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Ishikawa Y, Umezawa R, Yamamoto T, Takahashi N, Takeda K, Suzuki Y, Kishida K, Omata S, Teramura S, Ito K, Yamada T, Jingu K. Glasgow prognostic score for assessing the efficacy of whole-brain radiation therapy in cases of recursive partitioning analysis class 2 and class 3 multiple brain metastases: a retrospective study. Acta Neurol Belg 2024; 124:231-239. [PMID: 37747688 PMCID: PMC10874307 DOI: 10.1007/s13760-023-02384-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/07/2023] [Indexed: 09/26/2023]
Abstract
PURPOSE Whole-brain radiotherapy (WBRT) may not be beneficial for patients with brain metastases (BMs). The Glasgow Prognostic Score (GPS) is a suggested prognostic factor for malignancies. However, GPS has never been assessed in patients with BMs who have undergone WBRT. The purpose of this study was to determine whether GPS can be used to identify subgroups of patients with BMs who have a poor prognosis, such as recursive partitioning analysis (RPA) Class 2 and Class 3, and who will not receive clinical prognostic benefits from WBRT. MATERIALS AND METHODS A total of 180 Japanese patients with BMs were treated with WBRT between May 2008 and October 2015. We examined GPS, age, Karnofsky Performance Status (KPS), RPA, graded prognostic assessment (GPA), number of lesions, tumor size, history of brain surgery, presence of clinical symptoms, and radiation doses. RESULTS The overall median survival time (MST) was 6.1 months. seventeen patients (9.4%) were alive more than 2 years after WBRT. In univariate analysis, KPS ≤ 70 (p = 0.0066), GPA class 0-2 (p = 0.0008), > 3 BMs (p = 0.012), > 4 BMs (p = 0.02), patients who received ≥ 3 Gy per fraction (p = 0.0068), GPS ≥ 1 (p = 0.0003), and GPS ≥ 2 (p = 0.0009) were found to significantly decrease the MST. Patients who had brain surgery before WBRT (p = 0.036) had a longer survival. On multivariate analysis, GPS ≥ 1 (p = 0.008) was found to significantly decrease MST. CONCLUSION Our results suggest that GPS ≥ 1 indicates a poor prognosis in patients undergoing WBRT for intermediate and poor prognosis BMs.
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Affiliation(s)
- Yojiro Ishikawa
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
- Division of Radiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, 1-15-1 Fukumuro, Miyagino-ku, Sendai, Miyagi, 983-8536, Japan.
| | - Rei Umezawa
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Takaya Yamamoto
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Noriyoshi Takahashi
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Kazuya Takeda
- Department of Radiation Oncology, South Miyagi Medical Center, Ogawara, 989-1253, Japan
| | - Yu Suzuki
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Keita Kishida
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - So Omata
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Satoshi Teramura
- Division of Radiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, 1-15-1 Fukumuro, Miyagino-ku, Sendai, Miyagi, 983-8536, Japan
| | - Kengo Ito
- Division of Radiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, 1-15-1 Fukumuro, Miyagino-ku, Sendai, Miyagi, 983-8536, Japan
| | - Takayuki Yamada
- Division of Radiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, 1-15-1 Fukumuro, Miyagino-ku, Sendai, Miyagi, 983-8536, Japan
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
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Nieder C, Andratschke NH, Grosu AL. Brain Metastases: Is There Still a Role for Whole-Brain Radiation Therapy? Semin Radiat Oncol 2023; 33:129-138. [PMID: 36990630 DOI: 10.1016/j.semradonc.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
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.
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Prognostic factors and survival after whole-brain radiotherapy for initial brain metastases arising from non-small cell lung cancer. JOURNAL OF RADIOTHERAPY IN PRACTICE 2021. [DOI: 10.1017/s1460396921000030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Aim:
To identify prognostic factors and investigate patient survival after whole-brain radiotherapy (WBRT) for initial brain metastases arising from non-small cell lung cancer (NSCLC).
Methods:
Patients diagnosed with NSCLC between 1 January 2010 and 30 September 2019, and who received WBRT upon first developing a brain metastasis, were investigated. Overall survival was determined as related to age, sex, duration between initial examination and brain metastasis detection, stage at the first examination, presence of metastases outside the brain, blood analysis findings, brain metastasis symptoms, radiotherapy dose and completion, imaging findings, therapeutic course of chemotherapy and/or radiation therapy, histological type, and gene mutation status.
Results:
Thirty-one consecutive patients (20 men and 11 women) with a mean age of 63·8 years and median survival of 129 days were included. Multivariate analysis with stepwise testing was performed to investigate differences in survival according to gene mutation status, lactate dehydrogenase (LDH) level, irradiation dose, WBRT completion and Stage status. Of these, a statistically significant difference in survival was observed in patients with gene mutation status (hazard ratio: 0·31, 95% CI: 0·11–0·86, p = 0·025), LDH levels <230 vs. ≥230 IU/L (hazard ratio: 4·08, 95% CI: 1·45–11·5, p < 0·01) received 30 Gy, 30 Gy/10 fractions to 35 Gy/14 fractions, and 37·5 Gy/15 fractions (hazard ratio: 0·26, 95% CI: 0·09–0·71, p < 0·01), and stage IV versus non-stage IV (hazard ratio: 0·13, 95 CI:0·02–0·64, p < 0·01)
Findings:
Gene mutation, LDH, radiation dose and Stage are prognostic factors for patients with initial brain metastases who are treated with WBRT.
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Nieder C, Mehta MP, Guckenberger M, Gaspar LE, Rusthoven CG, Sahgal A, Grosu AL, De Ruysscher D. Assessment of extracranial metastatic disease in patients with brain metastases: How much effort is needed in the context of evolving survival prediction models? Radiother Oncol 2021; 159:17-20. [PMID: 33675870 DOI: 10.1016/j.radonc.2021.02.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/20/2021] [Accepted: 02/23/2021] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway; Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway.
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, USA
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Laurie E Gaspar
- Department of Radiation Oncology, University of Colorado and Banner MDAnderson of Northern Colorado, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, Anschutz Medical Campus, Aurora, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre and University of Toronto, Canada
| | - Anca L Grosu
- Department of Radiation Oncology, Medical Center, Medical Faculty, University Freiburg, Germany
| | - Dirk De Ruysscher
- Department of Radiation Oncology (MAASTRO Clinic), Maastricht University Medical Center, GROW, The Netherlands
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Liu AK, Wu J, Berthelet E, Lalani N, Chau N, Tran E, Hamilton SN. Clinical features of head and neck cancer patients with brain metastases: A retrospective study of 88 cases. Oral Oncol 2020; 112:105086. [PMID: 33186892 DOI: 10.1016/j.oraloncology.2020.105086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/07/2020] [Accepted: 10/27/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Brain metastases (BM) arising from head and neck cancer (HNC) are rare and not well characterized. This study aims to describe the clinicopathological features, treatments, prognostic factors, and survival in HNC patients with BM. MATERIALS AND METHODS Non-thyroid HNC patients referred to BC Cancer from 1998 to 2016 were retrospectively reviewed for BM. The Kaplan-Meier method, log-rank test, and Cox regression analysis were used to assess post-BM survival and prognostic factors. RESULTS Out of 9432 HNC patients, 88 patients developed BM (0.9%, median follow-up 3.4 years). On average, the BM were diagnosed 18.5 months after the primary diagnosis and tended to arise after distant metastases to extracranial sites (85%) such as the lungs (78%). At BM presentation, 84% were symptomatic and two thirds had a poor performance status (ECOG ≥ 2, 68%). The median post-BM survival was 2.5 months (95% CI 2.1-3.3 months). On multivariable analysis, management of BM with radiotherapy (RT) alone (3.3 months, 95% CI 2.3-4.6, p = 0.005) and RT with surgery (4.4 months, 95% CI 2.8-6.9, p < 0.001) was associated with longer survival compared to best supportive care alone (1.4 months, 95% CI 1.0-2.0 months). Age, sex, performance status, sub-localization of the primary HNC, presence of extracranial metastases, and number of intracranial metastases were not associated with post-BM survival (all p ≥ 0.05). CONCLUSION This is the largest study to date in BM from HNC. BM occur late in the course of HNC and carry a poor prognosis. Treatment with intracranial radiotherapy both with and without surgery was associated with improved survival.
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Affiliation(s)
- Alvin K Liu
- University of British Columbia, Faculty of Medicine, 317 - 2194 Health Sciences Mall, Vancouver, British Columbia V6T 1Z3, Canada
| | - Jonn Wu
- University of British Columbia, Department of Surgery, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada; BC Cancer Vancouver, Department of Radiation Oncology, 600 West 10th Avenue, Vancouver, British Columbia V5Z 4E6, Canada
| | - Eric Berthelet
- University of British Columbia, Department of Surgery, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada; BC Cancer Vancouver, Department of Radiation Oncology, 600 West 10th Avenue, Vancouver, British Columbia V5Z 4E6, Canada
| | - Nafisha Lalani
- University of British Columbia, Department of Surgery, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada; BC Cancer Vancouver, Department of Radiation Oncology, 600 West 10th Avenue, Vancouver, British Columbia V5Z 4E6, Canada
| | - Nicole Chau
- University of British Columbia, Faculty of Medicine, 317 - 2194 Health Sciences Mall, Vancouver, British Columbia V6T 1Z3, Canada; BC Cancer Vancouver, Department of Medical Oncology, 600 West 10th Avenue, Vancouver, British Columbia V5Z 4E6, Canada
| | - Eric Tran
- University of British Columbia, Department of Surgery, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada; BC Cancer Vancouver, Department of Radiation Oncology, 600 West 10th Avenue, Vancouver, British Columbia V5Z 4E6, Canada
| | - Sarah Nicole Hamilton
- University of British Columbia, Department of Surgery, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada; BC Cancer Vancouver, Department of Radiation Oncology, 600 West 10th Avenue, Vancouver, British Columbia V5Z 4E6, Canada.
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Datsenko PV, Gerasimov VA, Belikova AA. [Short-term survival prediction scale in patients with metastatic brain disease caused by lung and breast cancer]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:26-35. [PMID: 32759924 DOI: 10.17116/neiro20208404126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To develop a prognostic scale suitable for distinguishing a group of poor prognosis with low survival prior to deciding on the appropriateness of radiotherapy. MATERIAL AND METHODS We analyzed only those patients with reliably known date of death after previous WBRT to determine objective criteria allowing WBRT abandonment. WBRT was carried out in 100 patients with non-small cell lung cancer (n=49) and breast cancer (n=51) and confirmed metastatic brain disease. All procedures have been conducted at the radiotherapy department of the Herzen Moscow Oncology Research Institute since January 2014. The prescribed dose of 3 Gy was ensured in all patients. Total focal dose of 30 Gy delivered in 10 fractions was achieved in 77 cases, 36 Gy delivered in 12 fractions - in 23 cases. RESULTS Death date was recorded in all patients (n=100) by January 2020. In the electronic SPSS database, death information was digitized for each patient up to 2-24 months, respectively. We identified eight the most significant factors by using of correlation analysis: primary tumor (controlled (0), uncontrolled (1)), number of brain metastases (<17 (0), ≥17 (1)), volume of brain metastases (<48 cm3 (0) ≥48 cm3 (1)), extracranial control (no metastases (0), metastases with positive dynamics after chemotherapy (1), continued growth after chemotherapy (2)), metastatic lesion of liver and lungs, respectively (no (0), yes (1)), functional status (≥ 70% (0), ≤ 60% (1)), carcinomatosis of the meninges (no (0), yes (1)). A simple summation of digital variables for factors 1-8 in each patient resulted a prognostic scale. Low risk of early mortality after WBRT was determined by 0-3 scores, intermediate risk - 4-5 scores, high risk - 6-9 scores. According to univariate analysis (log-rank 0.000), median survival rate varied in these groups: low risk - 15.5 months (11.4-19.7), intermediate risk - 5.26 months (4.6-6.0), high risk - only 1.35 months (0.9-1.8). Only 1 out of 15 high-risk patients (6-9 scores) survived 3 months (3.25 months). Inclusion of all eight factors into multivariate analysis revealed significant impact of only risk group on short-term survival. A 3-month survival in the high-risk group was 20.6 times lower (p=0.002) compared to the low and intermediate risk groups. CONCLUSION High significance of prognostic model and low informative value of each of the included factors emphasize the advisability of determining risk groups for short-term survival according to the suggested scale for each patient scheduled for WBRT. A simple assessment of separate predictors is pointless to decide whether WBRT is necessary.
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Affiliation(s)
- P V Datsenko
- Herzen Moscow Oncology Research Institute, Moscow, Russia
| | - V A Gerasimov
- Herzen Moscow Oncology Research Institute, Moscow, Russia
| | - A A Belikova
- Herzen Moscow Oncology Research Institute, Moscow, Russia
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Gilbride L, Siker M, Bovi J, Gore E, Schultz C, Hall WA. Current Predictive Indices and Nomograms To Enable Personalization of Radiation Therapy for Patients With Secondary Malignant Neoplasms of the Central Nervous System: A Review. Neurosurgery 2019; 82:595-603. [PMID: 29669114 DOI: 10.1093/neuros/nyx631] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 02/16/2018] [Indexed: 01/03/2023] Open
Abstract
The proper treatment of brain metastases continues to be a challenge for oncologists given the variability of individual patients' prognoses and the variety of treatment options available to address brain metasteses. There have been efforts since the 1990s to develop prognostic indices and nomograms to help clinicians determine the best approach for individuals with secondary malignant neoplasms of the central nervous system. A literature search was performed to identify the existing prognostic tools published between January 1995 and January 2017. While there have been several reported indices, many are limited by the number of patients analyzed or lack of generalizability. The most robust prognostic tools available are the Disease Specific Graded Prognostic Assessment and the Barnholtz-Sloan nomogram, both of which have online tools available to help clinicians. While these tools are helpful in stratifying different patients' outcomes, they are limited by their retrospective nature and likely underestimate survival in the modern era, where there is a rapidly growing arsenal of systemic agents available to patients with metastatic disease.
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Affiliation(s)
- Lucas Gilbride
- Medical College of Wisconsin, Department of Radiation Oncology
| | - Malika Siker
- Medical College of Wisconsin, Department of Radiation Oncology
| | - Joseph Bovi
- Medical College of Wisconsin, Department of Radiation Oncology
| | - Elizabeth Gore
- Medical College of Wisconsin, Department of Radiation Oncology.,Clement J. Zablocki, VA Medical Center
| | | | - William A Hall
- Medical College of Wisconsin, Department of Radiation Oncology.,Clement J. Zablocki, VA Medical Center
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Lewitzki V, Klement RJ, Hess S, Kosmala R, Nieder C, Flentje M. External validation of a prognostic score predicting overall survival for patients with brain metastases based on extracranial factors. Clin Transl Radiat Oncol 2019; 16:15-20. [PMID: 30906886 PMCID: PMC6411583 DOI: 10.1016/j.ctro.2019.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 02/23/2019] [Indexed: 12/25/2022] Open
Abstract
We provide an external validation of the extracranial prognostic score developed by Nieder et al. This extracranial score could effectively define the patients with very short survival. 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.
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Affiliation(s)
- Victor Lewitzki
- University of Würzburg, Department of Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Rainer J Klement
- Department of Radiation Oncology, Leopoldina Hospital Schweinfurt, 97422 Schweinfurt, Germany
| | - Sebastian Hess
- University of Würzburg, Department of Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Rebekka Kosmala
- University of Würzburg, Department of Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Carsten Nieder
- Department of Clinical Medicine, Faculty of Health Science, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Oncology and Palliative Medicine, Nordland Hospital Trust, 8092 Bodø, Norway
| | - Michael Flentje
- University of Würzburg, Department of Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
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Nieder C, Haukland E, Mannsåker B, Pawinski AR, Yobuta R, Dalhaug A. Presence of Brain Metastases at Initial Diagnosis of Cancer: Patient Characteristics and Outcome. Cureus 2019; 11:e4113. [PMID: 31058007 PMCID: PMC6476608 DOI: 10.7759/cureus.4113] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objective To describe the characteristics of patients who present with brain metastases already at first diagnosis of cancer and to evaluate overall survival (OS) and long-term survival. Methods Retrospective uni- and multivariate analyses in a group of 84 patients treated with different approaches. Results With respect to primary cancer type, the largest entities were adenocarcinoma non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) (34.5 and 21.4%, respectively). The most common diagnostic setting was symptomatic brain metastases (64 patients, 76.2%). Median OS was 7.2 months (one-year survival rate 31%). Four patients survived for at least three years, all had solitary metastases. The best survival was observed in the group managed with neurosurgical resection, median 17.7 months. Systemic treatment was also associated with better survival (median 9.7 vs. 2.8 months, p = 0.0001). Multivariate analysis revealed two prognostic baseline factors for OS, Karnofsky performance status (KPS) and number of brain metastases. Neurologic cause of death was uncommon (n = 14, 17%). Conclusion Long-term survival was limited and observed exclusively in the setting of a solitary brain metastasis. In patients with good KPS and limited number of brain metastases, systemic treatment as well as effective local treatment, such as resection and/or radiotherapy with sufficiently high equivalent dose, is warranted.
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Nieder C, Guckenberger M, Gaspar LE, Rusthoven CG, De Ruysscher D, Sahgal A, Nguyen T, Grosu AL, Mehta MP. Management of patients with brain metastases from non-small cell lung cancer and adverse prognostic features: multi-national radiation treatment recommendations are heterogeneous. Radiat Oncol 2019; 14:33. [PMID: 30770745 PMCID: PMC6377775 DOI: 10.1186/s13014-019-1237-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/08/2019] [Indexed: 12/25/2022] Open
Abstract
Background Different management options exist for patients with brain metastases from non-small cell lung cancer (NSCLC), patients whose treatment with whole brain radiotherapy (WBRT) has become more controversial over the last decade. It is not trivial to find the optimal balance of over- versus undertreatment in these patients. Several recent trials, including the randomized QUARTZ trial now influence the decision to recommend or withhold WBRT for patients with unfavorable prognosis, and similarly, for favorable prognosis patients, the balance between radiosurgery alone or WBRT has become a nuanced decision. Additionally, the availability of intracranially active targeted agent for some subsets of these patients has added another layer of complexity to the decision-making. Methods A multinational consortium of expert radiation oncologists was established with the aim of compiling treatment recommendations for challenging scenarios, in this case the choice between optimal supportive care (SC), WBRT and other types of radiation therapy (RT). We distributed 17 cases to 7 radiation oncologists who were allowed to involve coworkers to provide their treatment recommendations. The cases differed in extra- and intracranial disease extent, histology, age and other prognostic factors. Expert recommendations were tabulated with the aim of providing guidance. Results Regarding willingness to include the 17 patients in the QUARTZ trial, the rates of trial inclusion were low (range 0/7 to 3/7). Experts not recommending trial inclusion provided their treatment recommendations. These suggestions differed widely for most of the patients. It was not uncommon to see 3 or 4 different recommendations. In general, few (0–2) recommended SC. Some kind of local treatment was suggested by the majority of experts for all 17 patients. Commonly, stereotactic single-fraction radiosurgery (SRS) or stereotactic fractionated radiotherapy (SFRT) were recommended by many experts, also for patients with 5–7 lesions. The highest proportion of recommendations towards WBRT in any patient was 3/7. It was also quite common for patients with multiple metastases of varying size that experts suggested combinations of resection, post-operative SRS/SFRT and SRS/SFRT to intact lesions. Despite recommending active treatment, experts were often willing to include the patients in a hypothetical protocol investigating radiotherapy utilization in the last 30 days of life (assessment of factors predicting early death). Conclusions WBRT was infrequently recommended. Even in patients with adverse prognostic features that raised the experts’ awareness of an increased risk for futile treatment near the end of life, SRS/SFRT were more often recommended than optimal supportive care, unless a patient decided to forego active treatment. Electronic supplementary material The online version of this article (10.1186/s13014-019-1237-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway. .,Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway.
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Laurie E Gaspar
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Dirk De Ruysscher
- Department of Radiation Oncology (MAASTRO Clinic), Maastricht University Medical Center, GROW, Maastricht, The Netherlands
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| | - Timothy Nguyen
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| | - Anca L Grosu
- Department of Radiation Oncology, University Hospital Freiburg, Freiburg, Germany
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA
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Agarwal JP, Chakraborty S, Laskar SG, Mummudi N, Patil VM, Upasani M, Prabhash K, Noronha V, Joshi A, Purandare N, Tandon S, Arora J, Badhe R. Applying the QUARTZ Trial Results in Clinical Practice: Development of a Prognostic Model Predicting Poor Outcomes for Non-small Cell Lung Cancers with Brain Metastases. Clin Oncol (R Coll Radiol) 2018; 30:382-390. [PMID: 29499878 DOI: 10.1016/j.clon.2018.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 12/21/2017] [Accepted: 01/05/2018] [Indexed: 01/21/2023]
Abstract
AIMS The role of whole brain radiotherapy (WBRT) in patients with brain metastases from non-small cell lung cancers (NSCLC) has been questioned. However, no reliable criteria exist to identify patients who do not benefit from WBRT. The objective of the current study was to develop a prognostic model to identify such patients whose survival matches that of the Quality of Life after Treatment for Brain Metastases (QUARTZ) study. MATERIALS AND METHODS Outcome data of patients with NSCLC with brain metastases undergoing WBRT enrolled in a prospective observational study in a tertiary cancer centre were used to develop a prognostic model. Baseline clinico-radiological factors were used for development of the model. The model was internally validated and calibration accuracy was checked for prediction of 70 day mortality. The generated prognostic model was presented as a nomogram. RESULTS The median overall survival of 140 patients enrolled in the study was 166 days (95% confidence interval 108-242 days). The prognostic model identified gender, Karnofsky performance status and epidermal growth factor receptor activating mutation status as significant factors influencing overall survival. The model showed a modest discriminative ability with an optimism-corrected C-index of 0.64. However, model calibration error did reveal a moderate degree of calibration error. The high-risk subgroup identified by the model had a median overall survival of 67 days (95% confidence interval 56-101 days), which was similar to that observed in the QUARTZ trial. CONCLUSION This prognostic model derived from traditional clinico-radiological features had a modest ability to identify patients with poor prognosis who may not benefit from WBRT. However, the high-risk subgroup identified using this prognostic model had a survival similar to that observed for patients in the QUARTZ trial.
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Affiliation(s)
- J P Agarwal
- Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India
| | - S Chakraborty
- Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India.
| | - S G Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India
| | - N Mummudi
- Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India
| | - V M Patil
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, India
| | - M Upasani
- Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India
| | - K Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, India
| | - V Noronha
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, India
| | - A Joshi
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, India
| | - N Purandare
- Department of Radiology, Tata Memorial Hospital, Parel, Mumbai, India
| | - S Tandon
- Department of Pulmonary Medicine, Tata Memorial Hospital, Parel, Mumbai, India
| | - J Arora
- Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India
| | - R Badhe
- Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India
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12
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Nieder C, Norum J, Hintz M, Grosu AL. Short Survival Time after Palliative whole Brain Radiotherapy: Can We Predict Potential Overtreatment by Use of a Nomogram? J Cancer 2017; 8:1525-1529. [PMID: 28775771 PMCID: PMC5535707 DOI: 10.7150/jca.18600] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 02/04/2017] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Many patients with brain metastases undergoing whole brain radiotherapy (WBRT) have very limited survival. The purpose of this study was to validate a nomogram derived from a large American database and to examine its ability to better predict short survival (cut-off 2 months) than previous models. MATERIAL AND METHODS This retrospective study included 254 European patients treated with primary WBRT. In addition, an exploratory analysis of patients managed with best supportive care (BSC) was performed too. RESULTS Median survival after WBRT was 3.0 months. The median nomogram point sum was 122 (range 31-212). The nomogram-predicted median survival for a patient with 122 points is 3.3 months. Despite the nomogram's ability to stratify the patients into different prognostic groups, the survival curves of patients with intermediate point sum in the range of 90-139 points were largely superimposable. The poorest prognostic group with ≥180 points had a median and maximum survival of 1.8 and 4.6 months, respectively. Among these 18 patients (7%) 9 survived for less than and 9 for more than 2 months. Comparable survival outcomes were observed after BSC in a smaller group of 8 patients with ≥180 points. CONCLUSIONS Because of several differences between the original and validation findings, the nomogram should be examined in additional large databases. Its ability to predict poor survival is promising and possibly comparable to our previously published models. The final goal of developing a validated model that allows poor prognosis patients to safely forego WBRT without compromising survival or quality of life requires further research efforts.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodø, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, 9037 Tromsø, Norway
| | - Jan Norum
- Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, 9037 Tromsø, Norway.,Northern Norway Regional Health Authority trust, 8038 Bodø, Norway
| | - Mandy Hintz
- Department of Radiation Oncology, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Anca L Grosu
- Department of Radiation Oncology, University Hospital Freiburg, 79106 Freiburg, Germany.,German Cancer Consortium (DKTK), Freiburg, and German Cancer Research Centre (DKFZ), D-69121 Heidelberg, Germany
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13
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Nieder C, Hintz M, Grosu AL. Predicted survival in patients with brain metastases from colorectal cancer: Is a current nomogram helpful? Clin Neurol Neurosurg 2016; 143:107-10. [PMID: 26914143 DOI: 10.1016/j.clineuro.2016.02.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 02/15/2016] [Accepted: 02/16/2016] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To examine the clinical applicability of a new nomogram by comparing survival of patients with brain metastases from colorectal cancer treated with surgery and/or radiotherapy in the authors' institutions with nomogram-predicted median survival. METHODS Retrospective analysis of 64 patients treated with comparable approaches and during the same time period as the patients in the nomogram study. Points were assigned for age, performance status, number and site of brain metastases, as required for nomogram use. RESULTS In 46 patients (72%), the observed survival was shorter than the predicted median. The median deviation was -1.4 months. The nomogram underestimated the survival of patients treated with radiosurgery/surgery by a median of 4.2 months, whereas it overestimated the survival of patients treated with whole-brain radiotherapy (WBRT) by a median of 2.1 months (p=0.0001). Nevertheless, all 5 patients with predicted median survival ≤3 months died within 3 months. Among 8 patients with predicted median survival >12 months, 6 (75%) survived for >12 months. Not all prognostic factors in the nomogram correlated with survival. In the multivariate Cox model, only performance status and number of brain metastases were significant, both with p=0.0001. CONCLUSION Despite differences in prognostic factors and survival of many individual patients, especially those with intermediate prognosis, the nomogram performed promising in poor- and good-prognosis patients. Evaluation of separate prediction tools for patients treated with WBRT and more aggressive local approaches appears warranted in order to minimize the influence of better local control of the brain metastases.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway; Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway.
| | - Mandy Hintz
- Department of Radiation Oncology, University Hospital Freiburg, Freiburg, Germany
| | - Anca L Grosu
- Department of Radiation Oncology, University Hospital Freiburg, Freiburg, Germany
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14
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Reali A, Allis S, Girardi A, Verna R, Bianco L, Redda MGR. Is Karnofsky Performance Status Correlate with Better Overall Survival in Palliative Conformal Whole Brain Radiotherapy? Our Experience. Indian J Palliat Care 2015; 21:311-6. [PMID: 26600700 PMCID: PMC4617039 DOI: 10.4103/0973-1075.164891] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AIM Brain metastases (BMs) are a common event in the progression of many human cancers. The aim of this study was to evaluate the potential prognostic factors for the clinical identification of a subgroup of patients that could benefit from whole brain conformal radiotherapy (WBRT). MATERIALS AND METHODS From January 2010 to February 2014, 80 patients with a diagnosis of BMs underwent WBRT at our Radiation Oncology Department, San Luigi Hospital, Italy. Among them, 36 medical records were retrospective reviewed. Gender, age, Karnofsky performance status (KPS), number of BMs on computed tomography and/or magnetic resonance images, presence or absence of perilesional edema, presence or absence of necrosis pattern, and histology of primary tumor were analyzed. Univariate and multivariate analyses were performed. RESULTS In our cohort of patients, significant prognostic factors for 20 months overall survival was KPS> 70, while a statistical trend (P = 0.098) was registered regarding primary breast. CONCLUSION WBRT can be still considered a standard and effective treatment in patients with BMs. High KPS and breast cancer primary tumor seem to be useful parameters for characterize a subgroup of patients with more favorable prognosis.
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Affiliation(s)
- Alessia Reali
- Department of Oncology, Radiation Oncology Unit, University of Turin, S. Luigi Hospital, Orbassano, Italy
| | - Simona Allis
- Department of Oncology, Radiation Oncology Unit, University of Turin, S. Luigi Hospital, Orbassano, Italy
| | - Andrea Girardi
- Department of Oncology, Radiation Oncology Unit, University of Turin, S. Luigi Hospital, Orbassano, Italy
| | - Roberta Verna
- Department of Oncology, Radiation Oncology Unit, University of Turin, S. Luigi Hospital, Orbassano, Italy
| | - Lavinia Bianco
- Department of Oncology, Radiation Oncology Unit, University of Turin, S. Luigi Hospital, Orbassano, Italy
| | - Maria Grazia Ruo Redda
- Department of Oncology, Radiation Oncology Unit, University of Turin, S. Luigi Hospital, Orbassano, Italy
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15
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Jones JA, Lutz ST, Chow E, Johnstone PA. Palliative radiotherapy at the end of life: a critical review. CA Cancer J Clin 2014; 64:296-310. [PMID: 25043971 DOI: 10.3322/caac.21242] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 06/10/2014] [Accepted: 06/10/2014] [Indexed: 12/25/2022] Open
Abstract
When delivered with palliative intent, radiotherapy can help to alleviate a multitude of symptoms related to advanced cancer. In general, time to symptom relief is measured in weeks to months after the completion of radiotherapy. Over the past several years, an increasing number of studies have explored rates of radiotherapy use in the final months of life and have found variable rates of radiotherapy use. The optimal rate is unclear, but would incorporate anticipated efficacy in patients whose survival allows it and minimize overuse among patients with expected short survival. Clinician prediction has been shown to overestimate the length of survival in repeated studies. Prognostic indices can provide assistance with estimations of survival length and may help to guide treatment decisions regarding palliative radiotherapy in patients with potentially short survival times. This review explores the recent studies of radiotherapy near the end of life, examines general prognostic models for patients with advanced cancer, describes specific clinical circumstances when radiotherapy may and may not be beneficial, and addresses open questions for future research to help clarify when palliative radiotherapy may be effective near the end of life.
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Affiliation(s)
- Joshua A Jones
- Assistant Professor, Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
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16
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Nieder C, Grosu AL, Gaspar LE. Stereotactic radiosurgery (SRS) for brain metastases: a systematic review. Radiat Oncol 2014; 9:155. [PMID: 25016309 PMCID: PMC4107473 DOI: 10.1186/1748-717x-9-155] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/09/2014] [Indexed: 01/10/2023] Open
Abstract
In many patients with brain metastases, the primary therapeutic aim is symptom palliation and maintenance of neurologic function, but in a subgroup, long-term survival is possible. Local control in the brain, and absent or controlled extracranial sites of disease are prerequisites for favorable survival. Stereotactic radiosurgery (SRS) is a focal, highly precise treatment option with a long track record. Its clinical development and implementation by several pioneering institutions eventually rendered possible cooperative group randomized trials. A systematic review of those studies and other landmark studies was undertaken. Most clinicians are aware of the potential benefits of SRS such as a short treatment time, a high probability of treated-lesion control and, when adhering to typical dose/volume recommendations, a low normal tissue complication probability. However, SRS as sole first-line treatment carries a risk of failure in non-treated brain regions, which has resulted in controversy around when to add whole-brain radiotherapy (WBRT). SRS might also be prescribed as salvage treatment in patients relapsing despite previous SRS and/or WBRT. An optimal balance between intracranial control and side effects requires continued research efforts.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodø, Norway.
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17
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Lester-Coll NH, Dosoretz AP, Yu JB. Decision analysis of stereotactic radiation surgery versus stereotactic radiation surgery and whole-brain radiation therapy for 1 to 3 brain metastases. Int J Radiat Oncol Biol Phys 2014; 89:563-8. [PMID: 24751412 DOI: 10.1016/j.ijrobp.2014.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 02/27/2014] [Accepted: 03/01/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE Although whole-brain radiation therapy (WBRT) is effective for controlling intracranial disease, it is also associated with neurocognitive side effects. It is unclear whether a theoretically improved quality of life after stereotactic radiation surgery (SRS) alone relative to that after SRS with adjuvant WBRT would justify the omission of WBRT, given the higher risk of intracranial failure. This study compares SRS alone with SRS and WBRT, to evaluate the theoretical benefits of intracranial tumor control with adjuvant WBRT against its possible side effects, using quality-adjusted life expectancy (QALE) as a primary endpoint. METHODS AND MATERIALS A Markov decision analysis model was used to compare QALE in a cohort of patients with 1 to 3 brain metastases and Karnofsky performance status of at least 70. Patients were treated with SRS alone or with SRS immediately followed by WBRT. Patients treated with SRS alone underwent surveillance magnetic resonance imaging and received salvage WBRT if they developed intracranial relapse. All patients whose cancer relapsed after WBRT underwent simulation as dying of intracranial progression. Model parameters were estimated from published literature. RESULTS Treatment with SRS yielded 6.2 quality-adjusted life months (QALMs). The addition of initial WBRT reduced QALE by 1.2 QALMs. On one-way sensitivity analysis, the model was sensitive only to a single parameter, the utility associated with the state of no evidence of disease after SRS alone. At values greater than 0.51, SRS alone was preferred. CONCLUSIONS In general, SRS alone is suggested to have improved quality of life in patients with 1 to 3 brain metastases compared to SRS and immediate WBRT. Our results suggest that immediate treatment with WBRT after SRS can be reserved for patients who would have a poor performance status regardless of treatment. These findings are stable under a wide range of assumptions.
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Affiliation(s)
- Nataniel H Lester-Coll
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut.
| | - Arie P Dosoretz
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - James B Yu
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale Comprehensive Cancer Center, and Yale University School of Medicine, New Haven, Connecticut
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18
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Nieder C, Marienhagen K, Dalhaug A, Aandahl G, Haukland E, Pawinski A. Prognostic models predicting survival of patients with brain metastases: integration of lactate dehydrogenase, albumin and extracranial organ involvement. Clin Oncol (R Coll Radiol) 2014; 26:447-52. [PMID: 24702741 DOI: 10.1016/j.clon.2014.03.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 02/17/2014] [Accepted: 02/18/2014] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- C Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway; Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway.
| | - K Marienhagen
- Department of Oncology, University Hospital of North Norway, Tromsø, Norway
| | - A Dalhaug
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway; Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - G Aandahl
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway
| | - E Haukland
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway
| | - A Pawinski
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway
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Nieder C, Marienhagen K, Dalhaug A, Aandahl G, Haukland E, Pawinski A. Impact of systemic treatment on survival after whole brain radiotherapy in patients with brain metastases. Med Oncol 2014; 31:927. [PMID: 24647787 DOI: 10.1007/s12032-014-0927-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 03/12/2014] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway,
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20
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Survival prediction score: a simple but age-dependent method predicting prognosis in patients undergoing palliative radiotherapy. ISRN ONCOLOGY 2014; 2014:912865. [PMID: 25006508 PMCID: PMC3977506 DOI: 10.1155/2014/912865] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 02/13/2014] [Indexed: 11/25/2022]
Abstract
Purpose. Validation of a Canadian three-tiered prognostic model (survival prediction score, SPS) in Norwegian cancer patients referred for palliative radiotherapy (PRT), and evaluation of age-dependent performance of the model. Patients and Methods. We analyzed all 579 PRT courses administered at a dedicated PRT facility between 20.06.07 and 31.12.2009. SPS was assigned as originally described, That is, by taking into consideration three variables: primary cancer type, site of metastases, and performance status. Results. Patients with poor prognosis (non-breast cancer, metastases other than bone, and Karnofsky performance status (KPS) ≤ 60) had median survival of 13 weeks. Those with intermediate prognosis (two of these parameters) survived for a median of 29 weeks, and patients with good prognosis for a median of 114 weeks, P < 0.001. While this model performed well in patients who were 60 years or older, it was less satisfactory in younger patients (no significant difference between the good and intermediate prognosis groups). Conclusion. SPS should mainly be used to predict survival of elderly cancer patients. However, even in this group accuracy is limited because the good prognosis group contained patients with short survival, while the poor prognosis group contained long-term survivors. Thus, improved models should be developed.
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