1
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Silvestri VL, Tran AD, Chung M, Chung N, Gril B, Robinson C, Difilippantonio S, Wei D, Kruhlak MJ, Peer CJ, Figg WD, Khan I, Steeg PS. Distinct uptake and elimination profiles for trastuzumab, human IgG, and biocytin-TMR in experimental HER2+ brain metastases of breast cancer. Neuro Oncol 2024; 26:1067-1082. [PMID: 38363979 PMCID: PMC11145443 DOI: 10.1093/neuonc/noae025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND The aim of this study is an improved understanding of drug distribution in brain metastases. Rather than single point snapshots, we analyzed the time course and route of drug/probe elimination (clearance), focusing on the intramural periarterial drainage (IPAD) pathway. METHODS Mice with JIMT1-BR HER2+ experimental brain metastases were injected with biocytin-TMR and either trastuzumab or human IgG. Drugs/probes circulated for 5 min to 48 h, followed by perfusion. Brain sections were stained for human IgG, vascular basement membrane proteins laminin or collagen IV, and periarterial α-SMA. A machine learning algorithm was developed to identify metastases, metastatic microenvironment, and uninvolved brain in confocally scanned brain sections. Drug/probe intensity over time and total imaged drug exposure (iAUC) were calculated for 27,249 lesions and co-immunofluorescence with IPAD-vascular matrix analyzed in 11,668 metastases. RESULTS In metastases, peak trastuzumab levels were 5-fold higher than human IgG but 4-fold less than biocytin-TMR. The elimination phase constituted 85-93% of total iAUC for all drugs/probes tested. For trastuzumab, total iAUC during uptake was similar to the small molecule drug probe biocytin-TMR, but slower trastuzumab elimination resulted in a 1.7-fold higher total iAUC. During elimination trastuzumab and IgG were preferentially enriched in the α-SMA+ periarterial vascular matrix, consistent with the IPAD clearance route; biocytin-TMR showed heterogeneous elimination pathways. CONCLUSIONS Drug/probe elimination is an important component of drug development for brain metastases. We identified a prolonged elimination pathway for systemically administered antibodies through the periarterial vascular matrix that may contribute to the sustained presence and efficacy of large antibody therapeutics.
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Affiliation(s)
- Vanesa L Silvestri
- Women’s Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Andy D Tran
- Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
- CCR Microscopy Core, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Monika Chung
- Women’s Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Natalie Chung
- Women’s Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Brunilde Gril
- Women’s Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Christina Robinson
- Laboratory Animal Sciences Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Simone Difilippantonio
- Laboratory Animal Sciences Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Debbie Wei
- Women’s Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Michael J Kruhlak
- Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
- CCR Microscopy Core, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Cody J Peer
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - W Douglas Figg
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Imran Khan
- Women’s Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Patricia S Steeg
- Women’s Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
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Wallace G, Kundalia R, Vallebuona E, Cao B, Kim Y, Forsyth P, Soyano A, Smalley I, Pina Y. Factors associated with overall survival in breast cancer patients with leptomeningeal disease (LMD): a single institutional retrospective review. Breast Cancer Res 2024; 26:55. [PMID: 38553702 PMCID: PMC10979566 DOI: 10.1186/s13058-024-01789-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 02/15/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Breast cancer-related leptomeningeal disease (BC-LMD) is a dire diagnosis for 5-8% of patients with breast cancer (BC). We conducted a retrospective review of BC-LMD patients diagnosed at Moffitt Cancer Center from 2011 to 2020, to determine the changing incidence of BC-LMD, factors which are associated with the progression of BC CNS metastasis to BC-LMD, and factors which are associated with OS for patients with BC-LMD. METHODS Patients with BC and brain/spinal metastatic disease were identified. For those who eventually developed BC-LMD, we used Kaplan-Meier survival curve, log-rank test, univariable, and multivariate Cox proportional hazards regression model to identify factors affecting time from CNS metastasis to BC-LMD and OS. RESULTS 128 cases of BC-LMD were identified. The proportion of BC-LMD to total BC patients was higher between 2016 and 2020 when compared to 2011-2015. Patients with HR+ or HER2 + BC experienced longer times between CNS metastasis and LMD than patients with triple-negative breast cancer (TNBC). Systemic therapy and whole-brain radiation therapy (WBRT) was associated with prolonged progression to LMD in all patients. Hormone therapy in patients with HR + BC were associated with a delayed BC-CNS metastasis to LMD progression. Lapatinib treatment was associated with a delayed progression to LMD in patients with HER2 + BC. Patients with TNBC-LMD had shorter OS compared to those with HR + and HER2 + BC-LMD. Systemic therapy, intrathecal (IT) therapy, and WBRT was associated with prolonged survival for all patients. Lapatinib and trastuzumab therapy was associated with improved OS in patients with HER2 + BC-LMD. CONCLUSIONS Increasing rates of BC-LMD provide treatment challenges and opportunities for clinical trials. Prospective trials testing lapatinib and/or similar tyrosine kinase inhibitors, IT therapies, and combination treatments are urgently needed.
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Affiliation(s)
- Gerald Wallace
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
- Department of Neurology, Medical College of Georgia, Augusta, GA, USA
| | - Ronak Kundalia
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
- Department of Metabolism and Physiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Ethan Vallebuona
- Department of Metabolism and Physiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Biwei Cao
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Youngchul Kim
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Peter Forsyth
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
- Department of Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Aixa Soyano
- Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Inna Smalley
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA.
| | - Yolanda Pina
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA.
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3
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Sevieri M, Mazzucchelli S, Barbieri L, Garbujo S, Carelli S, Bonizzi A, Rey F, Recordati C, Recchia M, Allevi R, Sitia L, Morasso C, Zerbi P, Prosperi D, Corsi F, Truffi M. Ferritin nanoconjugates guide trastuzumab brain delivery to promote an antitumor response in murine HER2 + breast cancer brain metastasis. Pharmacol Res 2023; 196:106934. [PMID: 37734460 DOI: 10.1016/j.phrs.2023.106934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/31/2023] [Accepted: 09/18/2023] [Indexed: 09/23/2023]
Abstract
Brain metastasis (BM) represents a clinical challenge for patients with advanced HER2 + breast cancer (BC). The monoclonal anti-HER2 antibody trastuzumab (TZ) improves survival of BC patients, but it has low central nervous system penetrance, being ineffective in treating BM. Previous studies showed that ferritin nanoparticles (HFn) may cross the blood brain barrier (BBB) through binding to the transferrin receptor 1 (TfR1). However, whether this has efficacy in promoting the trans-BBB delivery of TZ and combating BC BM was not studied yet. Here, we investigated the potential of HFn to drive TZ brain delivery and promote a targeted antitumor response in a murine model of BC BM established by stereotaxic injection of engineered BC cells overexpressing human HER2. HFn were covalently conjugated with TZ to obtain a nanoconjugate endowed with HER2 and TfR1 targeting specificity (H-TZ). H-TZ efficiently achieved TZ brain delivery upon intraperitoneal injection and triggered stable targeting of cancer cells. Treatment with H-TZ plus docetaxel significantly reduced tumor growth and shaped a protective brain microenvironment by engaging macrophage activation toward cancer cells. H-TZ-based treatment also avoided TZ-associated cardiotoxicity by preventing drug accumulation in the heart and did not induce any other major side effects when combined with docetaxel. These results provided in vivo demonstration of the pharmacological potential of H-TZ, able to tackle BC BM in combination with docetaxel. Indeed, upon systemic administration, the nanoconjugate guides TZ brain accumulation, reduces BM growth and limits side effects in off-target organs, thus showing promise for the management of HER2 + BC metastatic to the brain.
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Affiliation(s)
- Marta Sevieri
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, via G.B. Grassi 74, 20157 Milan, Italy
| | - Serena Mazzucchelli
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, via G.B. Grassi 74, 20157 Milan, Italy
| | - Linda Barbieri
- Department of Biotechnology and Biosciences, University of Milano-Bicocca, P.zza della Scienza 2, 20126 Milano, Italy
| | - Stefania Garbujo
- Department of Biotechnology and Biosciences, University of Milano-Bicocca, P.zza della Scienza 2, 20126 Milano, Italy
| | - Stephana Carelli
- Pediatric Clinical Research Center "Romeo ed Enrica Invernizzi", Department of Biomedical and Clinical Science, University of Milan, 20157 Milan, Italy; Center of Functional Genomics and Rare Diseases, Department of Pediatrics, Buzzi Children's Hospital, Milano, Italy
| | - Arianna Bonizzi
- Istituti Clinici Scientifici Maugeri IRCCS, via Maugeri 4, 27100 Pavia, Italy
| | - Federica Rey
- Pediatric Clinical Research Center "Romeo ed Enrica Invernizzi", Department of Biomedical and Clinical Science, University of Milan, 20157 Milan, Italy; Center of Functional Genomics and Rare Diseases, Department of Pediatrics, Buzzi Children's Hospital, Milano, Italy
| | - Camilla Recordati
- Mouse and Animal Pathology Laboratory, Fondazione Unimi, viale Ortles 22/4, 20139 Milano, Italy; Dipartimento di Medicina Veterinaria e Scienze Animali, Università di Milano, via dell'Università 6, 26900 Lodi, Italy
| | - Matteo Recchia
- Mouse and Animal Pathology Laboratory, Fondazione Unimi, viale Ortles 22/4, 20139 Milano, Italy; Dipartimento di Medicina Veterinaria e Scienze Animali, Università di Milano, via dell'Università 6, 26900 Lodi, Italy
| | - Raffaele Allevi
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, via G.B. Grassi 74, 20157 Milan, Italy
| | - Leopoldo Sitia
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, via G.B. Grassi 74, 20157 Milan, Italy
| | - Carlo Morasso
- Istituti Clinici Scientifici Maugeri IRCCS, via Maugeri 4, 27100 Pavia, Italy
| | - Pietro Zerbi
- Anatomia Patologica, ASST Santi Paolo e Carlo, via Pio II, 3, Milano, Italy
| | - Davide Prosperi
- Department of Biotechnology and Biosciences, University of Milano-Bicocca, P.zza della Scienza 2, 20126 Milano, Italy
| | - Fabio Corsi
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, via G.B. Grassi 74, 20157 Milan, Italy; Istituti Clinici Scientifici Maugeri IRCCS, via Maugeri 4, 27100 Pavia, Italy.
| | - Marta Truffi
- Istituti Clinici Scientifici Maugeri IRCCS, via Maugeri 4, 27100 Pavia, Italy.
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4
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Wallace G, Kundalia R, Cao B, Kim Y, Smalley I, Forsyth P, Soyano A, Pina Y. Factors improving overall survival in breast cancer patients with leptomeningeal disease (LMD): A single institutional retrospective review. RESEARCH SQUARE 2023:rs.3.rs-2981094. [PMID: 37333166 PMCID: PMC10275046 DOI: 10.21203/rs.3.rs-2981094/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Background Breast cancer-related leptomeningeal disease (BC-LMD) is a dire diagnosis for 5-8% of patients with breast cancer (BC). We conducted a retrospective review of BC-LMD patients diagnosed at Moffitt Cancer Center (MCC) from 2011-2020, to determine the changing incidence of BC-LMD, which factors impact progression of BC CNS metastasis to BC-LMD, and which factors affect OS for patients with BC-LMD. Methods Patients with BC and brain/spinal metastatic disease were identified. For those who eventually developed BC-LMD, we used Kaplan-Meier survival curve, log-rank test, univariable, and multivariate Cox proportional hazards regression model to identify factors affecting time from CNS metastasis to BC-LMD and OS. Results 128 cases of BC-LMD were identified. The proportion of BC-LMD to total BC patients was higher between 2016-2020 when compared to 2011-2015. Patients with HR + or HER2 + BC experienced longer times between CNS metastasis and LMD than patients with triple-negative breast cancer (TNBC). Systemic therapy and whole-brain radiation therapy (WBRT) prolonged progression to LMD in all patients. Hormone therapy in patients with HR + BC delayed BC-CNS metastasis to LMD progression. Lapatinib delayed progression to LMD in patients with HER2 + BC. Patients with TNBC-LMD had shorter OS compared to those with HR + and HER2 + BC-LMD. Systemic therapy, intrathecal (IT) therapy, and WBRT prolonged survival for all patients. Lapatinib and trastuzumab improved OS in patients with HER2 + BC-LMD. Conclusions Increasing rates of BC-LMD provide treatment challenges and opportunities for clinical trials. Trials testing lapatinib and/or similar tyrosine kinase inhibitors, IT therapies, and combination treatments are urgently needed.
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Affiliation(s)
| | | | - Biwei Cao
- H. Lee Moffitt Cancer Center and Research Institute
| | | | - Inna Smalley
- H. Lee Moffitt Cancer Center and Research Institute
| | | | - Aixa Soyano
- H. Lee Moffitt Cancer Center and Research Institute
| | - Yolanda Pina
- H. Lee Moffitt Cancer Center and Research Institute
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5
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Chang CA, Jen J, Jiang S, Sayad A, Mer AS, Brown KR, Nixon AM, Dhabaria A, Tang KH, Venet D, Sotiriou C, Deng J, Wong KK, Adams S, Meyn P, Heguy A, Skok JA, Tsirigos A, Ueberheide B, Moffat J, Singh A, Haibe-Kains B, Khodadadi-Jamayran A, Neel BG. Ontogeny and Vulnerabilities of Drug-Tolerant Persisters in HER2+ Breast Cancer. Cancer Discov 2022; 12:1022-1045. [PMID: 34911733 PMCID: PMC8983469 DOI: 10.1158/2159-8290.cd-20-1265] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 10/14/2021] [Accepted: 12/10/2021] [Indexed: 11/16/2022]
Abstract
Resistance to targeted therapies is an important clinical problem in HER2-positive (HER2+) breast cancer. "Drug-tolerant persisters" (DTP), a subpopulation of cancer cells that survive via reversible, nongenetic mechanisms, are implicated in resistance to tyrosine kinase inhibitors (TKI) in other malignancies, but DTPs following HER2 TKI exposure have not been well characterized. We found that HER2 TKIs evoke DTPs with a luminal-like or a mesenchymal-like transcriptome. Lentiviral barcoding/single-cell RNA sequencing reveals that HER2+ breast cancer cells cycle stochastically through a "pre-DTP" state, characterized by a G0-like expression signature and enriched for diapause and/or senescence genes. Trajectory analysis/cell sorting shows that pre-DTPs preferentially yield DTPs upon HER2 TKI exposure. Cells with similar transcriptomes are present in HER2+ breast tumors and are associated with poor TKI response. Finally, biochemical experiments indicate that luminal-like DTPs survive via estrogen receptor-dependent induction of SGK3, leading to rewiring of the PI3K/AKT/mTORC1 pathway to enable AKT-independent mTORC1 activation. SIGNIFICANCE DTPs are implicated in resistance to anticancer therapies, but their ontogeny and vulnerabilities remain unclear. We find that HER2 TKI-DTPs emerge from stochastically arising primed cells ("pre-DTPs") that engage either of two distinct transcriptional programs upon TKI exposure. Our results provide new insights into DTP ontogeny and potential therapeutic vulnerabilities. This article is highlighted in the In This Issue feature, p. 873.
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Affiliation(s)
- Chewei Anderson Chang
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jayu Jen
- Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Shaowen Jiang
- Applied Bioinformatics Laboratories, Office of Science and Research, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Azin Sayad
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Arvind Singh Mer
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Kevin R. Brown
- Donnelly Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Avantika Dhabaria
- Proteomics Laboratory, Division of Advanced Research and Technology, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA.,Department of Biochemistry and Molecular Pharmacology, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Kwan Ho Tang
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - David Venet
- Breast Cancer Translational Research Laboratory, Institut Jules Bordet Brussels and Université Libre de Bruxelles (ULB), Belgium
| | - Christos Sotiriou
- Breast Cancer Translational Research Laboratory, Institut Jules Bordet Brussels and Université Libre de Bruxelles (ULB), Belgium.,Medical Oncology Department, Institut Jules Bordet Brussels and Université Libre de Bruxelles (ULB), Belgium
| | - Jiehue Deng
- Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA.,Division of Hematology and Medical Oncology, Department of Medicine, Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Kwok-kin Wong
- Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA.,Division of Hematology and Medical Oncology, Department of Medicine, Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Sylvia Adams
- Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA.,Division of Hematology and Medical Oncology, Department of Medicine, Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Peter Meyn
- Genome Technology Center, Division of Advanced Research Technologies, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Adriana Heguy
- Genome Technology Center, Division of Advanced Research Technologies, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Jane A. Skok
- Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA.,Department of Pathology, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Aristotelis Tsirigos
- Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA.,Applied Bioinformatics Laboratories, Office of Science and Research, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA.,Department of Pathology, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Beatrix Ueberheide
- Proteomics Laboratory, Division of Advanced Research and Technology, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA.,Department of Biochemistry and Molecular Pharmacology, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Jason Moffat
- Donnelly Centre, University of Toronto, Toronto, Ontario, Canada.,Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada.,Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Abhyudai Singh
- Department of Electrical and Computer Engineering, University of Delaware, Newark, Delaware, USA.,Department of Biomedical Engineering, University of Delaware, Newark, Delaware, USA
| | - Benjamin Haibe-Kains
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Computer Science, University of Toronto, Toronto, Ontario, Canada.,Ontario Institute for Cancer Research, Toronto, Ontario, Canada.,Vector Institute for Artificial Intelligence, Toronto, Ontario, Canada
| | - Alireza Khodadadi-Jamayran
- Applied Bioinformatics Laboratories, Office of Science and Research, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Benjamin G. Neel
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA.,Division of Hematology and Medical Oncology, Department of Medicine, Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, New York University Langone Health, New York, New York, USA
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6
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Ippolito E, Silipigni S, Matteucci P, Greco C, Carrafiello S, Palumbo V, Tacconi C, Talocco C, Fiore M, D’Angelillo RM, Ramella S. Radiotherapy for HER 2 Positive Brain Metastases: Urgent Need for a Paradigm Shift. Cancers (Basel) 2022; 14:cancers14061514. [PMID: 35326665 PMCID: PMC8946529 DOI: 10.3390/cancers14061514] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 01/09/2023] Open
Abstract
Brain metastases (BMs) are common among patients affected by HER2+ metastatic breast cancer (>30%). The management of BMs is usually multimodal, including surgery, radiotherapy, systemic therapy and palliative care. Standard brain radiotherapy (RT) includes the use of stereotactic radiotherapy (SRT) for limited disease and whole brain radiotherapy (WBRT) for extensive disease. The latter is an effective palliative treatment but has a reduced effect on brain local control and BM overall survival, as it is also associated with severe neurocognitive sequelae. Recent advances both in radiation therapy and systemic treatment may change the paradigm in this subset of patients who can experience long survival notwithstanding BMs. In fact, in recent studies, SRT for multiple BM sites (>4) has shown similar efficacy when compared to irradiation of a limited number of lesions (one to three) without increasing toxicity. These findings, in addition to the introduction of new drugs with recognized intracranial activity, may further limit the use of WBRT in favor of SRT, which should be employed for treatment of both multiple-site BMs and for oligo-progressive brain disease. This review summarizes the supporting literature and highlights the need for optimizing combinations of the available treatments in this setting, with a particular focus on radiation therapy.
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Affiliation(s)
- Edy Ippolito
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
| | - Sonia Silipigni
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
| | - Paolo Matteucci
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
- Correspondence: ; Tel.: +39-06225411708
| | - Carlo Greco
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
| | - Sofia Carrafiello
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
| | - Vincenzo Palumbo
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
| | - Claudia Tacconi
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
| | - Claudia Talocco
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
| | - Michele Fiore
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
| | | | - Sara Ramella
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
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7
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Lim M, Nguyen TH, Niland C, Reid LE, Jat PS, Saunus JM, Lakhani SR. Landscape of Epidermal Growth Factor Receptor Heterodimers in Brain Metastases. Cancers (Basel) 2022; 14:cancers14030533. [PMID: 35158800 PMCID: PMC8833370 DOI: 10.3390/cancers14030533] [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: 12/26/2021] [Revised: 01/18/2022] [Accepted: 01/20/2022] [Indexed: 12/10/2022] Open
Abstract
Simple Summary HER2+ breast cancer patients are treated with agents that tag HER2+ tumour cells for elimination by the immune system, down-modulate HER2 activity and/or block the formation of HER2 dimers, including the neuregulin-1 receptor, HER2-HER3. HER2-targeted therapies prolong survival by lowering the risk of relapse, but do not prevent brain metastases. The reasons for this are not fully understood. We quantified HER2-HER3 dimers in 203 brain metastases, and 34 primary breast tumour samples. Dimer frequency was relatively high in brain metastases from breast, ovarian, lung and kidney cancers, and in brain metastases compared to patient-matched breast tumours; but did not reliably correlate with HER2/HER3 expression or activation. In in vitro experiments, pertuzumab failed to suppress HER2-HER3 dimers in HER2+ breast cancer cells provided with a saturating concentration of neuregulin-1. These findings may provide insights about the differences in intracranial versus extracranial efficacy of HER2-targeted therapies. Abstract HER2+ breast cancer patients have an elevated risk of developing brain metastases (BM), despite adjuvant HER2-targeted therapy. The mechanisms underpinning this reduced intracranial efficacy are unclear. We optimised the in situ proximity ligation assay (PLA) for detection of the high-affinity neuregulin-1 receptor, HER2-HER3 (a key target of pertuzumab), in archival tissue samples and developed a pipeline for high throughput extraction of PLA data from fluorescent microscope image files. Applying this to a large BM sample cohort (n = 159) showed that BM from breast, ovarian, lung and kidney cancers have higher HER2-HER3 levels than other primary tumour types (melanoma, colorectal and prostate cancers). HER2 status, and tumour cell membrane expression of pHER2(Y1221/1222) and pHER3(Y1222) were positively, but not exclusively, associated with HER2-HER3 frequency. In an independent cohort (n = 78), BM had significantly higher HER2-HER3 levels than matching primary tumours (p = 0.0002). For patients who had two craniotomy procedures, HER2-HER3 dimer levels were lower in the consecutive lesion (n = 7; p = 0.006). We also investigated the effects of trastuzumab and pertuzumab on five different heterodimers in vitro: HER2-EGFR, HER2-HER4, HER2-HER3, HER3-HER4, HER3-EGFR. Treatment significantly altered the absolute frequencies of individual complexes in SKBr3 and/or MDA-MB-361 cells, but in the presence of neuregulin-1, the overall distribution was not markedly altered, with HER2-HER3 and HER2-HER4 remaining predominant. Together, these findings suggest that markers of HER2 and HER3 expression are not always indicative of dimerization, and that pertuzumab may be less effective at reducing HER2-HER3 dimerization in the context of excess neuregulin.
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Affiliation(s)
- Malcolm Lim
- Faculty of Medicine, UQ Centre for Clinical Research, The University of Queensland, Herston, QLD 4029, Australia; (M.L.); (C.N.); (L.E.R.)
| | - Tam H. Nguyen
- Flow Cytometry and Imaging Facility, QIMR Berghofer Medical Research Institute, Brisbane, QLD 4006, Australia;
| | - Colleen Niland
- Faculty of Medicine, UQ Centre for Clinical Research, The University of Queensland, Herston, QLD 4029, Australia; (M.L.); (C.N.); (L.E.R.)
| | - Lynne E. Reid
- Faculty of Medicine, UQ Centre for Clinical Research, The University of Queensland, Herston, QLD 4029, Australia; (M.L.); (C.N.); (L.E.R.)
| | - Parmjit S. Jat
- Department of Neurodegenerative Disease and MRC Prion Unit, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK;
| | - Jodi M. Saunus
- Faculty of Medicine, UQ Centre for Clinical Research, The University of Queensland, Herston, QLD 4029, Australia; (M.L.); (C.N.); (L.E.R.)
- Correspondence: (J.M.S.); (S.R.L.)
| | - Sunil R. Lakhani
- Faculty of Medicine, UQ Centre for Clinical Research, The University of Queensland, Herston, QLD 4029, Australia; (M.L.); (C.N.); (L.E.R.)
- Pathology Queensland, Royal Brisbane Women’s Hospital, Herston, QLD 4029, Australia
- Correspondence: (J.M.S.); (S.R.L.)
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8
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Chilà G, Guarini V, Galizia D, Geuna E, Montemurro F. The Clinical Efficacy and Safety of Neratinib in Combination with Capecitabine for the Treatment of Adult Patients with Advanced or Metastatic HER2-Positive Breast Cancer. Drug Des Devel Ther 2021; 15:2711-2720. [PMID: 34188449 PMCID: PMC8232377 DOI: 10.2147/dddt.s281599] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/07/2021] [Indexed: 11/23/2022] Open
Abstract
Human epidermal growth factor receptor 2 (HER2) positive cancers account for 15–20% of all breast tumors. Several drugs have been approved in the metastatic setting, including monoclonal antibodies, tyrosine kinase inhibitors (TKI) and, more recently, antibody-drug conjugates. Neratinib is a pan-HER, irreversible TKI with potent preclinical activity against trastuzumab-resistant breast cancer models. Based on Phase I and II clinical trials, the combination of neratinib plus capecitabine was compared to lapatinib and capecitabine, an established regimen for trastuzumab-resistant disease, in the randomized, Phase III NALA trial. In this trial, neratinib yielded increased progression-free survival, response duration and a benefit in time to intervention for CNS progression. However, there was no overall survival benefit, no increase in overall response rate and no improvement in QoL. The most frequent adverse event in the neratinib arm was diarrhea, which was manageable with prophylactic treatment with loperamide. Conclusion: Neratinib is a valuable addition to the therapeutic armamentarium to treat metastatic, HER2-positive breast cancer. The current positioning of the combination of neratinib and capecitabine based on the results of the NALA trial needs to consider the rapidly evolving scenario due to the recent introduction of new drugs, like the pure-HER2 TKI tucatinib and the antibody drug-conjugate trastuzumab-deruxtecan.
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Affiliation(s)
- Giovanna Chilà
- Multidisciplinary Oncology Outpatient Clinic, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, 10060, Italy
| | - Vincenzo Guarini
- Multidisciplinary Oncology Outpatient Clinic, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, 10060, Italy
| | - Danilo Galizia
- Multidisciplinary Oncology Outpatient Clinic, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, 10060, Italy
| | - Elena Geuna
- Multidisciplinary Oncology Outpatient Clinic, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, 10060, Italy
| | - Filippo Montemurro
- Multidisciplinary Oncology Outpatient Clinic, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, 10060, Italy
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9
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Ratosa I, Vidmar MS. Stereotactic radiosurgery for patients with breast cancer brain oligometastases - molecular subtypes and clinical outcomes. ACTA ACUST UNITED AC 2021; 26:1-11. [PMID: 33948296 DOI: 10.5603/rpor.a2021.0001] [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: 06/26/2020] [Accepted: 12/07/2020] [Indexed: 11/25/2022]
Abstract
Background We sought to determine the clinical outcomes of patients with breast cancer (BC) who had undergone stereotactic radiosurgery (SRS) for a limited number of brain metastases (BM) and to identify factors influencing overall survival (OS) and local control. Materials and methods The records of 45 patients who underwent SRS for 72 brain lesions were retrospectively evaluated. Statistics included the chi-squared test, Kaplan-Meier method, and the multivariate Cox model. Results The median number of treated BM was 2 (range 1-10). Median OS from BM diagnosis and post-SRS were 27.6 [95% confidence interval (CI): 14.8-40.5) and 18.5 months (95% CI: 11.1-25.8), respectively. One-year and two-year survival rates after BM diagnosis were 55% and 41%, respectively. In a univariate analysis, the Luminal-B-human-epidermal-growth-receptor-positive (HER2+) subtype had the longest median OS at 39.1 months (95% CI: 34.1-44.1, p = 0.004). In an adjusted analysis, grade 2 [hazard ratio (HR): 0.1; 95% CI: 0.1-0.6, p = 0.005), craniotomy (HR: 0.3; 95% CI: 0.1-0.7; p = 0.006), and ≥ 2 systemic therapies received (HR: 0.3; 95% CI: 0.1-0.9, p = 0.028) were associated with improved OS. One-year and two-year intracranial progression-free survival rates were 85% and 63%, respectively. Four factors for a higher risk of any intracranial recurrence remained significant in the adjusted analysis, as follows: age < 50 years (HR: 4.2; 95% CI: 1.3-36.3; p = 0.014), grade 3 (HR: 3.7; 95% CI: 1.1-13.2; p = 0.038), HER2+ (HR: 6.9; 95% CI: 1.3-36.3; p = 0.023), and whether the brain was the first metastatic site (HR: 4.7; 95% CI: 1.6-14.5; p = 0.006). Conclusion Intrinsic BC characteristics are important determinants for both survival and intracranial control for patients undergoing SRS for oligometastatic brain disease.
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Affiliation(s)
- Ivica Ratosa
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Marija Skoblar Vidmar
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
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10
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Bai X, Lin X, Song J, Chang JH, Han LL, Fan C. Incidence of central nervous system metastases in patients with human epidermal growth factor receptor 2-positive metastatic breast cancer treated with trastuzumab: A meta-analysis. Clinics (Sao Paulo) 2021; 76:e2653. [PMID: 34406268 PMCID: PMC8341052 DOI: 10.6061/clinics/2021/e2653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/03/2021] [Indexed: 11/18/2022] Open
Abstract
This study aimed to estimate the incidence of central nervous system (CNS) metastases in patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (MBC) treated with trastuzumab. Studies were identified through a literature search of electronic databases. Random-effects meta-analyses were performed to estimate the incidence rate of CNS metastases, trastuzumab therapy duration, and time from trastuzumab therapy to CNS metastasis diagnosis. A meta-analysis of odds ratios was performed to evaluate the significance of a difference in CNS metastasis incidence between patients with and without trastuzumab treatment. Thirty studies (8121 trastuzumab-treated and 3972 control patients) were included. The follow-up duration was 18.9 months (95% confidence interval [CI]: 13.8, 24.1). The trastuzumab treatment duration was 9.0 months (95% CI: 7.0, 11.0). The median interval between the start of trastuzumab therapy and CNS metastasis diagnosis was 12.2 months (95% CI: 9.5, 14.7). The incidence of CNS metastasis after the start of trastuzumab therapy was 22% (95% CI: 16, 27). The incidence of CNS metastases was significantly higher in trastuzumab-treated than in non-trastuzumab-treated patients (odds ratio: 1.39 [95% CI: 1.06, 1.82], p=0.02). The survival time from the start of the study was 23.4 months (95% CI: 19.7, 27.1) in trastuzumab-treated patients and 18.4 months (95% CI: 12.7, 24.1) in patients treated with control regimens. The survival time after the development of CNS metastases in trastuzumab-treated patients was 19.2 months (95% CI: 15.6, 25.9). Approximately 22% of patients with HER2-positive MBC who were treated with trastuzumab developed CNS metastases. However, trastuzumab-treated patients had a longer survival than patients who were not treated with trastuzumab.
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Affiliation(s)
- Xue Bai
- Corresponding author. E-mail:
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11
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Santos J, Arantes J, Carneiro E, Ferreira D, Silva SM, Palma de Sousa S, Arantes M. Brain metastases from breast cancer. Clin Neurol Neurosurg 2020; 197:106150. [PMID: 32920499 DOI: 10.1016/j.clineuro.2020.106150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/07/2020] [Accepted: 08/09/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Breast cancer (BC) is one of the commonest causes of brain metastases (BM): approximately 10-16 % of patients diagnosed with metastatic breast cancer will eventually develop BM during the course of their disease, however, certain subtypes have a higher risk of this event. The aim of this analysis was therefore to evaluate the prognosis and the pattern and imaging features of BM according to different BC subtypes. PATIENTS AND METHODS We retrospectively reviewed the case records of patients with breast cancer and evidence of brain metastases from the database of IPO Porto between 2014-2018. The data obtained were statistically analysed. RESULTS We analysed 147 patients with BM from BC. The triple-negative subtype had the shortest overall survival (OS) after BM, besides a short period of time between BC and BM. HER2 overexpressing tumors had the longest OS. The estrogen-receptor positive group had the greatest interval between initial BC diagnosis and diagnosis of BM. Larger lesions showed a heterogeneous contrast enhancement and were heterogeneous pn T2WI sequences; a hyposignal on T2*WI was also associated with larger lesions. Triple-negative BC tended to have more heterogeneous lesions on T1WI. We noticed that the hippocampus is rarely affected by metastatic lesions. CONCLUSIONS Based on the BC subtype it is possible to make a prediction about the prognosis of the disease and some imaging features of the BM, but not about their pattern of distribution. These data support further research concerning prevention, early detection, and treatment of BM from BC.
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Affiliation(s)
- Joana Santos
- Faculty of Medicine of the University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Joana Arantes
- Psychology School, University of Minho, Campus de Gualtar, 4710-057 Braga, Portugal
| | - Eduarda Carneiro
- Division of Neuroradiology, Department of Radiology, Portuguese Institute of Oncology, R. Dr. António Bernardino de Almeida 865, 4200-072 Porto, Portugal
| | - Diana Ferreira
- Division of Neuroradiology, Department of Radiology, Portuguese Institute of Oncology, R. Dr. António Bernardino de Almeida 865, 4200-072 Porto, Portugal
| | - Susana Maria Silva
- Faculty of Medicine of the University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal; Unit of Anatomy, Department of Biomedicine, Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Rua Dr. Plácido Da Costa, s/n, 4200-450 Porto, Portugal
| | - Susana Palma de Sousa
- Department of Medical Oncology, Portuguese Institute of Oncology, R. Dr. António Bernardino de Almeida 865, 4200-072 Porto, Portugal
| | - Mavilde Arantes
- Faculty of Medicine of the University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal; Division of Neuroradiology, Department of Radiology, Portuguese Institute of Oncology, R. Dr. António Bernardino de Almeida 865, 4200-072 Porto, Portugal; Unit of Anatomy, Department of Biomedicine, Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Rua Dr. Plácido Da Costa, s/n, 4200-450 Porto, Portugal.
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12
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Zimmer AS, Steinberg SM, Smart DD, Gilbert MR, Armstrong TS, Burton E, Houston N, Biassou N, Gril B, Brastianos PK, Carter S, Lyden D, Lipkowitz S, Steeg PS. Temozolomide in secondary prevention of HER2-positive breast cancer brain metastases. Future Oncol 2020; 16:899-909. [PMID: 32270710 PMCID: PMC7270957 DOI: 10.2217/fon-2020-0094] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 03/25/2020] [Indexed: 01/11/2023] Open
Abstract
Brain metastases occur in up to 25-55% of patients with metastatic HER2-positive breast cancer. Standard treatment has high rates of recurrence or progression, limiting survival and quality of life in most patients. Temozolomide (TMZ) is known to penetrate the blood-brain barrier and is US FDA approved for treatment of glioblastoma. Our group has demonstrated that low doses of TMZ administered in a prophylactic, metronomic fashion can significantly prevent development of brain metastases in murine models of breast cancer. Based on these findings, we initiated a secondary-prevention clinical trial with oral TMZ given to HER2-positive breast cancer patients with brain metastases after recent local treatment in combination with T-DM1 for systemic control of disease. Primary end point is freedom from new brain metastases at 1 year. (NCT03190967).
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Affiliation(s)
- Alexandra S Zimmer
- Women's Malignancies Branch, National Cancer Institute, NIH, Bethesda, MD 20814, USA
| | - Seth M Steinberg
- Biostatistics & Data Management Section, National Cancer Institute, NIH, Bethesda, MD 20814, USA
| | - Dee Dee Smart
- Radiation Oncology Branch, National Cancer Institute, NIH, Bethesda, MD 20814, USA
| | - Mark R Gilbert
- Neuro-Oncology Branch, National Cancer Institute, NIH, Bethesda, MD 20814, USA
| | - Terri S Armstrong
- Neuro-Oncology Branch, National Cancer Institute, NIH, Bethesda, MD 20814, USA
| | - Eric Burton
- Neuro-Oncology Branch, National Cancer Institute, NIH, Bethesda, MD 20814, USA
| | - Nicole Houston
- Women's Malignancies Branch, National Cancer Institute, NIH, Bethesda, MD 20814, USA
| | - Nadia Biassou
- Neuro-Radiology, Clinical Center, NIH, Bethesda, MD 20814, USA
| | - Brunilde Gril
- Women's Malignancies Branch, National Cancer Institute, NIH, Bethesda, MD 20814, USA
| | - Priscilla K Brastianos
- Central Nervous System Metastases Program, Massachusetts General Hospital/Harvard Cancer Center Boston, MA 02114, USA
| | - Scott Carter
- Biostatistics and Computation Biology, Dana-Farber Cancer Institute, Boston, MA 02114, USA
| | - David Lyden
- Pediatric Hematology Oncology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Stanley Lipkowitz
- Women's Malignancies Branch, National Cancer Institute, NIH, Bethesda, MD 20814, USA
| | - Patricia S Steeg
- Women's Malignancies Branch, National Cancer Institute, NIH, Bethesda, MD 20814, USA
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13
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Risk factors for breast cancer brain metastases: a systematic review. Oncotarget 2020; 11:650-669. [PMID: 32110283 PMCID: PMC7021234 DOI: 10.18632/oncotarget.27453] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/04/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Brain metastasis (BM) is an increasingly common and devastating complication of breast cancer (BC). Methods: A systematic literature search of EMBASE and MEDLINE was conducted to elucidate the current state of knowledge on known and novel prognostic factors associated with 1) the risk for BCBM and 2) the time to brain metastases (TTBM). Results: A total of 96 studies involving institutional records from 28 countries were identified. Of these, 69 studies reported risk factors of BCBM, 46 factors associated with the TTBM and twenty studies examined variables for both outcomes. Young age, estrogen receptor negativity (ER-), overexpression of human epidermal factor (HER2+), and higher presenting stage, histological grade, tumor size, Ki67 labeling index and nodal involvement were consistently found to be independent risk factors of BCBM. Of these, triple-negative BC (TNBC) subtype, ER-, higher presenting histological grade, tumor size, and nodal involvement were also reported to associate with shorter TTBM. In contrast, young age, hormone receptor negative (HR-) status, higher presenting stage, nodal involvement and development of liver metastasis were the most important risk factors for BM in HER2-positive patients. Conclusions: The study provides a comprehensive and individual evaluation of the risk factors that could support the design of screening tools and interventional trials for early detection of BCBM.
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14
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Jiang J, Wu L, Yuan F, Ji J, Lin X, Yang W, Wu J, Shi M, Yang H, Ma Y, Song X, Zhu Z, Zhang H, Zhang J. Characterization of the immune microenvironment in brain metastases from different solid tumors. Cancer Med 2020; 9:2299-2308. [PMID: 32017467 PMCID: PMC7131856 DOI: 10.1002/cam4.2905] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 01/19/2020] [Accepted: 01/21/2020] [Indexed: 12/26/2022] Open
Abstract
Background Brain metastases are one of the most common intracranial neoplasms. Increasing evidence have indicated that systemic immunotherapy may provide long‐term benefits for brain metastases. Herein, we presented the results of an immune oncology panel RNA sequencing platform for patients with brain metastases from different primary sites. Methods We investigated 25 samples of human brain metastases from lung cancer (n = 12), breast cancer (n = 6), and colorectal cancer (n = 7). Besides, 13 paired samples of adjacent noncancerous brain tissue (10 from patients with lung cancer and 3 from patients with breast cancer) were collected as controls. By comparing the brain metastases and paired samples of adjacent noncancerous brain tissue from 13 patients, we detected three upregulated and six downregulated genes, representing the malignant properties of cancer cells and increased immune infiltration in the microenvironment. Next, we profiled the immune‐related genes in brain metastases from three primary cancer types. Results A group of genes were significantly overexpressed in the microenvironment of brain metastases from lung cancer, covering the checkpoint pathways, lymphocyte infiltration, and TCR‐coexpression. Especially, immune checkpoint molecules, PD‐L1, PD‐L2, and IDO1 were expressed at higher levels in brain metastases from lung cancer than those from the other two cancer types. Conclusions This study presents an immune landscape of brain metastases from different cancer types. With high RNA expression levels of PD‐1/PD‐L1 axis and immune infiltration in brain metastases, it would be worthwhile to explore the efficacy of immune checkpoint blockade for lung cancer patients with intracranial metastases.
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Affiliation(s)
- Jinling Jiang
- Department of Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lihong Wu
- Genecast Precision Medicine Technology Institute, Beijing, China
| | - Fei Yuan
- Department of Pathology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jun Ji
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaojing Lin
- Genecast Precision Medicine Technology Institute, Beijing, China
| | - Wanning Yang
- Genecast Precision Medicine Technology Institute, Beijing, China
| | - Junwei Wu
- Department of Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Min Shi
- Department of Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hui Yang
- Department of Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yanna Ma
- Genecast Precision Medicine Technology Institute, Beijing, China
| | - Xue Song
- Genecast Precision Medicine Technology Institute, Beijing, China
| | - Zhenggang Zhu
- Department of Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Henghui Zhang
- Institute of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Jun Zhang
- Department of Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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15
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Liang Y, Zhang H, Song X, Yang Q. Metastatic heterogeneity of breast cancer: Molecular mechanism and potential therapeutic targets. Semin Cancer Biol 2019; 60:14-27. [PMID: 31421262 DOI: 10.1016/j.semcancer.2019.08.012] [Citation(s) in RCA: 391] [Impact Index Per Article: 78.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 08/11/2019] [Accepted: 08/12/2019] [Indexed: 02/08/2023]
Abstract
Breast cancer is one of the most common malignancies among women throughout the world and is the major cause of most cancer-related deaths. Several explanations account for the high rate of mortality of breast cancer, and metastasis to vital organs is identified as the principal cause. Over the past few years, intensive efforts have demonstrated that breast cancer exhibits metastatic heterogeneity with distinct metastatic precedence to various organs, giving rise to differences in prognoses and responses to therapy in breast cancer patients. Bone, lung, liver, and brain are generally accepted as the primary target sites of breast cancer metastasis. However, the underlying molecular mechanism of metastatic heterogeneity of breast cancer remains to be further elucidated. Recently, the advent of novel genomic and pathologic approaches as well as technological breakthroughs in imaging analysis and animal modelling have yielded an unprecedented change in our understanding of the heterogeneity of breast cancer metastasis and provided novel insight for establishing more effective therapeutics. This review summarizes recent molecular mechanisms and emerging concepts on the metastatic heterogeneity of breast cancer and discusses the potential of identifying specific molecules against tumor cells or tumor microenvironments to thwart the development of metastatic disease and improve the prognosis of breast cancer patients.
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Affiliation(s)
- Yiran Liang
- Department of Breast Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, 250012, PR China
| | - Hanwen Zhang
- Department of Breast Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, 250012, PR China
| | - Xiaojin Song
- Department of Breast Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, 250012, PR China
| | - Qifeng Yang
- Department of Breast Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, 250012, PR China; Pathology Tissue Bank, Qilu Hospital, Shandong University, Jinan, Shandong, 250012, PR China.
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16
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Komorowski AS, Warner E, MacKay HJ, Sahgal A, Pritchard KI, Jerzak KJ. Incidence of Brain Metastases in Nonmetastatic and Metastatic Breast Cancer: Is There a Role for Screening? Clin Breast Cancer 2019; 20:e54-e64. [PMID: 31447286 DOI: 10.1016/j.clbc.2019.06.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 03/24/2019] [Accepted: 06/28/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Current National Comprehensive Cancer Network and American Society of Clinical Oncology guidelines recommend against screening breast cancer patients for asymptomatic brain metastases. Because brain metastases are a major cause of morbidity and mortality from breast cancer, we undertook a literature review to ascertain whether there might be a role for brain metastases screening in high-risk patient subgroups. MATERIALS AND METHODS A literature search was conducted on the OvidSP platform in the MedLine database, using MeSH terms and subject headings related to breast cancer, brain metastases, and incidence. The search was conducted without language or publication restrictions, and included articles indexed from January 1, 2006 to June 10, 2018. Experimental and observational studies that reported the incidence of brain metastases in patients with nonmetastatic or metastatic breast cancer were included. RESULTS One hundred seventy studies were identified, with 33 included in the final analysis. Among nonmetastatic breast cancer patients, incidence of brain metastases as site of first recurrence per year of median follow-up ranged from 0.1% to 3.2%. Although incidence of brain metastases was much higher among the metastatic breast cancer population overall, it was particularly high among metastatic HER2-overexpressing (HER2+) and triple-negative populations, ranging between 22% and 36% for the former, and 15%-37% for the latter in the absence of screening. CONCLUSION In patients with nonmetastatic breast cancer, screening for asymptomatic brain metastases cannot currently be justified. However, due to the high incidence of brain metastases among patients with metastatic HER2+ and triple-negative breast cancer, studies to determine the value of screening for brain metastases should be undertaken in these subgroups.
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Affiliation(s)
- Adam S Komorowski
- Division of Medical Microbiology, McMaster University, Hamilton, Ontario, Canada
| | - Ellen Warner
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Helen J MacKay
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kathleen I Pritchard
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Katarzyna J Jerzak
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
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17
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Maurer C, Tulpin L, Moreau M, Dumitrescu C, de Azambuja E, Paesmans M, Nogaret JM, Piccart MJ, Awada A. Risk factors for the development of brain metastases in patients with HER2-positive breast cancer. ESMO Open 2018; 3:e000440. [PMID: 30425844 PMCID: PMC6212674 DOI: 10.1136/esmoopen-2018-000440] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 09/11/2018] [Accepted: 09/13/2018] [Indexed: 12/02/2022] Open
Abstract
Background Patients with metastatic human epidermal growth factor receptor 2-positive breast cancer (HER2+ BC) frequently experience brain metastases (BM). We aimed to define risk factors for the development of BM in patients with HER2+ BC and to report on their outcome. Methods This is a retrospective analysis of patients diagnosed with HER2+ BC between January 2000 and December 2014 at Institut Jules Bordet, Belgium. Statistical analyses were conducted with SAS V.9.4 using Kaplan-Meier method and Cox regression analyses. Results A total of 483 patients were included of whom 108 (22.4%) developed metastases and 52 (10.8%) BM. Among 96 metastatic patients without BM at diagnosis, 40 (41.7%) developed BM in the course of their disease. In multivariate analysis, risk factors for the development of BM were age ≤40 years (HR 2.10, 95 % CI 1.02 to 4.36), tumour size >2 cm (HR 4.94, 95% CI 1.69 to 14.47), nodal involvement (HR 3.48, 95% CI 1.47 to 8.25), absence or late start (≥6 months after initial diagnosis) of adjuvant anti-HER2 treatment (HR 3.79, 95% CI 1.52 to 9.43 or HR 2.65, 95% CI 1.03 to 6.82) and the development of lung metastases as first site of relapse (HR 6.97, 95% CI 3.41 to 14.24). Twenty-two patients with HER2+ BC and BM sent to our institute for further treatment were included in the outcome analysis. Asymptomatic patients at the time of BM diagnosis showed a better overall survival than symptomatic patients (HR 0.49, 95% CI 0.25 to 0.94). Conclusion A considerable number of patients with metastatic HER2+ BC will develop BM. Screening of patients with risk factors for BM might lead to early detection and better outcome. However, randomised controlled trials examining the use of MRI as a screening method for BM in patients with metastatic BC are warranted before such an approach can be recommended.
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Affiliation(s)
- Christian Maurer
- Department I of Internal Medicine and Center of Integrated Oncology Cologne Bonn, University of Cologne, Cologne, Germany.,Department of Medical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - Lorraine Tulpin
- Department of Medical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - Michel Moreau
- Unité de Gestion de l'Information, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - Cristina Dumitrescu
- Department of Medical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium.,Medical Oncology Clinic, Charleroi Universitary Hospital, Université Libre de Bruxelles (U.L.B.), Charleroi, Belgium
| | - Evandro de Azambuja
- Department of Medical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - Marianne Paesmans
- Unité de Gestion de l'Information, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - Jean-Marie Nogaret
- Department of Surgery, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - Martine J Piccart
- Department of Medical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - Ahmad Awada
- Department of Medical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
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18
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Baker JHE, Kyle AH, Reinsberg SA, Moosvi F, Patrick HM, Cran J, Saatchi K, Häfeli U, Minchinton AI. Heterogeneous distribution of trastuzumab in HER2-positive xenografts and metastases: role of the tumor microenvironment. Clin Exp Metastasis 2018; 35:691-705. [PMID: 30196384 PMCID: PMC6209006 DOI: 10.1007/s10585-018-9929-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/13/2018] [Indexed: 12/11/2022]
Abstract
Most HER2-positive metastatic breast cancer patients continue to relapse. Incomplete access to all target HER2-positive cells in metastases and tumor tissues is a potential mechanism of resistance to trastuzumab. The location of locally bound trastuzumab was evaluated in HER2-positive tissues in vivo and as in vivo xenografts or metastases models in mice. Microenvironmental elements of tumors were related to bound trastuzumab using immunohistochemical staining and include tight junctions, vasculature, vascular maturity, vessel patency, hypoxia and HER2 to look for correlations. Trastuzumab was evaluated alone and in combination with bevacizumab. Dynamic contrast-enhanced magnetic resonance imaging parameters of overall vascular function, perfusion and apparent permeability were compared with matched histological images of trastuzumab distribution and vascular patency. Trastuzumab distribution is highly heterogeneous in all models examined, including avascular micrometastases of the brain and lung. Trastuzumab distributes well through the extravascular compartment even in conditions of high HER2 expression and poor convective flow in vivo. Microregional patterns of trastuzumab distribution in vivo do not consistently correlate with vascular density, patency, function or maturity; areas of poor trastuzumab access are not necessarily those with poor vascular supply. The number of vessels with perivascular trastuzumab increases with time and higher doses and dramatically decreases when pre-treated with bevacizumab. Areas of HER2-positive tissue without bound trastuzumab persist in all conditions. These data directly demonstrate tissue- and vessel-level barriers to trastuzumab distribution in vivo that can effectively limit access of the drug to target cells in brain metastases and elsewhere.
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Affiliation(s)
- Jennifer Hazel Elizabeth Baker
- Integrative Oncology - Radiation Biology Unit, BC Cancer Research Centre, 675 West 10th Ave, Vancouver, BC V5Z 1L3 Canada
| | - Alastair Hugh Kyle
- Integrative Oncology - Radiation Biology Unit, BC Cancer Research Centre, 675 West 10th Ave, Vancouver, BC V5Z 1L3 Canada
| | | | - Firas Moosvi
- Department of Physics & Astronomy, University of British Columbia, Vancouver, Canada
| | - Haley Margaret Patrick
- Integrative Oncology - Radiation Biology Unit, BC Cancer Research Centre, 675 West 10th Ave, Vancouver, BC V5Z 1L3 Canada
| | - Jordan Cran
- Integrative Oncology - Radiation Biology Unit, BC Cancer Research Centre, 675 West 10th Ave, Vancouver, BC V5Z 1L3 Canada
| | - Katayoun Saatchi
- Department of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Urs Häfeli
- Department of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Andrew Ivor Minchinton
- Integrative Oncology - Radiation Biology Unit, BC Cancer Research Centre, 675 West 10th Ave, Vancouver, BC V5Z 1L3 Canada
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19
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Rothwell WT, Bell P, Richman LK, Limberis MP, Tretiakova AP, Li M, Wilson JM. Intrathecal Viral Vector Delivery of Trastuzumab Prevents or Inhibits Tumor Growth of Human HER2-Positive Xenografts in Mice. Cancer Res 2018; 78:6171-6182. [PMID: 30154145 DOI: 10.1158/0008-5472.can-18-0363] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 07/09/2018] [Accepted: 08/23/2018] [Indexed: 11/16/2022]
Abstract
Breast cancer brain metastases are a deadly sequela of primary breast tumors that overexpress human epidermal growth factor receptor 2 (HER2); median survival for patients with these tumors is 10 to 13 months from the time of diagnosis. Current treatments for HER2-positive breast cancer brain metastases are invasive, toxic, and largely ineffective. Here, we have developed an adeno-associated virus serotype 9 (AAV9) vector to express the anti-HER2 monoclonal antibody trastuzumab (Herceptin) in vivo A single prophylactic intrathecal administration of AAV9.trastuzumab vector in a novel orthotopic Rag1-/- murine xenograft model of HER2-positive breast cancer brain metastases significantly increased median survival, attenuated brain tumor growth, and preserved both the HER2 antigen specificity and the natural killer cell-associated mechanism of action of trastuzumab. When administered as a tumor treatment, AAV9.trastuzumab increased median survival. Dose-escalation studies revealed that higher doses of AAV9.trastuzumab resulted in smaller tumor volumes. Our results indicate that intrathecal AAV9.trastuzumab may provide significant antitumor activity in patients with HER2-positive breast cancer brain metastases.Significance: Intrathecal delivery of trastuzumab via adeno-associated virus has the potential to become a novel, integral part of adjuvant therapy for patients with HER2-positive breast cancer brain metastases. Cancer Res; 78(21); 6171-82. ©2018 AACR.
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Affiliation(s)
- William T Rothwell
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter Bell
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura K Richman
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria P Limberis
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anna P Tretiakova
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mingyao Li
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James M Wilson
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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20
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Duchnowska R, Loibl S, Jassem J. Tyrosine kinase inhibitors for brain metastases in HER2-positive breast cancer. Cancer Treat Rev 2018; 67:71-77. [PMID: 29772459 DOI: 10.1016/j.ctrv.2018.05.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 01/11/2023]
Abstract
Approximately 30-50% of advanced HER2-positive breast cancer patients will develop central nervous system (CNS) metastases, with an annual risk of around 10%, and a half of them will die from brain progression. An increased risk of brain metastases is also seen in patients with early HER2-positive breast cancer administered curative therapy. Brain metastases in HER2-positive breast cancer patients usually constitute the first site of recurrence. The administration of anti-HER2 monoclonal antibodies, trastuzumab and pertuzumab, considerably delays the onset of symptomatic brain disease: however, the limited penetration of these compounds into the CNS hinders their efficacy. The small-molecule tyrosine kinase inhibitors of epidermal growth factor receptors family have established activity in HER2-positive breast cancer in both advanced disease and neoadjuvant setting. Favorable physico-chemical properties of these compounds allow them for a more efficient penetration through the blood-brain barrier, and hold the promise for more effective prevention and treatment of brain metastases. In this article we review the role of currently available or investigational HER2 tyrosine kinase inhibitors: lapatinib, neratinib, afatinib and tucatinib in the treatment of brain metastases in HER2-positive breast cancer patients.
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Affiliation(s)
- Renata Duchnowska
- Military Institute of Medicine, Department of Oncology, Warsaw, Poland.
| | - Sibylle Loibl
- German Breast Group, Neu-Isenburg, Germany; Sana-Klinikum Offenbach, Germany.
| | - Jacek Jassem
- Medical University of Gdańsk, Department of Oncology and Radiotherapy, Gdańsk, Poland.
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21
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Lai SF, Chen YH, Liang THK, Hsu CY, Lien HC, Lu YS, Huang CS, Kuo SH. The breast graded prognostic assessment is associated with the survival outcomes in breast cancer patients receiving whole brain re-irradiation. J Neurooncol 2018; 138:637-647. [PMID: 29557535 DOI: 10.1007/s11060-018-2833-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 02/18/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Whole brain (WB) re-irradiation for breast cancer patients with progressive brain metastasis after first-course WB radiotherapy (WBRT) is controversial. In this study, we sought to investigate the association between the molecular sub-classifications and breast-specific Graded Prognostic Assessment (GPA, which includes the Karnofsky performance status, molecular subtypes, and age as its indices) and the outcomes of breast cancer patients who received WB re-irradiation. METHODS Twenty-three breast cancer patients who received WB re-irradiation for relapsed and progressive intracranial lesions after first-course WBRT between 2004 and 2016 were retrospectively reviewed. Patients were divided according to the 4 molecular subtypes of luminal A/B (hormone receptor [HR]+/human epidermal growth factor receptor 2 [HER2]-), luminal HER2 (HR+/HER2+), HER2 (HR-/HER2+), and triple negative (HR-/HER2-). The clinical and radiological responses and survival rates after WB re-irradiation were analyzed. RESULTS At 1 month after WB re-irradiation, 13 of 23 patients (56.5%) exhibited disappearance or alleviation of neurological symptoms. The median survival time after WB re-irradiation was 2.93 months (95% confidence interval [CI], 1.79-4.08). After WB re-irradiation, patients with HER2-negative tumors had poorer median survival times than those with HER2-positive tumors (2.23 vs. 3.0 months, respectively; p = 0.022). Furthermore, patients with high breast GPA scores (2.5-4.0, n = 11) had longer median survivals than those with low-scores (0-2.0, n = 12) after WB re-irradiation (4.37 vs. 1.57 months, respectively; p < 0.005). CONCLUSIONS WB re-irradiation may be a feasible treatment option for certain breast cancer patients who develop brain metastatic lesions after first-course WBRT when these lesions are ineligible for radiosurgery or surgery.
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Affiliation(s)
- Shih-Fan Lai
- Institute of Biomedical Engineering, National Taiwan University, Taipei, Taiwan.,Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Hsuan Chen
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Tony Hsiang-Kuang Liang
- Institute of Biomedical Engineering, National Taiwan University, Taipei, Taiwan.,Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Che-Yu Hsu
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Huang-Chun Lien
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Sen Lu
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,National Taiwan University Cancer Center, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chiun-Sheng Huang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Hsin Kuo
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan. .,National Taiwan University Cancer Center, College of Medicine, National Taiwan University, Taipei, Taiwan. .,Cancer Research Center, National Taiwan University College of Medicine, Taipei, Taiwan. .,Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan.
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22
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Kabraji S, Ni J, Lin NU, Xie S, Winer EP, Zhao JJ. Drug Resistance in HER2-Positive Breast Cancer Brain Metastases: Blame the Barrier or the Brain? Clin Cancer Res 2018; 24:1795-1804. [PMID: 29437794 DOI: 10.1158/1078-0432.ccr-17-3351] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 01/06/2018] [Accepted: 02/01/2018] [Indexed: 12/11/2022]
Abstract
The brain is the most common site of first metastasis for patients with HER2-positive breast cancer treated with HER2-targeting drugs. However, the development of effective therapies for breast cancer brain metastases (BCBM) is limited by an incomplete understanding of the mechanisms governing drug sensitivity in the central nervous system. Pharmacodynamic data from patients and in vivo models suggest that inadequate drug penetration across the "blood-tumor" barrier is not the whole story. Using HER2-positive BCBMs as a case study, we highlight recent data from orthotopic brain metastasis models that implicate brain-specific drug resistance mechanisms in BCBMs and suggest a translational research paradigm to guide drug development for treatment of BCBMs. Clin Cancer Res; 24(8); 1795-804. ©2018 AACR.
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Affiliation(s)
- Sheheryar Kabraji
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts. .,Department of Cancer Biology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Jing Ni
- Department of Cancer Biology, Dana Farber Cancer Institute, Boston, Massachusetts.,Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, Massachusetts
| | - Nancy U Lin
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Shaozhen Xie
- Department of Cancer Biology, Dana Farber Cancer Institute, Boston, Massachusetts.,Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, Massachusetts
| | - Eric P Winer
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Jean J Zhao
- Department of Cancer Biology, Dana Farber Cancer Institute, Boston, Massachusetts. .,Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, Massachusetts
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23
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Wolf A, Kvint S, Chachoua A, Pavlick A, Wilson M, Donahue B, Golfinos JG, Silverman J, Kondziolka D. Toward the complete control of brain metastases using surveillance screening and stereotactic radiosurgery. J Neurosurg 2018; 128:23-31. [DOI: 10.3171/2016.10.jns161036] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe incidence of brain metastases is increasing with improved systemic therapies, many of which have a limited impact on intracranial disease. Stereotactic radiosurgery (SRS) is a first-line management option for brain metastases. The purpose of this study was to determine if there is a threshold tumor size below which local control (LC) rates approach 100%, and to relate these findings to the use of routine surveillance brain imaging.METHODSFrom a prospective registry, 200 patients with 1237 brain metastases were identified who underwent SRS between December 2012 and May 2015. The median imaging follow-up duration was 7.9 months, and the median margin dose was 18 Gy. The maximal diameter and volume of tumors were measured. Histological analysis included 96 patients with non–small cell lung cancers (NSCLCs), 40 with melanoma, 35 with breast cancer, and 29 with other histologies.RESULTSAlmost 50% of brain metastases were NSCLCs and commonly measured less than 6 mm in maximal diameter or 70 mm3 in volume. Thirty-three of 1237 tumors had local progression at a median of 8.8 months. The 1- and 2-year actuarial LC rates were 97% and 93%, respectively. LC of 100% was achieved for all intracranial metastases less than 100 mm3 in volume or 6 mm in diameter. Patients whose tumors at first SRS were less than 10 mm maximal diameter or a volume of 250 mm3 had improved overall survival.CONCLUSIONSSRS can achieve LC rates approaching 100% for subcentimeter metastases. The earlier initial detection and prompt treatment of small intracranial metastases may prevent the development of neurological symptoms and the need for resection, and improve overall survival. To identify tumors when they are small, routine surveillance brain imaging should be considered as part of the standard of care for lung, breast, and melanoma metastases.■ CLASSIFICATION OF EVIDENCE Type of question: prognostic; study design: retrospective cohort; evidence: Class II.
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Affiliation(s)
| | | | | | | | | | - Bernadine Donahue
- 3Radiation Oncology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York University, New York, New York
| | | | - Joshua Silverman
- 3Radiation Oncology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York University, New York, New York
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24
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Nam JY, O’Brien BJ. Current chemotherapeutic regimens for brain metastases treatment. Clin Exp Metastasis 2017; 34:391-399. [DOI: 10.1007/s10585-017-9861-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 09/06/2017] [Indexed: 01/19/2023]
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25
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26
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27
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Dagogo-Jack I, Gill CM, Cahill DP, Santagata S, Brastianos PK. Treatment of brain metastases in the modern genomic era. Pharmacol Ther 2016; 170:64-72. [PMID: 27773784 DOI: 10.1016/j.pharmthera.2016.10.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Development of brain metastasis (BM) portends a dismal prognosis for patients with cancer. Melanomas and carcinomas of the lung, breast, and kidney are the most common malignancies to metastasize to the brain. Recent advances in molecular genetics have enabled the identification of actionable, clinically relevant genetic alterations within primary tumors and their corresponding metastases. Adoption of genotype-guided treatment strategies for the management of systemic malignancy has resulted in dramatic and durable responses. Unfortunately, despite these therapeutic advances, central nervous system (CNS) relapses are not uncommon. Although these relapses have historically been attributed to limited blood brain barrier penetration of anti-neoplastic agents, recent work has demonstrated genetic heterogeneity such that metastatic sites, including BM, harbor relevant genetic alterations that are not present in primary tumor biopsies. This improved insight into molecular mechanisms underlying site specific recurrences can inform strategies for targeting these oncogenic drivers. Thus, development of rational, genomically guided CNS-penetrant therapies is crucial for ongoing therapeutic success.
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Affiliation(s)
- Ibiayi Dagogo-Jack
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Corey M Gill
- Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Daniel P Cahill
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Sandro Santagata
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Priscilla K Brastianos
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
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28
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Gene Expression Profiling of Breast Cancer Brain Metastasis. Sci Rep 2016; 6:28623. [PMID: 27340107 PMCID: PMC4919653 DOI: 10.1038/srep28623] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 06/06/2016] [Indexed: 12/11/2022] Open
Abstract
The biology of breast cancer brain metastasis (BCBM) is poorly understood. We aimed to explore genes that are implicated in the process of brain metastasis of primary breast cancer (BC). NanoString nCounter Analysis covering 252 target genes was used for comparison of gene expression levels between 20 primary BCs that relapsed to brain and 41 BCBM samples. PAM50-based intrinsic subtypes such as HER2-enriched and basal-like were clearly over-represented in BCBM. A panel of 22 genes was found to be significantly differentially expressed between primary BC and BCBM. Five of these genes, CXCL12, MMP2, MMP11, VCAM1, and MME, which have previously been associated with tumor progression, angiogenesis, and metastasis, clearly discriminated between primary BC and BCBM. Notably, the five genes were significantly upregulated in primary BC compared to BCBM. Conversely, SOX2 and OLIG2 genes were upregulated in BCBM. These genes may participate in metastatic colonization but not in primary tumor development. Among patient-matched paired samples (n = 17), a PAM50 molecular subtype conversion was observed in eight cases (47.1%), with a trend toward unfavorable subtypes in patients with the distinct gene expression. Our findings, although not conclusive, reveal differentially expressed genes that might mediate the brain metastasis process.
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29
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Venur VA, Ahluwalia MS. Targeted Therapy in Brain Metastases: Ready for Primetime? Am Soc Clin Oncol Educ Book 2016; 35:e123-e130. [PMID: 27249714 DOI: 10.1200/edbk_100006] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Brain metastasis is a serious complication of cancer that causes significant morbidity for patients. Over the last decade, numerous new driver somatic mutations have been recognized and targeted therapies are changing the landscape of treatment in lung cancer, breast cancer, and melanoma, which are also the three most common cancers that result in brain metastases. The common actionable mutations include the EGFR mutation and anaplastic lymphoma kinase (ALK) translocations in non-small cell lung cancer, the HER2 mutation in breast cancer, and the BRAF mutation in melanoma. However, most of the early trials with targeted agents excluded patients with brain metastases. With a better understanding of the biology, several recent trials of targeted therapy that focus on brain metastases have been reported and others are ongoing. Novel agents with better penetration across the blood-brain barrier are currently being investigated for patients with brain metastases. In this review, we discuss the current state of use and future directions of targeted therapies in brain metastases.
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Affiliation(s)
- Vyshak A Venur
- From the Division of Hematology and Oncology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA; Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Medicine, Neurologic Institute, Cleveland Clinic, Cleveland, OH; Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Manmeet S Ahluwalia
- From the Division of Hematology and Oncology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA; Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Medicine, Neurologic Institute, Cleveland Clinic, Cleveland, OH; Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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30
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Murrell DH, Hamilton AM, Mallett CL, van Gorkum R, Chambers AF, Foster PJ. Understanding Heterogeneity and Permeability of Brain Metastases in Murine Models of HER2-Positive Breast Cancer Through Magnetic Resonance Imaging: Implications for Detection and Therapy. Transl Oncol 2015; 8:176-84. [PMID: 26055175 PMCID: PMC4487267 DOI: 10.1016/j.tranon.2015.03.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 03/20/2015] [Accepted: 03/24/2015] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES: Brain metastases due to breast cancer are increasing, and the prognosis is poor. Lack of effective therapy is attributed to heterogeneity of breast cancers and their resulting metastases, as well as impermeability of the blood–brain barrier (BBB), which hinders delivery of therapeutics to the brain. This work investigates three experimental models of HER2 + breast cancer brain metastasis to better understand the inherent heterogeneity of the disease. We use magnetic resonance imaging (MRI) to quantify brain metastatic growth and explore its relationship with BBB permeability. DESIGN: Brain metastases due to breast cancer cells (SUM190-BR3, JIMT-1-BR3, or MDA-MB-231-BR-HER2) were imaged at 3 T using balanced steady-state free precession and contrast-enhanced T1-weighted spin echo sequences. The histology and immunohistochemistry corresponding to MRI were also analyzed. RESULTS: There were differences in metastatic tumor appearance by MRI, histology, and immunohistochemistry (Ki67, CD31, CD105) across the three models. The mean volume of an MDA-MB-231-BR-HER2 tumor was significantly larger compared to other models (F2,12 = 5.845, P < .05); interestingly, this model also had a significantly higher proportion of Gd-impermeable tumors (F2,12 = 22.18, P < .0001). Ki67 staining indicated that Gd-impermeable tumors had significantly more proliferative nuclei compared to Gd-permeable tumors (t[24] = 2.389, P < .05) in the MDA-MB-231-BR-HER2 model. CD31 and CD105 staining suggested no difference in new vasculature patterns between permeable and impermeable tumors in any model. CONCLUSION: Significant heterogeneity is present in these models of brain metastases from HER2 + breast cancer. Understanding this heterogeneity, especially as it relates to BBB permeability, is important for improvement in brain metastasis detection and treatment delivery.
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Affiliation(s)
- Donna H Murrell
- Imaging, Robarts Research Institute, London, Ontario, Canada; Medical Biophysics, Western University, London, Ontario, Canada.
| | | | | | | | - Ann F Chambers
- Medical Biophysics, Western University, London, Ontario, Canada; London Regional Cancer Program, London, Ontario, Canada
| | - Paula J Foster
- Imaging, Robarts Research Institute, London, Ontario, Canada; Medical Biophysics, Western University, London, Ontario, Canada
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Inoue K, Kuroi K, Shimizu S, Rai Y, Aogi K, Masuda N, Nakayama T, Iwata H, Nishimura Y, Armour A, Sasaki Y. Safety, pharmacokinetics and efficacy findings in an open-label, single-arm study of weekly paclitaxel plus lapatinib as first-line therapy for Japanese women with HER2-positive metastatic breast cancer. Int J Clin Oncol 2015; 20:1102-9. [PMID: 25967286 PMCID: PMC4666271 DOI: 10.1007/s10147-015-0832-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 04/14/2015] [Indexed: 11/25/2022]
Abstract
Background Lapatinib is the human epidermal growth factor receptor 2 (HER2) targeting agent approved globally for HER2-positive metastatic breast cancer (MBC). The efficacy, safety and pharmacokinetics (PK) of lapatinib combined with paclitaxel (L+P) were investigated in this study, to establish clear evidence regarding the combination in Japanese patients. Methods In this two-part, single-arm, open-label study, the tolerability of L+P as first-line treatment in Japanese patients with HER2-positive MBC was evaluated in six patients in the first part, and the safety, efficacy and PK were evaluated in a further six patients (making a total of twelve patients) in the second part. Eligible women were enrolled and received lapatinib 1500 mg once daily and paclitaxel 80 mg/m2 weekly for at least 6 cycles. Results The only dose-limiting toxicity reported was Grade 3 diarrhea in one patient. The systemic exposure to maximum plasma concentration and area under the plasma concentration curve (AUC) for lapatinib, as well as the AUC of paclitaxel, were increased when combined. The most common adverse events (AEs) related to the study treatment were alopecia, diarrhea and decreased hemoglobin. The majority of drug-related AEs were Grade 1 or 2. The median overall survival was 35.6 months (95 % confidence interval 23.9, not reached). The response rate and clinical benefit rate were both 83 % (95 % confidence interval 51.6, 97.9). Conclusions The L+P treatment was well tolerated in Japanese patients with HER2-positive MBC. Although the PK profiles of lapatinib and paclitaxel influenced each other, the magnitudes were not greatly different from those in non-Japanese patients.
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Affiliation(s)
- Kenichi Inoue
- Division of Breast Oncology, Saitama Cancer Center, 780 Komuro, Ina-machi, Kita-adachi-gun, Saitama, 362-0806, Japan.
| | - Katsumasa Kuroi
- Department of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Satoru Shimizu
- Department of Breast Oncology and Endocrine Surgery, Kanagawa Cancer Center, Yokohama, Kanagawa, Japan
| | - Yoshiaki Rai
- Hakuaikai Medical Corporation, Sagara Hospital, Kagoshima, Japan
| | - Kenjiro Aogi
- Department of Surgery, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
| | - Norikazu Masuda
- Department of Surgery, Breast Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Takahiro Nakayama
- Department of Breast and Endocrine Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
- Department of Breast and Endocrine Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Hiroji Iwata
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yuichiro Nishimura
- Development and Medical Affairs Division, GlaxoSmithKline K.K., Tokyo, Japan
| | - Alison Armour
- Research and Development, GlaxoSmithKline, Philadelphia, PA, USA
| | - Yasutsuna Sasaki
- Department of Medical Oncology, Saitama Medical University International Medical Center, Saitama, Japan
- Division of Medical Oncology, Department of Medicine, Showa University Hospital, Tokyo, Japan
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Castaneda CA, Flores R, Rojas KY, Castillo M, Dolores-Cerna K, Flores C, Belmar-Lopez C, Milla E, Gomez H. Prognostic factors for patients with newly diagnosed brain metastasis from breast cancer. CNS Oncol 2015; 4:137-45. [PMID: 25906174 DOI: 10.2217/cns.15.5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM This retrospective study determined features associated with brain metastasis (BM) in women with breast cancer. PATIENTS & METHODS A total of 215 initially early breast cancer cases were included. We reviewed files and CT scan images of BM. RESULTS Median age was 47 years and most of our cases were stage III (58.6%), grade III (62.8%), ER negative (62.3%) and nonluminal (59.1%). Median survival after BM was 4 months. Nonluminal, extracranial disease, time to CNS shorter than 15 months, >three brain lesions and poor breast-graded prognostic assessment and recursive partitioning analysis scores were associated with shorter survival. Adding extracranial disease to breast-graded prognostic assessment score also predicted survival after BM. Radiation response was assessed in 57 patients and response tended to be associated with nonluminal phenotype but not with survival. CONCLUSION Factors associated with both initial tumor and clinical features at BM time are associated with shorter survival in our Latinas population.
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Affiliation(s)
- Carlos A Castaneda
- Medical Oncology Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
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Park Y, Kim H, Kim EH, Suh CO, Lee S. Effective Treatment of Solitary Pituitary Metastasis with Panhypopituitarism in HER2-Positive Breast Cancer by Lapatinib. Cancer Res Treat 2015; 48:403-8. [PMID: 25715765 PMCID: PMC4720106 DOI: 10.4143/crt.2014.165] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 10/16/2014] [Indexed: 01/25/2023] Open
Abstract
Brain metastasis affects one third of patients with HER2-positive breast cancer after treatment with trastuzumab. Surgical resection and radiation therapy are often unsuccessful at accomplishing complete control of metastasis. Lapatinib is presumed to cross the blood-brain barrier, and exhibits clinical activities for treatment of HER2-positive breast cancer. A 43-year-old woman was treated for early breast carcinoma with total mastectomy, axillary lymph-node dissection, and adjuvant chemotherapy with cyclophosphamide plus doxorubicin. After the end of adjuvant trastuzumab therapy, she was diagnosed with panhypopituitarism due to pituitary metastasis. Surgical removal and whole brain radiation therapy were performed, but a portion of viable tumor remained. Only taking lapatinib, the size of the metastatic lesion began to shrink. Trastuzumab may have controlled the micro-metastasis of breast cancer, but it was unable to control its progression to the central nervous system. Lapatinib is a possible option for HER2-positive metastatic breast cancer patients with brain metastasis.
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Affiliation(s)
- Youngmok Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyemin Kim
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Eui-Hyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Soohyeon Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; Division of Medical Oncology, Yonsei University College of Medicine, Seoul, Korea
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Disease progression pattern in metastatic breast cancer patients treated with anti-HER2 therapies. Clin Transl Oncol 2015; 17:530-8. [DOI: 10.1007/s12094-015-1274-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 01/02/2015] [Indexed: 10/24/2022]
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Pivot X, Manikhas A, Żurawski B, Chmielowska E, Karaszewska B, Allerton R, Chan S, Fabi A, Bidoli P, Gori S, Ciruelos E, Dank M, Hornyak L, Margolin S, Nusch A, Parikh R, Nagi F, DeSilvio M, Santillana S, Swaby RF, Semiglazov V. CEREBEL (EGF111438): A Phase III, Randomized, Open-Label Study of Lapatinib Plus Capecitabine Versus Trastuzumab Plus Capecitabine in Patients With Human Epidermal Growth Factor Receptor 2-Positive Metastatic Breast Cancer. J Clin Oncol 2015; 33:1564-73. [PMID: 25605838 DOI: 10.1200/jco.2014.57.1794] [Citation(s) in RCA: 165] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE CEREBEL compared the incidence of CNS metastases as first site of relapse in patients with human epidermal growth factor receptor 2-positive metastatic breast cancer receiving lapatinib-capecitabine or trastuzumab-capecitabine. PATIENTS AND METHODS Patients without baseline CNS metastases were randomly assigned (1:1) to receive lapatinib-capecitabine (lapatinib 1,250 mg per day; capecitabine 2,000 mg/m(2) per day on days 1 to 14 every 21 days) or trastuzumab-capecitabine (trastuzumab loading dose of 8 mg/kg followed by an infusion of 6 mg/kg every 3 weeks; capecitabine 2,500 mg/m(2) per day on days 1 to 14 every 21 days). The primary end point was incidence of CNS metastases as first site of relapse. Secondary end points included progression-free survival (PFS) and overall survival (OS). RESULTS The study was terminated early with 540 enrolled patients (271 received lapatinib-capecitabine, and 269 received trastuzumab-capecitabine). Incidence of CNS metastases as first site of relapse was 3% (eight of 251 patients) for lapatinib-capecitabine and 5% (12 of 250 patients) for trastuzumab-capecitabine (treatment differences, -1.6%; 95% CI, -2% to 5%; P = .360). PFS and OS were longer with trastuzumab-capecitabine versus lapatinib-capecitabine (hazard ratio [HR] for PFS, 1.30; 95% CI, 1.04 to 1.64; HR for OS, 1.34; 95% CI, 0.95 to 1.64). Serious adverse events were reported in 13% (34 of 269 patients) and 17% (45 of 267 patients) of patients in the lapatinib-capecitabine and trastuzumab-capecitabine arms, respectively. CONCLUSION CEREBEL is inconclusive for the primary end point, and no difference was detected between lapatinb-capecitabine and trastuzumab-capecitabine for the incidence of CNS metastases. A better outcome was observed with trastuzumab-capecitabine in the overall population. However, lapatinib-capecitabine efficacy may have been affected by previous exposure to a trastuzumab regimen and/or when treatment was given as first- or second-line therapy in the metastatic setting.
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Affiliation(s)
- Xavier Pivot
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA.
| | - Alexey Manikhas
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Bogdan Żurawski
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Ewa Chmielowska
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Boguslawa Karaszewska
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Rozenn Allerton
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Stephen Chan
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Alessandra Fabi
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Paolo Bidoli
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Stefania Gori
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Eva Ciruelos
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Magdolna Dank
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Lajos Hornyak
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Sara Margolin
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Arnd Nusch
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Roma Parikh
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Fareha Nagi
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Michelle DeSilvio
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Sergio Santillana
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Ramona F Swaby
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
| | - Vladimir Semiglazov
- Xavier Pivot, Centre Hospitalier Universitaire, Hôpital Jean Minjoz, Besançon, France; Alexey Manikhas, St Petersburg City Oncology Dispensary; Vladimir Semiglazov, Petrov Research Institute of Oncology, St Petersburg, Russian Federation; Bogdan Żurawski, Franciszek Lukaszczyk Oncology Center, Bydgoszcz; Ewa Chmielowska, Centrum Onkologii im. Prof Franciszka Lukaszczyka Oddzial Kliniczny Onkologii, Bydgoszcz, and Uniwersytet Mikolaja Kopernika Torun, Torun; Boguslawa Karaszewska, Przychodnia Lekarska KOMED, ul Wojska Polskiego 6, Konin, Poland; Rozenn Allerton, The Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Stephen Chan, Nottingham University Hospital, Nottingham; Roma Parikh and Fareha Nagi, GlaxoSmithKline, Uxbridge, United Kingdom; Alessandra Fabi, "Regina Elena" National Cancer Institute, Rome; Paolo Bidoli, Azienda Ospedaliera San Gerardo di Monza U.O. Oncologia Medica, Monza, Lombardia; Stefania Gori, Azienda Ospedaliera di Perugia, Ospedale S. Maria della Misericordia, Struttura Complessa di Oncologia Medica, Perugia, Umbria, and Azienda Ospedaliera Sacro Cuore-Don Calabria-Negrar, Negrar, Verona, Italy; Eva Ciruelos, Hospital Universitario 12 de Octubre, Madrid, Spain; Magdolna Dank, SE Radiológiai és Onkoterápiás Klinika; Lajos Hornyak, Veszprém Megyei Csolnoky Ferenc Kórház, Onkológiai Osztály, Budapest, Hungary; Sara Margolin, Karolinska University Hospital, Stockholm, Sweden; Arnd Nusch, Gem Praxis Drs Nusch, Kalhori und Langer, Friedrichstr, Velbert, Germany; and Michelle DeSilvio, Sergio Santillana, and Ramona F. Swaby, GlaxoSmithKline, Collegeville, PA
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Predicting early brain metastases based on clinicopathological factors and gene expression analysis in advanced HER2-positive breast cancer patients. J Neurooncol 2015; 122:205-16. [PMID: 25559688 PMCID: PMC4353882 DOI: 10.1007/s11060-014-1704-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 12/21/2014] [Indexed: 12/21/2022]
Abstract
The overexpression or amplification of the human epidermal growth factor receptor 2 gene (HER2/neu) is associated with high risk of brain metastasis (BM). The identification of patients at highest immediate risk of BM could optimize screening and facilitate interventional trials. We performed gene expression analysis using complementary deoxyribonucleic acid-mediated annealing, selection, extension and ligation and real-time quantitative reverse transcription PCR (qRT-PCR) in primary tumor samples from two independent cohorts of advanced HER2 positive breast cancer patients. Additionally, we analyzed predictive relevance of clinicopathological factors in this series. Study group included discovery Cohort A (84 patients) and validation Cohort B (75 patients). The only independent variables associated with the development of early BM in both cohorts were the visceral location of first distant relapse [Cohort A: hazard ratio (HR) 7.4, 95 % CI 2.4-22.3; p < 0.001; Cohort B: HR 6.1, 95 % CI 1.5-25.6; p = 0.01] and the lack of trastuzumab administration in the metastatic setting (Cohort A: HR 5.0, 95 % CI 1.4-10.0; p = 0.009; Cohort B: HR 10.0, 95 % CI 2.0-100.0; p = 0.008). A profile including 13 genes was associated with early (≤36 months) symptomatic BM in the discovery cohort. This was refined by qRT-PCR to a 3-gene classifier (RAD51, HDGF, TPR) highly predictive of early BM (HR 5.3, 95 % CI 1.6-16.7; p = 0.005; multivariate analysis). However, predictive value of the classifier was not confirmed in the independent validation Cohort B. The presence of visceral metastases and the lack of trastuzumab administration in the metastatic setting apparently increase the likelihood of early BM in advanced HER2-positive breast cancer.
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De Boer R, Beith J, Chirgwin J, Chua S, Colosimo M, Francis P, Green M, Pittman K, White M, Wilcken N, Zdenkowski N, Bell R. Systemic treatment of HER2+ metastatic breast cancer: clinical conundrums and future perspectives. Asia Pac J Clin Oncol 2015; 10 Suppl S4:15-25. [PMID: 24797446 DOI: 10.1111/ajco.12207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2014] [Indexed: 11/30/2022]
Abstract
Improvements in the treatment of metastatic HER2-positive breast cancer constitute one of the great advances in breast cancer medicine of the last generation. From being a highly aggressive fatal condition, the use of anti-HER2-targeted therapies, in particular trastuzumab, has led to significant improvements in disease outcomes. There are reports of increasing numbers of patients alive and well more than 5 years from diagnosis of metastatic disease. Nevertheless, there remain many complex and clinically difficult scenarios where there is little in the way of randomized evidence or published guidelines to guide decision making. As a companion piece to our review of HER2-targeted therapies in the metastatic setting, we decided to focus on a series of clinical scenarios that fell outside of the standard trial-based settings and where opinions and guidance from experienced clinicians and experts in the field would be considered useful to help develop safe and effective treatment strategies. The following eight cases were put forward by our panel of experts, voted on by their peers to select the most relevant and interesting cases, and the discussions worked on by teams of two followed by review and commentary by another team of two.
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Arslan C, Dizdar O, Altundag K. Chemotherapy and biological treatment options in breast cancer patients with brain metastasis: an update. Expert Opin Pharmacother 2014; 15:1643-58. [PMID: 25032884 DOI: 10.1517/14656566.2014.929664] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Breast cancer (BC) is the second most common cause of CNS metastasis. Ten to 20% of all, and 38% of human epidermal growth factor-2(+), metastatic BC patients experience brain metastasis (BM). Prolonged survival with better control of systemic disease and limited penetration of drugs to CNS increased the probability of CNS metastasis as a sanctuary site of relapse. Treatment of CNS disease has become an important component of overall disease control and quality of life. AREAS COVERED Current standard therapy for BM is whole-brain radiotherapy, surgery, stereotactic body radiation therapy for selected cases, corticosteroids and systemic chemotherapy. Little progress has been made in chemotherapy for the treatment of BM in patients with BC. Nevertheless, new treatment choices have emerged. In this review, we aimed to update current and future treatment options in systemic treatment for BM of BC. EXPERT OPINION Cornerstone local treatment options for BM of BC are radiotherapy and surgery in selected cases. Efficacy of cytotoxic chemotherapeutics is limited. Among targeted therapies, lapatinib has activity in systemic treatment of BM particularly when used in combination with capecitabine. Novel agents are currently investigated.
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Affiliation(s)
- Cagatay Arslan
- Izmir University Medical Park Hospital, Department of Medical Oncology , Izmir , Turkey
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Swain SM, Baselga J, Miles D, Im YH, Quah C, Lee LF, Cortés J. Incidence of central nervous system metastases in patients with HER2-positive metastatic breast cancer treated with pertuzumab, trastuzumab, and docetaxel: results from the randomized phase III study CLEOPATRA. Ann Oncol 2014; 25:1116-21. [PMID: 24685829 PMCID: PMC4037862 DOI: 10.1093/annonc/mdu133] [Citation(s) in RCA: 160] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Results from the phase III trial CLEOPATRA in human epidermal growth factor receptor 2-positive first-line metastatic breast cancer demonstrated significant improvements in progression-free and overall survival with pertuzumab, trastuzumab, and docetaxel over placebo, trastuzumab, and docetaxel. We carried out exploratory analyses of the incidence and time to development of central nervous system (CNS) metastases in patients from CLEOPATRA. PATIENTS AND METHODS Patients received pertuzumab/placebo: 840 mg in cycle 1, then 420 mg; trastuzumab: 8 mg/kg in cycle 1, then 6 mg/kg; docetaxel: initiated at 75 mg/m(2). Study drugs were administered i.v. every 3 weeks. The log-rank test was used for between-arm comparisons of time to CNS metastases as first site of disease progression and overall survival in patients with CNS metastases as first site of disease progression. The Kaplan-Meier approach was used to estimate median time to CNS metastases as first site of disease progression and median overall survival. RESULTS The incidence of CNS metastases as first site of disease progression was similar between arms; placebo arm: 51 of 406 (12.6%), pertuzumab arm: 55 of 402 (13.7%). Median time to development of CNS metastases as first site of disease progression was 11.9 months in the placebo arm and 15.0 months in the pertuzumab arm; hazard ratio (HR) = 0.58, 95% confidence interval (CI) 0.39-0.85, P = 0.0049. Overall survival in patients who developed CNS metastases as first site of disease progression showed a trend in favor of pertuzumab, trastuzumab, and docetaxel; HR = 0.66, 95% CI 0.39-1.11. Median overall survival was 26.3 versus 34.4 months in the placebo and pertuzumab arms, respectively. Treatment comparison of the survival curves was not statistically significant for the log-rank test (P = 0.1139), but significant for the Wilcoxon test (P = 0.0449). CONCLUSIONS While the incidence of CNS metastases was similar between arms, our results suggest that pertuzumab, trastuzumab, and docetaxel delays the onset of CNS disease compared with placebo, trastuzumab, and docetaxel. CLINICALTRIALSGOV NCT00567190.
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Affiliation(s)
- S M Swain
- Washington Cancer Institute, MedStar Washington Hospital Center, Washington
| | - J Baselga
- Memorial Sloan-Kettering Cancer Center, Memorial Hospital, New York, USA
| | - D Miles
- Mount Vernon Cancer Centre, Middlesex, UK
| | - Y-H Im
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - C Quah
- Genentech, Inc., South San Francisco, USA
| | - L F Lee
- Genentech, Inc., South San Francisco, USA
| | - J Cortés
- Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
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Ahmed R, Oborski MJ, Hwang M, Lieberman FS, Mountz JM. Malignant gliomas: current perspectives in diagnosis, treatment, and early response assessment using advanced quantitative imaging methods. Cancer Manag Res 2014; 6:149-70. [PMID: 24711712 PMCID: PMC3969256 DOI: 10.2147/cmar.s54726] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Malignant gliomas consist of glioblastomas, anaplastic astrocytomas, anaplastic oligodendrogliomas and anaplastic oligoastrocytomas, and some less common tumors such as anaplastic ependymomas and anaplastic gangliogliomas. Malignant gliomas have high morbidity and mortality. Even with optimal treatment, median survival is only 12–15 months for glioblastomas and 2–5 years for anaplastic gliomas. However, recent advances in imaging and quantitative analysis of image data have led to earlier diagnosis of tumors and tumor response to therapy, providing oncologists with a greater time window for therapy management. In addition, improved understanding of tumor biology, genetics, and resistance mechanisms has enhanced surgical techniques, chemotherapy methods, and radiotherapy administration. After proper diagnosis and institution of appropriate therapy, there is now a vital need for quantitative methods that can sensitively detect malignant glioma response to therapy at early follow-up times, when changes in management of nonresponders can have its greatest effect. Currently, response is largely evaluated by measuring magnetic resonance contrast and size change, but this approach does not take into account the key biologic steps that precede tumor size reduction. Molecular imaging is ideally suited to measuring early response by quantifying cellular metabolism, proliferation, and apoptosis, activities altered early in treatment. We expect that successful integration of quantitative imaging biomarker assessment into the early phase of clinical trials could provide a novel approach for testing new therapies, and importantly, for facilitating patient management, sparing patients from weeks or months of toxicity and ineffective treatment. This review will present an overview of epidemiology, molecular pathogenesis and current advances in diagnoses, and management of malignant gliomas.
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Affiliation(s)
- Rafay Ahmed
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew J Oborski
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Misun Hwang
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Frank S Lieberman
- Department of Neurology and Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - James M Mountz
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA, USA
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Le Saux O, You B, Freyer G. Antiangiogenic therapy in patients with HER2-positive metastatic breast cancer: a case series. Clin Breast Cancer 2014; 14:e89-94. [PMID: 24424314 DOI: 10.1016/j.clbc.2013.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Revised: 11/11/2013] [Accepted: 11/17/2013] [Indexed: 11/17/2022]
Affiliation(s)
- Olivia Le Saux
- Department of Medical Oncology, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France.
| | - Benoît You
- Department of Medical Oncology, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Gilles Freyer
- Department of Medical Oncology, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
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Chamberlain MC. Anticancer therapies and CNS relapse: overcoming blood–brain and blood–cerebrospinal fluid barrier impermeability. Expert Rev Neurother 2014; 10:547-61. [DOI: 10.1586/ern.10.14] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kaplan MA, Ertugrul H, Firat U, Kucukoner M, İnal A, Urakci Z, Pekkolay Z, Isikdogan A. Brain metastases in HER2-positive metastatic breast cancer patients who received chemotherapy with or without trastuzumab. Breast Cancer 2014; 22:503-9. [PMID: 24385387 DOI: 10.1007/s12282-013-0513-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 12/18/2013] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The aim of this study was to assess whether trastuzumab usage is a risk factor for the development of brain metastasis (BM) in human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (MBC) and factors affecting survival after development of BM. MATERIALS AND METHODS One hundred thirty-two patients treated with (treatment group) or without trastuzumab (control group) with brain metastasis were retrospectively analyzed. RESULTS Ninety of the 132 HER2-positive MBC patients were in the treatment group and 42 were in the control group. BM was significantly increased in patients who were treated with trastuzumab in two or more lines (58.5 vs 24.1 %, p < 0.001). Trastuzumab and lapatinib usage after BM and age were independent prognostic factors for overall survival in univariate and multivariate analysis. CONCLUSION The risk for BM was increased in patients who were treated with trastuzumab in two or more lines. Using trastuzumab and lapatinib after BM and age were independent prognostic factors for time to death from BM.
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Affiliation(s)
- Muhammet Ali Kaplan
- Department of Medical Oncology, Dicle University School of Medicine, Diyarbakir, Turkey,
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Molecular interactions in the development of brain metastases. Int J Mol Sci 2013; 14:17157-67. [PMID: 23965978 PMCID: PMC3759957 DOI: 10.3390/ijms140817157] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Revised: 08/09/2013] [Accepted: 08/09/2013] [Indexed: 12/11/2022] Open
Abstract
Brain metastases are a much-feared complication of cancer. The development of brain metastases requires a malignant cell to acquire characteristics that facilitate dissemination away from the primary site, entrance into the nervous system, and establishment in the brain. This review summarizes recent work focused on the molecular derangements leading to brain metastases and outlines areas in need of greater understanding.
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Renfrow JJ, Lesser GJ. Molecular Subtyping of Brain Metastases and Implications for Therapy. Curr Treat Options Oncol 2013; 14:514-27. [DOI: 10.1007/s11864-013-0248-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Stark AM, Schem C, Maass N, Hugo HH, Jonat W, Mehdorn HM, Held-Feindt J. Expression of metastasis suppressor gene maspin is reduced in breast cancer brain metastases and correlates with the estrogen receptor status. Neurol Res 2013; 32:303-8. [DOI: 10.1179/016164109x12518779082192] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Abstract
PURPOSE OF REVIEW To review the state of the art and new developments in the field of targeted agents for brain metastases. RECENT FINDINGS The huge amount of information on new molecular compounds and the advances in understanding the molecular pathways that mediate brain colonization have led to an increase of interest in preclinical and clinical investigations in the field of brain metastases. Targeted therapies can be employed either on established brain metastases or in a prevention setting. Targeting angiogenesis is an attractive approach. Up to date, large clinical trial datasets have shown that antiangiogenic agents do not increase the risk of bleeding into the brain. Bevacizumab (an anti-VEGF agent) is undergoing investigation in clinical trials on brain metastases from non-small cell lung cancer (NSCLC), breast cancer and melanoma. Sunitinib, a multitarget small molecule tyrosine kinase inhibitor (TKI), is a promising agent in brain metastases from renal cell cancer. The EGFR inhibitors gefitinib and erlotinib have a definite activity in brain metastases from NSCLC with activating EGFR mutations. Regarding HER2-positive breast cancer patients with established brain metastases, lapatinib (small molecule TKI) seems particularly active in association with capecitabine. Lapatinib alone is attractive in the prevention setting. Brain metastases from melanoma with BRAF V600E mutations respond to a specific inhibitor, such as vemurafenib. The immunomodulator ipilimumab is also active on brain metastases from melanoma. SUMMARY The use of targeted agents in brain metastases from solid tumors is promising. The setting of prevention will be probably expanded in the next years. Well designed clinical trials with proper endpoints are needed.
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Daphu I, Sundstrøm T, Horn S, Huszthy PC, Niclou SP, Sakariassen PØ, Immervoll H, Miletic H, Bjerkvig R, Thorsen F. In vivo animal models for studying brain metastasis: value and limitations. Clin Exp Metastasis 2013; 30:695-710. [DOI: 10.1007/s10585-013-9566-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 01/07/2013] [Indexed: 01/16/2023]
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Chien AJ, Rugo HS. Emerging treatment options for the management of brain metastases in patients with HER2-positive metastatic breast cancer. Breast Cancer Res Treat 2013; 137:1-12. [PMID: 23143215 PMCID: PMC3528960 DOI: 10.1007/s10549-012-2328-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 10/30/2012] [Indexed: 11/10/2022]
Abstract
The widespread use of trastuzumab in the past decade has led to a significant and measureable improvement in the survival of patients with human epidermal growth factor receptor-2 (HER2) overexpressing breast cancer, and in many ways has redefined the natural history of this aggressive breast cancer subtype. Historically, survival in patients with HER2-positive disease was dictated by the systemic disease course, and what appears to be the central nervous system (CNS) tropism associated with HER2-amplified tumors was not clinically evident. With improved systemic control and prolonged survival, the incidence of brain metastases has increased, and CNS disease, often in the setting of well-controlled extracranial disease, is proving to be an increasingly important and clinically challenging cause of morbidity and mortality in patients with HER2-positive advanced breast cancer. This review summarizes the known clinical data for the systemic treatment of HER2-positive CNS metastases and includes information about ongoing clinical trials of novel therapies as well as emerging strategies for early detection and prevention.
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Affiliation(s)
- A. Jo Chien
- University of California San Francisco Helen Diller Family Comprehensive Cancer Center, 1600 Divisidero Street, Box 1710, San Francisco, CA 94143-1710 USA
| | - Hope S. Rugo
- University of California San Francisco Helen Diller Family Comprehensive Cancer Center, 1600 Divisidero Street, Box 1710, San Francisco, CA 94143-1710 USA
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Combined targeting of HER2 and VEGFR2 for effective treatment of HER2-amplified breast cancer brain metastases. Proc Natl Acad Sci U S A 2012; 109:E3119-27. [PMID: 23071298 DOI: 10.1073/pnas.1216078109] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Brain metastases are a serious obstacle in the treatment of patients with human epidermal growth factor receptor-2 (HER2)-amplified breast cancer. Although extracranial disease is controlled with HER2 inhibitors in the majority of patients, brain metastases often develop. Because these brain metastases do not respond to therapy, they are frequently the reason for treatment failure. We developed a mouse model of HER2-amplified breast cancer brain metastasis using an orthotopic xenograft of BT474 cells. As seen in patients, the HER2 inhibitors trastuzumab and lapatinib controlled tumor progression in the breast but failed to contain tumor growth in the brain. We observed that the combination of a HER2 inhibitor with an anti-VEGF receptor-2 (VEGFR2) antibody significantly slows tumor growth in the brain, resulting in a striking survival benefit. This benefit appears largely due to an enhanced antiangiogenic effect: Combination therapy reduced both the total and functional microvascular density in the brain xenografts. In addition, the combination therapy led to a marked increase in necrosis of the brain lesions. Moreover, we observed even better antitumor activity after combining both trastuzumab and lapatinib with the anti-VEGFR2 antibody. This triple-drug combination prolonged the median overall survival fivefold compared with the control-treated group and twofold compared with either two-drug regimen. These findings support the clinical development of this three-drug regimen for the treatment of HER2-amplified breast cancer brain metastases.
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