61.0% (P < 0.01), respectively. Compared to those with normal LDH levels, patients with increased mLDH levels had a higher cumulative risk of intracranial metastasis (hazard ratio [HR] 3.87; 95% confidence interval [CI] 1.73-8.63; P < 0.01) and worse overall survival (HR 2.59; 95% CI 1.67-4.04; P < 0.01). The factors LDH level at baseline or changes between pretreatment level and maximum level during treatment failed to predict brain metastases or OS with statistical significance. In the multivariate analyses, both mLDH during treatment (HR 3.53; 95% CI 1.57-7.92; P = 0.002) and patient age ≥ 60 (HR 2.46; 95% CI 1.22-4.94; P = 0.012) were independently associated with worse IPFS. Factors significantly associated with worse OS included mLDH during treatment (HR 2.45; 95% CI 1.56-3.86; P < 0.001), IIIB stage (HR 1.75; 95% CI 1.06-2.88; P = 0.029), and conventional radiotherapy applied in TRT (HR 1.66; 95% CI 1.04-2.65; P = 0.034). CONCLUSION The mLDH level during treatment predicts brain metastasis and survival in LS-SCLC patients treated with TRT and PCI, which may provide valuable information for identifying patients with poor survival outcomes and possible candidates for treatment intensification.
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Affiliation(s)
- Jianjiang Liu
- Department of Radiation Oncology, Shaoxing People's Hospital, 312000, Shaoxing, Zhejiang, China
| | - Dongping Wu
- Department of Radiation Oncology, Shaoxing People's Hospital, 312000, Shaoxing, Zhejiang, China
| | - Bin Shen
- Department of Radiation Oncology, Shaoxing People's Hospital, 312000, Shaoxing, Zhejiang, China
| | - Mengyuan Chen
- Department of Thoracic Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China.,Zhejiang Key Laboratory of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
| | - Xia Zhou
- Department of Thoracic Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China.,Zhejiang Key Laboratory of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
| | - Peng Zhang
- Zhejiang Key Laboratory of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
| | - Guoqin Qiu
- Department of Thoracic Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China.,Zhejiang Key Laboratory of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
| | - Yongling Ji
- Department of Thoracic Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China.,Zhejiang Key Laboratory of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
| | - Xianghui Du
- Department of Thoracic Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China.,Zhejiang Key Laboratory of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
| | - Yang Yang
- Department of Thoracic Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China. .,Zhejiang Key Laboratory of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China.
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12
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Qiu J, Ke D, Yu Y, Lin H, Zheng Q, Li H, Zheng H, Liu L, Wang Z, Wu Y, Liu T, Li J. A New Nomogram and Risk Stratification of Brain Metastasis by Clinical and Inflammatory Parameters in Stage III Small Cell Lung Cancer Without Prophylactic Cranial Irradiation. Front Oncol 2022; 12:882744. [PMID: 35875127 PMCID: PMC9300937 DOI: 10.3389/fonc.2022.882744] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/27/2022] [Indexed: 11/17/2022] Open
Abstract
Background This study was conducted to determine risk factors for developing brain metastasis (BM) and to predict brain metastasis free survival (BMFS) and overall survival (OS) by combining several clinical parameters and inflammatory indexes. Materials and Methods A nomogram and risk stratification were developed based on multivariate analysis results. The prognostic index (PI) predicting the high risk of BM was calculated by multiplying the weighted factor (β coefficient) with each variable. Results Thirty-two of one hundred patients (32.0%) developed BM. Multivariate cox regression analysis revealed that concurrent chemoradiotherapy (CCRT; hazard ratio (HR), 3.356; p = 0.020), monocyte–lymphocyte ratio (MLR; HR, 4.511; p = 0.002), neutrophil–lymphocyte ratio (NLR; HR, 4.023; p = 0.033), and prognostic-nutrition index (PNI; HR, 2.902; p = 0.018) were independent prognostic factors of BMFS. The nomogram has good accuracy in predicting BMFS, and the C-index was 0.73. The ROC curve showed that these risk factors have good discriminant ability. Similarly, tumor location (HR, 1.675; p = 0.035) and MLR (HR, 2.076; p = 0.013) were independent prognostic factors of OS. In the subgroup analysis of OS, the good group had a better prognosis than the other groups. Risk stratification by PI: the high-risk group had worse BMFS than the low-risk group, which also has certain practical significance for clinical practice in OS. Conclusion We developed a nomogram and corresponding risk stratification in stage III SCLC patients who developed BM. This model and risk stratification can help clinicians improve patient treatment management and better deliver personalized therapy.
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13
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Gaebe K, Li AY, Park A, Parmar A, Lok BH, Sahgal A, Chan KKW, Erickson AW, Das S. Stereotactic radiosurgery versus whole brain radiotherapy in patients with intracranial metastatic disease and small-cell lung cancer: a systematic review and meta-analysis. Lancet Oncol 2022; 23:931-939. [DOI: 10.1016/s1470-2045(22)00271-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 12/14/2022]
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14
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Tsui DCC, Camidge DR, Rusthoven CG. Managing Central Nervous System Spread of Lung Cancer: The State of the Art. J Clin Oncol 2022; 40:642-660. [PMID: 34985937 DOI: 10.1200/jco.21.01715] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Brain metastases (BrM) are common in both non-small-cell lung cancer and small-cell lung cancer. Substantial progress in BrM management has occurred in the past decade related to advances in both radiation and medical oncology. Recent and ongoing radiation trials have focused on increasing the candidacy for focal therapy of BrM with stereotactic radiosurgery; reducing the toxicity and improving patient selection for whole brain radiotherapy; and, in small-cell lung cancer, evaluating brain magnetic resonance imaging surveillance without prophylactic cranial irradiation, hippocampal avoidance in prophylactic cranial irradiation and whole brain radiotherapy, and the role of upfront stereotactic radiosurgery for BrM. In medical oncology, the development of multiple tyrosine kinase inhibitors with encouraging CNS activity and emerging data on the CNS activity of immune checkpoint inhibitors in some patients have opened the door to novel systemic and multidisciplinary treatment strategies for the management of BrM. Future research will focus on more robust characterizations of the CNS activity of targeted therapy and immunotherapies, as well as optimal integration and patient selection for multidisciplinary strategies involving CNS-active drugs, radiation therapy, and CNS surveillance.
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Affiliation(s)
- David Chun Cheong Tsui
- Division of Medical Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
| | - D Ross Camidge
- Division of Medical Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
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15
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Yu NY, Sio TT, Ernani V, Savvides P, Schild SE. Role of Prophylactic Cranial Irradiation in Extensive-Stage Small Cell Lung Cancer. J Natl Compr Canc Netw 2021; 19:1465-1469. [PMID: 34902829 DOI: 10.6004/jnccn.2021.7105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/21/2021] [Indexed: 11/17/2022]
Abstract
Patients with small cell lung cancer (SCLC) are at significant risk of developing brain metastases during their disease course. Prophylactic cranial irradiation (PCI) has been incorporated into SCLC treatment guidelines to diminish the risk of developing brain metastases. In 2007, a randomized trial suggested that PCI decreases the incidence of brain metastases and prolongs overall survival (OS) in patients with extensive-stage SCLC (ES-SCLC) who have responded to initial therapy. However, this study did not include modern central nervous system imaging with CT or MRI prior to randomization. A more recent Japanese trial with MRI staging and surveillance demonstrated that PCI diminished the incidence of brain metastases but did not improve survival. This review examines the largest clinical studies, controversies, and future directions of PCI in patients with ES-SCLC.
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Affiliation(s)
| | | | - Vinicius Ernani
- Division of Hematology and Medical Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - Panayiotis Savvides
- Division of Hematology and Medical Oncology, Mayo Clinic Hospital, Phoenix, Arizona
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16
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Rinehardt H, Kassem M, Morgan E, Palettas M, Stephens JA, Suresh A, Ganju A, Lustberg M, Wesolowski R, Sardesai S, Stover D, Vandeusen J, Cherian M, Prieto Eibl MDPG, Miah A, Alnahhas I, Giglio P, Puduvalli VK, Ramaswamy B, Williams N, Noonan AM. Assessment of Leptomeningeal Carcinomatosis Diagnosis, Management and Outcomes in Patients with Solid Tumors Over a Decade of Experience. Eur J Breast Health 2021; 17:371-377. [PMID: 34651117 DOI: 10.4274/ejbh.galenos.2021.2021-4-10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/18/2021] [Indexed: 12/01/2022]
Abstract
Objective Leptomeningeal carcinomatosis (LMC), a common complication of advanced malignancies, is associated with high morbidity and mortality, yet diagnosis and treatment decisions remain challenging. This study describes the diagnostic and treatment modalities for LMC and identifies factors associated with overall survival (OS). Materials and Methods We performed a single-institution retrospective study (registration #: OSU2016C0053) of 153 patients diagnosed with LMC treated at The Ohio State University, Comprehensive Cancer Center, (OSUCCC)-James between January 1, 2010 and December 31, 2015. Results Median age at diagnosis was 55.7 years, and 61% had Eastern Cooperative Oncology Group baseline performance status ≤1. Most common primary tumors were breast (43%), lung (26%), and cutaneous melanoma (10%). At presentation, most patients were stage III-IV (71%) with higher grade tumors (grade III: 46%). Metastases to bone (36%), brain (33%), and lung (12%) were the most common sites with a median of 0.5 years (range, 0-14.9 years) between the diagnosis of first metastasis and of LMC. 153 (100%) patients had MRI evidence of LMC. Of the 67 (44%) who underwent lumbar puncture (LP), 33 (22%) had positive cerebrospinal fluid (CSF) cytology. Most patients received radiotherapy for LMC (60%) and chemotherapy (93%) for either the primary disease or LMC. 28 patients received intrathecal chemotherapy, 22 of whom had a primary diagnosis of breast cancer. 98% died with median OS of all patients was 1.9 months (95% CI: 1.3-2.5 months). Conclusion Despite improved treatments and targeted therapies, outcomes of LMC remain extremely poor. Positive CSF cytology was associated with lower OS in patients who had cytology assessed and specifically in patients with breast cancer. CSF cytology serves as an important indicator for prognosis and helps aid in developing individualized therapeutic strategies for patients with LMC.
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Affiliation(s)
- Hannah Rinehardt
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Mahmoud Kassem
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Evan Morgan
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Marilly Palettas
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine Columbus, OH, USA
| | - Julie A Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine Columbus, OH, USA
| | - Anupama Suresh
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Akansha Ganju
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Maryam Lustberg
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Robert Wesolowski
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Sagar Sardesai
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Daniel Stover
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Jeffrey Vandeusen
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Mathew Cherian
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | | | - Abdul Miah
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Iyad Alnahhas
- Division of Neuro-oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Pierre Giglio
- Division of Neuro-oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Vinay K Puduvalli
- Division of Neuro-oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Bhuvaneswari Ramaswamy
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Nicole Williams
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Anne M Noonan
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Abstract
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.
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Affiliation(s)
- Nayan Lamba
- Harvard Radiation Oncology Program, Boston, Massachusetts, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ayal A Aizer
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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18
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Viani GA, Gouveia AG, Louie AV, Moraes FY. Stereotactic radiosurgery for brain metastases from small cell lung cancer without prior whole-brain radiotherapy: A meta-analysis. Radiother Oncol 2021; 162:45-51. [PMID: 34171453 DOI: 10.1016/j.radonc.2021.06.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/16/2021] [Accepted: 06/16/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Assess upfront Stereotactic radiosurgery (SRS) effectiveness for small cell lung cancer (SCLC) brain metastases (BM). Where possible, a comparison with whole-brain radiotherapy (WBRT) was performed. METHODS Following PRISMA and MOOSE guidelines, eligible studies were identified on Medline, Embase, Cochrane Library, and proceedings of annual meetings between inception and July 01, 2020. RESULTS Nine observational studies with 1638 patients were included. The median overall survival (OS) was 8.3 months (95% CI 7.1-9.5 months, I2 = 0%). OS rate at 12 months was 39% (95% CI 31-44%, I2 = 0%). The relative risk between SRS and WBRT for the OS at 12 months was 1.33 (95% CI 1.13-1.51, P = 0.0001). The projected OS for 6, 12, 18- and 24-months comparing SRS with WBRT was 67% vs. 57%, 39% vs. 29%, 22% vs. 15% and 15% vs 9%, favoring SRS (P < 0.001). The LC rate at 12 months was 93% (95% CI 91-94%, I2 = 0%). The distant brain failure rate (DBFR) at 12 months was 41% (95% CI 33-48%, I2 = 52%, P = 0.08). The SRS or WBRT as salvage treatment after upfront SRS was 32% and 19%, respectively. The freedom from neurologic death at 12 months was 87% (95% CI 84-89%). CONCLUSION Based on the pooling of a large sample of retrospective studies our meta-analysis suggests that for high selected SCLC patients with limited BM upfront SRS produces favorable lesion control and survival outcomes. These findings support the design of randomized clinical trial to confirm the role of SRS in this clinical scenario.
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Affiliation(s)
- G A Viani
- Ribeirão Preto Medical School, Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Brazil.
| | - A G Gouveia
- Radiation Oncology Department - Americas Centro de Oncologia Integrado, Rio de Janeiro, Brazil
| | - A V Louie
- Sunnybrook Health Sciences Centre, Toronto, Canada
| | - F Y Moraes
- Department of Oncology - Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, Canada
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19
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Cho Y, Lee J, Lee IJ, Kim JW, Baek JG, Jung DM, Cho BC, Hong MH, Kim HR, Lee CG, Yoon HI. Intracranial failure after hippocampal-avoidance prophylactic cranial irradiation in limited-stage small-cell lung cancer patients. Sci Rep 2021; 11:7435. [PMID: 33795826 PMCID: PMC8016941 DOI: 10.1038/s41598-021-86851-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 03/22/2021] [Indexed: 11/20/2022] Open
Abstract
We evaluated intracranial failure after hippocampus-avoidance-prophylactic cranial irradiation (HA-PCI) for limited-stage small-cell lung cancer (SCLC). Data of 106 patients who received PCI with 25 Gy were retrospectively reviewed. The patients were divided into two groups based on whether they underwent HA-PCI: the HA-PCI group (n = 48) and the conventional PCI (C-PCI) group (n = 58). Twenty-one patients experienced intracranial failure: 11 and 10 patients in the C-PCI and HA-PCI groups, respectively. Using the log-rank test, the intracranial failure rate was not significantly different between the groups (p = 0.215). No clinical factor was significantly associated with intracranial failure in multivariate Cox regression analysis, but HA-PCI tended to be associated with increased incidence of intracranial failure (HR 2.87, 95% CI 0.86–9.58, p = 0.087). Among patients who received HA-PCI, two developed peri-hippocampal recurrence. A higher thoracic radiotherapy dose (≥ 60 Gy) was significantly associated with DFS (HR 0.52, p = 0.048) and OS (HR 0.35, p = 0.003). However, HA-PCI was associated with neither DFS nor OS. Although HA-PCI may be associated with an increased risk of intracranial failure, HA-PCI did not impair disease control or survival. Future prospective randomized trials are needed to reach a definite conclusion.
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Affiliation(s)
- Yeona Cho
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joongyo Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Geol Baek
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Dong Min Jung
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Byoung Chul Cho
- Department of Internal Medicine, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Hee Hong
- Department of Internal Medicine, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Ryun Kim
- Department of Internal Medicine, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chang Geol Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hong In Yoon
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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20
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Cifarelli CP, Vargo JA, Fang W, Liscak R, Guseynova K, Warnick RE, Lee CC, Yang HC, Borghei-Razavi H, Maiti T, Siddiqui ZA, Yuan JC, Grills IS, Mathieu D, Touchette CJ, Cordeiro D, Chiang V, Hess J, Tien CJ, Faramand A, Kano H, Barnett GH, Sheehan JP, Lunsford LD. Role of Gamma Knife Radiosurgery in Small Cell Lung Cancer: A Multi-Institutional Retrospective Study of the International Radiosurgery Research Foundation (IRRF). Neurosurgery 2021; 87:664-671. [PMID: 31599324 DOI: 10.1093/neuros/nyz428] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 08/04/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Despite a high incidence of brain metastases in patients with small-cell lung cancer (SCLC), limited data exist on the use of stereotactic radiosurgery (SRS), specifically Gamma Knife™ radiosurgery (Elekta AB), for SCLC brain metastases. OBJECTIVE To provide a detailed analysis of SCLC patients treated with SRS, focusing on local failure, distant brain failure, and overall survival (OS). METHODS A multi-institutional retrospective review was performed on 293 patients undergoing SRS for SCLC brain metastases at 10 medical centers from 1991 to 2017. Data collection was performed according to individual institutional review boards, and analyses were performed using binary logistic regression, Cox-proportional hazard models, Kaplan-Meier survival analysis, and competing risks analysis. RESULTS Two hundred thirty-two (79%) patients received SRS as salvage following prior whole-brain irradiation (WBRT) or prophylactic cranial irradiation, with a median marginal dose of 18 Gy. At median follow-up after SRS of 6.4 and 18.0 mo for surviving patients, the 1-yr local failure, distant brain failure, and OS were 31%, 49%, and 28%. The interval between WBRT and SRS was predictive of improved OS for patients receiving SRS more than 1 yr after initial treatment (21%, <1 yr vs 36%, >1 yr, P = .01). On multivariate analysis, older age was the only significant predictor for OS (hazard ratio 1.63, 95% CI 1.16-2.29, P = .005). CONCLUSION SRS plays an important role in the management of brain metastases from SCLC, especially in salvage therapy following WBRT. Ongoing prospective trials will better assess the value of radiosurgery in the primary management of SCLC brain metastases and potentially challenge the standard application of WBRT in SCLC patients.
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Affiliation(s)
- Christopher P Cifarelli
- Department of Neurosurgery, School of Medicine, West Virginia University, Morgantown, West Virginia.,Department of Radiation Oncology, School of Medicine, West Virginia University, Morgantown, West Virginia
| | - John A Vargo
- Department of Neurosurgery, School of Medicine, West Virginia University, Morgantown, West Virginia.,Department of Radiation Oncology, School of Medicine, West Virginia University, Morgantown, West Virginia
| | - Wei Fang
- West Virginia Clinical and Translational Science Institute, School of Medicine, West Virginia University, Morgantown, West Virginia
| | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Khumar Guseynova
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | | | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Tonmoy Maiti
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Zaid A Siddiqui
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Justin C Yuan
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - David Mathieu
- Division of Neurosurgery, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Canada
| | - Charles J Touchette
- Division of Neurosurgery, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Canada
| | - Diogo Cordeiro
- Department of Neurosurgery, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Veronica Chiang
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut.,Department of Radiation Oncology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Judith Hess
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut.,Department of Radiation Oncology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Christopher J Tien
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut.,Department of Radiation Oncology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Andrew Faramand
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hideyuki Kano
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gene H Barnett
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Jason P Sheehan
- Department of Neurosurgery, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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21
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Pereira I, Slotman B, Rusthoven CG, Katz MS, Simcock R, Saeed H. Stereotactic radiosurgery (SRS) - A new normal for small cell lung cancer? Clin Transl Radiat Oncol 2020; 25:10-15. [PMID: 33294642 PMCID: PMC7695539 DOI: 10.1016/j.ctro.2020.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 08/27/2020] [Indexed: 12/25/2022] Open
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22
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Yu J, Ouyang W, Yang Y, Zhang X, Zhou Y, Zhang J, Xie C. Prophylactic cranial irradiation for extensive-stage small cell lung cancer: Analysis based on active brain MRI surveillance. Clin Transl Radiat Oncol 2020; 25:16-21. [PMID: 32995574 PMCID: PMC7508717 DOI: 10.1016/j.ctro.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/20/2020] [Accepted: 09/09/2020] [Indexed: 11/05/2022] Open
Abstract
The value of PCI remains controversial in ES-SCLC. Under the active brain MRI surveillance, PCI improve the PFS and BSS for ES-SCLC. PCI reduce the incidence of BM for ES-SCLC.
Background and purpose The value of prophylactic cranial irradiation (PCI) for extensive-stage small-cell lung cancer (ES-SCLC) has recently been challenged. This study was conducted to evaluate the role of PCI for ES-SCLC under active brain magnetic resonance imaging (MRI) surveillance. Materials and methods Patients with ES-SCLC who showed any responses after first-line chemotherapy and no initial brain metastasis (BM) were retrospectively included. Active brain MRI surveillance was performed for all patients. Progression-free survival (PFS) and overall survival (OS) were compared between PCI and non-PCI patients. The time-related hazard of BM was evaluated in non-PCI patients. Results One hundred and eighteen consecutive patients were included in the study. The median follow-up time was 26.5 months (3–72 months). The median PFS and OS were better in the PCI cohort than in the non-PCI group. Multivariate analyses revealed first-line chemotherapy cycles (> 4 vs. ≤ 4 cycles, HR: 0.29; 95% CI: 0.15–0.55, P < 0.01) and PCI (Yes vs. No, HR: 0.54; 95% CI: 0.29–0.99, P = 0.04) were independent prognostic factors for disease progression. In the non-PCI group, 47.4% (46/97) of the patients developed BM and the hazard of BM increased continuously in three-quarters of the first year since diagnosis. Conclusion Under active brain MRI surveillance, PCI could be beneficial for patients with ES-SCLC who show good responses after first-line chemotherapy.
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Affiliation(s)
- Jing Yu
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China.,Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China.,Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Wen Ouyang
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China.,Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China.,Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Yong Yang
- Cancer Hospital and Institute, Peking Union Medical College (PUMC) and Chinese Academy of Medical Sciences (CAMS), Beijing 100021, China
| | - Xiaoyue Zhang
- Department of Biological Repositories, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Yan Zhou
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China.,Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China.,Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Junhong Zhang
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China.,Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China.,Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Conghua Xie
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China.,Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China.,Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
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23
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Rusthoven CG, Camidge DR, Robin TP, Brown PD. Radiosurgery for Small-Cell Brain Metastases: Challenging the Last Bastion of Preferential Whole-Brain Radiotherapy Delivery. J Clin Oncol 2020; 38:3587-3591. [PMID: 32776807 DOI: 10.1200/jco.20.01823] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - D Ross Camidge
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Tyler P Robin
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MD
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24
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Lin Y, Chen P, Shueng P, Lin H, Lai L. Evaluation of various head flexion angles in hippocampal-avoidance whole-brain radiotherapy using volumetric modulated arc therapy. Radiat Phys Chem Oxf Engl 1993 2020. [DOI: 10.1016/j.radphyschem.2020.108884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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25
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Stewart CA, Gay CM, Xi Y, Sivajothi S, Sivakamasundari V, Fujimoto J, Bolisetty M, Hartsfield PM, Balasubramaniyan V, Chalishazar MD, Moran C, Kalhor N, Stewart J, Tran H, Swisher SG, Roth JA, Zhang J, de Groot J, Glisson B, Oliver TG, Heymach JV, Wistuba I, Robson P, Wang J, Byers LA. Single-cell analyses reveal increased intratumoral heterogeneity after the onset of therapy resistance in small-cell lung cancer. NATURE CANCER 2020; 1:423-436. [PMID: 33521652 PMCID: PMC7842382 DOI: 10.1038/s43018-019-0020-z] [Citation(s) in RCA: 179] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 12/12/2019] [Indexed: 01/10/2023]
Abstract
The natural history of small cell lung cancer (SCLC) includes rapid evolution from chemosensitivity to chemoresistance, although mechanisms underlying this evolution remain obscure due to scarcity of post-relapse tissue samples. We generated circulating tumor cell (CTC)-derived xenografts (CDXs) from SCLC patients to study intratumoral heterogeneity (ITH) via single-cell RNAseq of chemo-sensitive and -resistant CDXs and patient CTCs. We found globally increased ITH including heterogeneous expression of therapeutic targets and potential resistance pathways, such as EMT, between cellular subpopulations following treatment-resistance. Similarly, serial profiling of patient CTCs directly from blood confirmed increased ITH post-relapse. These data suggest that treatment-resistance in SCLC is characterized by coexisting subpopulations of cells with heterogeneous gene expression leading to multiple, concurrent resistance mechanisms. These findings emphasize the need for clinical efforts to focus on rational combination therapies for treatment-naïve SCLC tumors to maximize initial responses and counteract the emergence of ITH and diverse resistance mechanisms.
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Affiliation(s)
- C Allison Stewart
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carl M Gay
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yuanxin Xi
- Department of Bioinformatics and Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Junya Fujimoto
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mohan Bolisetty
- The Jackson Laboratory for Genomic Medicine, Farmington, CT, USA
| | - Patrice M Hartsfield
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Milind D Chalishazar
- Department of Oncological Sciences, University of Utah, Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Cesar Moran
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neda Kalhor
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John Stewart
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hai Tran
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stephen G Swisher
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jack A Roth
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jianjun Zhang
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John de Groot
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bonnie Glisson
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Trudy G Oliver
- Department of Oncological Sciences, University of Utah, Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - John V Heymach
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ignacio Wistuba
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Robson
- The Jackson Laboratory for Genomic Medicine, Farmington, CT, USA
| | - Jing Wang
- Department of Bioinformatics and Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren Averett Byers
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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26
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Whole brain radiation therapy plus focal boost may be a suitable strategy for brain metastases in SCLC patients: a multi-center study. Radiat Oncol 2020; 15:70. [PMID: 32213185 PMCID: PMC7093941 DOI: 10.1186/s13014-020-01509-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 03/02/2020] [Indexed: 12/03/2022] Open
Abstract
Background The treatment for brain metastases in small cell lung cancer (SCLC) is still controversial. The purpose of this study was to compare different brain radiotherapy treatments on SCLC patients with brain metastases. Methods In this multi-center retrospective study, SCLC patients who had undergone whole brain radiation therapy (WBRT) or stereotactic radiosurgery (SRS) for brain metastases from January 2012 to December 2018 were retrospectively screened. Results A total of 263 eligible SCLC patients were included in this study, among whom, 73 were women and 190 were men. According to accepted brain radiotherapy, the remaining patients were divided into WBRT plus focal radiation boost (WBRT+boost), WBRT, and SRS groups. In pairwise comparisons of the overall survival (OS), WBRT+boost group led to longer survival than did WBRT both in all patients (17.9 vs 8.7 months; P < 0.001) and 140 matched patients (17.9 vs 11.7 months; P = 0.045). There were no significant differences in OS between WBRT+boost and SRS groups in all patients (17.9 vs 14.5 months; P = 0.432). Among 74 matched patients between WBRT+boost and SRS groups, however, patients who received WBRT+boost led to a longer survival than did SRS alone (21.8 vs 12.9 months; P = 0.040). In pairwise comparison of the intracranial progression-free survival time (iPFS), WBRT+boost group also showed survival advantages over WBRT (10.8 vs 6.5 months; P = 0.005) and SRS groups (10.8 vs 7.5 months; P = 0.032). Conclusion Due to the SCLC-derived multiple brain metastases and better survival time, focal radiation boost combined with adjuvant WBRT may be a preferred strategy for SCLC patients with brain metastases.
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27
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Buszek SM, Chung C. Radiotherapy in Leptomeningeal Disease: A Systematic Review of Randomized and Non-randomized Trials. Front Oncol 2019; 9:1224. [PMID: 31803614 PMCID: PMC6872542 DOI: 10.3389/fonc.2019.01224] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 10/25/2019] [Indexed: 01/12/2023] Open
Abstract
Background: Leptomeningeal disease (LMD), also known as neoplastic meningitis, leptomeningeal carcinomatosis, or carcinomatous meningitis, is a rare cancer complication occurring in ~5% of cases and ultimately leads to significant morbidity and mortality. In the modern era, incidence of this condition continues to rise with longer survival of patients with advanced and even metastatic disease due to continued improvements in systemic therapies that are providing prolonged control of distant disease, but with limited effect in the central nervous system (CNS). Typical treatment strategies include optimal systemic therapy for the primary disease, as well as neuroaxis directed therapies, which may include intrathecal chemotherapy (ITC) or radiotherapy (RT). Methods: A systematic review of radiotherapy for LMD was performed. Medline, EMBASE, and Cochrane databases were searched from 1946 to 2018 for clinical trials, retrospective/prospective reviews, and case series with ≥2 human subjects that used radiation therapy techniques in the treatment of LMD. The outcome measures of interest included: characteristics of trial participants, inclusion/exclusion criteria, study type, number of participants, primary cancer histology, type of intervention for LMD, survival results if reported, length of follow up, and study conclusion. Results: Of 547 unique citations, 62 studies met the pre-specified eligibility criteria. These studies included 36 retrospective cohorts, 11 prospective series, 12 case series, and a single citation of guidelines, NCDB analysis, and a randomized control trial. Owing to study heterogeneity, meta-analyses of the endpoint data could not be performed. Conclusions: LMD is a devastating complication of cancer with reported survivals ranging from 2 to 4 months. Based on this systematic review, the recommendation for the treatment of LMD is for multimodality discussion of cases and treatment, including the use of radiotherapy, for LMD. However, with continued advances in systemic therapy as well as imaging advances, the landscape of LMD is evolving rapidly and the role of RT will likely also continue to evolve and advance. There is limited high-quality evidence to guide the optimal use of RT for the treatment of LMD, and there is a great need for prospective, histology specific investigation of the role of radiotherapy for LMD in the era of modern systemic therapies.
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Affiliation(s)
- Samantha M Buszek
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Caroline Chung
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
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28
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Nesbit EG, Leal TA, Kruser TJ. What is the role of radiotherapy for extensive-stage small cell lung cancer in the immunotherapy era? Transl Lung Cancer Res 2019; 8:S153-S162. [PMID: 31673520 DOI: 10.21037/tlcr.2019.05.01] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Small cell lung cancer has been a difficult disease to treat with poor survival and few significant improvements in outcomes in the last three decades. Most recently the addition of atezolizumab to chemotherapy in the first-line treatment of extensive-stage small cell lung cancer (ES-SCLC) resulted in improved overall survival and progression-free survival compared to chemotherapy alone. Recent randomized studies examining both consolidative thoracic radiotherapy and prophylactic cranial irradiation (PCI) in ES-SCLC have impacted the utilization of these interventions. The approval of immune checkpoint inhibitors (ICIs) to platinum/etoposide chemotherapy for the treatment of ES-SCLC in the front-line setting may also further impact the role of radiotherapy in this disease. In this article, we review the current evidence supporting thoracic radiotherapy in ES-SCLC and discuss the promising therapeutic implications of thoracic radiation in light of the inclusion of ICIs. We also address how the increasing routine use of surveillance brain magnetic resonance imaging (MRI) and ICIs may diminish the use of PCI in ES-SCLC.
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Affiliation(s)
- Eric G Nesbit
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ticiana A Leal
- Division of Hematology & Oncology, University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | - Tim J Kruser
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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29
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Anami S, Doi H, Nakamatsu K, Uehara T, Wada Y, Fukuda K, Inada M, Ishikawa K, Kanamori S, Nishimura Y. Serum lactate dehydrogenase predicts survival in small-cell lung cancer patients with brain metastases that were treated with whole-brain radiotherapy. JOURNAL OF RADIATION RESEARCH 2019; 60:257-263. [PMID: 30576550 PMCID: PMC6430245 DOI: 10.1093/jrr/rry107] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/03/2018] [Indexed: 05/17/2023]
Abstract
This study aimed to identify factors that predict prognosis after radiotherapy for brain metastases (BMs) from small-cell lung cancer (SCLC). This study retrospectively evaluated 48 consecutive patients who underwent whole-brain radiotherapy (WBRT) for BMs from SCLC between February 2008 and December 2017. WBRT was delivered at a median dose of 30 Gy (range: 30-40 Gy) in 10 fractions (range: 10-16 fractions). Clinical factors were tested for associations with overall survival after WBRT. The median survival and 1-year overall survival rate after WBRT treatment were 232 days and 34.4%, respectively. Univariate analyses revealed that longer survival was associated with Eastern Cooperative Oncology Group performance status of 0-1, asymptomatic BMs, lactate dehydrogenase (LDH) in the normal range, Radiation Therapy Oncology Group-recursive partitioning analysis class 2, and a graded prognostic assessment score of ≥1.5 (P < 0.01, P < 0.01, P < 0.01, P < 0.01 and P < 0.05, respectively). In the multivariate analyses, longer survival was independently associated with asymptomatic BMs [hazard ratio for death (HR), 0.32; 95% confidence interval (CI), 0.12-0.79; P < 0.05] and LDH in the normal range (HR, 0.42; 95% CI, 0.21-0.83; P < 0.05). The presence of symptoms due to BMs and LDH values independently predicted prognosis after WBRT for BMs from SCLC. Elevated LDH may provide valuable information for identifying patients with BMs who could have poor survival outcomes.
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Affiliation(s)
- Shimpei Anami
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Ohno-higashi, Osaka-Sayama, Osaka, Japan
| | - Hiroshi Doi
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Ohno-higashi, Osaka-Sayama, Osaka, Japan
- Corresponding author. Department of Radiation Oncology, Kindai University Faculty of Medicine, 377-2, Ohno-higashi, Osaka-Sayama, Osaka, Japan. Tel.: +81-72-366-0221; Fax: +81-72-368-2388; E-mail:
| | - Kiyoshi Nakamatsu
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Ohno-higashi, Osaka-Sayama, Osaka, Japan
| | - Takuya Uehara
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Ohno-higashi, Osaka-Sayama, Osaka, Japan
| | - Yutaro Wada
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Ohno-higashi, Osaka-Sayama, Osaka, Japan
| | - Kohei Fukuda
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Ohno-higashi, Osaka-Sayama, Osaka, Japan
| | - Masahiro Inada
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Ohno-higashi, Osaka-Sayama, Osaka, Japan
| | - Kazuki Ishikawa
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Ohno-higashi, Osaka-Sayama, Osaka, Japan
| | - Shuichi Kanamori
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Ohno-higashi, Osaka-Sayama, Osaka, Japan
| | - Yasumasa Nishimura
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Ohno-higashi, Osaka-Sayama, Osaka, Japan
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30
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El Shafie RA, Böhm K, Weber D, Lang K, Schlaich F, Adeberg S, Paul A, Haefner MF, Katayama S, Sterzing F, Hörner-Rieber J, Löw S, Herfarth K, Debus J, Rieken S, Bernhardt D. Outcome and prognostic factors following palliative craniospinal irradiation for leptomeningeal carcinomatosis. Cancer Manag Res 2019; 11:789-801. [PMID: 30697071 PMCID: PMC6340499 DOI: 10.2147/cmar.s182154] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Leptomeningeal carcinomatosis (LC) is a severe complication of metastatic tumor spread to the central nervous system. Prognosis is dismal with a median overall survival (OS) of ~10–15 weeks. Treatment options include radiotherapy (RT) to involved sites, systemic chemo- or targeted therapy, intrathecal chemotherapy and best supportive care with dexamethasone. Craniospinal irradiation (CSI) is a more aggressive radiotherapeutic approach, for which very limited data exists. Here, we report on our 10-year experience with palliative CSI of selected patients with LC. Patients and methods Twenty-five patients received CSI for the treatment of LC at our institution between 2008 and 2018. Patients were selected individually for CSI based on clinical performance, presenting symptoms and estimated benefit. Median patient age was 53 years (IQR: 45–59), and breast cancer was the most common primary. Additional brain metastases were found in 18 patients (72.0%). RT was delivered at a TomoTherapy machine, using helical intensity-modulated radiotherapy (IMRT). The most commonly prescribed dose was 36 Gy in 20 fractions, corresponding to a median biologically equivalent dose of 40.8 Gy (IQR: 39.0–2.5). Clinical performance and neurologic function were assessed before and in response to therapy, and deficits were retrospectively quantified on the 5-point neurologic function scale (NFS). A Cox proportional hazards model with univariate and multivariate analyses was fitted for survival. Results Twenty-one patients died and four were alive at the time of analysis. Median OS from LC diagnosis was 19.3 weeks (IQR: 9.3–34.0, 95% CI: 11.0–32.0). In univariate analysis, a Karnofsky performance scale index (KPI) ≥70% (P=0.001), age ≤55 years at LC diagnosis (P=0.022), cerebrospinal fluid (CSF) protein <100 mg/dL (P=0.018) and no more than mild or moderate neurologic deficits (NFS ≤2; P=0.007) were predictive of longer OS. So were the neurologic response to treatment (P=0.018) and the application of systemic therapy after RT completion (P=0.029). The presence of CSF flow obstruction was predictive of shorter OS (P=0.026). In multivariate analysis, age at LC diagnosis (P=0.018), KPI (P<0.001) and neurologic response (P=0.037) remained as independent prognostic factors for longer OS. Treatment-associated toxicity was manageable and mostly grades I and II according to the Common Terminology Criteria for Adverse Events v4.0. Eight patients (32%) developed grade III myelosuppression. Neurologic symptom stabilization could be achieved in 40.0% and a sizeable improvement in 28.0% of all patients. Conclusion CSI for the treatment of LC is feasible and may have therapeutic value in carefully selected patients, alleviating symptoms or delaying neurologic deterioration. OS after CSI was comparable to the rates described in current literature for patients with LC. The use of modern irradiation techniques such as helical IMRT is warranted to limit toxicity. Patient selection should take into account prognostic factors such as age, clinical performance, neurologic function and the availability of systemic treatment options.
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Affiliation(s)
- Rami A El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Karina Böhm
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Dorothea Weber
- Institute of Medical Biometry and Informatics (IMBI), Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Kristin Lang
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Fabian Schlaich
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Sebastian Adeberg
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Angela Paul
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Matthias F Haefner
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Sonja Katayama
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Florian Sterzing
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Department of Radiation Oncology, Klinikum Kempten, Kempten 87439, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Sarah Löw
- Department of Neurology, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg 69120, Germany.,German Cancer Research Center (DKFZ), Heidelberg 69120, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
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31
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El Shafie RA, Böhm K, Weber D, Lang K, Schlaich F, Adeberg S, Paul A, Haefner MF, Katayama S, Hörner-Rieber J, Hoegen P, Löw S, Debus J, Rieken S, Bernhardt D. Palliative Radiotherapy for Leptomeningeal Carcinomatosis-Analysis of Outcome, Prognostic Factors, and Symptom Response. Front Oncol 2019; 8:641. [PMID: 30671384 PMCID: PMC6331444 DOI: 10.3389/fonc.2018.00641] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 12/06/2018] [Indexed: 12/18/2022] Open
Abstract
Introduction: The purpose of this article is to report our institution's 10-year experience on palliative radiotherapy for the treatment of leptomeningeal carcinomatosis (LC), assessing survival, neurologic outcome, and prognostic factors. Patients and methods: We retrospectively analyzed 110 patients who received palliative radiotherapy for LC between 2008 and 2018. The most common histologies were breast cancer (n = 43, 39.1%) and non-small cell lung cancer (NSCLC) (n = 31, 28.2%). Radiotherapy was administered as whole-brain radiotherapy (WBRT) (n = 51, 46.4%), focal spinal RT (n = 11, 10.0%) or both (n = 47, 42.7%). Twenty-five patients (22.7%) were selected for craniospinal irradiation. Clinical performance and neurologic function were quantified on the neurologic function scale (NFS) before and in response to therapy. A Cox Proportional Hazards model with univariate and multivariate analysis was fitted for survival. Results: Ninety-eight patients (89.1%) died and 12 (10.9%) were alive at the time of analysis. Median OS from LC diagnosis and from the beginning of RT was 13.9 weeks (IQR: 7.1-34.0) and 9.9 weeks (IQR: 5.3-26.3), respectively. In univariate analysis, prognostic of longer OS were a Karnofsky performance scale index (KPI) of ≥70% (HR 0.20, 95%-CI: [0.13; 0.32], p < 0.001), initially moderate neurological deficits (NFS ≤2) (HR 0.32, 95% CI: [0.19; 0.52], p < 0.001), symptom response to RT (HR 0.41, 95%-CI: [0.26; 0.67], p < 0.001) and the administration of systemic therapy (HR 0.51, 95%-CI: [0.33; 0.78], p = 0.002). Prognostic of inferior OS were high-grade myelosuppression (HR 1.78, 95% CI: [1.06; 3.00], p = 0.03) and serum LDH levels >500 U/l (HR 3.62, 95% CI: [1.76; 7.44], p < 0.001). Clinical performance, symptom response and serum LDH stayed independently prognostic for survival in multivariate analysis. RT was well-tolerated and except for grade III myelosuppression in 19 cases (17.3%), no high-grade acute toxicities were observed. Neurologic symptom stabilization was achieved in 83 cases (75.5%) and a sizeable improvement in 39 cases (35.5%). Conclusion: Radiotherapy is a well-tolerated and efficacious means of providing symptom palliation for patients with LC, delaying neurologic deterioration while probably not directly influencing survival. Prognostic factors such as clinical performance, neurologic response and serum LDH can be used for patient stratification to facilitate treatment decisions.
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Affiliation(s)
- Rami A. El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Karina Böhm
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Dorothea Weber
- Institute of Medical Biometry and Informatics, Heidelberg University Hospital, Heidelberg, Germany
| | - Kristin Lang
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Fabian Schlaich
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Angela Paul
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias F. Haefner
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Sonja Katayama
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Philipp Hoegen
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Sarah Löw
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology (E050), German Cancer Research Center (DKFZ), Heidelberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
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Suzuki R, Wei X, Allen PK, Welsh JW, Cox JD, Komaki R, Lin SH. Outcomes of re-irradiation for brain recurrence after prophylactic or therapeutic whole-brain irradiation for small cell lung Cancer: a retrospective analysis. Radiat Oncol 2018; 13:258. [PMID: 30594213 PMCID: PMC6310962 DOI: 10.1186/s13014-018-1205-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 12/18/2018] [Indexed: 12/31/2022] Open
Abstract
Background Small cell lung cancer (SCLC) can recur in the brain after whole-brain irradiation (WBI). We documented outcomes after treatment of such recurrences and sought predictors of local control and overall survival (OS). Materials and methods Eighty-five patients with SCLC and brain recurrence after prophylactic or therapeutic WBI in 1998–2015 were identified and data were extracted from the medical records. Survival was estimated with the Kaplan-Meier method, and univariate and multivariate Cox proportional hazards modeling was used to identify factors associated with OS or further brain progression. Results Brain recurrence was treated by stereotactic radiosurgery (SRS) in 33 patients (39%), repeat WBI in 14 (16%), chemotherapy-only in 16 (19%), and observation in 22 (26%). Median OS time after brain recurrence (OSrec) was 4.3 months for all patients; 6-month OSrec rates were 58% after SRS, 21% after repeat WBI, 50% after chemotherapy-only, and 5% after observation (P < 0.001). Inferior OSrec was associated with poor performance status (ECOG score ≥ 3) and uncontrolled extracranial disease. Superior OSrec was associated with receipt of ≥4 chemotherapy cycles before brain recurrence and receipt of chemotherapy, SRS, or repeat WBI afterward. Receipt of chemotherapy after brain recurrence correlated with brain progression. Conclusions Some patients with brain recurrence after WBI for SCLC can survive for extended periods with appropriate intervention, especially those with adequate performance status or controlled extracranial disease.
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Affiliation(s)
- Ryoko Suzuki
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - Xiong Wei
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - Pamela K Allen
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - James W Welsh
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - James D Cox
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - Ritsuko Komaki
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - Steven H Lin
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA. .,Present address: Department of Radiation Oncology, Tokyo Medical and Dental University, 1 Chome-5-45 Yushima, Bunkyō, Tokyo, 113-8510, Japan.
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33
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Soon YY, Zheng H, Ho SZ, Koh WY, Leong CN, Tey JCS, Vellayappan B, Yap SP, Tham IWK, Fong KW. Adoption of prophylactic cranial irradiation (PCI) for extensive stage small cell lung cancer (ES-SCLC): a population based outcome study. Radiat Oncol 2018; 13:247. [PMID: 30547818 PMCID: PMC6295074 DOI: 10.1186/s13014-018-1184-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 11/14/2018] [Indexed: 11/23/2022] Open
Abstract
Background The survival benefit of PCI in ES-SCLC reported by a European randomized trial (RCT) in 2007 was not replicated by a Japanese RCT published in 2017. This study aimed to evaluate the uptake of PCI before and after publication of the European RCT and its association with survival in ES-SCLC. Methods We identified eligible patients in the only two Singapore national cancer centres from 2003 to 2010. We linked their electronic medical records to the national death registry. We described the utilization of PCI in patients diagnosed from 2003 to 2006 (pre-adoption cohort) with patients diagnosed from 2007 to 2010 (post-adoption cohort). We performed univariable and multivariable Cox regression analysis to assess the association between PCI and survival. Results We identified 224 patients with ES-SCLC with no brain metastases. Among the 71 patients who had at least stable disease after first line chemotherapy, there was an increase in the use of PCI from the period 2007 to 2010 compared with 2003 to 2006 (32% versus 10%, P = 0.044). PCI was associated with improved OS (hazard ratio 0.22, 95% CI 0.10 to 0.47, P < 0.001) compared to no PCI in the multivariable analysis. Conclusion There was an increase in the adoption of PCI for ES-SCLC since 2007. PCI was associated with improved survival in patients who did not have mandatory MRI brain imaging prior to PCI and had stable disease or better after first line chemotherapy, suggesting that the results of the European RCT are reproducible in the real-world practice.
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Affiliation(s)
- Yu Yang Soon
- Department of Radiation Oncology, National University Cancer Institute, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore. .,National University Hospital, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore. .,National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore. .,National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore.
| | - Huili Zheng
- National Registry of Disease Office, Research & Surveillance Division, Health Promotion Board, Singapore, Singapore
| | - Shaun Zhirui Ho
- Division of Radiation Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Wee Yao Koh
- Department of Radiation Oncology, National University Cancer Institute, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore
| | - Cheng Nang Leong
- Department of Radiation Oncology, National University Cancer Institute, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore.,National University Hospital, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore.,National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore.,National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore
| | - Jeremy Chee Seong Tey
- Department of Radiation Oncology, National University Cancer Institute, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore.,National University Hospital, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore.,National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore.,National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore
| | - Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore.,National University Hospital, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore.,National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore.,National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore
| | - Swee Peng Yap
- Division of Radiation Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Ivan Weng Keong Tham
- Department of Radiation Oncology, National University Cancer Institute, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore.,National University Hospital, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore.,National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore.,National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore
| | - Kam Weng Fong
- Division of Radiation Oncology, National Cancer Center Singapore, Singapore, Singapore
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MiR-423-5p in brain metastasis: potential role in diagnostics and molecular biology. Cell Death Dis 2018; 9:936. [PMID: 30224667 PMCID: PMC6141540 DOI: 10.1038/s41419-018-0955-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/04/2018] [Accepted: 04/10/2018] [Indexed: 01/05/2023]
Abstract
During the last several years, a growing number of studies have shown that microRNAs (miRNAs) participate in cancer metastasis. Brain metastasis (BM) is a frequent complication of lung adenocarcinoma (LAD), and the incidence of locally advanced LAD with BM can be as high as 30-50%. This study was performed to identify the miRNA expression patterns of LAD with BM and to determine the biological role that miRNAs play in tumorigenesis. To this end, we conducted microarray and quantitative PCR analyses to evaluate BM-related miRNAs independently validated from a total of 155 patients with LAD. A series of in vivo and in vitro assays were also conducted to verify the impact of miRNAs on BM. We found significantly increased expression of miR-423-5p, and BM was predicted in non-small cell lung cancer when compared to LAD without BM. We next examined the function of miR-423-5p and discovered that it significantly promoted colony formation, cell motility, migration, and invasion in vitro. We computationally and experimentally confirmed that metastasis suppressor 1 (MTSS1) was a direct miR-423-5p target. Through a combination of image, histological, and molecular analyses, we found that miR-423-5p overexpression significantly increased tumor burden, local invasion, and distant BM. The level of MTSS1 expression was inversely correlated with miR-423-5p upregulation in the LAD specimens and was associated with survival of patients with BM. MiR-423-5p promoted BM in LAD and inhibited MTSS1 expression. Together, these results show that MiR-423-5p has the potential to be a marker of BM and/or a therapeutic target in LAD.
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Turkaj A, Morelli AM, Vavalà T, Novello S. Management of Leptomeningeal Metastases in Non-oncogene Addicted Non-small Cell Lung Cancer. Front Oncol 2018; 8:278. [PMID: 30140655 PMCID: PMC6094962 DOI: 10.3389/fonc.2018.00278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/04/2018] [Indexed: 12/13/2022] Open
Abstract
Brain metastases in non-small cell lung cancer (NSCLC) patients are more often detected due to imaging modalities improvements but also emerge because of improved treatments of the primary tumor which lead to a longer survival. In this context, development of leptomeningeal metastases (LM) is a devastating complication and its prognosis remains poor despite advances in systemic and local approaches. Histology characterization of NSCLC and molecular expression influence LM management. For those with “oncogene addiction,” new generation epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) were developed to strongly penetrate the blood-brain barrier (BBB) with the aim to prevent central nervous system cancer dissemination, eventually impacting on LM appearance and its subsequent management. Systemic chemotherapy, often combined with intrathecal chemotherapy (when possible), was one of common indications for lung cancer patients affected by LM, without driver mutations and a good performance status but currently, with the advent of innovative systemic approaches treatment solutions in this subgroup of patients are rapidly evolving. Whole brain radiation therapy (WBRT) is the conventional treatment for patients with brain metastases. Furthermore, modern radiation techniques, as stereotactic radiotherapy (SRT), improve outcomes in those cases with a limited number of lesions. However, LM represent a minority of CNS metastases and few literature data are available to drive the radiotherapy approach. Considering all relevant progress made in this setting, after a literature review, the aim of this paper is to discuss about recent developments and therapeutic options in LM management of non-oncogene addicted NSCLC.
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Affiliation(s)
- Ana Turkaj
- Department of Oncology, University of Torino, Ospedale San Luigi Gonzaga, Orbassano, Italy
| | - Anna M Morelli
- Department of Oncology, University of Torino, Ospedale San Luigi Gonzaga, Orbassano, Italy
| | - Tiziana Vavalà
- SC of Oncology, ASL CN1, Ospedale Civile di Saluzzo, Saluzzo, Italy
| | - Silvia Novello
- Department of Oncology, University of Torino, Ospedale San Luigi Gonzaga, Orbassano, Italy
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Abstract
Leptomeningeal metastasis (LM) results from dissemination of cancer cells to both the leptomeninges (pia and arachnoid) and cerebrospinal fluid (CSF) compartment. Breast cancer, lung cancer, and melanoma are the most common solid tumors that cause LM. Recent approval of more active anticancer therapies has resulted in improvement in survival that is partly responsible for an increased incidence of LM. Neurologic deficits, once manifest, are mostly irreversible, and often have a significant impact on patient quality of life. LM-directed therapy is based on symptom palliation, circumscribed use of neurosurgery, limited field radiotherapy, intra-CSF and systemic therapies. Novel methods of detecting LM include detection of CSF circulating tumor cells and tumor cell-free DNA. A recent international guideline for a standardization of response assessment in LM may improve cross-trial comparisons as well as within-trial evaluation of treatment. An increasing number of retrospective studies suggest that molecular-targeted therapy, such as EGFR and ALK inhibitors in lung cancer, trastuzumab in HER2+ breast cancer, and BRAF inhibitors in melanoma, may be effective as part of the multidisciplinary management of LM. Prospective randomized trials with standardized response assessment are needed to further validate these preliminary findings.
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Bernhardt D, Hommertgen A, Schmitt D, El Shafie R, Paul A, König L, Mair-Walther J, Krisam J, Klose C, Welzel T, Hörner-Rieber J, Kappes J, Thomas M, Heußel CP, Steins M, Kieser M, Debus J, Rieken S. Whole brain radiation therapy alone versus radiosurgery for patients with 1-10 brain metastases from small cell lung cancer (ENCEPHALON Trial): study protocol for a randomized controlled trial. Trials 2018; 19:388. [PMID: 30012190 PMCID: PMC6048892 DOI: 10.1186/s13063-018-2745-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 06/15/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Conventional whole brain radiotherapy (WBRT) has been established as the treatment standard in patients with cerebral metastases from small-cell lung cancer (SCLC), however, it has only modest efficacy and limited prospective data is available for WBRT as well as local treatments such as stereotactic radiosurgery (SRS). METHODS/DESIGN The present single-center prospective randomized study, conducted at Heidelberg University Hospital, compares neurocognitive function, as objectively measured by significant deterioration in Hopkins Verbal Learning Test - Revised total recall at 3 months. Fifty-six patients will be randomized to receive either SRS of all brain metastases (up to ten lesions) or WBRT. Secondary endpoints include intracranial progression (local tumor progression and number of new cerebral metastases), extracranial progression, overall survival, death due to brain metastases, local (neurological) progression-free survival, progression-free survival, changes in other cognitive performance measures, quality of life and toxicity. DISCUSSION Recent evidence suggests that SRS might be a promising treatment option for SCLC patients with brain metastases. The present trial is the first to prospectively investigate the treatment response, toxicity and neurocognition of WBRT and SRS in SCLC patients. TRIAL REGISTRATION Clinicaltrials.gov NCT03297788 . Registered September 29, 2017.
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Affiliation(s)
- Denise Bernhardt
- Department of Radiation Oncology, University Hospital Heidelberg, INF 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Adriane Hommertgen
- Department of Radiation Oncology, University Hospital Heidelberg, INF 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Daniela Schmitt
- Department of Radiation Oncology, University Hospital Heidelberg, INF 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Rami El Shafie
- Department of Radiation Oncology, University Hospital Heidelberg, INF 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Angela Paul
- Department of Radiation Oncology, University Hospital Heidelberg, INF 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, University Hospital Heidelberg, INF 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Johanna Mair-Walther
- Department of Neurooncology, University Hospital of Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - Johannes Krisam
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Christina Klose
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Thomas Welzel
- Department of Radiation Oncology, University Hospital Heidelberg, INF 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, University Hospital Heidelberg, INF 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Jutta Kappes
- Department of Pneumology, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Michael Thomas
- Department of Thoracic Oncology. Translational Lung Research Centre Heidelberg (TLRC-H), Thoraxklinik, Heidelberg University, Heidelberg, Germany
- Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Claus Peter Heußel
- Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
- Department of Neurooncology, University Hospital of Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Martin Steins
- Department of Thoracic Oncology. Translational Lung Research Centre Heidelberg (TLRC-H), Thoraxklinik, Heidelberg University, Heidelberg, Germany
- Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, INF 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, University Hospital Heidelberg, INF 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
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Abstract
Brain metastases from solid tumors are associated with increased morbidity and mortality. Standard treatment is local therapy with surgery and/or radiation therapy although there is increasing interest in systemic therapies that can control both intracranial and extracranial disease. We review the most recent data for local therapy and systemic therapy options. Active areas of research within radiation oncology include hippocampal sparing whole brain radiation therapy and stereotactic approaches for patients with more than 4 brain metastases. Newer targeted therapies with better central nervous system penetration and immunotherapies have demonstrated promising results in clinical trials of patients with brain metastases.
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Affiliation(s)
- Ayal A Aizer
- Department of Radiation Oncology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Eudocia Q Lee
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA; Center for Neuro-Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Department of Neurology, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Hematologic variables associated with brain failure in patients with small-cell lung cancer. Radiother Oncol 2018; 128:505-512. [PMID: 29907337 DOI: 10.1016/j.radonc.2018.05.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/23/2018] [Accepted: 05/24/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE We sought factors associated with the development of brain metastases after treatment of small cell lung cancer (SCLC) in patients without brain involvement at diagnosis. METHODS We analyzed 293 patients with SCLC without brain metastases who received chemotherapy, thoracic radiation therapy (TRT), or both in 2001-2015. Pretreatment hematologic markers (platelet count, neutrophil count, lymphocyte count, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and lactate dehydrogenase) and other clinical characteristics were evaluated for correlation with brain metastases-free survival (BMFS). Cutoffs were established with receiver operating characteristics curves. Factors significant in univariate analysis were used to build a multivariate Cox model for BMFS. RESULTS Median follow-up time was 14.3 months. Brain metastases developed in 115 patients (39%)-32% of those with low pretreatment platelet counts (PPC) (≤270 × 109/L) and 46% of those with high PPC (>270 × 109/L). Median BMFS time for all patients was 27.9 months. Two-year BMFS rates were worse for patients with high PPC (14.6% vs. 22.1% low, P = 0.009). High PPC was independently associated with inferior BMFS (P = 0.038), as were receipt of TRT <45 Gy and no prophylactic cranial irradiation (both P < 0.001). CONCLUSIONS High PPC was associated with increased rates of brain metastasis in patients with SCLC with no evidence of brain disease at diagnosis.
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40
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Is prophylactic cranial irradiation indicated for patients with extensive-stage small cell lung cancer with a complete response to first-line treatment? Radiother Oncol 2018; 127:339-343. [DOI: 10.1016/j.radonc.2018.03.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 03/31/2018] [Indexed: 01/17/2023]
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Tanner K. Perspective: The role of mechanobiology in the etiology of brain metastasis. APL Bioeng 2018; 2:031801. [PMID: 31069312 PMCID: PMC6324204 DOI: 10.1063/1.5024394] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 04/18/2018] [Indexed: 12/11/2022] Open
Abstract
Tumor latency and dormancy are obstacles to effective cancer treatment. In brain
metastases, emergence of a lesion can occur at varying intervals from diagnosis
and in some cases following successful treatment of the primary tumor. Genetic
factors that drive brain metastases have been identified, such as those involved
in cell adhesion, signaling, extravasation, and metabolism. From this wealth of
knowledge, vexing questions still remain; why is there a difference in strategy
to facilitate outgrowth and why is there a difference in latency? One missing
link may be the role of tissue biophysics of the brain microenvironment in
infiltrating cells. Here, I discuss the mechanical cues that may influence
disseminated tumor cells in the brain, as a function of age and disease. I
further discuss in vitro and in vivo
preclinical models such as 3D culture systems and zebrafish to study the role of
the mechanical environment in brain metastasis in an effort of providing novel
targeted therapeutics.
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Affiliation(s)
- Kandice Tanner
- Laboratory of Cell Biology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA
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42
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Sharma S, McMillan MT, Doucette A, Cohen RB, Berman A, Levin W, Simone CB, Shabason J. Effect of Prophylactic Cranial Irradiation on Overall Survival in Metastatic Small-Cell Lung Cancer: A Propensity Score-Matched Analysis. Clin Lung Cancer 2018; 19:260-269.e3. [PMID: 29358031 PMCID: PMC5912974 DOI: 10.1016/j.cllc.2017.12.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 12/05/2017] [Accepted: 12/07/2017] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Patients with small-cell lung cancer (SCLC) have a high incidence of occult brain metastases and are often treated with prophylactic cranial irradiation (PCI). Despite a small survival advantage in some studies, the role of PCI in extensive stage SCLC remains controversial. We used the National Cancer Database to assess survival of patients with metastatic SCLC treated with PCI. PATIENTS AND METHODS Metastatic SCLC patients without brain metastases were identified. To minimize treatment selection bias, patients with an overall survival (OS) < 6 months were excluded. Cox regression identified variables associated with OS. Patients were propensity score-matched on factors associated with receipt of PCI or OS. The effect of PCI on OS was examined using Kaplan-Meier estimates. RESULTS In the overall cohort (n = 4257), treatment with PCI (n = 473) was associated with improved survival (hazard ratio, 0.66; 95% confidence interval, 0.60-0.74; P < .0001). Comparisons of propensity score-matched cohorts revealed a significant survival benefit for patients who received PCI in median OS (13.9 vs. 11.1 months; P < .0001), as well as 1- and 2-year OS (61.2% vs. 44.0% and 19.8% vs. 11.5%, respectively; P < .0001). This survival benefit persisted even after excluding patients who survived < 9 months (median: 15.3 vs. 12.9 months; P < .0001). In multivariable analysis, predictors of receipt of PCI were Caucasian race, younger age, and lower Charlson-Deyo score. CONCLUSION Using a modern population-based data set, we showed that metastatic SCLC patients treated with PCI have significantly improved OS. This large retrospective study helps address the conflicting prospective data.
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Affiliation(s)
- Sonam Sharma
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthew T McMillan
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Abigail Doucette
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Roger B Cohen
- Department of Medical Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Abigail Berman
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - William Levin
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Jacob Shabason
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
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Bernhardt D, König L, Aufderstrasse S, Krisam J, Hoerner-Rieber J, Adeberg S, Bozorgmehr F, El Shafie R, Lang K, Kappes J, Thomas M, Herth F, Heußel CP, Warth A, Marcrom S, Debus J, Steins M, Rieken S. Generation of a New Disease-specific Prognostic Score for Patients With Brain Metastases From Small-cell Lung Cancer Treated With Whole Brain Radiotherapy (BMS-Score) and Validation of Two Other Indices. Clin Lung Cancer 2017; 19:340-345. [PMID: 29373273 DOI: 10.1016/j.cllc.2017.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/22/2017] [Accepted: 12/08/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Patients with small-cell lung cancer (SCLC) demonstrate an exception in the treatment of brain metastases (BM), because in patients with SCLC whole brain radiotherapy (WBRT) only is the preferred treatment modality. The purpose of this study was to develop a prognostic score for patients with brain metastases from SCLC treated with WBRT. PATIENTS AND METHODS The present study was conducted utilizing a single-institution, previously described, retrospective database of patients with SCLC who were treated with WBRT (n = 221). Univariate and multivariate analyses were performed to generate the "brain metastases from SCLC score" (BMS score) based on favorable prognostic factors: Karnofsky performance status (KPS > 70), extracerebral disease status (stable disease/controlled), and time of appearance of BM (synchronous). Furthermore, the disease-specific graded prognostic assessment score as well as the recursive partitioning analysis (RPA) were performed and compared with the new BMS score by using the log-rank (Mantel-Cox) test. RESULTS BMS score and RPA showed the most significant differences between classes (P < .001). BMS score revealed a mean overall survival (OS) of 2.62 months in group I (0-1 points), 6.61 months in group II (2-3 points), and 12.31 months in group III (4 points). The BMS score also identified the group with the shortest survival (2.62 months in group I), and the numbers of patients in each group were most equally distributed with the BMS score. CONCLUSION The new BMS score was more prognostic than the RPA and disease-specific graded prognostic assessment scores. The BMS score is easy to use and reflects known prognostic factors in contemporary patients with SCLC treated with WBRT. Future studies are necessary to validate these findings.
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Affiliation(s)
- Denise Bernhardt
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany.
| | - Laila König
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Sophie Aufderstrasse
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Johannes Krisam
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Juliane Hoerner-Rieber
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Sebastian Adeberg
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Farastuk Bozorgmehr
- Department of Thoracic Oncology, Thoraxklinik, Heidelberg University, Translational Lung Research Centre Heidelberg (TLRC-H), Heidelberg, Germany; Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Rami El Shafie
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Kristin Lang
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Jutta Kappes
- Department of Pneumology, Thoraxklinik, Heidelberg University, Heidelberg, Germany; Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Michael Thomas
- Department of Thoracic Oncology, Thoraxklinik, Heidelberg University, Translational Lung Research Centre Heidelberg (TLRC-H), Heidelberg, Germany; Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Felix Herth
- Department of Pneumology, Thoraxklinik, Heidelberg University, Heidelberg, Germany; Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Claus Peter Heußel
- Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, Germany; Diagnostic and Interventional Radiology at University of Heidelberg, Heidelberg, Germany
| | - Arne Warth
- Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Institute of Pathology, Heidelberg University, Heidelberg, Germany
| | - Samuel Marcrom
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Jürgen Debus
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Martin Steins
- Department of Thoracic Oncology, Thoraxklinik, Heidelberg University, Translational Lung Research Centre Heidelberg (TLRC-H), Heidelberg, Germany
| | - Stefan Rieken
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
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Corkum MT, Rodrigues GB. Patient selection for thoracic radiotherapy in extensive-stage small-cell lung cancer. Lung Cancer Manag 2017; 6:47-53. [PMID: 30643570 PMCID: PMC6310308 DOI: 10.2217/lmt-2017-0006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 07/04/2017] [Indexed: 01/29/2023] Open
Abstract
Treatment of extensive-stage small-cell lung cancer remains a challenge with poor local control and overall survival. Chemotherapy is the mainstay of treatment, consisting of a combination of a platinum agent plus etoposide. The role of consolidative chest radiotherapy in extensive-stage small-cell lung cancer remains controversial. Two randomized clinical trials have been published demonstrating improved intrathoracic disease control with a small survival benefit, though interpretation and application of these results to clinical practice has been debated. These two trials examined different radiotherapy techniques and doses, with a third trial treating consolidative chest and oligometastatic disease having closed prematurely due to an interim analysis demonstrating treatment futility plus increased toxicity. Patients with residual intrathoracic disease after chemotherapy appear to benefit the most from consolidative chest radiotherapy, offering a potential tool to help select appropriate patients.
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Affiliation(s)
- Mark T Corkum
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario N6A 4L6, Canada
| | - George B Rodrigues
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario N6A 4L6, Canada
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Kesarwala AH, Lu DJ, Xanthopoulos E, Apisarnthanarax S, Cengel KA, Evans TL, Aggarwal C, Cohen RB, Langer CJ, Rengan R, Simone CB. The Role of Advanced Imaging in Assessing Response to Definitive Chemoradiation Before Prophylactic Cranial Irradiation in Limited-Stage Small-Cell Lung Cancer. Clin Lung Cancer 2017; 19:e205-e209. [PMID: 29153967 DOI: 10.1016/j.cllc.2017.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 07/26/2017] [Accepted: 10/04/2017] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Prophylactic cranial irradiation (PCI) improves survival for small-cell lung cancer (SCLC). Evidence for PCI in limited-stage SCLC largely derives from studies requiring only chest x-ray (CXR) to determine remission status. We analyzed thoracic chemoradiation therapy (TCRT) outcomes according to imaging modality to determine which patients benefitted most from PCI. PATIENTS AND METHODS All limited-stage SCLC patients who received TCRT as well as PCI at our institution were reviewed. Imaging between TCRT end and PCI start was characterized as complete (CR), partial (PR), or other response. RESULTS Thirty-eight consecutive patients were assessed for TCRT response before PCI with CXR (n = 21), chest computed tomography (CT; n = 27), and/or positron emission tomography (PET)/CT (n = 11). CR was identified on 71% of CXRs, 41% of CT scans, and 18% of PET/CT scans. Median survival was 28.3 months for the entire cohort and did not differ for patients who had CXR alone versus CT and/or PET/CT for restaging (P = .78) or those with PR using any modality versus CR using all modalities (22.6 months vs. 45.5 months; P = .22). CT CR patients had numerical but not statistically significant improved 2-year (P = .18) and 3-year (P = .13) survival compared with CT PR. CONCLUSION CXR remains an appropriate modality to assess TCRT response before PCI in limited-stage SCLC. Advanced imaging did not inform the decision to offer PCI in this study. Because of similar excellent survival profiles independent of imaging modality and TCRT response, this analysis suggests limited-stage SCLC patients with PR using any modality should not be denied PCI, akin to standards for extensive-stage SCLC.
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Affiliation(s)
- Aparna H Kesarwala
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD.
| | - Diana J Lu
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Eric Xanthopoulos
- Department of Radiation Oncology, Columbia University Medical Center, New York, NY
| | - Smith Apisarnthanarax
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA
| | - Keith A Cengel
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Tracey L Evans
- Division of Hematology/Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Charu Aggarwal
- Division of Hematology/Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Roger B Cohen
- Division of Hematology/Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Corey J Langer
- Division of Hematology/Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ramesh Rengan
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD
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46
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Singh M, Bakhshinyan D, Venugopal C, Singh SK. Preclinical Modeling and Therapeutic Avenues for Cancer Metastasis to the Central Nervous System. Front Oncol 2017; 7:220. [PMID: 28971065 PMCID: PMC5609558 DOI: 10.3389/fonc.2017.00220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 09/01/2017] [Indexed: 12/31/2022] Open
Abstract
Metastasis is the dissemination of cells from the primary tumor to other locations within the body, and continues to be the predominant cause of death among cancer patients. Metastatic progression within the adult central nervous system is 10 times more frequent than primary brain tumors. Metastases affecting the brain parenchyma and leptomeninges are associated with grave prognosis, and even after successful control of the primary tumor the median survival is a dismal 2-3 months with treatment options typically limited to palliative care. Current treatment options for brain metastases (BM) and disseminated brain tumors are scarce, and the improvement of novel targeted therapies requires a broader understanding of the biological complexity that characterizes metastatic progression. In this review, we provide insight into patterns of BM progression and leptomeningeal spread, outlining the development of clinically relevant in vivo models and their contribution to the discovery of innovative cancer therapies. In vivo models paired with manipulation of in vitro methods have expanded the tools available for investigators to develop agents that can be used to prevent or treat metastatic disease. The knowledge gained from the use of such models can ultimately lead to the prevention of metastatic dissemination and can extend patient survival by transforming a uniformly fatal systemic disease into a locally controlled and eminently more treatable one.
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Affiliation(s)
- Mohini Singh
- McMaster Stem Cell and Cancer Research Institute, McMaster University, Hamilton, ON, Canada.,Faculty of Health Sciences, Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
| | - David Bakhshinyan
- McMaster Stem Cell and Cancer Research Institute, McMaster University, Hamilton, ON, Canada.,Faculty of Health Sciences, Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
| | - Chitra Venugopal
- McMaster Stem Cell and Cancer Research Institute, McMaster University, Hamilton, ON, Canada.,Faculty of Health Sciences, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Sheila K Singh
- McMaster Stem Cell and Cancer Research Institute, McMaster University, Hamilton, ON, Canada.,Faculty of Health Sciences, Department of Surgery, McMaster University, Hamilton, ON, Canada
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Postmus PE, Smit EF. Prophylactic cranial irradiation for stage IV small cell lung cancer, live longer or reduce morbidity of brain metastases? J Thorac Dis 2017; 9:3572-3575. [PMID: 29268344 DOI: 10.21037/jtd.2017.09.50] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Pieter E Postmus
- Department of Medical Oncology, Clatterbridge Cancer Centre, Liverpool Heart & Chest Hospital, University of Liverpool, Liverpool, UK
| | - Egbert F Smit
- Department of Thoracic Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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48
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Aizer AA, Mak R, Alexander BM. Prophylactic cranial irradiation in patients with extensive-stage small cell lung cancer. Neuro Oncol 2017; 19:1015-1016. [PMID: 28854622 PMCID: PMC5570200 DOI: 10.1093/neuonc/nox113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ayal A Aizer
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Raymond Mak
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Brian M Alexander
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts
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49
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Outcome and prognostic factors in patients with brain metastases from small-cell lung cancer treated with whole brain radiotherapy. J Neurooncol 2017; 134:205-212. [PMID: 28560661 DOI: 10.1007/s11060-017-2510-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/20/2017] [Indexed: 12/20/2022]
Abstract
The purpose of this study was to evaluate prognostic factors associated with overall survival (OS) and neurological progression free survival (nPFS) in small-cell lung cancer (SCLC) patients with brain metastases who received whole-brain radiotherapy (WBRT). From 2003 to 2015, 229 SCLC patients diagnosed with brain metastases who received WBRT were analyzed retrospectively. In this cohort 219 patients (95%) received a total photon dose of 30 Gy in 10 fractions. The prognostic factors evaluated for OS and nPFS were: age, Karnofsky Performance Status (KPS), number of brain metastases, synchronous versus metachronous disease, initial response to chemotherapy, the Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class and thoracic radiation. Median OS after WBRT was 6 months and the median nPFS after WBRT was 11 months. Patients with synchronous cerebral metastases had a significantly better median OS with 8 months compared to patients with metachronous metastases with a median survival of 3 months (p < 0.0001; HR 0.46; 95% CI 0.31-0.67). Based on RPA classification median survival after WBRT was 17 months in RPA class I, 7 months in class II and 3 months in class III (p < 0.0001). Karnofsky performance status scale (KPS < 70%) was significantly associated with OS in both univariate (HR 2.84; p < 0.001) and multivariate analyses (HR 2.56; p = 0.011). Further, metachronous brain metastases (HR 1.8; p < 0.001), initial response to first-line chemotherapy (HR 0.51, p < 0.001) and RPA class III (HR 2.74; p < 0.001) were significantly associated with OS in univariate analysis. In multivariate analysis metachronous disease (HR 1.89; p < 0.001) and initial response to chemotherapy (HR 0.61; p < 0.001) were further identified as significant prognostic factors. NPFS was negatively significantly influenced by poor KPS (HR 2.56; p = 0.011), higher number of brain metastases (HR 1.97; p = 0.02), and higher RPA class (HR 2.26; p = 0.03) in univariate analysis. In this series, the main prognostic factors associated with OS were performance status, time of appearance of intracranial disease (synchronous vs. metachronous), initial response to chemotherapy and higher RPA class. NPFS was negatively influenced by poor KPS, multiplicity of brain metastases, and higher RPA class in univariate analysis. For patients with low performance status, metachronous disease or RPA class III, WBRT should be weighed against supportive therapy with steroids alone or palliative chemotherapy.
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Frontline Systemic Therapy With Pemetrexed-Platinum in Nonsquamous Non-Small-Cell Lung Cancer With Asymptomatic Brain Metastases. Am J Ther 2017; 24:e111-e120. [PMID: 25153672 DOI: 10.1097/mjt.0000000000000106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The incidence of brain metastases from nonsquamous non-small-lung cancer is increasing as a result of superior imaging techniques for early detection of distant metastases. Although whole-brain radiation therapy and stereotactic radiosurgery along with systemic chemotherapy have shown to be effective in alleviating symptoms and improving outcomes, the approach to patients with asymptomatic brain metastases remains elusive. We explored the literature for a possible role of frontline systemic chemotherapy in asymptomatic brain metastases from nonsquamous non-small-lung cancer and found promising evidence that upfront systemic therapy with pemetrexed-platinum regimens might be a reasonable option for these patients and would forestall the need for upfront brain radiation therapy. More large-scale phase II and phase III clinical trials are needed to further investigate the frontline use of pemetrexed-platinum regimens in this setting.
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