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Heo JW, Yeo CD, Park CK, Kim SK, Kim JS, Kim JW, Kim SJ, Lee SH, Kang HS. Smoking is associated with pneumonia development in lung cancer patients. BMC Pulm Med 2020; 20:117. [PMID: 32357887 PMCID: PMC7195765 DOI: 10.1186/s12890-020-1160-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 04/20/2020] [Indexed: 02/07/2023] Open
Abstract
Background Various host factors can promote pneumonia susceptibility of lung cancer patients. However, data about risk factors for pneumonia in lung cancer patients receiving active treatments such as chemotherapy, radiotherapy, and surgical intervention are limited. Thus, the purpose of this study was to identify risk factors for pneumonia development in lung cancer patients. Methods The present study used a lung cancer cohort of the Catholic Medical Center at the Catholic University of Korea from January 2015 to December 2018. Pneumonia was defined by the presence of a new or progressive infiltration on chest imaging together with any of the following: new onset purulent sputum, change in character of chronic sputum, and fever. We ruled out noninfectious infiltration such as drug or radiation toxicity and hydrostatic pulmonary edema. We especially excluded those if computed tomography revealed sharp demarcation consolidation or ground glass opacity limited radiation field. Results A total of 413 patients were enrolled in this study. Pneumonia occurred in 118 (28.6%) patients. The pneumonia group had significantly worse overall survival (OS) than the non-pneumonia group (456.7 ± 35.0 days vs. 813.4 ± 36.1 days, log rank p < 0.001). In patients with pneumonia, OS was shorter in ex-smokers and current smokers than in never smokers (592.0 ± 101.0 days vs. 737.0 ± 102.8 days vs. 1357.0 days, log rank p < 0.001). Age (hazard ratio [HR]: 1.046; 95% confidence interval [CI]: 1.019–1.074; p = 0.001), clinical stage IV (HR: 1.759; 95% CI: 1.004–3.083; p = 0.048), neutropenia (HR: 2.620; 95% CI: 1.562–4.396; p < 0.001], and smoking (HR: 2.040; 95% CI: 1.100–3.784; p = 0.024) were independent risk factors of pneumonia development in lung cancer patients in multivariate analysis. In subgroup analysis for patients treated with chemotherapy, age (HR: 1.043; 95% CI: 1.012–1.074; p = 0.006), neutropenia (HR: 3.199; 95% CI: 1.826–5.605; p < 0.001), and smoking (HR: 2.125; 95% CI: 1.071–4.216; p = 0.031) were independent risk factors of pneumonia development. Conclusions Smoking and neutropenia were risk factors affecting pneumonia development in the total group and subgroup of patients with lung cancer.
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Affiliation(s)
- Jung Won Heo
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chang Dong Yeo
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chan Kwon Park
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung Kyoung Kim
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ju Sang Kim
- Division of Pulmonary, Critical Care and Sleep Allergy, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Woo Kim
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung Joon Kim
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Haak Lee
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hye Seon Kang
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 327, Sosa-ro, Bucheon-si, Gyeonggi-do, 14647, Republic of Korea.
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2
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Sun A, Hu C, Wong SJ, Gore E, Videtic G, Dutta S, Suntharalingam M, Chen Y, Gaspar LE, Choy H. Prophylactic Cranial Irradiation vs Observation in Patients With Locally Advanced Non-Small Cell Lung Cancer: A Long-term Update of the NRG Oncology/RTOG 0214 Phase 3 Randomized Clinical Trial. JAMA Oncol 2020; 5:847-855. [PMID: 30869743 DOI: 10.1001/jamaoncol.2018.7220] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Brain metastasis (BM) rates are high in locally advanced non-small cell lung cancer (LA-NSCLC), approaching rates seen in small cell lung cancer, where prophylactic cranial irradiation (PCI) is standard of care. Although PCI decreases the incidence of BM in LA-NSCLC, a survival advantage has not yet been shown. Objective To determine if PCI improves survival in LA-NSCLC. Design, Setting, and Participants Radiation Therapy Oncology Group (RTOG) 0214 was a randomized phase 3 clinical trial in stage III NSCLC stratified by stage (IIIA vs IIIB), histologic characteristics (nonsquamous vs squamous) and therapy (no surgery vs surgery). The study took place at 291 institutions in the United States, Canada, and internationally. Of 356 patients with stage III NSCLC entered onto this study, 16 were ineligible; therefore, 340 patients were randomized. Intervention for Clinical Trials Observation vs PCI. Main Outcomes and Measures The primary outcome was overall survival (OS). The secondary end points were disease-free survival (DFS) and incidence of BM. Results Of the 340 total participants, mean (SD) age was 61 years; 213 of the participants were men and 127 were women. The median follow-up time was 2.1 years for all patients, and 9.2 years for living patients. The OS for PCI was not significantly better than observation (hazard ratio [HR], 0.82; 95% CI, 0.63-1.06; P = .12; 5- and 10-year rates, 24.7% and 17.6% vs 26.0% and 13.3%, respectively), while the DFS (HR, 0.76; 95% CI, 0.59-0.97; P = .03; 5- and 10-year rates, 19.0% and 12.6% vs 16.1% and 7.5% for PCI vs observation) and BM (HR, 0.43; 95% CI, 0.24-0.77; P = .003; 5- and 10-year rates, 16.7% vs 28.3% for PCI vs observation) were significantly different. Patients in the PCI arm were 57% less likely to develop BM than those in the observation arm. Younger patients (<60 years) and patients with nonsquamous disease developed more BM. On multivariable analysis, PCI was associated with decreased BM and improved DFS, but not improved OS. Multivariable analysis within the nonsurgical arm suggests that PCI effectively prolongs OS, DFS, and BM. Conclusions and Relevance In patients with stage III LA-NSCLC without progression of disease after therapy, PCI decreased the 5- and 10-year rate of BM and improved 5- and 10-year DFS, but did not improve OS. Although this study did not meet its primary end point, the long-term results reveal many important findings that will benefit future trials. Identifying the appropriate patient population and a safe intervention is critical. Trial Registration ClinicalTrials.gov identifier: NCT00048997.
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Affiliation(s)
- Alexander Sun
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Chen Hu
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania.,Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | - Swati Dutta
- Michigan Cancer Research Consortium CCOP, Ann Arbor
| | | | | | | | - Hak Choy
- University of Texas Southwestern Medical Center, Dallas
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3
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McAleese J, Taylor A, Walls GM, Hanna GG. Differential Relapse Patterns for Non-small Cell Lung Cancer Subtypes Adenocarcinoma and Squamous Cell Carcinoma: Implications for Radiation Oncology. Clin Oncol (R Coll Radiol) 2019; 31:711-719. [PMID: 31351746 DOI: 10.1016/j.clon.2019.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 05/17/2019] [Accepted: 06/07/2019] [Indexed: 12/25/2022]
Abstract
AIMS Curative-intent (radical) radiotherapy aims to control local disease and cure non-small cell lung cancer (NSCLC). The predominant subtypes of NSCLC are adenocarcinoma and squamous cell carcinoma (SCC). The radiotherapy paradigm offered to patients does not differ according to these two subtypes. Relapse patterns and disease control rates for adenocarcinoma and SCC treated with radical radiotherapy were determined. MATERIALS AND METHODS A radical radiotherapy database covering the period from 2004 to June 2016 was examined to determine the first sites of relapse and the actuarial local and distant control rates. RESULTS In total, 537 patients with known pathological subtype were treated over the period. In 39 (7%), the site of first relapse was uncertain. Of the remainder, 203 (41%) had adenocarcinoma and 295 (59%) had SCC. At a median follow-up of 16.4 months, 58% had relapsed. There was a difference in relapse patterns (chi-squared test P < 0.0005), with a higher rate of first relapse locally in SCC (42% of all patients versus 24%) and a higher rate of first relapse in the brain for adenocarcinoma (14% versus 3%). The actuarial local control rate was worse for SCC (hazard ratio 0.6, 95% confidence interval 0.5-0.9, P = 0.002). The brain metastasis-free survival was worse for adenocarcinoma (hazard ratio 4.1, 95% confidence interval 2.2-7.5, P < 0.0001). CONCLUSION There is a difference in relapse patterns between NSCLC histological subtypes, indicating that these are distinct entities. This may have implications for follow-up policy and strategies to improve disease control.
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Affiliation(s)
- J McAleese
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Belfast, UK
| | - A Taylor
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Belfast, UK
| | - G M Walls
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Belfast, UK; Centre for Cancer Research & Cell Biology, Queen's University of Belfast, Belfast, UK.
| | - G G Hanna
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Belfast, UK; Centre for Cancer Research & Cell Biology, Queen's University of Belfast, Belfast, UK
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Ye JC, Ding L, Atay SM, Nieva JJ, McFadden PM, Chang E, Kim AW. Trimodality vs Chemoradiation and Salvage Resection in cN2 Stage IIIA Non-Small Cell Lung Cancer. Semin Thorac Cardiovasc Surg 2019; 32:153-159. [PMID: 31220530 DOI: 10.1053/j.semtcvs.2019.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 06/12/2019] [Indexed: 12/25/2022]
Abstract
To determine the overall survival (OS) in patients who underwent planned trimodality therapy (TMT) and those who underwent definitive concurrent chemoradiation (CRT), but later received salvage resection (SR) for stage IIIA (cN2) (AJCC 7th ed.) non-small cell lung cancer. National Cancer Database data set from 2004 to 2014 was queried. TMT was defined as multiagent CRT with dose >45 Gy, followed by lobectomy or pneumonectomy ≤90 days from end of CRT. SR was defined as multiagent CRT with dose >59 Gy and lobectomy or pneumonectomy performed >90 days from CRT completion. Propensity score weighting and propensity score matching methods were used to balance patient and tumor characteristics and to calculate hazard ratios. A total of 2025 (1899 TMT and 126 SR) patients were analyzed. TMT and SR groups shared similar characteristics. Surgery occurred at a median of 41 days (range 1-90) after CRT in the TMT group and 114 days (91-440) in the SR group. The 90-day mortality after surgery was 6.5% for TMT and 5% for SR (P = 0.43). The 3- and 5-year OS were 55.1% and 35.7% for TMT and 51.6% and 45.0% for SR (P = 0.92, 0.68), with no difference across unadjusted cohort and propensity-adjusted cohort. Patients with cN2 stage IIIA non-small cell lung cancer treated in the United States with definitive CRT followed by SR had similar OS as upfront TMT with similar postoperative mortality despite SR occurring >90 days after >59 Gy CRT. SR remains an option for medically appropriate patients after definitive dose CRT.
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Affiliation(s)
- Jason C Ye
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, California.
| | - Li Ding
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Scott M Atay
- Division of Thoracic Surgery, Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Jorge J Nieva
- Division of Oncology, Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
| | - P Michael McFadden
- Division of Thoracic Surgery, Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Eric Chang
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Anthony W Kim
- Division of Thoracic Surgery, Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
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5
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Jeene PM, de Vries KC, van Nes JGH, Kwakman JJM, Wester G, Rozema T, Braam PM, Zindler JD, Koper P, Nuyttens JJ, Vos-Westerman HA, Schmeets I, Niël CGHJ, Hutschemaekers S, van der Linden YM, Verhoeff JJC, Stalpers LJA. Survival after whole brain radiotherapy for brain metastases from lung cancer and breast cancer is poor in 6325 Dutch patients treated between 2000 and 2014. Acta Oncol 2018; 57:637-643. [PMID: 29276848 DOI: 10.1080/0284186x.2017.1418534] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Whole brain radiotherapy (WBRT) is considered standard of care for patients with multiple brain metastases or unfit for radical treatment modalities. Recent studies raised discussion about the expected survival after WBRT. Therefore, we analysed survival after WBRT for brain metastases 'in daily practice' in a large nationwide multicentre retrospective cohort. METHODS Between 2000 and 2014, 6325 patients had WBRT (20 Gy in 4 Gy fractions) for brain metastases from non-small cell lung cancer (NSCLC; 4363 patients) or breast cancer (BC; 1962 patients); patients were treated in 15 out of 21 Dutch radiotherapy centres. Survival was calculated by the Kaplan-Meier method from the first day of WBRT until death as recorded in local hospital data registration or the Dutch Municipal Personal Records Database. FINDINGS The median survival was 2.7 months for NSCLC and 3.7 months for BC patients (p < .001). For NSCLC patients aged <50, 50-60, 60-70 and >70 years, survival was 4.0, 3.0, 2.8 and 2.1 months, respectively (p < .001). For BC patients, survival was 4.5, 3.8, 3.2 and 2.9 months, respectively (p = .047). In multivariable analyses, higher age was related to poorer survival with hazard ratios (HR) for patients aged 50-60, 60-70 and >70 years being 1.05, 1.19 and 1.34, respectively. Primary BC (HR: 0.83) and female sex (HR: 0.85) were related to better survival (p < .001). INTERPRETATION The survival of patients after WBRT for brain metastases from NSCLC treated in Dutch 'common radiotherapy practice' is poor, in breast cancer and younger patients it is disappointingly little better. These results are in line with the results presented in the QUARTZ trial and we advocate a much more restrictive use of WBRT. In patients with a more favourable prognosis the optimal treatment strategy remains to be determined. Prospective randomized trials and individualized prognostic models are needed to identify these patients and to tailor treatment.
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Affiliation(s)
- Paul M. Jeene
- Department of Radiotherapy, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Radiotherapiegroep, Deventer, The Netherlands
| | - Kim C. de Vries
- Department of Radiotherapy, Antoni van Leeuwenhoek ziekenhuis, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Johannes J. M. Kwakman
- Department of Radiotherapy, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Tom Rozema
- Instituut Verbeeten, Tilburg, The Netherlands
| | - Pètra M. Braam
- Department of Radiotherapy, RadboudUMC, Nijmegen, The Netherlands
| | - Jaap D. Zindler
- MAASTRO Clinic Maastricht, GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Peter Koper
- Department of Radiotherapy, HaaglandenMC, The Hague, The Netherlands
| | - Joost J. Nuyttens
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Ilona Schmeets
- Department of Radiotherapy, Catharina ziekenhuis, Eindhoven, The Netherlands
| | | | | | | | - Joost J. C. Verhoeff
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lukas J. A. Stalpers
- Department of Radiotherapy, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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6
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Al Feghali KA, Ballout RA, Khamis AM, Akl EA, Geara FB. Prophylactic Cranial Irradiation in Patients With Non-Small-Cell Lung Cancer: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Front Oncol 2018; 8:115. [PMID: 29732317 PMCID: PMC5919944 DOI: 10.3389/fonc.2018.00115] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/29/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND We systematically reviewed the literature for trials addressing the efficacy of prophylactic cranial irradiation (PCI) in patients with non-small-cell lung cancer (NSCLC) treated with a curative intent. METHODS Randomized controlled trials (RCT) comparing PCI to no PCI in patients with NSCLC treated with a curative intent were eligible for inclusion. We searched EMBASE, MEDLINE, PubMed, and CENTRAL between 1946 and July 2016. We also received continual search alerts from PubMed through September 2017. Search terms included "non-small-cell lung carcinoma," "cranial irradiation," and "randomized controlled trials." We conducted meta-analyses using random-effects models for relative measures of treatment effect for the incidence of brain metastasis, overall survival (OS), and disease-free survival (DFS). We used Parmar's methodology to derive hazard ratios (HR) when not explicitly stated in RCTs. We narratively synthesized data for the impact of PCI on quality of life (QoL) and neurocognitive function (NCF). We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation methodology. RESULTS Out of 3,548 citations captured by the search strategy, we retained 8 papers and 1 abstract, reporting on 6 eligible trials. Patients who received PCI had a significant reduction in the risk of developing brain metastases as compared with patients who did not [relative risk (RR) = 0.37; 95% confidence interval (CI): 0.26-0.52; moderate quality evidence]. However, there was no OS benefit (HR = 1.08, 95% CI: 0.90-1.31; moderate quality evidence). Sensitivity analysis excluding older studies did not show substantively different findings. DFS was reported in the two most recent trials that included only stage III patients. There was significant improvement in DFS with PCI (HR = 0.67; 95% CI: 0.46-0.98; high quality evidence). Two studies that reported on QoL reported no statistically significant differences. There was no significant difference in NCF decline in the only study that reported on this outcome, except in immediate and delayed recall, as assessed by the Hopkins Verbal Learning Test. CONCLUSION There is moderate quality evidence that the use of PCI in patients with NSCLC decreases the risk of brain metastases, but does not provide an OS benefit. However, data limited to stage III patients suggests that PCI improves DFS, with no effect on QoL.
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Affiliation(s)
- Karine A. Al Feghali
- Department of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rami A. Ballout
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Assem M. Khamis
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Elie A. Akl
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fady B. Geara
- Department of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon
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7
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Soo RA, Stone ECA, Cummings KM, Jett JR, Field JK, Groen HJM, Mulshine JL, Yatabe Y, Bubendorf L, Dacic S, Rami-Porta R, Detterbeck FC, Lim E, Asamura H, Donington J, Wakelee HA, Wu YL, Higgins K, Senan S, Solomon B, Kim DW, Johnson M, Yang JCH, Sequist LV, Shaw AT, Ahn MJ, Costa DB, Patel JD, Horn L, Gettinger S, Peters S, Wynes MW, Faivre-Finn C, Rudin CM, Tsao A, Baas P, Kelly RJ, Leighl NB, Scagliotti GV, Gandara DR, Hirsch FR, Spigel DR. Scientific Advances in Thoracic Oncology 2016. J Thorac Oncol 2017; 12:1183-1209. [PMID: 28579481 DOI: 10.1016/j.jtho.2017.05.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 05/15/2017] [Accepted: 05/23/2017] [Indexed: 12/21/2022]
Abstract
Lung cancer care is rapidly changing with advances in genomic testing, the development of next-generation targeted kinase inhibitors, and the continued broad study of immunotherapy in new settings and potential combinations. The International Association for the Study of Lung Cancer and the Journal of Thoracic Oncology publish this annual update to help readers keep pace with these important developments. Experts in thoracic cancer and care provide focused updates across multiple areas, including prevention and early detection, molecular diagnostics, pathology and staging, surgery, adjuvant therapy, radiotherapy, molecular targeted therapy, and immunotherapy for NSCLC, SCLC, and mesothelioma. Quality and value of care and perspectives on the future of lung cancer research and treatment have also been included in this concise review.
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Affiliation(s)
- Ross A Soo
- Cancer Science Institute of Singapore, National University of Singapore, Singapore; Department of Haematology-Oncology, National University Cancer Institute of Singapore, Singapore; School of Surgery, University of Western Australia, Perth, Australia
| | - Emily C A Stone
- Department of Thoracic Medicine, St. Vincent's Hospital, Kinghorn Cancer Centre, Sydney, Australia
| | - K Michael Cummings
- Hollings Cancer Center Medical University of South Carolina, Charleston, South Carolina
| | | | - John K Field
- Roy Castle Lung Cancer Research Programme, Department of Molecular and Clinical Cancer Medicine, The University of Liverpool, Liverpool, United Kingdom
| | - Harry J M Groen
- Department of Pulmonary Diseases, University Medical Center Groningen, Groningen, The Netherlands
| | - James L Mulshine
- Internal Medicine, Graduate College, Rush University Medical Center, Chicago, Illinois
| | - Yasushi Yatabe
- Department of Pathology and Molecular Diagnostics, Aichi Cancer Center, Nagoya, Japan
| | - Lukas Bubendorf
- Institute of Pathology, University Hospital Basel, Basel, Switzerland
| | - Sanja Dacic
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ramon Rami-Porta
- Department of Thoracic Surgery, Hospital Universitari Mutua Terrassa, University of Barcelona, Network of Biomedical Research Centers in Respiratory Diseases (CIBERES) Lung Cancer Group, Terrassa, Barcelona, Spain
| | | | - Eric Lim
- Academic Division of Thoracic Surgery, The Royal Brompton Hospital and Imperial College, London, United Kingdom
| | - Hisao Asamura
- Division of Thoracic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Jessica Donington
- Cardiothoracic Surgery, New York University School of Medicine, New York, New York
| | - Heather A Wakelee
- Department of Medicine, Division of Oncology, Stanford University School of Medicine, Stanford, California
| | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Kristin Higgins
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Suresh Senan
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Benjamin Solomon
- Department of Medical Oncology, Peter MacCallum Cancer Center, Melbourne, Australia
| | - Dong-Wan Kim
- Seoul National University Hospital, Seoul, Republic of Korea
| | | | - James C H Yang
- Department of Oncology, National Taiwan University Hospital, Taipei, Republic of China
| | - Lecia V Sequist
- Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Alice T Shaw
- Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Myung-Ju Ahn
- Section of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Daniel B Costa
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jyoti D Patel
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Leora Horn
- Division of Hematology/Oncology, Vanderbilt Ingram Cancer Center, Nashville, Tennessee
| | - Scott Gettinger
- Medical Oncology, Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Solange Peters
- Medical Oncology and Thoracic Malignancies, Oncology Department, University Hospital Center Vaudois, Lausanne, Switzerland
| | - Murry W Wynes
- International Association for the Study of Lung Cancer, Aurora, Colorado
| | - Corinne Faivre-Finn
- Radiotherapy Related Research, Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Christie Hospital NHS Trust, Manchester, United Kingdom
| | - Charles M Rudin
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne Tsao
- Mesothelioma Program, Thoracic Chemo-Radiation Program, Department of Thoracic/Head and Neck Medical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Paul Baas
- Department of Chest Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Ronan J Kelly
- Deptartment of Medical Oncology, Sidney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Natasha B Leighl
- Division of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | | | - David R Gandara
- Thoracic Oncology Program, University of California Davis Comprehensive Cancer Center, Sacramento, California
| | - Fred R Hirsch
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora.
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8
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Lee Y, Han JY, Moon SH, Nam BH, Lim KY, Lee GK, Kim HT, Yun T, An HJ, Lee JS. Incorporating Erlotinib or Irinotecan Plus Cisplatin into Chemoradiotherapy for Stage III Non-small Cell Lung Cancer According to EGFR Mutation Status. Cancer Res Treat 2017; 49:981-989. [PMID: 28111430 PMCID: PMC5654157 DOI: 10.4143/crt.2016.522] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 12/27/2016] [Indexed: 12/28/2022] Open
Abstract
Purpose Concurrent chemoradiotherapy (CCRT) is the standard care for stage III non-small cell lung cancer (NSCLC) patients; however, a more effective regimen is needed to improve the outcome by better controlling occult metastases. We conducted two parallel randomized phase II studies to incorporate erlotinib or irinotecan-cisplatin (IP) into CCRT for stage III NSCLC depending on epidermal growth factor receptor (EGFR) mutation status. Materials and Methods Patients with EGFR-mutant tumors were randomized to receive three cycles of erlotinib first and then either CCRT with erlotinib followed by erlotinib (arm A) or CCRT with IP only (arm B). Patients with EGFR unknown or wild-type tumors were randomized to receive either three cycles of IP before (arm C) or after CCRT with IP (arm D). Results Seventy-three patients were screened and the study was closed early because of slow accrual after 59 patients were randomized. Overall, there were seven patients in arm A, five in arm B, 22 in arm C, and 25 in arm D. The response rate was 71.4% and 80.0% for arm A and B, and 70.0% and 73.9% for arm C and D. The median overall survival (OS) was 39.3 months versus 31.2 months for arm A and B (p=0.442), and 16.3 months versus 25.3 months for arm C and D (p=0.050). Patients with sensitive EGFR mutations had significantly longer OS than EGFR-wild patients (74.8 months vs. 25.3 months, p=0.034). There were no unexpected toxicities. Conclusion Combined-modality treatment by molecular diagnostics is feasible in stage III NSCLC. EGFR-mutant patients appear to be a distinct subset with longer survival.
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Affiliation(s)
- Youngjoo Lee
- Center for Lung Cancer, National Cancer Center, Goyang, Korea
| | - Ji-Youn Han
- Center for Lung Cancer, National Cancer Center, Goyang, Korea
| | - Sung Ho Moon
- Center for Proton Therapy, National Cancer Center, Goyang, Korea
| | - Byung-Ho Nam
- Center for Clinical Trials, National Cancer Center, Goyang, Korea
| | - Kun Young Lim
- Center for Lung Cancer, National Cancer Center, Goyang, Korea
| | - Geon Kook Lee
- Center for Lung Cancer, National Cancer Center, Goyang, Korea
| | - Heung Tae Kim
- Center for Lung Cancer, National Cancer Center, Goyang, Korea
| | - Tak Yun
- Center for Lung Cancer, National Cancer Center, Goyang, Korea
| | - Hye Jin An
- Center for Lung Cancer, National Cancer Center, Goyang, Korea
| | - Jin Soo Lee
- Center for Lung Cancer, National Cancer Center, Goyang, Korea
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Bruynzeel AME, Lagerwaard FJ. Whole brain radiotherapy for brain metastases from non-small cell lung cancer: the end of an era? J Thorac Dis 2016; 8:E1525-E1527. [PMID: 28066650 DOI: 10.21037/jtd.2016.11.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Anna M E Bruynzeel
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Frank J Lagerwaard
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
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Mulvenna P, Nankivell M, Barton R, Faivre-Finn C, Wilson P, McColl E, Moore B, Brisbane I, Ardron D, Holt T, Morgan S, Lee C, Waite K, Bayman N, Pugh C, Sydes B, Stephens R, Parmar MK, Langley RE. Dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ): results from a phase 3, non-inferiority, randomised trial. Lancet 2016; 388:2004-2014. [PMID: 27604504 PMCID: PMC5082599 DOI: 10.1016/s0140-6736(16)30825-x] [Citation(s) in RCA: 409] [Impact Index Per Article: 51.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Whole brain radiotherapy (WBRT) and dexamethasone are widely used to treat brain metastases from non-small cell lung cancer (NSCLC), although there have been no randomised clinical trials showing that WBRT improves either quality of life or overall survival. Even after treatment with WBRT, the prognosis of this patient group is poor. We aimed to establish whether WBRT could be omitted without a significant effect on survival or quality of life. METHODS The Quality of Life after Treatment for Brain Metastases (QUARTZ) study is a non-inferiority, phase 3 randomised trial done at 69 UK and three Australian centres. NSCLC patients with brain metastases unsuitable for surgical resection or stereotactic radiotherapy were randomly assigned (1:1) to optimal supportive care (OSC) including dexamethasone plus WBRT (20 Gy in five daily fractions) or OSC alone (including dexamethasone). The dose of dexamethasone was determined by the patients' symptoms and titrated downwards if symptoms improved. Allocation to treatment group was done by a phone call from the hospital to the Medical Research Council Clinical Trials Unit at University College London using a minimisation programme with a random element and stratification by centre, Karnofsky Performance Status (KPS), gender, status of brain metastases, and the status of primary lung cancer. The primary outcome measure was quality-adjusted life-years (QALYs). QALYs were generated from overall survival and patients' weekly completion of the EQ-5D questionnaire. Treatment with OSC alone was considered non-inferior if it was no more than 7 QALY days worse than treatment with WBRT plus OSC, which required 534 patients (80% power, 5% [one-sided] significance level). Analysis was done by intention to treat for all randomly assigned patients. The trial is registered with ISRCTN, number ISRCTN3826061. FINDINGS Between March 2, 2007, and Aug 29, 2014, 538 patients were recruited from 69 UK and three Australian centres, and were randomly assigned to receive either OSC plus WBRT (269) or OSC alone (269). Baseline characteristics were balanced between groups, and the median age of participants was 66 years (range 38-85). Significantly more episodes of drowsiness, hair loss, nausea, and dry or itchy scalp were reported while patients were receiving WBRT, although there was no evidence of a difference in the rate of serious adverse events between the two groups. There was no evidence of a difference in overall survival (hazard ratio 1·06, 95% CI 0·90-1·26), overall quality of life, or dexamethasone use between the two groups. The difference between the mean QALYs was 4·7 days (46·4 QALY days for the OSC plus WBRT group vs 41·7 QALY days for the OSC group), with two-sided 90% CI of -12·7 to 3·3. INTERPRETATION Although the primary outcome measure result includes the prespecified non-inferiority margin, the combination of the small difference in QALYs and the absence of a difference in survival and quality of life between the two groups suggests that WBRT provides little additional clinically significant benefit for this patient group. FUNDING Cancer Research UK, Medical Research Council Clinical Trials Unit at University College London, and the National Health and Medical Research Council in Australia.
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Affiliation(s)
- Paula Mulvenna
- Northern Centre for Cancer Care, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Matthew Nankivell
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Rachael Barton
- Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Hull, UK
| | - Corinne Faivre-Finn
- Institute of Cancer Sciences, The University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - Paula Wilson
- Bristol Haematology and Oncology Centre, Bristol, UK
| | - Elaine McColl
- Newcastle Clinical Trials Unit and Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Iona Brisbane
- The Beatson West of Scotland Cancer Centre, Greater Glasgow Health Board and Clyde, Glasgow, UK
| | | | - Tanya Holt
- Trans Tasman Radiation Oncology Group, Waratah, NSW, Australia; University of Queensland, QLD, Australia
| | | | | | | | - Neil Bayman
- Institute of Cancer Sciences, The University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - Cheryl Pugh
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Benjamin Sydes
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Richard Stephens
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Mahesh K Parmar
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Ruth E Langley
- Medical Research Council Clinical Trials Unit at University College London, London, UK.
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Hsu F, De Caluwe A, Anderson D, Nichol A, Toriumi T, Ho C. EGFR mutation status on brain metastases from non-small cell lung cancer. Lung Cancer 2016; 96:101-7. [DOI: 10.1016/j.lungcan.2016.04.004] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 03/03/2016] [Accepted: 04/05/2016] [Indexed: 10/22/2022]
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12
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Cui S, Bai H, Dong L, Zhao Y, Gu A, Zhang W, Lou Y, Jiang L. [Analysis of Survival Predictors in Patients with Lung Cancer and Brain Metastases]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2015; 18:436-42. [PMID: 26182869 PMCID: PMC6000243 DOI: 10.3779/j.issn.1009-3419.2015.07.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
背景与目的 脑转移的肺癌患者预后差,采取积极治疗措施后也仅有约6个月的生存时间。本研究对可能影响肺癌脑转移生存的临床因素进行收集和分析,以期为指导临床实践提供一定的研究证据。 方法 回顾性收集上海交通大学附属胸科医院2002年-2008年有病理组织确诊并发生脑转移的肺癌病例。采用Kaplan-Meier生存曲线、Cox多因素生存分析模型进行生存分析,得到影响脑转移生存的独立预测因素。 结果 年龄、美国东部肿瘤协作组体能状态(Eastern Cooperative Oncology Group Performance Status, ECOG PS)评分、转移间隔时间、转移数目、治疗方法、治疗周期、脑转移症状、颅外转移、脑转移次序能够影响到肺癌脑转移患者的生存。采用Cox多因素回归分析得到治疗周期和颅外转移是肺癌脑转移生存时间的独立预测因素。 结论 治疗周期和颅外转移是肺癌脑转移生存时间的独立预测因素。
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Affiliation(s)
- Shaohua Cui
- Department of Pulmonary Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Hao Bai
- Department of Pulmonary Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Lili Dong
- Department of Pulmonary Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Yizhuo Zhao
- Department of Pulmonary Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Aiqin Gu
- Department of Pulmonary Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Wei Zhang
- Department of Pulmonary Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Yuqing Lou
- Department of Pulmonary Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Liyan Jiang
- Department of Pulmonary Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
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Lin CH, Hsu KH, Chang SN, Tsou HK, Sheehan J, Sheu ML, Pan HC. Increased survival with the combination of stereotactic radiosurgery and gefitinib for non-small cell lung cancer brain metastasis patients: a nationwide study in Taiwan. Radiat Oncol 2015; 10:127. [PMID: 26048754 PMCID: PMC4490645 DOI: 10.1186/s13014-015-0431-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 05/27/2015] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Whole brain irradiation (WBRT) either with or without resection has historically been the treatment for brain metastases from non-small cell lung cancer (NSCLC). The effect of gamma knife (GK) radiosurgery, chemotherapy, or the combination remains incompletely defined. In this study, we assessed the outcome of brain metastases from non-small cell lung cancer treated by WBRT followed by GK, gefitinib, or the combination of GK and gefitinib. MATERIAL AND METHODS We retrieved the records of NSCLC patients with brain metastases from the National Health Insurance Research Database (NHIRD) of Taiwan from 2004 to 2010. WBRT either with or without resection was the first line treatment for nearly all patients. The decision to add GK and/or gefitinib treatment was at the discretion of the treating physician and based upon a patient's medical records and imaging data. These patients were classified into four groups including WBRT, WBRT + gefitinib, WBRT + GK, WBRT + gefitinib + GK. These data was evaluated for difference in survival and factors that portended an extended survival from the time of brain metastasis diagnosis. RESULTS Of the 60194 patients with newly diagnosed NSCLC, 23874 (39.6 %) developed brain metastases. The distribution of patients for the groups was WBRT for 20241, WBRT + gefitinib for 3379, WBRT + GK for 155, and WBRT+ gefitinib + GK for 99 patients. The median survival for the time of brain metastasis diagnosis for WBRT, WBRT+ gefitinib, WBRT+ GK, WBRT+ gefitinib + GK groups was 0.53, 1.01, 1.46, and 2.25 years, respectively (p < 0.0001). The hazard ratio (95 % CI) for survival was 1, 0.56, 0.43, and 0.40, respectively (p < 0.001). The adjusted hazard ratio (95 % CI) by age, sex and Charlson comorbidity index (CCI) was 1, 0.73, 0.49, and 0.42, respectively (p < 0.001). CONCLUSION Patients with brain metastases from NSCLC receiving GK or gefitinib demonstrated extended survival. The improved survival seen with GK and gefitinib suggests a survival benefit in selected patients receiving the combined treatment. Further Phase II study should be conducted to assessment these influence.
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Affiliation(s)
- Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.
| | - Kuo-Hsuan Hsu
- Department of Chest Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.
| | - Shih-Ni Chang
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.
| | - Hsi-Kai Tsou
- Functional Neurosurgery Division, Neurosurgical Institute, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec.4, 40705, Taichung, Taiwan.
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.
| | - Meei-Ling Sheu
- Institute of Biomedical Sciences, National Chung-Hsing University, Taichung, Taiwan.
| | - Hung-Chuan Pan
- Functional Neurosurgery Division, Neurosurgical Institute, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec.4, 40705, Taichung, Taiwan. .,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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ACR Appropriateness Criteria(®) induction and adjuvant therapy for N2 non-small-cell lung cancer. Am J Clin Oncol 2015; 38:197-205. [PMID: 25803563 DOI: 10.1097/coc.0000000000000154] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The integration of chemotherapy, radiation therapy (RT), and surgery in the management of patients with stage IIIA (N2) non-small-cell lung carcinoma is challenging. The American College of Radiology (ACR) Appropriateness Criteria Lung Cancer Panel was charged to update management recommendations for this clinical scenario. The Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. There is limited level I evidence to guide patient selection for induction, postoperative RT (PORT), or definitive RT. Literature interpretation is complicated by inconsistent diagnostic procedures for N2 disease, disease heterogeneity, and pooled analysis with other stages. PORT is an appropriate therapy following adjuvant chemotherapy in patients with incidental pN2 disease. In patients with clinical N2 disease who are potential candidates for a lobectomy, both definitive and induction concurrent chemotherapy/RT are appropriate treatments. In N2 patients who require a pneumonectomy, definitive concurrent chemotherapy/RT is most appropriate although induction concurrent chemotherapy/RT may be considered in expert hands. Induction chemotherapy followed by surgery +/- PORT may also be an option in N2 patients. For preoperative RT and PORT, 3-dimensional conformal techniques and intensity-modulated RT are most appropriate.
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15
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Tang WH, Alip A, Saad M, Phua VCE, Chandran H, Tan YH, Tan YY, Kua VF, Wahid MI, Tho LM. Prognostic factors in patients with non-small cell lung carcinoma and brain metastases: a Malaysian perspective. Asian Pac J Cancer Prev 2015; 16:1901-6. [PMID: 25773842 DOI: 10.7314/apjcp.2015.16.5.1901] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Brain metastases occur in about 20-40% of patients with non-small-cell lung carcinoma (NSCLC), and are usually associated with a poor outcome. Whole brain radiotherapy (WBRT) is widely used but increasingly, more aggressive local treatments such as surgery or stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT) are being employed. In our study we aimed to describe the various factors affecting outcomes in NSCLC patients receiving local therapy for brain metastases. MATERIALS AND METHODS The case records of 125 patients with NSCLC and brain metastases consecutively treated with radiotherapy at two tertiary centres from January 2006 to June 2012 were analysed for patient, tumour and treatment-related prognostic factors. Patients receiving SRS/SRT were treated using Cyberknife. Variables were examined in univariate and multivariate testing. RESULTS Overall median survival was 3.4 months (95%CI: 1.7-5.1). Median survival for patients with multiple metastases receiving WBRT was 1.5 months, 1-3 metastases receiving WBRT was 3.6 months and 1-3 metastases receiving surgery or SRS/SRT was 8.9 months. ECOG score (≤2 vs >2, p=0.001), presence of seizure (yes versus no, p=0.031), treatment modality according to number of brain metastases (1-3 metastases+surgery or SRS/SRT±WBRT vs 1-3 metastases+WBRT only vs multiple metastases+WBRT only, p=0.007) and the use of post-therapy systemic treatment (yes versus no, p=0.001) emerged as significant on univariate analysis. All four factors remained statistically significant on multivariate analysis. CONCLUSIONS ECOG ≤2, presence of seizures, oligometastatic disease treated with aggressive local therapy (surgery or SRS/SRT) and the use of post-therapy systemic treatment are favourable prognostic factors in NSCLC patients with brain metastases.
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Affiliation(s)
- Weng Heng Tang
- Clinical Oncology Unit, University of Malaya Medical Centre, Kuala Lumpur, Malaysia E-mail :
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Li N, Zeng ZF, Wang SY, Ou W, Ye X, Li J, He XH, Zhang BB, Yang H, Sun HB, Fang Q, Wang BX. Randomized phase III trial of prophylactic cranial irradiation versus observation in patients with fully resected stage IIIA–N2 nonsmall-cell lung cancer and high risk of cerebral metastases after adjuvant chemotherapy. Ann Oncol 2015; 26:504-9. [DOI: 10.1093/annonc/mdu567] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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17
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Yalman D. Neoadjuvant radiotherapy/chemoradiotherapy in locally advanced non-small cell lung cancer. Balkan Med J 2015; 32:1-7. [PMID: 25759765 DOI: 10.5152/balkanmedj.2014.14573] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 09/09/2014] [Indexed: 12/25/2022] Open
Abstract
Locally advanced non-small cell lung cancer (NSCLC) consists of a heterogeneous group of patients, and the optimal treatment is still controversial. The current standard of care is concurrent chemoradiotherapy. The prognosis is still poor, with high rates of local and distant failure despite multimodality treatment. One of the efforts to improve outcomes in these patients is to use neoadjuvant treatment to improve resectability, and downstaging the nodal disease, which has a clear impact on prognosis. Radiotherapy as the sole neoadjuvant modality has been used historically without any survival benefit, but with increased toxicity. After the demonstrating a survival benefit by combining radiotherapy and chemotherapy, phase II studies were started to determine the neoadjuvant administration of these two modalities together. Although the results of these studies revealed a heterogeneous postinduction pathologic complete response, tumor and nodal down-staging can be achieved at the cost of a slightly higher morbidity and mortality. Subsequent phase III trials also failed to show a survival benefit to surgery, but indicated that there may be a subset of patients with locally advanced disease who can benefit from resection unless pneumonectomy is not provided. In order to increase the efficacy of radiotherapy, hyperfractionated-accelerated schedules have been used with promising complete pathologic response rates, which might improve prognosis. Recently, studies applying high radiotherapy doses in the neoadjuvant setting demonstrated the safety of resection after radiotherapy, with high nodal clearance rates and encouraging long-term survival results. In conclusion, neoadjuvant treatment of locally advanced NSCLC is one of the most challenging issues in the treatment of this disease, but it can be offered to appropriately selected patients, and should be done by a multidisciplinary team. Individual risk profiles, definite role of radiotherapy with optimal timing, and dose need to be clarified by carefully designed clinical trials.
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Affiliation(s)
- Deniz Yalman
- Department of Radiation Oncology, Ege University Faculty of Medicine, İzmir, Turkey
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18
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Zhang W, Jiang W, Luan L, Wang L, Zheng X, Wang G. Prophylactic cranial irradiation for patients with small-cell lung cancer: a systematic review of the literature with meta-analysis. BMC Cancer 2014; 14:793. [PMID: 25361811 PMCID: PMC4232715 DOI: 10.1186/1471-2407-14-793] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 10/17/2014] [Indexed: 12/14/2022] Open
Abstract
Background Small cell lung cancer (SCLC) accounts for about 13% of all lung cancer cases. Small cell lung cancer (SCLC) accounts for about 13% of all lung cancer cases. The purpose of the present article is to assess the role of prophylactic cranial irradiation (PCI) in small cell lung cancer (SCLC) by performing a systematic review of the randomized trials published in the literature. Methods Randomized controlled trials were identified that compared brain metastases incidence and overall survival between PCI and No PCI in patients with SCLC. Search strategies were limited to the English language and to articles published since 1997, and included: databases searched from 1997 to March 2013 –CINAHL, Embase, Medline, Web of Science, and CENTRAL. Methodological quality was assessed with the Jadad scale. The main end points were brain metastasis and survival. Results The review identified 5 trials, although few were of high quality. Two trials reported the one-year incidence of brain metastasis. PCI reduced the incidence of brain metastasis in one year, with a pooled relative risk of 0.45 (95% CI, 0.35 to 0.58; P < 0.00001). Four trials described the one year survival rate. The combined result revealed a significant (P = 0.01) survival benefit in the group assigned to PCI as compared with the control group, with a pooled relative risk of 0.87 (95% CI, 0.79 to 0.97). Three trials reported the three-year survival rate. The combined result revealed a great significant (P < 0.00001) survival benefit in the PCI group as compared with the No PCI group, with a pooled relative risk of 0.87 (95% CI, 0.83 to 0.91). the Five-year survival rate was compared in four trials Compared with the No PCI group, the PCI group had a significant (P < 0.00001) survival benefit with a pooled relative risk of 0.92 (95% CI, 0.88 to 0.95). Conclusions The present systematic review indicates that PCI decreases brain metastases incidence and that PCI improves survival in SCLC patients. Prophylactic cranial irradiation should be part of standard care for all patients with small-cell lung cancer who have a response to initial chemotherapy, and it should be part of the standard treatment in future studies involving these patients. Electronic supplementary material The online version of this article (doi:10.1186/1471-2407-14-793) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | | | | | - Gongchao Wang
- School of Nursing, Shandong University, Jinan 250012, China.
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Chamberlain MC. Anticancer therapies and CNS relapse: overcoming blood–brain and blood–cerebrospinal fluid barrier impermeability. Expert Rev Neurother 2014; 10:547-61. [DOI: 10.1586/ern.10.14] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tang YT, Jiang F, Guo L, Si MY, Jiao XY. Expression and significance of vascular endothelial growth factor A and C in leukemia central nervous system metastasis. Leuk Res 2013; 37:359-66. [PMID: 23137522 DOI: 10.1016/j.leukres.2012.10.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 10/03/2012] [Accepted: 10/12/2012] [Indexed: 02/05/2023]
Abstract
Metastasis to the central nervous system (CNS) is an obstacle for leukemia treatment, the mechanisms of which remain to be elucidated. VEGF-A and VEGF-C are suspected to participate in this process. Paired of cerebrospinal fluid (CSF) and serum samples were collected from leukemia and control cases. Levels of VEGF-A and VEGF-C in both CSF (VEGF-ACSF, VEGF-CCSF) and serum (VEGF-ASerum, VEGF-CSerum) were detected by ELISA. Our data show that higher levels of VEGF-ACSF are closely related to CNS leukemia (CNSL), and VEGF-ACSF may be a better predictor than the other risk factors elucidating the pathogenesis and development of CNSL.
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Affiliation(s)
- Yue-Ting Tang
- Department of Hematology Laboratory, First Affiliated Hospital of Shantou University Medical College, Guangdong, China
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Wan JF, Zhang SJ, Wang L, Zhao KL. Implications for preserving neural stem cells in whole brain radiotherapy and prophylactic cranial irradiation: a review of 2270 metastases in 488 patients. JOURNAL OF RADIATION RESEARCH 2013; 54:285-291. [PMID: 23022606 PMCID: PMC3589923 DOI: 10.1093/jrr/rrs085] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 08/24/2012] [Accepted: 08/24/2012] [Indexed: 06/01/2023]
Abstract
This study delineated the incidence of metastatic involvement of neural stem cell (NSC) regions and further aimed to explore the feasibility of selectively sparing the NSC compartments during whole brain radiotherapy (WBRT) and prophylactic cranial irradiation (PCI). A total of 2270 intracranial metastases in 488 patients were identified. Lesions were classified according to locations, including lesions in the NSC compartments (subventricular zone, SVZ, or hippocampus) and those in the rest of the brain/brainstem. The incidence of involvement of NSC regions was compared between oligometastatic patients (those with 1-4 lesions) and non-oligometastatic patients (those with 5 or more lesions) using a chi-square test. The volume of the NSC regions accounted for 2.23% of the whole brain, and the overall rate of metastatic lesions in NSC regions was 1.1% in 2270 metastases (25/2270), and 4.7% in 488 patients (23/488). Of the NSC region metastases, 7 (0.3%) involved the hippocampus and 18 (0.8%) occurred in the SVZ. Among the 7 hippocampal metastases identified in this study, 1/7 (14.3%) were found in oligometastatic patients, while 6/7 (85.7%) metastases were in non-oligometastatic patients. For metastases in the SVZ, all lesions occurred in non-oligometastatic patients with none in oligometastatic patients. Metastatic involvement of the NSC compartments was significantly lower in oligometastatic patients (0.15%, 1/670) than in non-oligometastatic patients (1.5%, 24/1600) (P < 0.001). Our retrospective review of 2270 metastases in 488 patients is that the volume of the compartments of NSC regions was 2.23% relative to the whole brain, but the incidence of involvement of the NSC compartments was 1.1%, and the vast majority of NSC lesions were found in non-oligometastatic patients. We believe our data supports selective reduction of doses for these aforementioned structures, when treating oligometastatic patients with WBRT and locally advanced-stage small-cell lung cancer patients with PCI.
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Affiliation(s)
- Jue-Feng Wan
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Sheng-Jian Zhang
- Department of Radiology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Lu Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Kuai-Le Zhao
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
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Cavallaro S. CXCR4/CXCL12 in non-small-cell lung cancer metastasis to the brain. Int J Mol Sci 2013; 14:1713-27. [PMID: 23322021 PMCID: PMC3565343 DOI: 10.3390/ijms14011713] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 01/04/2013] [Accepted: 01/07/2013] [Indexed: 01/02/2023] Open
Abstract
Lung cancer represents the leading cause of cancer-related mortality throughout the world. Patients die of local progression, disseminated disease, or both. At least one third of the people with lung cancer develop brain metastases at some point during their disease, even often before the diagnosis of lung cancer is made. The high rate of brain metastasis makes lung cancer the most common type of tumor to spread to the brain. It is critical to understand the biologic basis of brain metastases to develop novel diagnostic and therapeutic approaches. This review will focus on the emerging data supporting the involvement of the chemokine CXCL12 and its receptor CXCR4 in the brain metastatic evolution of non-small-cell lung cancer (NSCLC) and the pharmacological tools that may be used to interfere with this signaling axis.
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Affiliation(s)
- Sebastiano Cavallaro
- Functional Genomics Center, Institute of Neurological Sciences, Italian National Research Council, Via Paolo Gaifami, 18, Catania 95125, Italy.
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Langley RE, Stephens RJ, Nankivell M, Pugh C, Moore B, Navani N, Wilson P, Faivre-Finn C, Barton R, Parmar MKB, Mulvenna PM. Interim data from the Medical Research Council QUARTZ Trial: does whole brain radiotherapy affect the survival and quality of life of patients with brain metastases from non-small cell lung cancer? Clin Oncol (R Coll Radiol) 2012; 25:e23-30. [PMID: 23211715 DOI: 10.1016/j.clon.2012.11.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Revised: 10/01/2012] [Accepted: 10/02/2012] [Indexed: 10/27/2022]
Abstract
AIMS Over 30% of patients with non-small cell lung cancer (NSCLC) develop brain metastases. If inoperable, optimal supportive care (OSC), including steroids, and whole brain radiotherapy (WBRT) are generally considered to be standard care, although there is no randomised evidence demonstrating that the addition of WBRT to OSC improves survival or quality of life. MATERIALS AND METHODS QUARTZ is a randomised, non-inferiority, phase III trial comparing OSC + WBRT versus OSC in patients with inoperable brain metastases from NSCLC. The primary outcome measure is quality-adjusted life years (QALYs). QUARTZ was threatened with both loss of funding and early closure due to poor accrual. A lack of preliminary randomised data supporting the trial's hypotheses was thought to underlie the poor accrual, so, with no knowledge of the data, the independent trial steering committee agreed to the unusual step of releasing interim data. RESULTS Between March 2007 and April 2010, 151 (of the planned 534) patients were randomised (75 OSC + WBRT, 76 OSC). Participants' baseline demographics included median age 67 years (interquartile range 62-73), 60% male, 50% with a Karnofsky performance status <70; steroid usage was similar in the two groups; 64/75 (85%) received WBRT (20 Gy in five fractions). Median survival was: OSC + WBRT 49 days (95% confidence interval 39-61), OSC 51 days (95% confidence interval 27-57) - hazard ratio 1.11 (95% confidence interval 0.80-1.53) in favour of WBRT. Quality of life assessed using EQ-5D showed no evidence of a difference. The estimated mean QALYs was: OSC + WBRT 31 days and OSC 30 days, difference -1 day (95% confidence interval -12.0 to +13.2 days). CONCLUSION These interim data indicate no early evidence of detriment to quality of life, overall survival or QALYs for patients allocated to OSC alone. They provide key information for discussing the trial with patients and strengthen the argument for continuing QUARTZ to definitively answer this important clinical question.
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Abstract
Among all nonmetastatic non-small-cell lung cancer (NSCLC) patients, the best survival rates are observed in patients who undergo surgery. Nevertheless, 5-year survival rates vary between 20% and 60% depending on the stage of the disease. Several combined modality treatments have been investigated to improve outcome in localized NSCLC. These include local treatment, systemic before local treatment, concomitant systemic and local treatments, and systemic after local treatment. Preoperative irradiation was shown to be of no benefit on local recurrence rates or overall survival. Even doses of radiation >/=40 grays (Gy) were associated with lower survival rates. Postoperative irradiation did not influence survival in stage III disease and seemed to be deleterious in stages I and II disease. Modern radiotherapy techniques might be of interest in this setting but have been insufficiently tested. The early phase III studies of preoperative chemotherapy versus primary surgery in stage III NSCLC showed a tremendous difference in favor of chemotherapy. A larger study did not confirm these results but suggested that preoperative chemotherapy might have a greater effect in stages I and II of the disease. In locally advanced disease, chemotherapy followed by radiotherapy was shown to increase survival when compared with radiotherapy alone. Studies comparing concurrent chemoradiation with radiotherapy only were in favor of the concomitant schedule, which improved local control. Promising results have been reported with chemoradiation followed by surgery in stage IIIa and even stage IIIb disease. Randomized studies of postoperative chemotherapy demonstrated a 5% improvement in 5-year survival over adjuvant-free treatment. Postoperative chemoradiation showed no advantage over postoperative radiotherapy. Several trials that are ongoing or whose accrual was recently completed should further define the role of perioperative chemotherapy in resectable NSCLC and of trimodality treatments in advanced disease. Targeted agents are being developed in the postoperative setting. New schedules of chemoradiation with higher therapeutic indexes are also being investigated in nonresectable stage III NSCLC.
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Affiliation(s)
- Virginie Westeel
- Chest Disease Department, Jean Minjoz University Hospital, Besançon Cedex, France.
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Ding X, Dai H, Hui Z, Ji W, Liang J, Lv J, Zhou Z, Yin W, He J, Wang L. Risk factors of brain metastases in completely resected pathological stage IIIA-N2 non-small cell lung cancer. Radiat Oncol 2012; 7:119. [PMID: 22846375 PMCID: PMC3430600 DOI: 10.1186/1748-717x-7-119] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 07/14/2012] [Indexed: 12/04/2022] Open
Abstract
Background Brain metastases (BM) is one of the most common failures of locally advanced non-small cell lung cancer (LA-NSCLC) after combined-modality therapy. The outcome of trials on prophylactic cranial irradiation (PCI) has prompted us to identify the highest-risk subset most likely to benefit from PCI. Focusing on patients with completely resected pathological stage IIIA-N2 (pIIIA-N2) NSCLC, we aimed to assess risk factors of BM and to define the highest-risk subset. Methods Between 2003 and 2005, the records of 217 consecutive patients with pIIIA-N2 NSCLC in our institution were reviewed. The cumulative incidence of BM was estimated using the Kaplan–Meier method, and differences between the groups were analyzed using log-rank test. Multivariate Cox regression analysis was applied to assess risk factors of BM. Results Fifty-three (24.4 %) patients developed BM at some point during their clinical course. On multivariate analysis, non-squamous cell cancer (relative risk [RR]: 4.13, 95 % CI: 1.86–9.19; P = 0.001) and the ratio of metastatic to examined nodes or lymph node ratio (LNR) ≥ 30 % (RR: 3.33, 95 % CI: 1.79–6.18; P = 0.000) were found to be associated with an increased risk of BM. In patients with non-squamous cell cancer and LNR ≥ 30 %, the 5-year actuarial risk of BM was 57.3 %. Conclusions In NSCLC, patients with completely resected pIIIA-N2 non-squamous cell cancer and LNR ≥ 30 % are at the highest risk for BM, and are most likely to benefit from PCI. Further studies are warranted to investigate the effect of PCI on this subset of patients.
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Affiliation(s)
- Xiao Ding
- Department of Radiation Oncology, Cancer Hospital & Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Chao yang District, Beijing, China
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Abstract
Over 150,000 cancer patients will be diagnosed with brain metastases this year alone. Survival for those diagnosed with brain metastases remains poor despite multimodality management with surgery, chemotherapy, and radiation. Preventative strategies to mitigate brain metastases have met with mixed results. In leukemia and small cell lung cancer there are defined roles for preventative radiation to be delivered, which can result in improved local control and survival. There is a less defined role for preventative radiation in locally advanced non-small cell lung cancer and budding interest for radiation prevention in breast cancer. The potential impact preventative cranial irradiation may have on neurocognitive function and quality of life needs to be considered prior to its administration.
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Kyritsis AP, Markoula S, Levin VA. A systematic approach to the management of patients with brain metastases of known or unknown primary site. Cancer Chemother Pharmacol 2011; 69:1-13. [DOI: 10.1007/s00280-011-1775-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 10/20/2011] [Indexed: 12/13/2022]
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Ahluwalia MS, Wallace PK, Peereboom DM. Flow cytometry as a diagnostic tool in lymphomatous or leukemic meningitis. Cancer 2011; 118:1747-53. [DOI: 10.1002/cncr.26335] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 05/19/2011] [Accepted: 05/19/2011] [Indexed: 11/08/2022]
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Dimitropoulos C, Hillas G, Nikolakopoulou S, Kostara I, Sagris K, Vlastos F, Alchanatis M. Prophylactic cranial irradiation in non-small cell lung cancer patients: who might be the candidates? Cancer Manag Res 2011; 3:287-94. [PMID: 21931502 PMCID: PMC3173018 DOI: 10.2147/cmr.s22717] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objectives Brain metastases (BMs) often advance the course of non-small cell lung cancer (NSCLC). We performed an observational study in order to investigate the possible correlation of selected clinical and epidemiological factors with BM appearance in patients suffering from different histological subtypes of NSCLC stage I–IV. Methods The study included 161 consecutive patients with NSCLC. Analyzed data included patient- and tumor-related characteristics. Results Thirty-nine patients (24.2%) presented BMs within 12 (0–36) weeks of diagnosis. BMs decreased the mean overall survival significantly (15.6 versus 50.7 weeks, P < 0.001), with hazard ratio (95% confidence interval) 3.60 (2.42–5.35). The age of the patients with BM was significantly lower than that of the patients without BM (60.8 ± 8.9 versus 66.5 ± 8.5, P < 0.001). Patients with BM had significantly higher pack-years consumption (75.9 ± 23.9 versus 58.9 ± 31.9, P = 0.003) and larger tumor size compared with patients without BM (size in mm: 55.1 ± 20.1 versus 45.9 ± 19.3, P = 0.012). The presence of BM was also correlated with the absence of lung (P < 0.001), bone (P = 0.005), and adrenal (P = 0.046) metastases. Conclusion Younger NSCLC patients with high tobacco consumption, large tumor size, and absence of metastases in other organs (lung, bones, adrenal metastases) are at high risk of BM appearance during the course of NSCLC and are candidates for prophylactic cranial irradiation early in the course of the disease.
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Affiliation(s)
- Charalampos Dimitropoulos
- 9th Respiratory Medicine Department, University of Athens Medical School, "Sotiria" Chest Diseases Hospital, Athens, Greece
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Besse B, Massard C, Haddad V, Andre F, Dunant A, Pirker R, Olaussen K, Brambilla E, Fouret P, Soria J. ERCC1 influence on the incidence of brain metastases in patients with non-squamous NSCLC treated with adjuvant cisplatin-based chemotherapy. Ann Oncol 2011; 22:575-581. [DOI: 10.1093/annonc/mdq407] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Hubbs JL, Boyd JA, Hollis D, Chino JP, Saynak M, Kelsey CR. Factors associated with the development of brain metastases: analysis of 975 patients with early stage nonsmall cell lung cancer. Cancer 2010; 116:5038-46. [PMID: 20629035 DOI: 10.1002/cncr.25254] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The risk of developing brain metastases after definitive treatment of locally advanced nonsmall cell lung cancer (NSCLC) is approximately 30%-50%. The risk for patients with early stage disease is less defined. The authors sought to investigate this further and to study potential risk factors. METHODS The records of all patients who underwent surgery for T1-T2 N0-N1 NSCLC at Duke University between the years 1995 and 2005 were reviewed. The cumulative incidence of brain metastases and distant metastases was estimated by using the Kaplan-Meier method. A multivariate analysis assessed factors associated with the development of brain metastases. RESULTS Of 975 consecutive patients, 85% were stage I, and 15% were stage II. Adjuvant chemotherapy was given to 7%. The 5-year actuarial risk of developing brain metastases and distant metastases was 10%(95% confidence interval [CI], 8-13) and 34%(95% CI, 30-39), respectively. Of patients developing brain metastases, the brain was the sole site of failure in 43%. On multivariate analysis, younger age (hazard ratio [HR], 1.03 per year), larger tumor size (HR, 1.26 per cm), lymphovascular space invasion (HR, 1.87), and hilar lymph node involvement (HR, 1.18) were associated with an increased risk of developing brain metastases. CONCLUSIONS In this large series of patients treated surgically for early stage NSCLC, the 5-year actuarial risk of developing brain metastases was 10%. A better understanding of predictive factors and biological susceptibility is needed to identify the subset of patients with early stage NSCLC who are at particularly high risk.
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Affiliation(s)
- Jessica L Hubbs
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina, USA
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Sun A, Bae K, Gore EM, Movsas B, Wong SJ, Meyers CA, Bonner JA, Schild SE, Gaspar LE, Bogart JA, Werner-Wasik M, Choy H. Phase III trial of prophylactic cranial irradiation compared with observation in patients with locally advanced non-small-cell lung cancer: neurocognitive and quality-of-life analysis. J Clin Oncol 2010; 29:279-86. [PMID: 21135267 DOI: 10.1200/jco.2010.29.6053] [Citation(s) in RCA: 265] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There are scant data regarding the effects of prophylactic cranial irradiation (PCI) on neurocognitive function (NCF) and quality of life (QOL). Radiation Therapy Oncology Group trial 0214 showed no overall survival (OS) benefit for PCI in stage III non-small-cell lung cancer (NSCLC) at 1 year. However, there was a significant decrease in brain metastases (BM). This analysis focuses on the impact of PCI on NCF and QOL. PATIENTS AND METHODS Patients with stage III NSCLC who completed definitive therapy without progression were randomly assigned to PCI or observation. NCF was assessed with Mini-Mental Status Examination (MMSE), Activities of Daily Living Scale (ADLS), and Hopkins Verbal Learning Test (HVLT). QOL was assessed with the European Organisation for Research and Treatment of Cancer (EORTC) core tool (QOL Questionnaire-QLQC30) and brain module (QLQBN20). RESULTS There were no statistically significant differences at 1 year between the two arms in any component of the EORTC-QLQC30 or QLQBN20 (P > .05), although a trend for greater decline in patient-reported cognitive functioning with PCI was noted. There were no significant differences in MMSE (P = .60) or ADLS (P = .88). However, for HVLT, there was greater decline in immediate recall (P = .03) and delayed recall (P = .008) in the PCI arm at 1 year. CONCLUSION PCI in stage III NSCLC significantly decreases the risk of BM without improving 1-year OS. There were no significant differences in global cognitive function (MMSE) or QOL after PCI, but there was a significant decline in memory (HVLT) at 1 year. This study provides prospective data regarding the relative risks and benefits of PCI in this setting and the need to use sensitive cognitive assessments.
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Affiliation(s)
- Alexander Sun
- Princess Margaret Hospital-University Health Network, University of Toronto, 610 University Ave, Toronto, Ontario, Canada, M5G 2M9.
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Gore EM, Bae K, Wong SJ, Sun A, Bonner JA, Schild SE, Gaspar LE, Bogart JA, Werner-Wasik M, Choy H. Phase III comparison of prophylactic cranial irradiation versus observation in patients with locally advanced non-small-cell lung cancer: primary analysis of radiation therapy oncology group study RTOG 0214. J Clin Oncol 2010; 29:272-8. [PMID: 21135270 DOI: 10.1200/jco.2010.29.1609] [Citation(s) in RCA: 201] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE This study was conducted to determine if prophylactic cranial irradiation (PCI) improves survival in locally advanced non-small-cell lung cancer (LA-NSCLC). PATIENTS AND METHODS Patients with stage III NSCLC without disease progression after treatment with surgery and/or radiation therapy (RT) with or without chemotherapy were eligible. Participants were stratified by stage (IIIA v IIIB), histology (nonsquamous v squamous), and therapy (surgery v none) and were randomly assigned to PCI or observation. PCI was delivered to 30 Gy in 15 fractions. The primary end point of the study was overall survival (OS). Secondary end points were disease-free survival (DFS), neurocognitive function (NCF), and quality of life. Kaplan-Meier and log-rank analyses were used for OS and DFS. The incidence of brain metastasis (BM) was evaluated with the logistic regression model. RESULTS Overall, 356 patients were accrued of the targeted 1,058. The study was closed early because of slow accrual; 340 of the 356 patients were eligible. The 1-year OS (P = .86; 75.6% v 76.9% for PCI v observation) and 1-year DFS (P = .11; 56.4% v 51.2% for PCI v observation) were not significantly different. The hazard ratio for observation versus PCI was 1.03 (95% CI, 0.77 to 1.36). The 1-year rates of BM were significantly different (P = .004; 7.7% v 18.0% for PCI v observation). Patients in the observation arm were 2.52 times more likely to develop BM than those in the PCI arm (unadjusted odds ratio, 2.52; 95% CI, 1.32 to 4.80). CONCLUSION In patients with stage III disease without progression of disease after therapy, PCI decreased the rate of BM but did not improve OS or DFS.
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Affiliation(s)
- Elizabeth M Gore
- Department of Radiation Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53213, USA.
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Recurrent brain metastases from lung cancer: the impact of reoperation. Acta Neurochir (Wien) 2010; 152:1887-92. [PMID: 20617447 DOI: 10.1007/s00701-010-0721-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Accepted: 06/14/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The best treatment for solitary brain metastases from lung cancer is surgical resection followed by adjuvant treatment. However, about 50% of these patients develop recurrent brain metastases. There is no established treatment standard for this patient group. We therefore analyzed the survival, neurological function, and overall performance status of patients with recurrent solitary brain metastases from lung cancer after second microsurgical resection. MATERIALS AND METHODS Treatment outcome was analyzed in 25 patients (19 men, 6 women) with a mean age of 55.8 years (range, 38-78 years) who received a resection of recurrent solitary brain metastases. Eighty-four percent of all patients had non-small-cell lung cancer and 16% small cell lung cancer (SCLC). Eighty percent of the lesions were located supratentorially, 20% infratentorially. RESULTS The median overall survival after initial diagnosis was 26.9 months, 13.6 months after the first and 8.3 months after the second brain surgery, respectively. The median Karnofsky index improved significantly from 80 to 100 after the second brain surgery; 66.6% of all patients presenting with neurological impairment improved, and 50% regained normal function. No surgery-related morbidity or mortality was noted. Multivariate analysis indicated that the interval until first brain metastasis and between first and recurrent metastases was significantly predictive of survival. CONCLUSIONS The majority of patients in our study group showed significant functional benefit from surgical resection of recurrent brain metastases. This contributes to a better quality of life in this patient group showing a short overall survival time.
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Mulvenna PM. The management of brain metastases in patients with non-small cell lung cancer-is it time to go back to the drawing board? Clin Oncol (R Coll Radiol) 2010; 22:365-73. [PMID: 20395118 DOI: 10.1016/j.clon.2010.03.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 03/02/2010] [Accepted: 03/18/2010] [Indexed: 10/19/2022]
Abstract
Unless confirmation of a solitary brain metastasis is made in the context of absent extracranial disease and good performance status, patients with metastatic brain disease from non-small cell lung cancer fare badly. There are no level I recommendations for the management of those with multiple brain metastases. The role of whole brain radiotherapy is not certain in those of poorer performance status. This overview assesses what we know and what we are uncertain of in the context of a changing paradigm for some subsets of patients who may obtain superior palliation with treatments targeted at the histological or molecular level. Once the standard treatment is established (steroids plus or minus whole brain radiotherapy), those who are of better performance status may be considered for comparison of this standard with or without systemic management.
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Affiliation(s)
- P M Mulvenna
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK.
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Soffietti R, Akerley W, Jensen RL, Bischoff J, Regierer AC. The role of intra-cerebrospinal fluid treatment and prophylaxis in patients with solid tumors. Semin Oncol 2009; 36:S55-68. [PMID: 19660684 DOI: 10.1053/j.seminoncol.2009.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Metastasis to the central nervous system (CNS), including neoplastic meningitis (NM), is a devastating complication of systemic cancer. With the improved survival of cancer patients, the incidence of CNS metastasis is rising, especially among those with breast or lung carcinoma. New therapies that effectively treat these primary tumors outside of the CNS have underscored the significance of CNS metastases; they have become a significant clinical issue and a therapeutic challenge. This review discusses clinical situations in which treatment or chemoprophylaxis of CNS metastases and NM from breast or lung cancer may play an important role. Potential clinical trials to assess these assumptions also will be proposed.
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Affiliation(s)
- Riccardo Soffietti
- Department of Neuroscience, University and San Giovanni Battista Hospital, Torino, Italy.
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Risk factors for brain metastases after definitive chemoradiation for locally advanced non-small cell lung cancer. VOJNOSANIT PREGL 2009; 66:876-80. [DOI: 10.2298/vsp0911876p] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background/Aim. As therapy for locally advanced nonsmall cell lung carcinoma (NSCLC) improves, brain metastases (BM) still remain a great problem. The aim of the study was to analyze risk factors for BM in patients with locally advanced NSCLC after chemoradiation therapy. Methods. Records for 150 patients with non-resectable stage IIIA/IIIB NSCLC treated with combined chemoradiation therapy were analyzed. All of them had negative brain metastases imaging result before the treatment. Incidence of BM was examined in relation to age, sex, histological type, stage, performance status scale of wellbeing of cancer patients, weight loss, chemotherapy regimen and chemotherapy timing. Results. One- and 2-year incidence rates of BM were 19 and 31%, respectively. Among pretreatment parameters, stage IIIB was associated with a higher risk of BM (p < 0.004) vs stage IIIA. Histologically, the patients with nonsquamous tumors had an exceptionally high 2-year BM risk rate of 32% (p < 0.02). Examining treatment-related parameters, 1-year and 2-year actuarial risk of BM were 27 and 39%, respectively, in the patients receiving chemotherapy before radiotherapy and 15 and 20%, respectively, when radiotherapy was not delayed (p < 0.03). On multivariate analysis, timing of chemotherapy (p < 0.05) and stage IIIA vs IIIB (p < 0.01) remained statistically significant. Conclusion. Patients with IIIB stage, nonsquamous NSCLC, particularly those receiving sequential chemotherapy, had significantly high BM rates.
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Yavuz AA, Topkan E, Onal C, Yavuz MN. Prophylactic cranial irradiation in locally advanced non-small cell lung cancer: outcome of recursive partitioning analysis group 1 patients. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2008; 27:80. [PMID: 19055787 PMCID: PMC2612647 DOI: 10.1186/1756-9966-27-80] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Accepted: 12/04/2008] [Indexed: 12/20/2022]
Abstract
BACKGROUND Prophylactic cranial irradiation (PCI) has been demonstrated to reduce or delay the incidence of brain metastases (BM) in locally advanced non-small cell lung carcinoma (LA-NSCLC) patients with various prognostic groups. With this current cohort we planned to evaluate the potential usefulness of prophylactic cranial irradiation (PCI) specifically in recursive partitioning analysis (RPA) Group 1, which is the most favorable group of LA-NSCLC patients. METHODS Between March 2007 and February 2008, 62 patients in RPA group 1 were treated with sequential chemoradiotherapy and PCI for stage IIIB NSCLC. The induction chemotherapy consisted of 3 courses of cisplatin (80 mg/m2) and docetaxel (80 mg/m2); each course was given every 21 days. Thoracic radiotherapy (TRT) was given at a dose of 60 Gy using 3-D conformal planning. All patients received a total dose of 30 Gy PCI (2 Gy/fr, 5 days a week), beginning on the first day of the TRT. Then, all patients received 3 further courses of the same chemotherapy protocol. RESULTS Six (9.7%) patients developed brain metastases during their clinical course. Only one (2%) patient developed brain metastasis as the site of first treatment failure. Median brain metastasis-free survival, overall survival, and progression free survival were 16.6, 16.7, and 13.0 months, respectively. By univariate analysis, rates of BM were significantly higher in patients younger than 60 years of age (p = 0.03). Multivariate analysis showed no significant difference in BM-free survival according to gender, age, histology, and initial T- and N-stage. CONCLUSION The current finding of almost equal bone metastasis free survival and overall survival in patients with LA-NSCLC in RPA group 1 suggests a longer survival for patients who receive PCI, and thereby have a reduced risk of BM.
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Affiliation(s)
- Ali Aydin Yavuz
- Department of Radiation Oncology, Baskent University Medical Faculty, Adana Medical and Research Center, Kisla Saglik Yerleskesi, Adana, Turkey.
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Saad AG, Yeap BY, Thunnissen FBJM, Pinkus GS, Pinkus JL, Loda M, Sugarbaker DJ, Johnson BE, Chirieac LR. Immunohistochemical markers associated with brain metastases in patients with nonsmall cell lung carcinoma. Cancer 2008; 113:2129-38. [PMID: 18720359 DOI: 10.1002/cncr.23826] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND To the authors' knowledge, there are no reliable markers able to identify patients with nonsmall cell lung cancer (NSCLC) that will develop metastases to the brain. The authors investigated associations between immunohistochemical markers and the development of brain metastases in patients with NSCLC. METHODS This was a hospital-based, case-control study of patients who were newly diagnosed with NSCLC between 1989 and 2003, developed brain metastases, and had pathology material available from both the primary NSCLC and the brain metastases. These patients were compared with a control group of patients who had NSCLC and no evidence of brain metastases. NSCLC was examined for expression levels of Ki-67, caspase-3, vascular endothelial growth factor A (VEGF-A), VEGF-C, E-cadherin, and epidermal growth factor receptor (EGFR) in 54 surgical pathology specimens using immunohistochemistry, and associations were evaluated between those markers and the development of brain metastases. RESULTS Brain metastases developed after a median of 12.5 months (range, 1.7-89.4 months) after the diagnosis of NSCLC. A significantly increased risk of developing brain metastases was associated with patients with NSCLC who had primary tumors with high Ki-67 levels (adjusted odds ratio [OR] of 12.2; 95% confidence interval [95% CI], 2.4-70.4 [P < .001]), low caspase-3 expression (adjusted OR of 43; 95% CI, 5.3 to >100 [P < .001]), high VEGF-C expression (adjusted OR of 14.6; 95% CI, 2.0 to >100 [P < .001]), and low E-cadherin (adjusted OR of 3.6; 95% CI, 0.9-16.4 [P = .05]). No significant risk was associated with VEGF-A or EGFR expression. High Ki-67 expression also was associated with a shorter overall survival (P = .04). CONCLUSIONS The results of the current study indicated that patients with NSCLC who had high Ki-67 expression, low caspase-3 expression, high VEGF-C expression, and low E-cadherin expression in their tumors may benefit from close surveillance because they may have an increased risk of developing brain metastases.
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Affiliation(s)
- Ali G Saad
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA
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Pöttgen C, Eberhardt W, Grannass A, Korfee S, Stüben G, Teschler H, Stamatis G, Wagner H, Passlick B, Petersen V, Budach V, Wilhelm H, Wanke I, Hirche H, Wilke HJ, Stuschke M. Prophylactic cranial irradiation in operable stage IIIA non small-cell lung cancer treated with neoadjuvant chemoradiotherapy: results from a German multicenter randomized trial. J Clin Oncol 2007; 25:4987-92. [PMID: 17971598 DOI: 10.1200/jco.2007.12.5468] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To investigate the role of prophylactic cranial irradiation (PCI) within a trimodality protocol (chemotherapy, chemoradiotherapy, surgery) for patients with operable stage IIIA non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS After mediastinoscopic staging, patients with operable stage IIIA NSCLC were enrolled to a German multicenter trial and randomly assigned to receive either primary resection followed by adjuvant thoracic radiation therapy (50 to 60 Gy; arm A) or preoperative chemotherapy (cisplatin/etoposide [PE]; three cycles) followed by concurrent chemoradiotherapy (PE plus 45 Gy; 1.5 Gy twice per day) and definitive surgery (arm B), respectively. Patients in arm B were scheduled to receive PCI (30 Gy; 2 Gy daily fractions). RESULTS One hundred twelve patients were randomly assigned between November 1994 and July 2001. One hundred six patients were eligible (arm A: 51, arm B: 55), 90 males and 16 females, 50 with squamous cell, 16 with large cell, five with adenosquamous, and 35 with adenocarcenoma (median age, 57 years; range, 37 to 71 years). Forty-three patients received PCI as scheduled in arm B. Eleven long-term survivors (arm A: four; arm B: seven) underwent a comprehensive neuropsychological examination. PCI significantly reduced the probability of brain metastases as first site of failure (7.8% at 5 years v 34.7%; P = .02), the overall brain relapse rate was reduced comparably (9.1% at 5 years v 27.2%; P = .04). A slightly reduced neurocognitive performance in comparison with the age-matched normal population was found for patients in both treatment groups. No significant difference between patients who were treated with or without PCI could be noted. CONCLUSION PCI is effective in preventing brain metastases following this aggressive trimodality approach. Neurocognitive late effects are not significantly different between patients treated with or without PCI.
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Affiliation(s)
- Christoph Pöttgen
- Department of Radiotherapy, Institute for Biomathematics and Statistics, University of Duisburg-Essen, Essen, Germany.
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M18-04: Treatment and prevention of CNS metastases in NSCLC. J Thorac Oncol 2007. [DOI: 10.1097/01.jto.0000282983.03866.9d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chen AM, Jahan TM, Jablons DM, Garcia J, Larson DA. Risk of cerebral metastases and neurological death after pathological complete response to neoadjuvant therapy for locally advanced nonsmall-cell lung cancer: clinical implications for the subsequent management of the brain. Cancer 2007; 109:1668-75. [PMID: 17342770 DOI: 10.1002/cncr.22565] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The incidence and pattern of brain metastases was analyzed among patients who achieved a pathological complete response (pCR) after neoadjuvant chemotherapy or chemoradiotherapy for locally advanced nonsmall-cell lung cancer (NSCLC). METHODS Between 1990 and 2004, 211 patients were treated with neoadjuvant therapy before surgical resection for stage III NSCLC. The clinical course of 51 patients who demonstrated a pCR were reviewed. The neoadjuvant regimen consisted of either chemotherapy (29 patients) or chemoradiotherapy (22 patients). Histology was 45% adenocarcinoma, 41% squamous cell, and 14% large cell carcinoma. No patient received prophylactic cranial irradiation (PCI). RESULTS Overall survival at 1, 3, and 5 years was 82%, 63%, and 42%, respectively. The most common site of initial recurrence was the brain. Twenty-two (43%) patients developed brain metastasis as the site of first failure, which represented 71% of all isolated recurrences. Ultimately, 28 (55%) patients developed brain metastases at some point during their clinical course. The 5-year estimates of brain metastasis-free survival for patients with squamous and nonsquamous cancers were 57% and 34%, respectively (P = .02). Median survival from the time of brain metastasis was 10 and 5 months for those with isolated and nonisolated recurrences, respectively. CONCLUSION Patients with a pCR after multimodality therapy for locally advanced NSCLC are at excessively high risk for the subsequent development of brain metastases. Implications for management strategies including PCI and stereotactic radiosurgery (SRS) are discussed.
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Affiliation(s)
- Allen M Chen
- Department of Radiation Oncology, University of California, San Francisco (UCSF), School of Medicine, San Francisco, California, USA.
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Mazeron R, Le Péchoux C, Bruna A, Amarouch A, Bretel JJ, Ferreira I. Irradiation prophylactique cérébrale dans les cancers bronchopulmonaires non à petites cellules. Cancer Radiother 2007; 11:84-91. [PMID: 17005429 DOI: 10.1016/j.canrad.2006.07.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Accepted: 07/20/2006] [Indexed: 11/18/2022]
Abstract
Prophylactic cranial irradiation (PCI) has become part of the standard treatment in patients with small cell lung cancer (SCLC) in complete remission. Not only does it decrease the risk of brain recurrence by almost 50%, it has a significant positive effect on survival (5.4 percent increase at 3 years). As the prognosis of patients with locally advanced non-small cell lung cancer (NSCLC) has improved with combined modality treatment, brain metastases have also become an important cause of failure (10 to 30%, approaching 50% in certain studies as in SCLC). Survival after treatment of brain metastases is poor and impact on quality of life of patients is important. As in SCLC, 4 randomised evaluating PCI in NSCLC have been carried out in the seventies and early eighties. If 3 out of 4 trials have shown a significant decrease of brain metastases, none of them demonstrated any impact on survival. Thus PCI cannot be recommended as standard treatment in NSCLC, however new trials would be needed.
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Affiliation(s)
- R Mazeron
- Département de radiothérapie, institut Gustave-Roussy, 39, rue Camille-Desmoulins, 94800 Villejuif, France
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Stinchcombe TE, Fried D, Morris DE, Socinski MA. Combined modality therapy for stage III non-small cell lung cancer. Oncologist 2006; 11:809-23. [PMID: 16880240 DOI: 10.1634/theoncologist.11-7-809] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Lung cancer remains the leading cause of cancer death in the U.S. among both men and women. Approximately 45% of patients present with stage III disease. A proportion of these patients is amenable to surgical resection; however, the majority are "unresectable." For patients with unresectable stage IIIA/B disease, thoracic radiation therapy (TRT) was considered the standard of care until the late 1980s despite a very poor 5-year survival rate. Several clinical trials demonstrated that the combination of chemotherapy and TRT was superior to TRT alone. Based on these data, combined modality therapy became the standard of care for patients with good performance status. Recent trials have shown that concurrent chemoradiotherapy offers a significant survival advantage over sequential chemoradiotherapy. Despite a substantial number of clinical trials, important questions on the optimal treatment paradigm remain. The most effective chemotherapy combination, the use of induction or consolidation chemotherapy in addition to the concurrent portion of therapy, and the optimal dose of chemotherapy with concurrent TRT have yet to be determined. The optimal total dose, fractionation, acceleration, treatment volume, and tumor targeting remain questions related to the TRT portion of therapy. Although significant progress has been made, the majority of patients experience locoregional or distant progression of their disease and die within 5 years of diagnosis. Thus, continued development and participation in clinical trials is crucial to further improvements in the treatment of patients with stage III disease.
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Affiliation(s)
- Thomas E Stinchcombe
- Multidisciplinary Thoracic Oncology Program, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina 27599-7305, USA.
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Frezza G, Salvi F. Prophylactic cranial irradiation in non-small cell lung cancer. Ann Oncol 2006; 17 Suppl 2:ii76-78. [PMID: 16608992 DOI: 10.1093/annonc/mdj931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- G Frezza
- U.O. di Radioterapia Oncologica, Ospedale Bellaria, Bologna, Italy
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Gore E. Prophylactic Cranial Irradiation Versus Observation in Stage III Non–Small-Cell Lung Cancer. Clin Lung Cancer 2006; 7:276-8. [PMID: 16512983 DOI: 10.1016/s1525-7304(11)70694-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Elizabeth Gore
- Radiation Oncology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA.
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Lester JF, MacBeth FR, Coles B. Prophylactic cranial irradiation for preventing brain metastases in patients undergoing radical treatment for non–small-cell lung cancer: A Cochrane Review. Int J Radiat Oncol Biol Phys 2005; 63:690-4. [PMID: 15913909 DOI: 10.1016/j.ijrobp.2005.03.030] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2005] [Revised: 03/10/2005] [Accepted: 03/11/2005] [Indexed: 11/19/2022]
Abstract
PURPOSE To investigate whether prophylactic cranial irradiation (PCI) has a role in the management of patients with non-small-cell lung cancer (NSCLC) treated with curative intent. METHODS AND MATERIALS A search strategy was designed to identify randomized controlled trials (RCTs) comparing PCI with no PCI in NSCLC patients treated with curative intent. The electronic databases MEDLINE, EMBASE, LILACS, and Cancerlit were searched, along with relevant journals, books, and review articles to identify potentially eligible trials. Four RCTs were identified and reviewed. A total of 951 patients were randomized in these RCTs, of whom 833 were evaluable and reported. Forty-two patients with small-cell lung cancer were excluded, leaving 791 patients in total. Because of the small patient numbers and trial heterogeneity, no meta-analysis was attempted. RESULTS Prophylactic cranial irradiation did significantly reduce the incidence of brain metastases in three trials. No trial reported a survival advantage with PCI over observation. Toxicity data were poorly collected and no quality of life assessments were carried out in any trial. CONCLUSION Prophylactic cranial irradiation may reduce the incidence of brain metastases, but there is no evidence of a survival benefit. It was not possible to evaluate whether any radiotherapy regimen is superior, and the effect of PCI on quality of life is not known. There is insufficient evidence to support the use of PCI in clinical practice. Where possible, patients should be offered entry into a clinical trial.
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Affiliation(s)
- Jason Francis Lester
- Department of Oncology, Velindre Hospital, Whitchurch, Cardiff, Wales, United Kingdom.
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Furák J, Troján I, Szöke T, Agócs L, Csekeö A, Kas J, Svastics E, Eller J, Tiszlavicz L. Lung cancer and its operable brain metastasis: survival rate and staging problems. Ann Thorac Surg 2005; 79:241-7; discussion 241-7. [PMID: 15620950 DOI: 10.1016/j.athoracsur.2004.06.051] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2004] [Indexed: 11/18/2022]
Abstract
BACKGROUND We assessed the survival rates regarding different stages of operable lung cancers causing operable brain metastasis in patients with or without cancer-related symptoms. The correlation between survival rates and the disease-free interval between lung surgery and metastasectomy was studied. METHODS Sixty-five patients were operated on for lung cancer and brain metastases. The disease-free interval was divided into 5 subgroups: 0-2 months, 3-5 months, 6-11 months, 12-23 months, and 24 months and beyond. The study group comprised of patients with lung cancer in the following stages: 17 patients in stage I (1 patient in stage IA, 16 patients in stage IB), 16 patients in stage II (2 patients in stage IIA, 14 patients in stage IIB), 9 patients in stage IIIA, 4 patients in stage IIIB, and 19 patients in stage IV. Forty-four patients were symptom-free for lung cancer and 21 patients manifested lung cancer related symptoms. RESULTS The 5-year survival rates were as follows: stage I = 22%, stage II = 20%, stage IIIA = 22%, stage IIIB = 0%, and stage IV = 23% after lung resections. There were no significant differences in the 5-year survival rates regarding the disease-free interval subgroups after brain metastasectomies (p = 0.19): disease-free interval 0-2 months = 22% and disease-free interval 24 months and beyond = 23%. The 5-year survival rate after metastasectomy was significantly greater (26% vs 5%) in patients without lung cancer related symptoms (p = 0.05). CONCLUSIONS The 5-year survival rate in stage I, II, IIIA, and IV lung cancer with operable hematogenous brain metastases corresponds to that in the customary stage IIIA (23%). The disease-free interval exhibited no significant impact on the survival rate. The complaint-free status exhibits a significantly greater impact on the survival rate in hematogenic metastasis.
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Affiliation(s)
- József Furák
- Departments of Medical Informatics, Pathology, and Surgery, University of Szeged, Szeged.
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Cho LC, Dowell JE, Garwood D, Spangler A, Choy H. Prophylactic cranial irradiation with combined modality therapy for patients with locally advanced non-small cell lung cancer. Semin Oncol 2005; 32:293-8. [PMID: 15988684 DOI: 10.1053/j.seminoncol.2005.02.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Central nervous system (CNS) metastasis is a significant problem for many patients with non-small cell lung cancer (NSCLC). The earlier data reported a high incidence of CNS metastasis in patients with locally advanced NSCLC who were treated with radiotherapy alone. However, poor control of both thoracic and extracranial systemic disease dominated the results of the early trials. The risk for CNS metastasis as the first site of failure remains a significant concern for patients who have completed modern combined modality therapy. With improvements in the treatment of thoracic and systemic disease, there is renewed interest in prophylactic cranial irradiation (PCI). The results from the Radiation Therapy Oncology Group (RTOG) trial of PCI to prevent CNS relapse in patients with locally advanced NSCLC are anticipated.
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Affiliation(s)
- L Chinsoo Cho
- Department of Radiation Oncology, UT Southwestern Medical Center at Dallas, Moncrief Radiation Oncology Center, Harold C. Simmons Comprehensive Cancer Center, Dallas, TX 75390, USA.
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