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Pellerino A, Davidson TM, Bellur SS, Ahluwalia MS, Tawbi H, Rudà R, Soffietti R. Prevention of Brain Metastases: A New Frontier. Cancers (Basel) 2024; 16:2134. [PMID: 38893253 PMCID: PMC11171378 DOI: 10.3390/cancers16112134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/29/2024] [Accepted: 06/01/2024] [Indexed: 06/21/2024] Open
Abstract
This review discusses the topic of prevention of brain metastases from the most frequent solid tumor types, i.e., lung cancer, breast cancer and melanoma. Within each tumor type, the risk of brain metastasis is related to disease status and molecular subtype (i.e., EGFR-mutant non-small cell lung cancer, HER2-positive and triple-negative breast cancer, BRAF and NRAF-mutant melanoma). Prophylactic cranial irradiation is the standard of care in patients in small cell lung cancer responsive to chemotherapy but at the price of late neurocognitive decline. More recently, several molecular agents with the capability to target molecular alterations driving tumor growth have proven as effective in the prevention of secondary relapse into the brain in clinical trials. This is the case for EGFR-mutant or ALK-rearranged non-small cell lung cancer inhibitors, tucatinib and trastuzumab-deruxtecan for HER2-positive breast cancer and BRAF inhibitors for melanoma. The need for screening with an MRI in asymptomatic patients at risk of brain metastases is emphasized.
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Affiliation(s)
- Alessia Pellerino
- Division of Neuro-Oncology, Department of Neuroscience ‘Rita Levi Montalcini’, University and City of Health and Science Hospital, 10126 Turin, Italy;
| | - Tara Marie Davidson
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (T.M.D.); (H.T.)
| | - Shreyas S. Bellur
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL 33176, USA; (S.S.B.); (M.S.A.)
| | - Manmeet S. Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL 33176, USA; (S.S.B.); (M.S.A.)
| | - Hussein Tawbi
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (T.M.D.); (H.T.)
| | - Roberta Rudà
- Division of Neuro-Oncology, Department of Neuroscience ‘Rita Levi Montalcini’, University and City of Health and Science Hospital, 10126 Turin, Italy;
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Nakahara Y, Sasaki J, Fukui T, Otani S, Igawa S, Hayakawa K, Masuda N. The role of prophylactic cranial irradiation for patients with small-cell lung cancer. Jpn J Clin Oncol 2018; 48:26-30. [PMID: 29077861 DOI: 10.1093/jjco/hyx146] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 09/27/2017] [Indexed: 11/13/2022] Open
Abstract
Small-cell lung cancer (SCLC) has a particular propensity to metastasize to the brain, affecting ~10% of SCLC patients at diagnosis, but may occur in more than 50% of 2-year survivors. Most cytotoxic drugs have limited ability to cross the blood-brain barrier, and the effectiveness of chemotherapy for brain metastasis is limited. Therefore, prophylactic cranial irradiation (PCI) has been proposed to treat SCLC. A meta-analysis revealed that PCI significantly decreased the risk of brain metastasis and increased the 3-year survival rate; it has been established as a standard therapy for limited-disease SCLC. However, certain aspects of PCI remain unclarified, including the roles in resected SCLC and extensive-disease SCLC, and its neurotoxicities. In addition, information on PCI has been obtained from old clinical trials without the use of new imaging devices, such as magnetic resonance imaging. Evidence from advanced imaging techniques is needed in this era.
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Affiliation(s)
- Yoshiro Nakahara
- Department of Respiratory Medicine, Kitasato University School of Medicine
| | - Jiichiro Sasaki
- Research and Development Center for New Medical Frontiers, Kitasato University School of Medicine
| | - Tomoya Fukui
- Department of Respiratory Medicine, Kitasato University School of Medicine
| | - Sakiko Otani
- Department of Respiratory Medicine, Kitasato University School of Medicine
| | - Satoshi Igawa
- Department of Respiratory Medicine, Kitasato University School of Medicine
| | - Kazushige Hayakawa
- Department of Radiology and Radiation Oncology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Noriyuki Masuda
- Department of Respiratory Medicine, Kitasato University School of Medicine
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Socha J, Kępka L. Prophylactic cranial irradiation for small-cell lung cancer: how, when and for whom? Expert Rev Anticancer Ther 2012; 12:505-17. [PMID: 22500687 DOI: 10.1586/era.12.19] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Prophylactic cranial irradiation (PCI) reduces the incidence of brain metastases and improves overall survival in both limited disease (LD) and extensive disease (ED) small-cell lung cancer (SCLC), in complete and good responders to initial chemo(radio)therapy. In LD-SCLC, a standard dose of 25 Gy given in ten fractions is recommended, whereas in ED-SCLC a shorter schedule of 20 Gy in five fractions could be used. The issues of acute neurotoxicity (NT) and the potential impact of PCI on quality of life are of particular concern in ED-SCLC patients, as their expected survival is short. In LD-SCLC late neurologic sequelae may worsen quality-adjusted life expectancy for long-term survivors, as the pronounced effect of NT becomes apparent after several years. Some novel potential approaches to reduce the PCI-related late NT have recently been investigated. Despite the growing incidence of lung cancer in elderly people, there are no established standards of treatment for this subset of the population.
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Chi A, Komaki R. Treatment of brain metastasis from lung cancer. Cancers (Basel) 2010; 2:2100-37. [PMID: 24281220 PMCID: PMC3840463 DOI: 10.3390/cancers2042100] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Revised: 11/11/2010] [Accepted: 12/02/2010] [Indexed: 12/25/2022] Open
Abstract
Brain metastases are not only the most common intracranial neoplasm in adults but also very prevalent in patients with lung cancer. Patients have been grouped into different classes based on the presence of prognostic factors such as control of the primary tumor, functional performance status, age, and number of brain metastases. Patients with good prognosis may benefit from more aggressive treatment because of the potential for prolonged survival for some of them. In this review, we will comprehensively discuss the therapeutic options for treating brain metastases, which arise mostly from a lung cancer primary. In particular, we will focus on the patient selection for combined modality treatment of brain metastases, such as surgical resection or stereotactic radiosurgery (SRS) combined with whole brain irradiation; the use of radiosensitizers; and the neurocognitive deficits after whole brain irradiation with or without SRS. The benefit of prophylactic cranial irradiation (PCI) and its potentially associated neuro-toxicity for both small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) are also discussed, along with the combined treatment of intrathoracic primary disease and solitary brain metastasis. The roles of SRS to the surgical bed, fractionated stereotactic radiotherapy, WBRT with an integrated boost to the gross brain metastases, as well as combining WBRT with epidermal growth factor receptor (EGFR) inhibitors, are explored as well.
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Affiliation(s)
- Alexander Chi
- Department of Radiation Oncology, University of Arizona, 1501 N Campbell Ave., Tucson, AZ 85724, USA; E-Mail:
| | - Ritsuko Komaki
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
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Le Péchoux C, Arriagada R. Prophylactic cranial irradiation in small cell lung cancer. Hematol Oncol Clin North Am 2004; 18:355-72. [PMID: 15094176 DOI: 10.1016/j.hoc.2003.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Cécile Le Péchoux
- Department of Radiotherapy, Institut Gustave-Roussy, Villejuif 94805, France.
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Abstract
Prophylactic cranial irradiation is now known to improve survival to a significant degree in small-cell lung cancer (SCLC) patients; this is in addition to its established role in preventing the disabling symptoms of brain metastases. New information indicates that it confers a survival benefit for limited or extensive stage SCLC patients gaining a complete response in the chest. A review of causes of cerebral dysfunction as a complication indicates that such problems can be due to suboptimal radiation fractionation, chemotherapy, or an inappropriate combination of prophylactic brain irradiation with chemotherapy. Optimum treatment with prophylactic brain irradiation has been shown not to cause adverse effects with detailed psychometric testing. Several additional sources of information can be drawn together to suggest a dose-response pattern for prophylactic brain irradiation, leading to the recommendation that a dose of 25-36 Gy is optimal, delivered in 2-3 Gy daily fractions after the completion of chest irradiation and chemotherapy. This will be better defined in future clinical trials.
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Affiliation(s)
- G Y Yang
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia 30345, USA
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Kamath SS, McCarley DL, Zlotecki RA. Decreased metastasis and improved survival with early thoracic radiotherapy and prophylactic cranial irradiation in combined-modality treatment of limited-stage small cell lung cancer. RADIATION ONCOLOGY INVESTIGATIONS 1998; 6:226-32. [PMID: 9822169 DOI: 10.1002/(sici)1520-6823(1998)6:5<226::aid-roi4>3.0.co;2-h] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In an attempt to verify the relative efficacy of early concurrent vs. sequential timing of thoracic radiotherapy (TRT) and platinum/etoposide chemotherapy, 48 patients with limited-stage small cell lung cancer treated with either early-concurrent (29 patients) or sequential (19 patients) TRT and platinum/etoposide chemotherapy were evaluated. Disease-specific prognostic variables and the role of prophylactic cranial irradiation (PCI) were also analyzed. Thirty-four patients (71%) received TRT to a dose of 45 Gy in 25 fractions (range, 30-55 Gy). Most patients (75%) received 4-6 cycles of chemotherapy. Twenty-one of 27 patients achieving a complete response after completion of TRT and chemotherapy received PCI. Median follow-up was 29.3 months (range, 12-98 months). Variables of potential prognostic significance were evaluated by both univariate and multivariate analysis. The absolute and relapse-free survival rates for all patients were 42% and 35% at 2 years and 32% and 31% at 5 years, respectively. Thirty-six sites of failure were observed in 27 patients. Thoracic recurrence occurred in nine patients, and the central nervous system (CNS) was the most common site of distant failure (15 patients). Multivariate analysis demonstrated that (a) early concurrent TRT and chemotherapy vs. chemotherapy followed by sequential TRT and (b) disease volume [less than or greater than one-third of the thoracic width] were significantly predictive for survival (P=0.036 and P=0.05, respectively). Rates of control of thoracic disease were 79% for patients with a disease volume less than one-third of the thoracic width vs. 36% for disease volumes greater than one-third of the thoracic width (P=0.0009). Early concurrent TRT and chemotherapy resulted in a significantly lower incidence of distant metastasis (26% for concurrent vs. 63% for sequential; P=0.008). In patients who received PCI, the CNS control rate was 86% vs. 56% in patients not treated with PCI. Our findings suggest that (a) treatment with early concurrent TRT and platinum/etoposide chemotherapy may improve survival when compared with sequential treatment and (b) PCI for patients with complete systemic responses is effective in preventing CNS recurrence. We also conclude that thoracic disease volume is a significant prognostic factor for both local control and overall survival.
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Affiliation(s)
- S S Kamath
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, USA
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van de Pol M, ten Velde GP, Wilmink JT, Volovics A, Twijnstra A. Efficacy and safety of prophylactic cranial irradiation in patients with small cell lung cancer. J Neurooncol 1997; 35:153-60. [PMID: 9266453 DOI: 10.1023/a:1005761825766] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Prophylactic cranial irradiation (PCI) as part of the treatment regimen for patients with limited stage small cell lung cancer (SCLC) remains controversial. The present study was performed to analyze the efficacy and safety of PCI in patients with limited stage SCLC who achieved complete remission. PATIENTS AND METHODS Between 1983 and 1993, thirty-nine patients with limited stage SCLC who had shown complete remission after chemotherapy were enrolled prospectively into the non-randomized study. Eighteen of them received PCI (PCI+), while 21 did not (PCI-). Pretreatment CT or MRI of the brain was performed in all patients. Patients were prospectively evaluated by a neurologist at regular intervals. RESULTS Three PCI+ patients and seven PCI- patients developed brain metastases. The frequencies of brain metastases were not significantly different between the groups (Fisher's exact test, p = 0.207), but brain metastases in PCI+ patients tended to occur later (log rank, p = 0.008). Overall survival was significantly longer in PCI+ patients (log rank, p < 0.001). Early toxicity consisted of headache, nausea, fatigue, concentration problems and alopecia. These symptoms and signs were mild and usually reversible within a few months. Late toxicity was studied in patients whose survival exceeded two years. Seven PCI+ patients survived for more than two years, while no PCI- patients survived for more than two years. Memory problems were seen in six of the seven patients. These problems were non-disabling and, once established, remained stable for months to years. The most prominent radiologic abnormalities were cortical atrophy and leukoencephalopathy, found in four of the five patients who underwent radiologic follow-up examination. CONCLUSIONS This non-randomized study suggests that PCI may be effective by decreasing the frequency of brain metastases and by increasing the brain metastasis-free survival and overall survival, with a minor risk of clinical and radiologic neurotoxicity.
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Affiliation(s)
- M van de Pol
- Department of Neurology, University Hospital Maastricht, The Netherlands
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Gregor A. Prophylactic cranial irradiation in small cell lung cancer (SCLC) makes a comeback. Clin Oncol (R Coll Radiol) 1997; 9:148-9. [PMID: 9269544 DOI: 10.1016/s0936-6555(97)80069-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abstract
OBJECTIVE To review current applications of radiation therapy in the treatment of persons with lung cancer, providing the scientific basis for nursing management of disease and treatment effects. DATA SOURCES Published articles, book chapters, clinical trial data, and professional practice experience from the radiation oncology, radiobiology, and nursing literature. CONCLUSIONS Radiation therapy has an important role in lung cancer treatment, regardless of histopathologic type. Intent of radiation treatment may be to cure, control, or palliate the disease and its symptoms. Combined therapy (especially chemotherapy and radiation therapy) produces enhanced side effects as well as enhanced tumoricidal effect. IMPLICATIONS FOR NURSING PRACTICE Disease and treatment effects in the patient with lung cancer are particularly challenging to patients, family members, and care providers. Nurses have a major responsibility in patient/ family education and in providing the supportive care and self-help techniques needed for patients treated with radiation therapy.
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Work E, Bentzen SM, Nielsen OS, Fode K, Michalski W, Palshof T. Prophylactic cranial irradiation in limited stage small cell lung cancer: survival benefit in patients with favourable characteristics. Eur J Cancer 1996; 32A:772-8. [PMID: 9081352 DOI: 10.1016/0959-8049(95)00597-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The value of prophylactic cranial irradiation (PCI) in the treatment of small cell lung cancer (SCLC) remains controversial. As part of a randomised study investigating the timing of chest irradiation (CI) with respect to combination chemotherapy, the effect of PCI was evaluated. Between 1981 and 1989, patients were randomised to initial chest irradiation ICI (99 patients) or 18 weeks delayed late chest irradiation LCI (100 patients). PCI was given to 157 patients. In the beginning, only ICI patients received PCI, but in October 1984 the strategy was changed so that all patients received PCI. Thus, the patients who did not receive PCI were randomly allocated. The PCI dose was 33 Gy/11 fractions (45 patients) and 25 Gy/11 fractions (112 patients). The 2-year CNS-recurrence rate (+/- standard error) was significantly lower in patients who received PCI, 16.3 +/- 4.1%, than in those who did not, 55.1 +/- 12.4% (p = 0.01). In contrast, the 2-year cause-specific survival was not significantly different, 24.9 +/- 3.6% and 16.9 +/- 6.2% (p = 0.31). The 2-year progression-free rates with or without PCI were 18.5 +/- 3.3% and 11.4 +/- 5.4%, respectively (p = 0.58). To test the hypothesis that a benefit from PCI would mainly be expected among the patients with the best prognosis, a multivariate regression analysis of prognostic factors was undertaken. Based on weight loss, performance status, serum sodium and age, the third of the patients with the best prognosis were identified. In that group of patients, the survival advantage from PCI was statistically significant, 35.5 +/- 7.2% versus 14.1 +/- 8.0%, P = 0.029. These results are currently being tested in a Danish multicentre trial where patients with a good prognosis are randomised either to receive PCI or not to receive PCI.
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Affiliation(s)
- E Work
- Department of Oncology, Aarhus University Hospital, Denmark
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van Oosterhout AG, van de Pol M, ten Velde GP, Twijnstra A. Neurologic disorders in 203 consecutive patients with small cell lung cancer. Results of a longitudinal study. Cancer 1996; 77:1434-41. [PMID: 8608526 DOI: 10.1002/(sici)1097-0142(19960415)77:8<1434::aid-cncr3>3.0.co;2-c] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Neurologic complications of small cell lung cancer (SCLC) are manifold. The incidence and course of the various metastatic and nonmetastatic neurologic disorders were studied prospectively in a cohort of SCLC patients. METHODS The 203 patients underwent neurologic examinations on a regular basis, prior to therapy, during and after treatment, from 1983 through 1994. Routine computer tomography or magnetic resonance imaging of the brain was performed before therapy and after 2 years' survival. Other auxiliary diagnostic tests were performed as required. RESULTS The majority of the 174 neurologic disorders, diagnosed in 132 patients, were associated with metastases. A total of 79 patients developed brain metastases. The cumulative risk of brain metastases reached 47% for limited and 69% for extensive disease patients at 2 years from diagnosis. Survival following the diagnosis of brain metastases was significantly longer for patients with brain metastases at the initial diagnosis of SCLC than for patients with delayed brain metastases (P < 0.01, long rank test). The most frequent paraneoplastic syndrome with neurologic symptoms was that of inappropriate secretion of antidiuretic hormone (SIADH), which was diagnosed in 11 patients. Antibody-mediated paraneoplastic neurologic syndromes were diagnosed in five patients. Chemotherapy for SCLC caused SIADH to subside in most patients. In contrast, the antibody-mediated syndromes did not respond to SCLC therapy. Adverse effects of treatment included peripheral neuropathy, encephalopathy, radiation plexopathy, and steroid myopathy. However, unlike the other complications, peripheral neuropathy was reversible. CONCLUSIONS This clinical investigation confirmed the frequency of central nervous system metastatic involvement as well as the diversity of the neurologic complications in SCLC. The high frequency of brain metastases justifies a reappraisal of prophylactic cranial irradiation in this patient group.
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Affiliation(s)
- A G van Oosterhout
- Department of Neurology, University Hospital, Maastricht, The Netherlands
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Abstract
This synthesis of the literature on radiotherapy for lung cancer is based on 80 scientific articles, including 2 meta-analyses, 29 randomized studies, 19 prospective studies, and 21 retrospective studies. These studies involve 28172 patients. Basic treatment for limited-stage small cell lung cancer (SCLC), is chemotherapy. Addition of radiotherapy to the primary tumor and mediastinum reduces local recurrence, prolongs long-term survival, and is often indicated. Current, and future, studies can be expected to show successive improvements in results for SCLC by optimizing the combination of radiotherapy and chemotherapy. Should these treatments be given simultaneously or sequentially, and in which order? Which fractionation is best? Probably, no change in resource requirements for radiotherapy will be necessary, with the possible exception of changes in fractionation. Surgery constitutes primary treatment for nonsmall cell lung cancer (NSCLC) stages I and II. Radiotherapy may provide an alternative for patients who are inoperable for medical reasons. The value of radiotherapy following radical surgery for NSCLC remains to be shown. It is not indicated based on current knowledge. For NSCLC stage III, radiotherapy shrinks tumors and prolongs survival at 2 and 3 years. Whether it influences long-term survival after 5 years has not been shown. Considering the side effects of treatment, one must question whether limited improvements in survival motivate routine radiotherapy in these patients. Earlier attempts to add chemotherapy to radiotherapy to improve treatment results of NSCLC have not yielded convincing results. Several studies are currently on-going. Prophylactic cranial irradiation (PCI) greatly reduces the risk for brain metastases from SCLC. However, it has little influence on survival. Many treatment centers give PCI to SCLC patients who have achieved complete remission. This practice may be questioned since PCI is associated with serious complications. PCI is not indicated in patients with NSCLC. In SCLC, where the disease is extensive, only palliative radiotherapy is appropriate. Radiotherapy is an important treatment alternative in special palliative situations involving severe cough, severe bleeding, pain, pulmonary obstructions, and vena cava superior syndrome. In these situations, good results may be achieved with few fractions.
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Rubenstein JH, Dosoretz DE, Katin MJ, Blitzer PH, Salenius SA, Floody PA, Harwin WN, Teufel TE, Raymond MG, Reeves JA. Low doses of prophylactic cranial irradiation effective in limited stage small cell carcinoma of the lung. Int J Radiat Oncol Biol Phys 1995; 33:329-37. [PMID: 7673020 DOI: 10.1016/0360-3016(95)00166-v] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE Prophylactic cranial irradiation (PCI) for the prevention of brain metastasis in small cell lung cancer remains controversial, both in terms of efficacy and the optimal dose-fractionation scheme. We performed this study to evaluate the efficacy of PCI at low doses. METHODS AND MATERIALS One hundred and ninety-seven patients were referred to our institution for treatment of limited stage small cell carcinoma of the lung between June 1986 and December 1992. Follow-up ranged from 1.1 to 89.8 months, with a mean of 19 months. Eighty-five patients received PCI. RESULTS Patients receiving PCI exhibited brain failure in 15%, while 38% of untreated patients developed metastases. This degree of prophylaxis was achieved with a median total dose of 25.20 Gy and a median fraction size of 1.80 Gy. At these doses, acute and late complications were minimal. Patients receiving PCI had significantly better 1-year and 2-year overall survivals (68% and 46% vs. 33% and 13%). However, patients with a complete response (CR) to chemotherapy and better Karnofsky performance status (KPS) were overrepresented in the PCI group. In an attempt to compare similar patients in both groups (PCI vs. no PCI), only patients with KPS > or = 80, CR or near-CR to chemotherapy, and treatment with attempt to cure, were compared. In this good prognostic group, survival was still better in the PCI group (p = 0.0018). CONCLUSION In this patient population, relatively low doses of PCI have accomplished a significant reduction in the incidence of brain metastasis with little toxicity. Whether such treatment truly improves survival awaits the results of additional prospective randomized trials.
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Affiliation(s)
- J H Rubenstein
- Radiation Therapy Regional Center, Fort Myers, FL 33908, USA
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Komaki R, Meyers CA, Shin DM, Garden AS, Byrne K, Nickens JA, Cox JD. Evaluation of cognitive function in patients with limited small cell lung cancer prior to and shortly following prophylactic cranial irradiation. Int J Radiat Oncol Biol Phys 1995; 33:179-82. [PMID: 7642416 DOI: 10.1016/0360-3016(95)00026-u] [Citation(s) in RCA: 166] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE Cognitive deficits after treatment for small cell lung cancer (SCLC) have been attributed to prophylactic cranial irradiation (PCI). A prospective study of neuropsychological function was undertaken to document the evolution and magnitude of neuropsychologic deficits. METHODS AND MATERIALS Thirty patients with limited stage SCLC who responded well (29 complete response (CR), 1 partial response (PR)) to combination chemotherapy plus thoracic irradiation or resection were studied with neuropsychological tests in the cognitive domains of intelligence, frontal lobe function, language, memory, visual-perception, and motor dexterity prior to a planned course of PCI. Nine patients had a neurologic history that could influence testing. RESULTS An unexpected 97% (29 out 30) of patients had evidence of cognitive dysfunction prior to PCI. The most frequent impairment was verbal memory, followed by frontal lobe dysfunction, and fine motor incoordination. Of the patients with no prior neurologic or substance abuse history, 20 out of 21 (95%) had impairments on neuropsychological assessment. This neurologically normal group was just as impaired as the group with such a history with respect to delayed verbal memory and frontal lobe executive function. Eleven patients had neuropsychological testing 6 to 20 months after PCI; no significant differences were found from their pretreatment tests. CONCLUSIONS A high proportion of neurologically normal patients was limited SCLC and favorable responses to combination chemotherapy have specific cognitive deficits before receiving PCI. Short-term (6 to 20 months) observations after PCI have shown no significant deterioration.
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Affiliation(s)
- R Komaki
- Department of Radiotherapy, University of Texas M.D. Anderson Cancer Center, Houston 77030, USA
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Okunieff P, Morgan D, Niemierko A, Suit HD. Radiation dose-response of human tumors. Int J Radiat Oncol Biol Phys 1995; 32:1227-37. [PMID: 7607946 DOI: 10.1016/0360-3016(94)00475-z] [Citation(s) in RCA: 233] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE The dose of radiation that locally controls human tumors treated electively or for gross disease is rarely well defined. These doses can be useful in understanding the dose requirements of novel therapies featuring inhomogeneous dosimetry and in an adjuvant setting. The goal of this study was to compute the dose of radiation that locally controls 50% (TCD50) of tumors in human subjects. METHODS AND MATERIALS Logit regression was used with data collected from single institutions or from combinations of local control data accumulated from several institutions treating the same disease. RESULTS 90 dose response curves were calculated; 62 of macroscopic tumor therapy, 28 of elective therapy with surgery for primary control. The mean and median TCD50 for gross disease were 50.0 and 51.9 Gy, respectively. The mean and median TCD50 for microscopic disease control were 39.3 and 37.9 Gy, respectively. At the TCD50, an additional dose of 1 Gy controlled an additional 2.5% (median) additional patients with macroscopic disease and 4.2% (median) additional patients with microscopic disease. For both macro- and microscopic disease, an increase of 1% of dose at the TCD50 increased control rates approximately 1% (median) or 2-3% (mean). A predominance of dose response curves had shallow slopes accounting for the discrepancy between mean and median values. CONCLUSION Doses to control microscopic disease are approximately 12 Gy less than that required to control macroscopic disease, and are about 79% of the dose required to control macroscopic disease. The percentage increase in cures expected for a 1% increase in dose is similar for macroscopic microscopic disease, with a median value of approximately 1%/% and a mean of approximately 2.7%/%.
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Affiliation(s)
- P Okunieff
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
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Liengswangwong V, Bonner JA, Shaw EG, Foote RL, Frytak S, Richardson RL, Creagan ET, Eagan RT, Su JQ. Prophylactic cranial irradiation in limited-stage small cell lung cancer. Cancer 1995; 75:1302-9. [PMID: 7882280 DOI: 10.1002/1097-0142(19950315)75:6<1302::aid-cncr2820750612>3.0.co;2-e] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The role of prophylactic cranial irradiation (PCI) for patients with limited-stage small cell lung cancer (LSSCLC) remains a controversial issue. This study evaluated PCI in patients with LSSCLC who achieved a complete response to initial chemotherapy. METHODS A retrospective case study of all nonprotocol patients with LSSCLC examined at our institution from 1982 to 1990 was performed. Of the 67 nonprotocol patients who were treated with combination chemotherapy (cyclophosphamide-based) and thoracic radiotherapy during those years, 43 achieved a complete response. Twenty-four patients received prophylactic cranial irradiation (PCI+) (25-36 Gy in 10-16 fractions), and 19 did not (PCI-) at the physician's or patient's discretion. RESULTS The distribution of prognostic factors between the PCI+ and PCI- groups was well balanced. Of the PCI+ patients, the 2-year actuarial freedom from relapse in the central nervous system was 93% versus 47% for the PCI- patients (log rank analysis, P = 0.001). An initial central nervous system relapse developed in 2 of the 24 PCI+ patients as the only site of failure versus 7 of 19 PCI- patients (P = 0.003). The 2-year actuarial overall survival was 50% for the PCI+ patients versus 21% for the PCI- patients (P = 0.01). The addition of prophylactic cranial irradiation was the only significant factor contributing to an improvement in time to central nervous system relapse and survival for the PCI+ patients. There were five patients alive at the time of this report, and all received prophylactic cranial irradiation. None had cognitive or neurologic impairment. CONCLUSIONS Prophylactic cranial irradiation may contribute to improved survival in patients with LSSCLC who achieve a complete response after chemotherapy and thoracic radiation therapy.
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Affiliation(s)
- V Liengswangwong
- Division of Radiation Oncology, Mayo Clinic, Rochester, Minnesota 55905
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Withers HR, Peters LJ, Taylor JM. Dose-response relationship for radiation therapy of subclinical disease. Int J Radiat Oncol Biol Phys 1995; 31:353-9. [PMID: 7836089 DOI: 10.1016/0360-3016(94)00354-n] [Citation(s) in RCA: 148] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE To determine the dose-response relationship for elective treatment of subclinical metastatic deposits and validate a model for metastatic tumor cell burden. METHODS AND MATERIALS The incidence of overt metastases in electively irradiated potential sites of spread from carcinomas of the head and neck, breast, cervix, ovary, lung, and testis, and from melanomas and osteosarcomas, was compared with the incidence in patients not receiving elective irradiation. The reduction in incidence of metastases was analyzed as a function of radiation dose. RESULTS The dose-response curve for control of subclinical metastases is linear and shallow, and extrapolates to a dose intercept not demonstrably different from zero. A small threshold may reflect growth of residual micrometastases between treatment for the primary and elective irradiation. The shallow linear dose response reflects interpatient heterogeneity in metastatic tumor cell burden, ranging from 1 to M cells, where M is the upper limit of clinical undetectability. While a dose of 50 Gy in 2 Gy fractions is necessary to achieve an overall 90% reduction in the incidence of metastases, the metastatic cell burden in a proportion of patients can be eliminated by low doses. Thus, worthwhile rates of control can still be achieved when "tolerance" dictates lower than optimal doses, evidenced by the linearity and lack of significant threshold in the dose-response curve. This is an important difference from treatment of gross disease. The biological effectiveness of elective treatment is measured directly by the percent reduction in failure rate. Although it depends upon the log cell kill, it relates only to that proportion of patients harboring subclinical disease, and, therefore, is not well described by the increase in the cure rate for the total patient population. The linear dose-response relationship for reduction in failure rate is independent of the "natural" (untreated) incidence of subclinical metastasis, and, therefore, of site, histology, growth rate, stage, or other characteristics of the tumor. Conversely, the clinical effectiveness of elective treatment is measured by increase in tumor control rate and depends upon the "natural" incidence of metastasis: the higher it is, the greater the absolute increase in cure rate from a constant biological effect (log cell kill). CONCLUSIONS (a) High control rates for subclinical metastases require doses of about 50 Gy in 2 Gy fractions, but worthwhile benefits can be achieved by lower doses if necessitated by reduced tolerance; (b) elective treatment of subclinical metastases should be instituted close to the time of treatment of the primary; (c) the biological effectiveness of elective radiation (or chemotherapy) should be measured by the percentage decrease in metastasis, not by improvements in the rate of control; and (d) demonstration of success in clinical trials of adjuvant therapy is more likely the higher the incidence of metastases in untreated controls.
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Affiliation(s)
- H R Withers
- Department of Radiation Oncology, UCLA 90024-1714
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Cull A, Gregor A, Hopwood P, Macbeth F, Karnicka-Mlodkowska H, Thatcher N, Burt P, Stout R, Stepniewska K, Stewart M. Neurological and cognitive impairment in long-term survivors of small cell lung cancer. Eur J Cancer 1994; 30A:1067-74. [PMID: 7654431 DOI: 10.1016/0959-8049(94)90458-8] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Despite its effectiveness in reducing the rate of brain metastases, the role of prophylactic cranial irradiation (PCI) in the management of small cell lung cancer (SCLC) remains controversial because of concern about radiation-induced neurological morbidity. In order to evaluate morbidity and its impact on quality of life 64 patients surviving > or = 2 years in remission were recalled for assessment. 52 had received PCI. Most of the patients were well: 95% had performance status < or = 1 and nine out of 37 neurological examinations were abnormal. On neuropsychometric testing, only 19% of patients performed at the level expected for their age and intellectual ability on all four tests used. Fifty-four per cent of patients were impaired on two or more of the tests, suggesting a significant degree of measurable cognitive dysfunction. The number of patients who had not received PCI was insufficient for comparative analysis with the number who had, but among those treated with PCI, patients receiving 8 Gy in 1 fraction appeared less impaired than those receiving higher radiation doses in multiple fractions. The study showed that neuropsychometric testing is acceptable to patients, can be administered by non-psychologists in the clinic and is sensitive to otherwise undetected deficits of cognitive function in this patient population. Prospective evaluation of PCI should include neuropsychometric testing.
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Affiliation(s)
- A Cull
- ICRF Medical Oncology Unit, Western General Hospital, Edinburgh, U.K
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