Brain metastasis. Prognostic value of the number of involved extracranial organs

Correlation Between Oligometastatic Tumor in Two Other Visceral Organs and Prognosis in Patients With Brain Metastases

Background and Objective: A recent report indicated that metastases to other body organs commonly develop after stereotactic body radiation treatment for cure in patients with oligometastases (OGM) confined to one organ. This study was undertaken to determine if the presence of metastatic disease in two other visceral organs (TVO) in patients with conventionally treated brain metastases (BRM) was associated with poorer prognosis. Methods: This retrospective clinical investigation included 26 patients treated for palliation of OGM-BRM between May 1996 and February 2020. These individuals were classified according to the presence (13 patients) or absence (13 patients) of metastases in TVO. Results: With an overall mean follow-up of 16 months, 20 patients were deceased, and 6 patients were alive. The median survivals for the OGM-BRM-TVO and non-OGM-BRM-TVO subsets were 4 and 12 months, respectively; the corresponding crude survival rates at 12 months were 0% and 46% (p < 0.01). Subgroup analysis correlating prognosis to the number of BRM (single vs. multiple) and OGM-BRM categories (synchronous vs. metachronous) failed to reveal a survival advantage favoring a certain subgroup. Conclusion: Although the evidence is speculative, we believe that an aggressive disease condition is more likely present in patients with OGM-BRM-TVO. With the notion of an overall poor survival, we suggest a more tailored, less or nonharmful management approach (i.e., palliative therapy or hospice) for this particular patient cohort.

Brain Metastases: Is There Still a Role for Whole-Brain Radiation Therapy?

Whole-brain radiation therapy (WBRT) has commonly been prescribed to palliate symptoms from brain metastases, to reduce the risk of local relapse after surgical resection, and to improve distant brain control after resection or radiosurgery. While targeting micrometastases throughout the brain can be considered advantageous, the simultaneous exposure of healthy brain tissue might cause adverse events. Attempts to mitigate the risk of neurocognitive decline after WBRT include the selective avoidance of the hippocampi, among others. Besides selective dose reduction, dose escalation to boost volumes, for example, simultaneous integrated boost, aiming at increased tumor control probability is technically feasible. While up-front radiotherapy for newly diagnosed brain metastases often employs radiosurgery or other techniques targeting visible lesions only, sequential (delayed) salvage treatment with WBRT might still become necessary. In addition, the presence of leptomeningeal tumors or very widespread parenchymatous brain metastases might prompt clinicians to prescribe early WBRT.

Personalized treatment of brain metastases: Evolving survival prediction models may benefit from evaluation of serum tumor markers (narrative review)

Treatment of a limited number of brain metastases (oligometastases) might include complex and sometimes invasive approaches, e.g. neurosurgical resection followed by post-operative stereotactic radiotherapy, and thus, correct identification of patients who are appropriate candidates is crucial. Both, staging procedures that visualize the true number of metastastic lesions and prognostic assessments that identify patients with limited survival, who should be managed with less complex, palliative approaches, are necessary before proceeding with local treatment that aims at eradication of all oligometastases. Some of the prognostic models, e.g. the LabBM score (laboratory parameters in patients with brain metastases), include blood biomarkers believed to represent surrogate markers of disease extent. In a recent study, patients with oligometastases and a LabBM score of 0 (no abnormal biomarkers) had an actuarial 5-year survival rate of 27% after neurosurgical resection and 39% after stereotactic radiotherapy. Other studies have tied serum tumor markers such as carcinoembryonic antigen (CEA) to survival outcomes. Even if head-to-head comparisons and large-scale definitive analyses are lacking, the available data suggest that attempts to integrate tumor marker levels in blood biomarker-based survival prediction models are warranted.

Prognosis of lung cancer with simple brain metastasis patients and establishment of survival prediction models: a study based on real events

Objectives

The aim of this study was to explore risk factors for the prognosis of lung cancer with simple brain metastasis (LCSBM) patients and to establish a prognostic predictive nomogram for LCSBM patients.

Materials and methods

Three thousand eight hundred and six cases of LCSBM were extracted from the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015 using SEER Stat 8.3.5. Lung cancer patients only had brain metastasis with no other organ metastasis were defined as LCSBM patients. Prognostic factors of LCSBM were analyzed with log-rank method and Cox proportional hazards model. Independent risk and protective prognostic factors were used to construct nomogram with accelerated failure time model. C-index was used to evaluate the prediction effect of nomogram.

Results and conclusion

The younger patients (18–65 years old) accounted for 54.41%, while patients aged over 65 accounted for 45.59%.The ratio of male: female was 1:1. Lung cancer in the main bronchus, upper lobe, middle lobe and lower lobe were accounted for 4.91%, 62.80%, 4.47% and 27.82% respectively; and adenocarcinoma accounted for 57.83% of all lung cancer types. The overall median survival time was 12.2 months. Survival rates for 1-, 3- and 5-years were 28.2%, 8.7% and 4.7% respectively. We found female (HR = 0.81, 95% CI 0.75–0.87), the married (HR = 0.80; 95% CI 0.75–0.86), the White (HR = 0.90, 95% CI 0.84–0.95) and primary site (HR = 0.45, 95% CI 0.39–0.52) were independent protective factors while higher age (HR = 1.51, 95% CI 1.40–1.62), advanced grade (HR = 1.19, 95% CI 1.12–1.25) and advanced T stage (HR = 1.09, 95% CI 1.05–1.13) were independent risk prognostic factors affecting the survival of LCSBM patients. We constructed the nomogram with above independent factors, and the C-index value was 0.634 (95% CI 0.622–0.646). We developed a nomogram with seven significant LCSBM independent prognostic factors to provide prognosis prediction.

A new model outperforming RPA and DS-GPA scores for individualized survival prediction of patients following whole brain irradiation for brain metastasis

PURPOSE

Survival after whole brain radiation therapy (WBRT) in patients with multiple brain metastases (BM) is currently predicted by group-based scoring systems with limited usability for decision. We aimed to develop a more relevant individualized predictive model than Radiation Therapy Oncology Group - Recursive Partitioning Analysis (RTOG-RPA) and Diagnosis - Specific Graded Prognostic Assessment (DS-GPA) for patients with limited life-expectancy.

METHODS

Based on a Discovery cohort of patients undergoing WBRT, multivariable piecewise Cox regression models with time cut-offs at 1 and 3 months were developed to predict overall survival (OS). A final parsimonious model was defined, and an external validation cohort was used to assess its discrimination and calibration at one, six, and 12 months.

RESULTS

In the 173-patient Discovery cohort, the majority of patients had primary lung cancer (56%), presence of extracranial disease (ECD) (75%), Eastern Cooperative Oncolgy Group - Performance Status (ECOG-PS) score 1 (41%) and no intracranial hypertension (ICH) (74%). Most patients were classified as the RPA class II (48%). The final piecewise Cox model was based on primary site, age, ECD, ECOG-PS and ICH. An external validation of the model was carried out using a cohort of 79 patients. Individualized survival estimates obtained with this model outperformed the RPA and DS-GPA scores for overall survival prediction at 1-month, 6-months and 12- months in both Discovery and Validation cohorts. A R/Shiny web application was developed to obtain individualized predictions for new patients, providing an easy-to-use tool for clinicians and researchers.

CONCLUSION

Our model provides individualized estimates of survival for poor prognosis patients undergoing WBRT, outperforming actual scoring systems.

Assessment of extracranial metastatic disease in patients with brain metastases: How much effort is needed in the context of evolving survival prediction models?

Survival prediction models may serve as decision-support tools for clinicians who have to assign the right treatment to each patient, in a manner whereby harmful over- or undertreatment is avoided as much as possible. Current models differ regarding their components, the overall number of components and the weighting of individual components. Some of the components are easy to assess, such as age or primary tumor type. Others carry the risk of inter-assessor inconsistency and time-dependent variation. The present publication focuses on issues related to assessment of extracranial metastases and potential surrogates, e.g. blood biomarkers. It identifies areas of controversy and provides recommendations for future research projects, which may contribute to prognostic models with improved accuracy.

Computer Tomography Radiomics-Based Nomogram in the Survival Prediction for Brain Metastases From Non-Small Cell Lung Cancer Underwent Whole Brain Radiotherapy

Prognostic parameters and models were believed to be helpful in improving the treatment outcome for patients with brain metastasis (BM). The purpose of this study was to investigate the feasibility of computer tomography (CT) radiomics based nomogram to predict the survival of patients with BM from non-small cell lung cancer (NSCLC) treated with whole brain radiotherapy (WBRT). A total of 195 patients with BM from NSCLC who underwent WBRT from January 2012 to December 2016 were retrospectively reviewed. Radiomics features were extracted and selected from pretherapeutic CT images with least absolute shrinkage and selection operator (LASSO) regression. A nomogram was developed and evaluated by integrating radiomics features and clinical factors to predict the survival of individual patient. Five radiomics features were screened out from 105 radiomics features according to the LASSO Cox regression. According to the optimal cutoff value of radiomics score (Rad-score), patients were stratified into low-risk (Rad-score <= −0.14) and high-risk (Rad-score > −0.14) groups. Multivariable analysis indicated that sex, karnofsky performance score (KPS) and Rad-score were independent predictors for overall survival (OS). The concordance index (C-index) of the nomogram in the training cohort and validation cohort was 0.726 and 0.660, respectively. An area under curve (AUC) of 0.786 and 0.788 was achieved for the short-term and long-term survival prediction, respectively. In conclusion, the nomogram based on radiomics features from CT images and clinical factors was feasible to predict the OS of BM patients from NSCLC who underwent WBRT.

External Validation of a Prognostic Score for Patients with Brain Metastases: Extended Diagnosis-Specific Graded Prognostic Assessment

PURPOSE

The aim of our study was the external validation of an extended variant of the four-tiered diagnosis-specific graded prognostic assessment (DS-GPA) that includes more information about extracranial disease burden and blood test results, and predicts survival of patients with brain metastases. The extracranial DS-GPA (EC-GPA) includes serum albumin, lactate dehydrogenase, and number of extracranial organs involved. Originally, the score was developed in Germany.

PATIENTS AND METHODS

A retrospective analysis of 236 patients with brain metastases treated with primary whole-brain radiotherapy in North-Norway was performed (independent external validation cohort).

RESULTS

The four-tiered EC-GPA score showed good discrimination between all prognostic groups (log-rank test p < 0.05 for all pairwise comparisons). One-year survival was 0, 11, 30, and 100%, respectively. Median survival was 0.7 months (95% CI, 0.5-0.9) in the worst prognostic group, with a hazard ratio for death of 44.31 (95% CI, 5.78-339.50) compared to the best group. In the German database, the corresponding HR was 31.64 (median survival 0.4 months). The remaining hazard ratios in this validation study were 7.13 and 12.10, compared with 4.84 and 9.26 in the score development study.

CONCLUSIONS

This study provides an independent validation of the EC-GPA, which was the best prognostic model for defining patients who did not benefit from radiation therapy of brain metastases in terms of overall survival in the original German study. The proposed modification of the established DS-GPA should undergo further validation in multi-institutional databases.

Breast cancer patients with brain metastases or leptomeningeal disease: 10-year results of a national cohort with validation of prognostic indexes

Development of brain metastasis (BM) and leptomeningeal (LM) disease in breast cancer (BC) patients indicates poor prognosis and impairs patients' quality of life. Prognostic survival scores for BM can help predict expected survival in order to choose the most appropriate treatment. The aim of our study was to analyze national data for BC patients treated with radiation therapy for BM/LM disease and validate the applicability of different survival prognostic scores. We retrospectively evaluated medical records of 423 BC patients with BM/LM disease receiving radiation therapy between April 2005 and December 2015. Patients were classified by BC Recursive Partitioning Analysis (B-RPA), Breast Graded Prognostic Assessment (Breast-GPA), Modified Breast Graded Prognostic Assessment (MB-GPA), and Simple Survival score for patients with BM from BC (SS-BM). Overall survival (OS) was calculated from the development of BM/LM disease to death or last follow-up date. After a median follow-up of 7.5 years, the median OS was 6.9 months (95% CI 5.5-7.8, range 0-146.4) and 1- and 2-year survival rates were 35% and 17%, respectively. Survival analysis showed significant differences in median OS regarding biologic subtypes (P < 0.0001), as follows: 3.2 (95% Confidence Interval (CI) 2.5-3.9), 3.9 (95% CI 2.3-5.6), 7.1 (95% CI 4.3-9.8), 12.1 (95% CI 8.3-15.9), and 15.4 (95% CI 8.8-22.1) months for primary triple-negative BC (TNBC), Luminal B HER2-negative, Luminal A, HER2-enriched, and Luminal B HER2-positive tumors, respectively. Good Karnofsky Performance Status (KPS), single metastasis, and absence of LM or extracranial disease all demonstrated better OS in univariate and multivariate analysis. All four employed prognostic indexes provided good prognostic value in predicting survival. SS-BM and MB-GPA showed the best discriminating ability (Concordance indexes C were 0.768 and 0.738, respectively). This study presents one of the largest single-institution series validating prognostic scores for BC patients with BM/LM. SS-BM and MB-GPA proved to be useful tools in the clinical decision-making process.

External validation of a prognostic score predicting overall survival for patients with brain metastases based on extracranial factors

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We provide an external validation of the extracranial prognostic score developed by Nieder et al.

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This extracranial score could effectively define the patients with very short survival.

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A new combination of extracranial score with DS-GPA-score achieved an even better discrimination

Purpose

The aim of our study was an external validation of the extracranial prognostic score predicting survival of patients with brain metastases receiving cranial irradiation on data from a single institution.

Materials and methods

A retrospective analysis of 524 patients with brain metastases treated with cranial radiotherapy in a single tertiary center was performed. Three predictive scores were calculated and assessed for their ability to discriminate prognostic groups: (i) The Recursive Partitioning Analysis (RPA) score (available for 524 patients); (ii) the Diagnosis-Specific Graded Prognostic Assessment (DS-GPA) score (464 patients); (iii) the extracranial score (EC-S) developed by Nieder et al. which is based on serum albumin, lactate dehydrogenase (LDH) and the number of extracranial organs involved (157 patients). Discrimination of each score was assessed by Gönen & Heller’s concordance probability estimate (CPE). The calibration was checked by comparing median survival estimates of each risk group with the corresponding values of the datasets from which the scores were derived. Finally, a multivariable Cox regression model was built by using the least absolute shrinkage and selection operator on a large number of variables including all three scores.

Results

With a CPE = 0.626 ± 0.022, the EC-S had the best discriminatory power. The EC-S also appeared to be better calibrated and had the best ability to separate patients with a very poor prognosis: patients with combination of low albumin, elevated LDH and more than 1 extracranial organ with metastatic involvement had a median survival time of only 0.6 months (CI95% 0.1–1.1) and a hazard ratio for death of 6.36 (2.67–15.14) compared to patients with no extracranial metastases and normal levels of albumin and LDH. In the multivariable Cox model serum albumin, LDH, treatment modality, DS-GPA and EC-S were retained as prognostic factors. An ad hoc combination of both DS-GPA and EC-S into a new score was possible for 134 patients and indicated a slightly better discrimination (CPE = 0.636 ± 0.023) than either DS-GPA or EC-S alone.

Conclusions

This study provides an independent validation of the prognostic EC-S which was the best prognostic model for defining the patients who obviously did not benefit from radiation therapy of brain metastases in terms of overall survival. The combination of the EC-S with the established DS-GPA score resulted in a slight increase in discriminatory ability. The new EC-GPA score needs further validation in larger patient cohorts.

Prognostic factors in patients treated with surgery for brain metastases: A single-center retrospective analysis of 125 patients

BACKGROUD

Brain metastases are the most common malignant intracranial tumors, however, the prognosis of patients is still poor despite multiple treatment have been applicated. The aim of this study was to analyse parameters influence overall survival from patient, tumor and treatment. Summarized characteristics of long-time (>2 years) survivors furtherly.

MATERIALS AND METHODS

In total, clinical data of 125patients between 2004 and 2015 were collected and the parameters from patients, tumor and treatment were evaluated. Univariate analysis was performed using Kaplan-Meier and Log-rank test, multivariate analysis was performed using Cox proportional hazards regression model, respectively.

RESULTS

Median overall survival time was 14.5 (95% confidence interval were 12.3-16.7) months and median survival time was 34.5 (95% confidence interval were 30.1-38.9) months in long-time survivors, respectively.KPS, RPA, GPA, number of brain metastases, extracranial metastases, treatment pattern and resection method were identified influence survival time significantly by univariate analysis. KPS, number of brain metastases, extracranial metastases and treatment pattern were independent prognosis factors by multivariate analysis. Long-time survivors obtain higher KPS, complete resection, adjuvant therapy postoperative more commonly.

CONCLUSION

Higher KPS, GPA I,RPA3.5∼4, single brain metastases, adjuvant therapy postoperative and complete resection were significant improve survival time, however, extracranial metastases significant decreased survival time. Patients who have good status and received multimodality therapy involved complete resection can survive longer time more commonly.

Radiosurgery to the Postoperative Tumor Bed for Metastatic Carcinoma Versus Whole Brain Radiation After Surgery

Background

The treatment paradigm from postoperative whole brain radiation therapy (WBRT) to post-operative stereotactic radiosurgery (SRS) to the tumor bed has shifted with little data to evaluate whether each treatment modality confers equivalent tumor control and survival outcomes.

Methods

Patients with surgical resection of single brain metastases from January 2010 to December 2014 were treated postoperatively with either WBRT or SRS. Retrospective patient data was compared for local control, distant brain recurrence, overall survival, and radiation complications.

Results

Forty-six received WBRT, and 37 received tumor bed SRS. Twelve of 35 (34%) SRS patients experienced local recurrence compared to 17 of 31 (55%) WBRT patients (p = 0.09). The median survival was 440 days (14.7 months) for SRS and 202 days (6.7 months) for WBRT (p = 0.062, log-rank). SRS demonstrated improved survival benefit in the first six months (p = 0.0034; Wilcoxon). Radiation-related adverse changes after SRS (22%) were not statistically different from WBRT (8.7%) (p = 0.152). Age (p = 0.08), systemic cancer status (p = 0.30), Graded Prognostic Assessment (p = 0.28), number of brain metastases at diagnosis (p = 0.65), tumor volume at diagnosis (p = 0.13), new brain lesions (p = 0.74) and neurologic versus systemic cause of death (p = 0.11) did not differ between the groups.

Conclusions

Following surgical resection, tumor bed SRS can be used effectively in lieu of WBRT to treat brain metastases with comparable local control and distant control and without significantly more adverse events.

Postoperative brain metastases in soft tissue sarcomas

Brain metastases (BMs) from soft tissue sarcoma (STS) are rare but lethal. We reviewed 187 consecutive patients with STS treated with definitive surgery in Nagoya University Hospital from 2004 to 2014. There were 10 patients with neurofibromatosis-1 (NF-1). We investigated estimated brain metastasis free survival (BMFS) after surgery and overall survival (OS) after BMs in STS. The factors that affected BMFS were also investigated. Eight of 187 patients (4.3%) developed BM with a median period of 18.2 (range 8.8-42.6) months after surgery. Seven of 8 BM patients had metastases at other sites. Estimated 5 year BMFS rate after surgery was 95.2%, and 3 month OS rate after BM was 25.0%. NF-1 (p<0.0001), histological subtype of MPNST (p=0.008), and primary tumor size≥5 cm (p=0.021) were significantly associated with increasing incidence of BM. In this study, postoperative BMs were common in patients with NF-1, MPNST, and large tumors. Considering the impact of NF-1 on BMFS, careful follow up for BM is necessary for NF-1 patients with metastases at other sites.

Whole brain irradiation with hippocampal sparing and dose escalation on multiple brain metastases: Local tumour control and survival

PURPOSE

Hippocampal-avoidance whole brain radiotherapy (HA-WBRT) for multiple brain metastases may prevent treatment-related cognitive decline, compared to standard WBRT. Additionally, simultaneous integrated boost (SIB) on individual metastases may further improve the outcome. Here, we present initial data concerning local tumour control (LTC), intracranial progression-free survival (PFS), overall survival (OS), toxicity and safety for this new irradiation technique.

METHODS AND MATERIALS

Twenty patients, enrolled between 2011 and 2013, were treated with HA-WBRT (30 Gy in 12 fractions, D98% to hippocampus ≤ 9 Gy) and a SIB (51 Gy) on multiple (2-13) metastases using a volumetric modulated arc therapy (VMAT) approach based on 2-4 arcs. Metastases were evaluated bidimensionally along the two largest diameters in contrast-enhanced three-dimensional T1-weighed MRI.

RESULTS

Median follow-up was 40 weeks. The median time to progression of boosted metastases has not been reached yet, corresponding to a LTC rate of 73%. Median intracranial PFS was 40 weeks, corresponding to a 1-year PFS of 45.3%. Median OS was 71.5 weeks, corresponding to a 1-year OS of 60%. No obvious acute or late toxicities grade > 2 (NCI CTCAE v4.03) were observed. Dmean to the bilateral hippocampi was 6.585 Gy ± 0.847 (α/β = 2 Gy). Two patients developed a new metastasis in the area of hippocampal avoidance.

CONCLUSION

HA-WBRT (simultaneous integrated protection, SIP) with SIB to metastases is a safe and tolerable regime that shows favorable LTC for patients with multiple brain metastases, while it has the potential to minimize the side-effect of cognitive deterioration.

Prognostic models predicting survival of patients with brain metastases: integration of lactate dehydrogenase, albumin and extracranial organ involvement

AIMS

To explore the role of expanded assessment of metastatic extracranial organ involvement, as well as albumin and lactate dehydrogenase (LDH), i.e. surrogates of disease extent, in survival prediction models for patients with brain metastases.

MATERIALS AND METHODS

A retrospective analysis of 189 patients treated with whole brain radiotherapy was carried out. Uni- and multivariate analyses included recursive partitioning analysis classes, basic score for brain metastases and diagnosis-specific graded prognostic assessment (DS-GPA).

RESULTS

Elevated LDH correlated significantly with extracranial organ involvement, low albumin with primary tumour type and primary tumour control. Elevated LDH, low albumin and a combination of both correlated significantly with overall survival. LDH, albumin and the number of extracranial organs involved (none, one, two or more harbouring metastases) were independent prognostic factors in multivariate analyses (if added to the three established scores mentioned above and also if added to individual parameters such as age, performance status, etc.). A combination of these three new prognostic factors predicted very short survival (median 0.7 months if all three were present).

CONCLUSION

We have previously defined patient groups in whom foregoing radiotherapy was unlikely to compromise survival. These were patients with a DS-GPA score of 0-1.5 points and age ≥75 years or Karnofsky performance status ≤50 or uncontrolled primary tumour with extracranial metastases to at least two organs. Patients with a combination of three new adverse features (elevated LDH plus low albumin plus extracranial metastases to at least two organs) might also be considered for best supportive care. Furthermore, it appears warranted to study whether scores such as DS-GPA can be optimised by integrating information on these three parameters.

Impact of systemic treatment on survival after whole brain radiotherapy in patients with brain metastases

Most patients with brain metastases have active extracranial disease, which limits survival unless effective systemic therapy can be administered. Available options have increased over the last 5 years. Therefore, we analyzed patient cohorts treated with or without systemic treatment after completion of whole brain radiotherapy (WBRT). This study included retrospective uni- and multivariate analyses of 189 patients. Two landmark analyses requiring minimum survival of 1 or 2 months from start of WBRT were performed. Age and Karnofsky performance status (KPS) requirements were also applied in order to resemble a prospective trial that would limit inclusion to patients with defined baseline characteristics such as adequate KPS. Irrespective of these different statistical scenarios, systemic treatment significantly improved survival. For example, the 2-month landmark analysis with upper age limit and inclusion of patients with KPS > 60 only showed median survival of 9.0 versus 3.7 months, p = 0.001. All patients alive after more than 2 years had received systemic treatment (chemotherapy, endocrine therapy, tyrosine kinase inhibitors or other drugs). After WBRT, systemic treatment is a prerequisite for long-term survival. The exact magnitude of improvement can only be assessed in randomized trials because retrospective cohort studies, even if carefully designed, are not able to correct for all potential imbalances.