1
|
Strongyli E, Evangelidis P, Sakellari I, Gavriilaki M, Gavriilaki E. Change in Neurocognitive Function in Patients Who Receive CAR-T Cell Therapies: A Steep Hill to Climb. Pharmaceuticals (Basel) 2024; 17:591. [PMID: 38794161 PMCID: PMC11123727 DOI: 10.3390/ph17050591] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/01/2024] [Accepted: 05/02/2024] [Indexed: 05/26/2024] Open
Abstract
Immunotherapy with chimeric antigen receptor T (CAR-T) cell therapies has brought substantial improvement in clinical outcomes in patients with relapsed/refractory B cell neoplasms. However, complications such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) limit the therapeutic efficacy of this treatment approach. ICANS can have a broad range of clinical manifestations, while various scoring systems have been developed for its grading. Cognitive decline is prevalent in CAR-T therapy recipients including impaired attention, difficulty in item naming, and writing, agraphia, and executive dysfunction. In this review, we aim to present the diagnostic methods and tests that have been used for the recognition of cognitive impairment in these patients. Moreover, up-to-date data about the duration of cognitive impairment symptoms after the infusion are presented. More research on the risk factors, pathogenesis, preventive measures, and therapy of neurocognitive impairment is crucial for better outcomes for our patients.
Collapse
Affiliation(s)
- Evlampia Strongyli
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (E.S.); (I.S.)
| | - Paschalis Evangelidis
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
| | - Ioanna Sakellari
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (E.S.); (I.S.)
| | - Maria Gavriilaki
- 1st Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Eleni Gavriilaki
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (E.S.); (I.S.)
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
| |
Collapse
|
2
|
Aleksandrovic E, Zhang S, Yu D. From pre-clinical to translational brain metastasis research: current challenges and emerging opportunities. Clin Exp Metastasis 2024:10.1007/s10585-024-10271-9. [PMID: 38430319 DOI: 10.1007/s10585-024-10271-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/18/2024] [Indexed: 03/03/2024]
Abstract
Brain metastasis, characterized by poor clinical outcomes, is a devastating disease. Despite significant mechanistic and therapeutic advances in recent years, pivotal improvements in clinical interventions have remained elusive. The heterogeneous nature of the primary tumor of origin, complications in drug delivery across the blood-brain barrier, and the distinct microenvironment collectively pose formidable clinical challenges in developing new treatments for patients with brain metastasis. Although current preclinical models have deepened our basic understanding of the disease, much of the existing research on brain metastasis has employed a reductionist approach. This approach, which often relies on either in vitro systems or in vivo injection models in young and treatment-naive mouse models, does not give sufficient consideration to the clinical context. Given the translational importance of brain metastasis research, we advocate for the design of preclinical experimental models that take into account these unique clinical challenges and align more closely with current clinical practices. We anticipate that aligning and simulating real-world patient conditions will facilitate the development of more translatable treatment regimens. This brief review outlines the most pressing clinical challenges, the current state of research in addressing them, and offers perspectives on innovative metastasis models and tools aimed at identifying novel strategies for more effective management of clinical brain metastasis.
Collapse
Affiliation(s)
- Emilija Aleksandrovic
- Department of Pathology, Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, 6001 Forest Park Rd, Dallas, TX, 75235, USA
| | - Siyuan Zhang
- Department of Pathology, Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, 6001 Forest Park Rd, Dallas, TX, 75235, USA.
| | - Dihua Yu
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| |
Collapse
|
3
|
Sanchez-Aguilera A, Masmudi-Martín M, Navas-Olive A, Baena P, Hernández-Oliver C, Priego N, Cordón-Barris L, Alvaro-Espinosa L, García S, Martínez S, Lafarga M, Lin MZ, Al-Shahrour F, Menendez de la Prida L, Valiente M. Machine learning identifies experimental brain metastasis subtypes based on their influence on neural circuits. Cancer Cell 2023; 41:1637-1649.e11. [PMID: 37652007 PMCID: PMC10507426 DOI: 10.1016/j.ccell.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 05/26/2023] [Accepted: 07/26/2023] [Indexed: 09/02/2023]
Abstract
A high percentage of patients with brain metastases frequently develop neurocognitive symptoms; however, understanding how brain metastasis co-opts the function of neuronal circuits beyond a tumor mass effect remains unknown. We report a comprehensive multidimensional modeling of brain functional analyses in the context of brain metastasis. By testing different preclinical models of brain metastasis from various primary sources and oncogenic profiles, we dissociated the heterogeneous impact on local field potential oscillatory activity from cortical and hippocampal areas that we detected from the homogeneous inter-model tumor size or glial response. In contrast, we report a potential underlying molecular program responsible for impairing neuronal crosstalk by scoring the transcriptomic and mutational profiles in a model-specific manner. Additionally, measurement of various brain activity readouts matched with machine learning strategies confirmed model-specific alterations that could help predict the presence and subtype of metastasis.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Sonia Martínez
- Experimental Therapeutics Programme, CNIO, 28029 Madrid, Spain
| | - Miguel Lafarga
- Department of Anatomy and Cell Biology and CIBERNED, University of Cantabria- IDIVAL, 39011 Santander, Spain
| | - Michael Z Lin
- Departments of Neurobiology and Bioengineering, Stanford University, Stanford, CA 94305-5090, USA
| | | | | | | |
Collapse
|
4
|
Diehl CD, Giordano FA, Grosu AL, Ille S, Kahl KH, Onken J, Rieken S, Sarria GR, Shiban E, Wagner A, Beck J, Brehmer S, Ganslandt O, Hamed M, Meyer B, Münter M, Raabe A, Rohde V, Schaller K, Schilling D, Schneider M, Sperk E, Thomé C, Vajkoczy P, Vatter H, Combs SE. Opportunities and Alternatives of Modern Radiation Oncology and Surgery for the Management of Resectable Brain Metastases. Cancers (Basel) 2023; 15:3670. [PMID: 37509330 PMCID: PMC10377800 DOI: 10.3390/cancers15143670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Postsurgical radiotherapy (RT) has been early proven to prevent local tumor recurrence, initially performed with whole brain RT (WBRT). Subsequent to disadvantageous cognitive sequalae for the patient and the broad distribution of modern linear accelerators, focal irradiation of the tumor has omitted WBRT in most cases. In many studies, the effectiveness of local RT of the resection cavity, either as single-fraction stereotactic radiosurgery (SRS) or hypo-fractionated stereotactic RT (hFSRT), has been demonstrated to be effective and safe. However, whereas prospective high-level incidence is still lacking on which dose and fractionation scheme is the best choice for the patient, further ablative techniques have come into play. Neoadjuvant SRS (N-SRS) prior to resection combines straightforward target delineation with an accelerated post-surgical phase, allowing an earlier start of systemic treatment or rehabilitation as indicated. In addition, low-energy intraoperative RT (IORT) on the surgical bed has been introduced as another alternative to external beam RT, offering sterilization of the cavity surface with steep dose gradients towards the healthy brain. This consensus paper summarizes current local treatment strategies for resectable brain metastases regarding available data and patient-centered decision-making.
Collapse
Affiliation(s)
- Christian D Diehl
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 80336 München, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Anca-L Grosu
- Department of Radiation Oncology, University Medical Center, Medical Faculty, 79106 Freiburg, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Klaus-Henning Kahl
- Department of Radiation Oncology, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Julia Onken
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- Berlin Institute of Health, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- German Cancer Consortium (DKTK), Partner Site Berlin, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, 37075 Göttingen, Germany
- Comprehensive Cancer Center Niedersachsen (CCC-N), 37075 Göttingen, Germany
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Arthur Wagner
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Jürgen Beck
- Department of Neurosurgery, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Stefanie Brehmer
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Marc Münter
- Department of Radiation Oncology, Klinikum Stuttgart Katharinenhospital, 70174 Stuttgart, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Veit Rohde
- Department of Neurosurgery, Universitätsmedizin Göttingen, 37075 Göttingen, Germany
| | - Karl Schaller
- Department of Neurosurgery, University of Geneva Medical Center & Faculty of Medicine, 1211 Geneva, Switzerland
| | - Daniela Schilling
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Elena Sperk
- Mannheim Cancer Center, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 80336 München, Germany
| |
Collapse
|
5
|
Aizer AA, Lamba N, Ahluwalia MS, Aldape K, Boire A, Brastianos PK, Brown PD, Camidge DR, Chiang VL, Davies MA, Hu LS, Huang RY, Kaufmann T, Kumthekar P, Lam K, Lee EQ, Lin NU, Mehta M, Parsons M, Reardon DA, Sheehan J, Soffietti R, Tawbi H, Weller M, Wen PY. Brain metastases: A Society for Neuro-Oncology (SNO) consensus review on current management and future directions. Neuro Oncol 2022; 24:1613-1646. [PMID: 35762249 PMCID: PMC9527527 DOI: 10.1093/neuonc/noac118] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Brain metastases occur commonly in patients with advanced solid malignancies. Yet, less is known about brain metastases than cancer-related entities of similar incidence. Advances in oncologic care have heightened the importance of intracranial management. Here, in this consensus review supported by the Society for Neuro-Oncology (SNO), we review the landscape of brain metastases with particular attention to management approaches and ongoing efforts with potential to shape future paradigms of care. Each coauthor carried an area of expertise within the field of brain metastases and initially composed, edited, or reviewed their specific subsection of interest. After each subsection was accordingly written, multiple drafts of the manuscript were circulated to the entire list of authors for group discussion and feedback. The hope is that the these consensus guidelines will accelerate progress in the understanding and management of patients with brain metastases, and highlight key areas in need of further exploration that will lead to dedicated trials and other research investigations designed to advance the field.
Collapse
Affiliation(s)
- Ayal A Aizer
- Corresponding Author: Dr. Ayal A. Aizer, MD/MHS, Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA ()
| | | | | | - Kenneth Aldape
- Laboratory of Pathology, National Cancer Institute, Bethesda, Maryland, USA
| | - Adrienne Boire
- Department of Neurology, Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Priscilla K Brastianos
- Departments of Neuro-Oncology and Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - D Ross Camidge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Veronica L Chiang
- Departments of Neurosurgery and Radiation Oncology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael A Davies
- Department of Melanoma Medical Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Leland S Hu
- Department of Radiology, Neuroradiology Division, Mayo Clinic, Phoenix, Arizona, USA
| | - Raymond Y Huang
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | | | - Priya Kumthekar
- Department of Neurology at The Feinberg School of Medicine at Northwestern University and The Malnati Brain Tumor Institute at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois, USA
| | - Keng Lam
- Department of Neurology, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, California, USA
| | - Eudocia Q Lee
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Minesh Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida, USA
| | - Michael Parsons
- Departments of Oncology and Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David A Reardon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Riccardo Soffietti
- Division of Neuro-Oncology, Department of Neuroscience Rita Levi Montalcini, University of Turin, Turin, Italy
| | - Hussein Tawbi
- Department of Melanoma Medical Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Patrick Y Wen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| |
Collapse
|
6
|
Freeman M, Ennis M, Jerzak KJ. Karnofsky Performance Status (KPS) ≤60 Is Strongly Associated With Shorter Brain-Specific Progression-Free Survival Among Patients With Metastatic Breast Cancer With Brain Metastases. Front Oncol 2022; 12:867462. [PMID: 35965535 PMCID: PMC9364681 DOI: 10.3389/fonc.2022.867462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 06/14/2022] [Indexed: 11/22/2022] Open
Abstract
Objective To examine the association between Karnofsky Performance Status (“KPS”) and brain-specific progression-free survival (“bsPFS”) among patients with breast cancer brain metastases (“BCBrM”). Methods Using a previously compiled retrospective cohort of 683 patients who were treated for BCBrM with surgery and/or radiotherapy at the Sunnybrook Odette Cancer Centre from 2008-2018, electronic records were reviewed to impute KPS scores at the time of BCBrM diagnosis. Patients were then grouped into KPS ≤60 and KPS >60 cohorts. The dataset was analyzed to identify variables that were prognostic for bsPFS and/or overall survival (“OS”) using univariable and multivariable Cox proportional hazards models. Results The mean age of patients was 57 (range 24-93). Most patients (n=622, 91%) had extracranial metastatic disease and 174 (25%) had leptomeningeal disease. 247 patients (36%) had hormone receptor (“HR”)-positive/human endothelial growth factor receptor 2 (“HER2”)-negative tumours, 189 (28%) had HER2-positive disease, and 153 (22%) had triple-negative breast cancer. Of the 331 patients (48%) who could be assigned a KPS cohort, 102 (31%) had KPS ≤60. Most patients were treated with whole brain radiotherapy (n=498, 73%) and/or stereotactic radiosurgery (“SRS”) (n=128, 19%). Median bsPFS was 9 months (95% CI 8-10 months) and median OS was not reached. In univariable analyses, KPS ≤60, presence of leptomeningeal disease, neurological symptoms, ≥2 brain metastases, and not undergoing SRS were factors associated with shorter bsPFS. In a multivariable analysis, KPS ≤60 was the only statistically significant determinant of bsPFS (HR 1.86, 95% CI 1.20-2.88). Although survival data was limited, KPS ≤60 was associated with shorter OS in both univariable (HR 3.12, 95% CI 1.85-5.26) and multivariable (HR 2.95, 95% CI 1.55-5.58) analyses. Conclusion Patients with BCBrM who have a KPS ≤60 have significantly shorter bsPFS and OS than those with KPS >60. KPS should be documented routinely at the time of diagnosis of brain metastases to improve prognostication.
Collapse
Affiliation(s)
- Mark Freeman
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Katarzyna J. Jerzak
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Science Centre, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute (SRI), Toronto, ON, Canada
- *Correspondence: Katarzyna J. Jerzak,
| |
Collapse
|
7
|
Tsui DCC, Camidge DR, Rusthoven CG. Managing Central Nervous System Spread of Lung Cancer: The State of the Art. J Clin Oncol 2022; 40:642-660. [PMID: 34985937 DOI: 10.1200/jco.21.01715] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Brain metastases (BrM) are common in both non-small-cell lung cancer and small-cell lung cancer. Substantial progress in BrM management has occurred in the past decade related to advances in both radiation and medical oncology. Recent and ongoing radiation trials have focused on increasing the candidacy for focal therapy of BrM with stereotactic radiosurgery; reducing the toxicity and improving patient selection for whole brain radiotherapy; and, in small-cell lung cancer, evaluating brain magnetic resonance imaging surveillance without prophylactic cranial irradiation, hippocampal avoidance in prophylactic cranial irradiation and whole brain radiotherapy, and the role of upfront stereotactic radiosurgery for BrM. In medical oncology, the development of multiple tyrosine kinase inhibitors with encouraging CNS activity and emerging data on the CNS activity of immune checkpoint inhibitors in some patients have opened the door to novel systemic and multidisciplinary treatment strategies for the management of BrM. Future research will focus on more robust characterizations of the CNS activity of targeted therapy and immunotherapies, as well as optimal integration and patient selection for multidisciplinary strategies involving CNS-active drugs, radiation therapy, and CNS surveillance.
Collapse
Affiliation(s)
- David Chun Cheong Tsui
- Division of Medical Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
| | - D Ross Camidge
- Division of Medical Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
| |
Collapse
|
8
|
Parsons MW, Peters KB, Floyd SR, Brown P, Wefel JS. Preservation of neurocognitive function in the treatment of brain metastases. Neurooncol Adv 2021; 3:v96-v107. [PMID: 34859237 PMCID: PMC8633744 DOI: 10.1093/noajnl/vdab122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Neurocognitive function (NCF) deficits are common in patients with brain metastases, occurring in up to 90% of cases. NCF deficits may be caused by tumor-related factors and/or treatment for the metastasis, including surgery, radiation therapy, chemotherapy, and immunotherapy. In recent years, strategies to prevent negative impact of treatments and ameliorate cognitive deficits for patients with brain tumors have gained momentum. In this review, we report on research that has established the efficacy of preventative and rehabilitative therapies for NCF deficits in patients with brain metastases. Surgical strategies include the use of laser interstitial thermal therapy and intraoperative mapping. Radiotherapy approaches include focal treatments such as stereotactic radiosurgery and tailored approaches such as hippocampal avoidant whole-brain radiotherapy (WBRT). Pharmacologic options include use of the neuroprotectant memantine to reduce cognitive decline induced by WBRT and incorporation of medications traditionally used for attention and memory problems. Integration of neuropsychology into the care of patients with brain metastases helps characterize cognitive patterns, educate patients and families regarding their management, and guide rehabilitative therapies. These and other strategies will become even more important for long-term survivors of brain metastases as treatment options improve.
Collapse
Affiliation(s)
- Michael W Parsons
- Pappas Center for Neuro-Oncology, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Katherine B Peters
- Preston Robert Tisch Brain Tumor Center, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Scott R Floyd
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Paul Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey S Wefel
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
9
|
Gao YK, Kuksis M, Id Said B, Chehade R, Kiss A, Tran W, Sickandar F, Sahgal A, Warner E, Soliman H, Jerzak KJ. Treatment Patterns and Outcomes of Women with Symptomatic and Asymptomatic Breast Cancer Brain Metastases: A Single-Center Retrospective Study. Oncologist 2021; 26:e1951-e1961. [PMID: 34506676 DOI: 10.1002/onco.13965] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 08/31/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Breast cancer is the most common cancer among women worldwide and the second leading cause of brain metastases (BrM). We assessed the treatment patterns and outcomes of women treated for breast cancer BrM at our institution in the modern era of stereotactic radiosurgery (SRS). MATERIALS AND METHODS We conducted a retrospective analysis of women (≥18 years of age) with metastatic breast cancer who were treated with surgery, whole brain radiotherapy (WBRT), or SRS to the brain at the Sunnybrook Odette Cancer Centre, Toronto, Canada, between 2008 and 2018. Patients with a history of other malignancies and those with an uncertain date of diagnosis of BrM were excluded. Descriptive statistics were generated and survival analyses were performed with subgroup analyses by breast cancer subtype. RESULTS Among 683 eligible patients, 153 (22.4%) had triple-negative breast cancer, 188 (27.5%) had HER2+, 246 (36.0%) had hormone receptor (HR)+/HER2-, and 61 (13.3%) had breast cancer of an unknown subtype. The majority of patients received first-line WBRT (n = 459, 67.2%) or SRS (n = 126, 18.4%). The median brain-specific progression-free survival and median overall survival (OS) were 4.1 months (interquartile range [IQR] 1.0-9.6 months) and 5.1 months (IQR 2.0-11.7 months) in the overall patent population, respectively. Age >60 years, presence of neurological symptoms at BrM diagnosis, first-line WBRT, and HER2- subtype were independently prognostic for shorter OS. CONCLUSION Despite the use of SRS, outcomes among patients with breast cancer BrM remain poor. Strategies for early detection of BrM and central nervous system-active systemic therapies warrant further investigation. IMPLICATIONS FOR PRACTICE Although triple-negative breast cancer and HER2+ breast cancer have a predilection for metastasis to the central nervous system (CNS), patients with hormone receptor-positive/HER2- breast cancer represent a high proportion of patients with breast cancer brain metastases (BrM). Hence, clinical trials should include patients with BrM and evaluate CNS-specific activity of novel systemic therapies when feasible, irrespective of breast cancer subtype. In addition, given that symptomatic BrM are associated with shorter survival, this study suggests that screening programs for the early detection and treatment of breast cancer BrM warrant further investigation in an era of minimally toxic stereotactic radiosurgery.
Collapse
Affiliation(s)
- Yizhuo Kelly Gao
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Markus Kuksis
- School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Badr Id Said
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Rania Chehade
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Alex Kiss
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - William Tran
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Faisal Sickandar
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Ellen Warner
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Katarzyna J Jerzak
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
10
|
Parsons MW, Dietrich J. Assessment and Management of Cognitive Symptoms in Patients With Brain Tumors. Am Soc Clin Oncol Educ Book 2021; 41:e90-e99. [PMID: 34061562 DOI: 10.1200/edbk_320813] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Cognitive symptoms occur in almost all patients with brain tumors at varying points in the disease course. Deficits in neurocognitive function may be caused by the tumor itself, treatment (surgery, radiation, or chemotherapy), or other complicating factors (e.g., seizures, fatigue, mood disturbance) and can have a profound effect on functional independence and quality of life. Assessment of neurocognitive function is an important part of comprehensive care of patients with brain tumors. In the neuro-oncology clinic, assessment may include cognitive screening tools and inquiry into subjective cognitive function. Neuropsychological assessment is an important adjunct to identify cognitive symptoms and can be used as an opportunity to intervene through transformative feedback and treatment planning. Preventative measures can be taken to reduce cognitive side effects of treatment, such as awake craniotomies with intraoperative mapping during neurosurgery or prophylactic measures during radiation therapy (e.g., hippocampal avoidance, neuroprotectant treatment with memantine). Rehabilitative therapies, including cognitive rehabilitation and computerized cognitive exercise, are options for managing cognitive problems in an individualized manner. Pharmacotherapy, including use of stimulant medications and acetylcholinesterase inhibitors, has shown benefits for patients with brain tumors when tailored to an individual's cognitive profile. Identification and management of co-occurring issues, such as sleep disturbance, fatigue, and depression, can also improve neurocognitive function. There are promising therapies under development that may provide new options for treatment in the future. Integrating careful assessment and treatment of cognition throughout the disease course for patients with brain tumors can improve functional outcomes and quality of life.
Collapse
Affiliation(s)
- Michael W Parsons
- Pappas Center for Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Jörg Dietrich
- Pappas Center for Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| |
Collapse
|
11
|
Masmudi-Martín M, Zhu L, Sanchez-Navarro M, Priego N, Casanova-Acebes M, Ruiz-Rodado V, Giralt E, Valiente M. Brain metastasis models: What should we aim to achieve better treatments? Adv Drug Deliv Rev 2021; 169:79-99. [PMID: 33321154 DOI: 10.1016/j.addr.2020.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 11/16/2020] [Accepted: 12/04/2020] [Indexed: 02/07/2023]
Abstract
Brain metastasis is emerging as a unique entity in oncology based on its particular biology and, consequently, the pharmacological approaches that should be considered. We discuss the current state of modelling this specific progression of cancer and how these experimental models have been used to test multiple pharmacologic strategies over the years. In spite of pre-clinical evidences demonstrating brain metastasis vulnerabilities, many clinical trials have excluded patients with brain metastasis. Fortunately, this trend is getting to an end given the increasing importance of secondary brain tumors in the clinic and a better knowledge of the underlying biology. We discuss emerging trends and unsolved issues that will shape how we will study experimental brain metastasis in the years to come.
Collapse
|
12
|
Cifarelli CP, Vargo JA, Fang W, Liscak R, Guseynova K, Warnick RE, Lee CC, Yang HC, Borghei-Razavi H, Maiti T, Siddiqui ZA, Yuan JC, Grills IS, Mathieu D, Touchette CJ, Cordeiro D, Chiang V, Hess J, Tien CJ, Faramand A, Kano H, Barnett GH, Sheehan JP, Lunsford LD. Role of Gamma Knife Radiosurgery in Small Cell Lung Cancer: A Multi-Institutional Retrospective Study of the International Radiosurgery Research Foundation (IRRF). Neurosurgery 2021; 87:664-671. [PMID: 31599324 DOI: 10.1093/neuros/nyz428] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 08/04/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Despite a high incidence of brain metastases in patients with small-cell lung cancer (SCLC), limited data exist on the use of stereotactic radiosurgery (SRS), specifically Gamma Knife™ radiosurgery (Elekta AB), for SCLC brain metastases. OBJECTIVE To provide a detailed analysis of SCLC patients treated with SRS, focusing on local failure, distant brain failure, and overall survival (OS). METHODS A multi-institutional retrospective review was performed on 293 patients undergoing SRS for SCLC brain metastases at 10 medical centers from 1991 to 2017. Data collection was performed according to individual institutional review boards, and analyses were performed using binary logistic regression, Cox-proportional hazard models, Kaplan-Meier survival analysis, and competing risks analysis. RESULTS Two hundred thirty-two (79%) patients received SRS as salvage following prior whole-brain irradiation (WBRT) or prophylactic cranial irradiation, with a median marginal dose of 18 Gy. At median follow-up after SRS of 6.4 and 18.0 mo for surviving patients, the 1-yr local failure, distant brain failure, and OS were 31%, 49%, and 28%. The interval between WBRT and SRS was predictive of improved OS for patients receiving SRS more than 1 yr after initial treatment (21%, <1 yr vs 36%, >1 yr, P = .01). On multivariate analysis, older age was the only significant predictor for OS (hazard ratio 1.63, 95% CI 1.16-2.29, P = .005). CONCLUSION SRS plays an important role in the management of brain metastases from SCLC, especially in salvage therapy following WBRT. Ongoing prospective trials will better assess the value of radiosurgery in the primary management of SCLC brain metastases and potentially challenge the standard application of WBRT in SCLC patients.
Collapse
Affiliation(s)
- Christopher P Cifarelli
- Department of Neurosurgery, School of Medicine, West Virginia University, Morgantown, West Virginia.,Department of Radiation Oncology, School of Medicine, West Virginia University, Morgantown, West Virginia
| | - John A Vargo
- Department of Neurosurgery, School of Medicine, West Virginia University, Morgantown, West Virginia.,Department of Radiation Oncology, School of Medicine, West Virginia University, Morgantown, West Virginia
| | - Wei Fang
- West Virginia Clinical and Translational Science Institute, School of Medicine, West Virginia University, Morgantown, West Virginia
| | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Khumar Guseynova
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | | | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Tonmoy Maiti
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Zaid A Siddiqui
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Justin C Yuan
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - David Mathieu
- Division of Neurosurgery, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Canada
| | - Charles J Touchette
- Division of Neurosurgery, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Canada
| | - Diogo Cordeiro
- Department of Neurosurgery, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Veronica Chiang
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut.,Department of Radiation Oncology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Judith Hess
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut.,Department of Radiation Oncology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Christopher J Tien
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut.,Department of Radiation Oncology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Andrew Faramand
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hideyuki Kano
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gene H Barnett
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Jason P Sheehan
- Department of Neurosurgery, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
13
|
Gerstenecker A, Gammon M, Marotta D, Fiveash J, Nabors B, Mulhauser K, Triebel K. Clinical correlates of the ability to consent to research participation in brain metastasis. Psychooncology 2020; 29:1655-1661. [PMID: 33463869 DOI: 10.1002/pon.5487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Impairment in the ability to provide informed consent is common in persons with brain metastasis. However, little is known about what factors contribute to this impairment in the patient group. Our objective is to determine if the associations between demographic, cognitive, and clinical variables correlate with the ability to provide informed consent in persons with brain metastasis. METHODS We administered a comprehensive neuropsychological battery to a group of 61 persons with brain metastasis. Demographic and clinical information was also collected. All diagnoses were made by board-certified oncologists and were verified histologically. Statistical analyses included Pearson's product-moment correlations, point biserial correlations, and linear regression. RESULTS Results indicated that combinations of education, verbal memory, executive function, whole brain radiation therapy, and chemotherapy affected various aspects of the ability to provide informed consent. Subsequent regression models demonstrated that these variables contributed a significant amount of shared variance to the ability to provide informed consent. CONCLUSION We found that the ability of persons with brain metastasis to provide informed consent is a cognitively complex ability that is also affected by education and treatment variables. This information can help clinical researchers in identifying persons with brain metastasis at risk of an impaired ability to provide informed consent and aid in the consenting process.
Collapse
Affiliation(s)
- Adam Gerstenecker
- Department of Neurology, Division of Neuropsychology, University of Alabama, Birmingham, Alabama, USA.,Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Meredith Gammon
- Department of Neurology, Division of Neuropsychology, University of Alabama, Birmingham, Alabama, USA
| | - Dario Marotta
- Department of Neurology, Division of Neuropsychology, University of Alabama, Birmingham, Alabama, USA
| | - John Fiveash
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Burt Nabors
- Department of Neurology, Division of Neuropsychology, University of Alabama, Birmingham, Alabama, USA.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kyler Mulhauser
- Department of Neurology, Division of Neuropsychology, University of Alabama, Birmingham, Alabama, USA
| | - Kristen Triebel
- Department of Neurology, Division of Neuropsychology, University of Alabama, Birmingham, Alabama, USA.,Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, Birmingham, Alabama, USA.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
14
|
Eggen AC, Reyners AKL, Shen G, Bosma I, Jalving M, Leighl NB, Liu G, Richard NM, Mah K, Shultz DB, Edelstein K, Rodin G. Death Anxiety in Patients With Metastatic Non-Small Cell Lung Cancer With and Without Brain Metastases. J Pain Symptom Manage 2020; 60:422-429.e1. [PMID: 32145337 DOI: 10.1016/j.jpainsymman.2020.02.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/20/2020] [Accepted: 02/23/2020] [Indexed: 12/16/2022]
Abstract
CONTEXT Death anxiety is common in patients with metastatic cancer, but its relationship to brain metastases and cognitive decline is unknown. Early identification of death anxiety and its determinants allows proactive interventions to be offered to those in need. OBJECTIVES To identify psychological, physical, and disease-related (including brain metastases and cognitive impairment) factors associated with death anxiety in metastatic non-small cell lung cancer (mNSCLC) patients. METHODS A cross-sectional pilot study with mNSCLC outpatients completing standardized neuropsychological tests and validated questionnaires measuring death anxiety, cognitive concerns, illness intrusiveness, depression, demoralization, self-esteem, and common cancer symptoms. We constructed a composite for objective cognitive function (mean neuropsychological tests z-scores). RESULTS Study measures were completed by 78 patients (50% females; median age 62 years [range 37-82]). Median time since mNSCLC diagnosis was 11 months (range 0-89); 53% had brain metastases. At least moderate death anxiety was reported by 43% (n = 33). Objective cognitive impairment was present in 41% (n = 32) and perceived cognitive impairment in 27% (n = 21). Death anxiety, objective, and perceived cognitive impairment did not significantly differ between patients with and without brain metastases. In univariate analysis, death anxiety was associated with demoralization, depression, self-esteem, illness intrusiveness, common physical cancer symptoms, and perceived cognitive impairment. In multivariate analysis, demoralization (P < 0.001) and illness intrusiveness (P = 0.001) were associated with death anxiety. CONCLUSION Death anxiety and brain metastases are common in patients with mNSCLC but not necessarily linked. The association of death anxiety with both demoralization and illness intrusiveness highlights the importance of integrated psychological and symptom management. Further research is needed on the psychological impact of brain metastases.
Collapse
Affiliation(s)
- Annemarie C Eggen
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Anna K L Reyners
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Gerald Shen
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Ingeborg Bosma
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Mathilde Jalving
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Natasha B Leighl
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Geoffrey Liu
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Nadine M Richard
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Kenneth Mah
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - David B Shultz
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Kim Edelstein
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.
| |
Collapse
|
15
|
Mulhauser K, Marotta DA, Gerstenecker A, Wilhelm G, Myers T, Gammon M, Vance DE, Nabors B, Fiveash J, Triebel K. Capacity to consent to research participation in adults with metastatic cancer: comparisons of brain metastasis, non-CNS metastasis, and healthy controls. Neurooncol Pract 2020; 7:439-445. [PMID: 32765894 DOI: 10.1093/nop/npaa008] [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] [Indexed: 01/04/2023] Open
Abstract
Background To evaluate the ability of individuals with metastatic cancer to provide informed consent to research participation, we used a structured vignette-based interview to measure 4 consenting standards across 3 participant groups. Methods Participants included 61 individuals diagnosed with brain metastasis, 41 individuals diagnosed with non-CNS metastasis, and 17 cognitively intact healthy controls. All groups were evaluated using the Capacity to Consent to Research Instrument (CCRI), a performance-based measure of research consent capacity. The ability to provide informed consent to participate in research was evaluated across 4 consent standards: expressing choice, appreciation, reasoning, and understanding. Capacity performance ratings (intact, mild/moderate impairment, severe impairment) were identified based on control group performance. Results Results revealed that the brain metastasis group performed significantly lower than healthy controls on the consent standard of understanding, while both metastatic cancer groups performed below controls on the consent standard of reasoning. Both metastatic cancer groups performed similar to controls on the standards of appreciation and expressing choice. Approximately 60% of the brain metastasis group, 54% of the non-CNS metastasis group, and 18% of healthy controls showed impaired research consent capacity. Conclusions Our findings, using a performance-based assessment, are consistent with other research indicating that the research consent process may be overly cumbersome and confusing. This, in turn, may lead to research consent impairment not only in patient groups but also in some healthy adults with intact cognitive ability.
Collapse
Affiliation(s)
- Kyler Mulhauser
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, US.,O'Neal Comprehensive Cancer Center at UAB, Birmingham, Alabama, US
| | - Dario A Marotta
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, US.,O'Neal Comprehensive Cancer Center at UAB, Birmingham, Alabama, US.,Alabama College of Osteopathic Medicine, Dothan, Alabama, US
| | - Adam Gerstenecker
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, US
| | - Gabrielle Wilhelm
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, US.,O'Neal Comprehensive Cancer Center at UAB, Birmingham, Alabama, US
| | - Terina Myers
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, US.,O'Neal Comprehensive Cancer Center at UAB, Birmingham, Alabama, US
| | - Meredith Gammon
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, US.,O'Neal Comprehensive Cancer Center at UAB, Birmingham, Alabama, US
| | - David E Vance
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, US.,O'Neal Comprehensive Cancer Center at UAB, Birmingham, Alabama, US
| | - Burt Nabors
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, US.,O'Neal Comprehensive Cancer Center at UAB, Birmingham, Alabama, US
| | - John Fiveash
- O'Neal Comprehensive Cancer Center at UAB, Birmingham, Alabama, US.,Department of Radiation Oncology, University of Alabama at Birmingham, US
| | - Kristen Triebel
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, US.,O'Neal Comprehensive Cancer Center at UAB, Birmingham, Alabama, US
| |
Collapse
|
16
|
Ramakrishna R, Formenti S. Radiosurgery and Immunotherapy in the Treatment of Brain Metastases. World Neurosurg 2020; 130:615-622. [PMID: 31581411 DOI: 10.1016/j.wneu.2019.04.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/26/2019] [Accepted: 03/28/2019] [Indexed: 01/19/2023]
Abstract
Radiation therapy represents a mainstay of treatment for patients with brain metastases. Recently, the widespread adoption of immune checkpoint blockade has led to keen interest in treating cancers with checkpoint inhibitors in place of, or as an adjunct to, traditional chemotherapy. However, with the exception of melanoma, immune checkpoint blockade in solid tumors has failed to achieve significant brain control in patients with brain metastases. The possibility of combining immune checkpoint blockade with radiation for the treatment of brain and other metastases represents an exciting new strategy that is in its early stages of investigation. Success with this combinatorial strategy has the potential to result in enhanced rates of brain control, less brain exposure to radiation, and improved cognitive outcomes. In this review, we discuss the mechanisms behind this synergy, describe its limitations, and suggest ways to move the field forward.
Collapse
Affiliation(s)
- Rohan Ramakrishna
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA.
| | - Silvia Formenti
- Department of Radiation Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| |
Collapse
|
17
|
Schimmel WCM, Gehring K, Hanssens PEJ, Sitskoorn MM. Cognitive functioning and predictors thereof in patients with 1-10 brain metastases selected for stereotactic radiosurgery. J Neurooncol 2019; 145:265-276. [PMID: 31552588 PMCID: PMC6856035 DOI: 10.1007/s11060-019-03292-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 09/16/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE Information on predictive factors of cognitive functioning in patients with (multiple) brain metastases (BM) selected for radiosurgery may allow for more individual care and may play a role in predicting cognitive outcome after radiosurgery. The aim of this study was to evaluate cognitive performance, and predictors thereof, in patients with 1-10 BM before radiosurgery. METHODS Cognition was measured before radiosurgery using a standardized neuropsychological test battery in patients with 1-10 BM (expected survival > 3 months; KPS ≥ 70; no prior BM treatment). Regression formulae were constructed to calculate sociodemographically corrected z scores. Group and individual cognitive functioning was analyzed. Multivariable regression was used to explore potential predictors. RESULTS Patients (N = 92) performed significantly worse than controls (N = 104) on all 11 test variables (medium-large effect sizes for 8 variables). Percentages of impairment were highest for information processing (55.3%), dexterity (43.2%) and cognitive flexibility (28.7%). 62% and 46% of patients had impairments in at least two, or three test variables, respectively. Models including combinations of clinical and psychological variables were predictive of verbal memory, psychomotor speed, information processing and dexterity. Neither number nor volume of metastases predicted patients' test performance. CONCLUSIONS Already before radiosurgery, almost half of the patients suffered from severe cognitive deficits in at least three test variables. At group and individual level, information processing, cognitive flexibility, and dexterity were most affected. These cognitive impairments may impair daily functioning and patients' ability to make (shared) treatment decisions. Both clinical (symptomatic BM; timing of BM diagnosis) and psychological (mental fatigue) characteristics influenced cognitive performance. CLINICAL TRIAL INFORMATION Cognition and Radiation Study A (CAR-Study A; ClinicalTrials.gov Identifier: NCT02953756; Medical Ethics Committee file number: NL53472.028.15/P1515).
Collapse
Affiliation(s)
- Wietske C M Schimmel
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands. .,Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands. .,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands. .,Department of Cognitive Neuropsychology, Tilburg University, Simon Building; Room S221, P.O. Box 90153, 5000 LE, Tilburg, The Netherlands.
| | - Karin Gehring
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
| | - Patrick E J Hanssens
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.,Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Margriet M Sitskoorn
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
| |
Collapse
|
18
|
Noll KR, Bradshaw ME, Parsons MW, Dawson EL, Rexer J, Wefel JS. Monitoring of Neurocognitive Function in the Care of Patients with Brain Tumors. Curr Treat Options Neurol 2019; 21:33. [PMID: 31250277 DOI: 10.1007/s11940-019-0573-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW A detailed characterization of the nature of neurocognitive impairment in patients with brain tumors is provided, as well as considerations for clinical practice regarding neuropsychological assessment throughout the disease course. RECENT FINDINGS Neurocognitive impairment is common in patients with brain tumors and may result from the tumor itself, as a consequence of treatment, including surgery, chemotherapy, and radiation, or in association with supportive care medications (e.g., anticonvulsant and pain medications). Serial surveillance of neurocognitive functioning in this population can facilitate medical decision-making and inform recommendations to improve patient daily functioning and quality of life. Neuropsychological assessment is increasingly recognized as a critical component of the multidisciplinary care of patients with brain tumors and has already had practice-changing effects. Further understanding of genetic risk factors for neurocognitive decline along with the development of novel assessment and intervention strategies may further enhance functioning and general well-being in this patient population.
Collapse
Affiliation(s)
- Kyle R Noll
- Section of Neuropsychology, Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 431, Houston, TX, 77030, USA
| | - Mariana E Bradshaw
- Section of Neuropsychology, Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 431, Houston, TX, 77030, USA
| | - Michael W Parsons
- Department of Neuro-Oncology, Psychology Assessment Center, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Erica L Dawson
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, OH, 43210, USA
| | - Jennie Rexer
- Section of Neuropsychology, Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 431, Houston, TX, 77030, USA
| | - Jeffrey S Wefel
- Section of Neuropsychology, Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 431, Houston, TX, 77030, USA. .,Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.
| |
Collapse
|
19
|
Fecci PE, Champion CD, Hoj J, McKernan CM, Goodwin CR, Kirkpatrick JP, Anders CK, Pendergast AM, Sampson JH. The Evolving Modern Management of Brain Metastasis. Clin Cancer Res 2019; 25:6570-6580. [PMID: 31213459 DOI: 10.1158/1078-0432.ccr-18-1624] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/23/2019] [Accepted: 06/13/2019] [Indexed: 12/11/2022]
Abstract
The incidence of brain metastases is increasing as cancer therapies improve and patients live longer, providing new challenges to the multidisciplinary teams that care for these patients. Brain metastatic cancer cells possess unique characteristics that allow them to penetrate the blood-brain barrier, colonize the brain parenchyma, and persist in the intracranial environment. In addition, brain metastases subvert the innate and adaptive immune system, permitting evasion of the antitumor immune response. Better understanding of the above mechanisms will allow for development and delivery of more effective therapies for brain metastases. In this review, we outline the molecular mechanisms underlying development, survival, and immunosuppression of brain metastases. We also discuss current and emerging treatment strategies, including surgery, radiation, disease-specific and mutation-targeted systemic therapy, and immunotherapy.
Collapse
Affiliation(s)
- Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina.,Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
| | - Cosette D Champion
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina.,Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
| | - Jacob Hoj
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
| | - Courtney M McKernan
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina.,Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
| | - John P Kirkpatrick
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina.,Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina.,Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Carey K Anders
- Duke Cancer Institute, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Ann Marie Pendergast
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
| | - John H Sampson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina. .,Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
20
|
Abstract
Radiotherapy is used in >50% of patients with cancer, both for curative and palliative purposes. Radiotherapy uses ionizing radiation to target and kill tumour tissue, but normal tissue can also be damaged, leading to toxicity. Modern and precise radiotherapy techniques, such as intensity-modulated radiotherapy, may prevent toxicity, but some patients still experience adverse effects. The physiopathology of toxicity is dependent on many parameters, such as the location of irradiation or the functional status of organs at risk. Knowledge of the mechanisms leads to a more rational approach for controlling radiotherapy toxicity, which may result in improved symptom control and quality of life for patients. This improved quality of life is particularly important in paediatric patients, who may live for many years with the long-term effects of radiotherapy. Notably, signs and symptoms occurring after radiotherapy may not be due to the treatment but to an exacerbation of existing conditions or to the development of new diseases. Although differential diagnosis may be difficult, it has important consequences for patients.
Collapse
|
21
|
Schimmel WCM, Verhaak E, Hanssens PEJ, Gehring K, Sitskoorn MM. A randomised trial to compare cognitive outcome after gamma knife radiosurgery versus whole brain radiation therapy in patients with multiple brain metastases: research protocol CAR-study B. BMC Cancer 2018; 18:218. [PMID: 29466961 PMCID: PMC5822552 DOI: 10.1186/s12885-018-4106-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 02/08/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Gamma Knife radiosurgery (GKRS) is increasingly applied in patients with multiple brain metastases and is expected to have less adverse effects in cognitive functioning than whole brain radiation therapy (WBRT). Effective treatment with the least negative cognitive side effects is increasingly becoming important, as more patients with brain metastases live longer due to more and better systemic treatment options. There are no published randomized trials yet directly comparing GKRS to WBRT in patients with multiple brain metastases that include objective neuropsychological testing. METHODS CAR-Study B is a prospective randomised trial comparing cognitive outcome after GKRS or WBRT in adult patients with 11-20 newly diagnosed brain metastases on a contrast-enhanced MRI-scan, KPS ≥70 and life expectancy of at least 3 months. Randomisation by the method of minimization, is stratified by the cumulative tumour volume in the brain, systemic treatment, KPS, histology, baseline cognitive functioning and age. The primary endpoint is the between-group difference in the percentage of patients with significant memory decline at 3 months. Secondary endpoints include overall survival, local control, development of new brain metastases, cognitive functioning over time, quality of life, depression, anxiety and fatigue. Cognitive functioning is assessed by a standardised neuropsychological test battery. Assessments (cognitive testing, questionnaires and MRI-scans) are scheduled at baseline and at 3, 6, 9, 12 and 15 months after treatment. DISCUSSION Knowledge gained from this trial may be used to inform individual patients with BM more precisely about the cognitive effects they can expect from treatment, and to assist both doctors and patients in making (shared) individual treatment decisions. This trial is currently recruiting. Target accrual: 23 patients at 3-months follow-up in both groups. TRIAL REGISTRATION The Netherlands Trials Register number NTR5463. ClinicalTrials.gov registration number NCT02953717 , first received October 27, 2016, 8 patients were enrolled in this study on 31 July 2017.
Collapse
Affiliation(s)
- Wietske C. M. Schimmel
- Gamma Knife Centre Tilburg, Elisabeth TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB Tilburg, The Netherlands
| | - Eline Verhaak
- Gamma Knife Centre Tilburg, Elisabeth TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB Tilburg, The Netherlands
| | - Patrick E. J. Hanssens
- Gamma Knife Centre Tilburg, Elisabeth TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands
- Department Neurosurgery, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands
| | - Karin Gehring
- Gamma Knife Centre Tilburg, Elisabeth TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands
- Department Neurosurgery, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB Tilburg, The Netherlands
| | - Margriet M. Sitskoorn
- Department Neurosurgery, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB Tilburg, The Netherlands
| |
Collapse
|