1
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Doshi V, Thummar V, Mehta P. A Case Report on Trastuzumab Emtansine (T-DM1) in a Patient With Human Epidermal Growth Factor Receptor 2 (HER2)-Positive Metastatic Breast Cancer and Brain Metastases: Long-Term Treatment and Survival. Cureus 2024; 16:e63589. [PMID: 39087186 PMCID: PMC11290475 DOI: 10.7759/cureus.63589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2024] [Indexed: 08/02/2024] Open
Abstract
Breast cancer remains the most common cancer in women worldwide. Among women with breast cancer, brain metastases are very prevalent among HER2-positive and affect those in the advanced stages of the disease. Various factors, including molecular subtypes, performance status, extracranial disease status, leptomeningeal metastasis, and the number of lesions, significantly influence the prognosis of patients with brain metastases from breast cancer (BCBrM). Understanding and addressing the specific risks associated with different breast cancer subtypes is crucial for developing tailored and effective medical treatments. This report presents a case of a breast cancer patient with recurrent disease and brain metastases who achieved long-term survival following a treatment regimen that included radiotherapy and a T-DM1 biosimilar.
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Affiliation(s)
- Vipul Doshi
- Medical Oncology, Solapur Cancer Centre, Solapur, IND
| | | | - Priya Mehta
- Medical Affairs, Zydus Lifesciences Ltd, Ahmedabad, IND
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2
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Qu F, Liu Q, Lu R, Li W. Disitamab Vedotin (RC48) combined with bevacizumab for treatment of HR-negative/HER2-positive metastatic breast cancer with liver and brain involvement: A case report. Front Oncol 2023; 13:1245701. [PMID: 37711199 PMCID: PMC10498115 DOI: 10.3389/fonc.2023.1245701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/14/2023] [Indexed: 09/16/2023] Open
Abstract
Background The overexpression of human epidermal growth factor receptor 2 (HER2) is strongly correlated with an elevated risk of developing distant metastases, particularly brain metastases, in breast cancer (BC) cases. RC48 (also known as Disitamab vedotin), represents a promising antibody-drug conjugate (ADC), that comprises three well-defined components: hertuzumab against the prominent tumor target-HER2, monomethyl auristatin E (MMAE) and a cleavable linker. Preclinical studies have demonstrated its robust antitumor activity in BC patient-derived xenograft models with HER2-positive or HER2-low expression. Additionally, antiangiogenic drugs like bevacizumab have shown potential efficacy on advanced BC via inhibiting pathological neovascularizationits. Case presentation Here, we will share our experience in treating a 49-year-old woman initially diagnosed with stage IV breast cancer characterized by hormone receptor (HR)-negativity and HER2-positivity. This complex case entailed brain and liver metastases, and the patient exhibited resistance to various HER2-targeted treatment regimens. Finally, the patient received RC48 plus bevacizumab as the advanced forth-line treatment, which was well tolerated with no observed toxicities. Subsequent radiological assessments revealed remarkable regression in the brain metastatic lesions, classified as having partial response based on the RECIST 1.1 system. The period of progression-free survival (PFS) was 7 months. Conclusion The present study underscores the efficacy of systemic treatment with RC48 in conjunction, showcasing substantial enhancement in both radiographic indicators and clinical symptomatology among patients with brain metastatic breast cancer (BMBC). More specifically, the sequential application of ADCs in combination with antiangiogenics presents a novel avenue for advancing the treatment landscape of metastatic BC.
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Affiliation(s)
- Fei Qu
- Department of Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- The First Clinical College of Nanjing Medical University, Nanjing, China
| | - Qian Liu
- Department of Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- The First Clinical College of Nanjing Medical University, Nanjing, China
| | - Rongrong Lu
- Department of Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- The First Clinical College of Nanjing Medical University, Nanjing, China
| | - Wei Li
- Department of Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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3
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Mair MJ, Bartsch R, Le Rhun E, Berghoff AS, Brastianos PK, Cortes J, Gan HK, Lin NU, Lassman AB, Wen PY, Weller M, van den Bent M, Preusser M. Understanding the activity of antibody-drug conjugates in primary and secondary brain tumours. Nat Rev Clin Oncol 2023; 20:372-389. [PMID: 37085569 DOI: 10.1038/s41571-023-00756-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/23/2023]
Abstract
Antibody-drug conjugates (ADCs), a class of targeted cancer therapeutics combining monoclonal antibodies with a cytotoxic payload via a chemical linker, have already been approved for the treatment of several cancer types, with extensive clinical development of novel constructs ongoing. Primary and secondary brain tumours are associated with high mortality and morbidity, necessitating novel treatment approaches. Pharmacotherapy of brain tumours can be limited by restricted drug delivery across the blood-brain or blood-tumour barrier, although data from phase II studies of the HER2-targeted ADC trastuzumab deruxtecan indicate clinically relevant intracranial activity in patients with brain metastases from HER2+ breast cancer. However, depatuxizumab mafodotin, an ADC targeting wild-type EGFR and EGFR variant III, did not provide a definitive overall survival benefit in patients with newly diagnosed or recurrent EGFR-amplified glioblastoma in phase II and III trials, despite objective radiological responses in some patients. In this Review, we summarize the available data on the central nervous system activity of ADCs from trials involving patients with primary and secondary brain tumours and discuss their clinical implications. Furthermore, we explore pharmacological determinants of intracranial activity and discuss the optimal design of clinical trials to facilitate development of ADCs for the treatment of gliomas and brain metastases.
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Affiliation(s)
- Maximilian J Mair
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Personalized Immunotherapy, Medical University of Vienna, Vienna, Austria
| | - Rupert Bartsch
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Emilie Le Rhun
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Anna S Berghoff
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Personalized Immunotherapy, Medical University of Vienna, Vienna, Austria
| | - Priscilla K Brastianos
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Javier Cortes
- International Breast Cancer Center (IBCC), Pangaea Oncology, Quirónsalud Group, Madrid and Barcelona, Spain
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
- Medical Scientia Innovation Research (MEDSIR), Barcelona, Spain
| | - Hui K Gan
- Cancer Therapies and Biology Group, Centre of Research Excellence in Brain Tumours, Olivia Newton-John Cancer Wellness and Research Centre, Austin Hospital, Heidelberg, VIC, Australia
- La Trobe University School of Cancer Medicine, Heidelberg, VIC, Australia
- Department of Medicine, University of Melbourne, Heidelberg, VIC, Australia
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Andrew B Lassman
- Division of Neuro-Oncology, Department of Neurology, Herbert Irving Comprehensive Cancer Center, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, NY, USA
| | - Patrick Y Wen
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Martin van den Bent
- The Brain Tumour Center, Erasmus Medical Center Cancer Institute, Rotterdam, Netherlands
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
- Christian Doppler Laboratory for Personalized Immunotherapy, Medical University of Vienna, Vienna, Austria.
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4
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Yang X, Ren H, Xu Y, Peng X, Yu W, Shen Z. Combination of radiotherapy and targeted therapy for HER2-positive breast cancer brain metastases. Eur J Med Res 2023; 28:27. [PMID: 36642742 PMCID: PMC9841677 DOI: 10.1186/s40001-022-00894-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/09/2022] [Indexed: 01/17/2023] Open
Abstract
Radiotherapy and targeted therapy are essential treatments for patients with brain metastases from human epidermal growth factor receptor 2 (HER2)-positive breast cancer. However, the combination of radiotherapy and targeted therapy still needs to be investigated, and neurotoxicity induced by radiotherapy for brain metastases has also become an important issue of clinical concern. It remained unclear how to achieve the balance of efficacy and toxicity with the application of new radiotherapy techniques and new targeted therapy drugs. This article reviews the benefits and potential risk of combining radiotherapy and targeted therapy for HER2-positive breast cancer with brain metastases.
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Affiliation(s)
- Xiaojing Yang
- grid.16821.3c0000 0004 0368 8293Department of Oncology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600, Yishan Road, Shanghai, 200233 China ,grid.16821.3c0000 0004 0368 8293Department of Radiation Oncology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hanru Ren
- grid.8547.e0000 0001 0125 2443Department of Orthopedics, Pudong Medical Center, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Yi Xu
- grid.16821.3c0000 0004 0368 8293Department of Oncology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600, Yishan Road, Shanghai, 200233 China
| | - Xue Peng
- grid.16821.3c0000 0004 0368 8293Department of Breast Surgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenxi Yu
- grid.16821.3c0000 0004 0368 8293Department of Oncology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600, Yishan Road, Shanghai, 200233 China
| | - Zan Shen
- grid.16821.3c0000 0004 0368 8293Department of Oncology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600, Yishan Road, Shanghai, 200233 China
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Sanglier T, Shim J, Lamarre N, Peña-Murillo C, Antao V, Montemurro F. Trastuzumab emtansine vs lapatinib and capecitabine in HER2-positive metastatic breast cancer brain metastases: A real-world study. Breast 2023:S0960-9776(23)00007-3. [PMID: 36709091 DOI: 10.1016/j.breast.2023.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/13/2023] [Accepted: 01/14/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Trastuzumab emtansine (T-DM1) has demonstrated improvements in survival and neurological symptoms in patients with breast cancer with brain metastases (BCBM). This real-world study investigated the effectiveness of T-DM1 versus lapatinib plus capecitabine (LC) in patients with BCBM. METHODS This retrospective, observational study evaluated patients with HER2-positive BCBM using a real-world database. Eligible patients had initiated T-DM1 or LC with a prior diagnosis of brain metastasis and ≥1 prior metastatic breast cancer treatment. The primary endpoint was overall survival (OS); secondary endpoints were time to next relevant treatment or death (TTNT) and real-world progression-free survival (rwPFS). An inverse probability of treatment weighting (IPTW) approach was used to account for differences in potential baseline characteristics between treatment groups. Outcomes were described using the Kaplan-Meier method, and the average treatment effect of initiating T-DM1 versus LC was estimated using weighted Cox proportional hazard models and hazard ratio (HR). RESULTS A total of 214 patients were available for analysis (T-DM1, n = 161; LC, n = 53). Demographics and baseline characteristics were generally well-balanced between treatment groups after weighting. After weighting, median OS was 17.7 (T-DM1) versus 9.6 (LC) months (HR, 0.55 [95% CI, 0.34-0.89]; P=0.013). Median TTNT was 9.0 (T-DM1) versus 6.0 (LC) months (HR, 0.55 [95% CI, 0.36-0.85]; P = 0.005). After weighting, median rwPFS was 6.0 (T-DM1) versus 4.0 (LC) months (HR, 0.50 [95% CI, 0.36-0.69]; P < 0.001). CONCLUSIONS These results support the superior effectiveness and clinical relevance of T-DM1 versus LC in patients with HER2-positive BCBM in the real world.
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6
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Kabraji S, Ni J, Sammons S, Li T, Van Swearingen AE, Wang Y, Pereslete A, Hsu L, DiPiro PJ, Lascola C, Moore H, Hughes M, Raghavendra AS, Gule-Monroe M, Murthy RK, Winer EP, Anders CK, Zhao JJ, Lin NU. Preclinical and Clinical Efficacy of Trastuzumab Deruxtecan in Breast Cancer Brain Metastases. Clin Cancer Res 2023; 29:174-182. [PMID: 36074155 PMCID: PMC9811155 DOI: 10.1158/1078-0432.ccr-22-1138] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/01/2022] [Accepted: 09/06/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE Brain metastases can occur in up to 50% of patients with metastatic HER2-positive breast cancer. Because patients with active brain metastases were excluded from previous pivotal clinical trials, the central nervous system (CNS) activity of the antibody-drug conjugate trastuzumab deruxtecan (T-DXd) is not well characterized. EXPERIMENTAL DESIGN We studied how T-DXd affects growth and overall survival in orthotopic patient-derived xenografts (PDX) of HER2-positive and HER2-low breast cancer brain metastases (BCBM). Separately, we evaluated the effects of T-DXd in a retrospective cohort study of 17 patients with stable or active brain metastases. RESULTS T-DXd inhibited tumor growth and prolonged survival in orthotopic PDX models of HER2-positive (IHC 3+) and HER2-low (IHC 2+/FISH ratio < 2) BCBMs. T-DXd reduced tumor size and prolonged survival in a T-DM1-resistant HER2-positive BCBM PDX model. In a retrospective multi-institutional cohort study of 17 patients with predominantly HER2-positive BCBMs, the CNS objective response rate (ORR) was 73% (11/15) while extracranial response rate was 45% (5/11). In the subset of patients with untreated or progressive BCBM at baseline, the CNS ORR was 70% (7/10). The median time on treatment with T-DXd was 8.9 (1.3-16.2) months, with 42% (7/17) remaining on treatment at data cutoff. CONCLUSIONS T-DXd demonstrates evidence of CNS activity in HER2-positive and HER2-low PDX models of BCBM and preliminary evidence of clinical efficacy in a multi-institution case series of patients with BCBM. Prospective clinical trials to further evaluate CNS activity of T-DXd in patients with active brain metastases are warranted. See related commentary by Soffietti and Pellerino, p. 8.
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Affiliation(s)
| | - Jing Ni
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Tianyu Li
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Yanzhi Wang
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Liangge Hsu
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | | | | | | | | | | | | | | | - Jean J. Zhao
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nancy U. Lin
- Dana-Farber Cancer Institute, Boston, Massachusetts
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7
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Matsui JK, Perlow HK, Raj RK, Nalin AP, Lehrer EJ, Kotecha R, Trifiletti DM, McClelland S, Kendra K, Williams N, Owen DH, Presley CJ, Thomas EM, Beyer SJ, Blakaj DM, Ahluwalia MS, Raval RR, Palmer JD. Treatment of Brain Metastases: The Synergy of Radiotherapy and Immune Checkpoint Inhibitors. Biomedicines 2022; 10:2211. [PMID: 36140312 PMCID: PMC9496359 DOI: 10.3390/biomedicines10092211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/31/2022] [Accepted: 09/02/2022] [Indexed: 11/27/2022] Open
Abstract
Brain metastases are a devastating sequela of common primary cancers (e.g., lung, breast, and skin) and have limited effective therapeutic options. Previously, systemic chemotherapy failed to demonstrate significant benefit in patients with brain metastases, but in recent decades, targeted therapies and more recently immune checkpoint inhibitors (ICIs) have yielded promising results in preclinical and clinical studies. Furthermore, there is significant interest in harnessing the immunomodulatory effects of radiotherapy (RT) to synergize with ICIs. Herein, we discuss studies evaluating the impact of RT dose and fractionation on the immune response, early studies supporting the synergistic interaction between RT and ICIs, and ongoing clinical trials assessing the benefit of combination therapy in patients with brain metastases.
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Affiliation(s)
| | - Haley K. Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Rohit K. Raj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Ansel P. Nalin
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | | | - Shearwood McClelland
- Departments of Radiation Oncology and Neurological Surgery, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Kari Kendra
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Nicole Williams
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Dwight H. Owen
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Carolyn J. Presley
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Evan M. Thomas
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Sasha J. Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Manmeet S. Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Raju R. Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Joshua D. Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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8
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Liu K, Mao X, Li T, Xu Z, An R. Immunotherapy and immunobiomarker in breast cancer: current practice and future perspectives. Am J Cancer Res 2022; 12:3532-3547. [PMID: 36119833 PMCID: PMC9442024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/28/2022] [Indexed: 06/15/2023] Open
Abstract
Among the new cancer cases and resulting deaths among women worldwide, breast cancer is the most significant threat to women's health. In recent years, immunotherapy was initially used to treat patients with metastatic breast cancer, where it demonstrated its unique value by providing a novel way to improve therapeutic effects and prolong survival time. With the development of clinical trials related to immunotherapy for breast cancer, tumour vaccines, such as DNA vaccines, have been observed to improve the disease-free survival (DFS) and overall survival (OS) of patients. Monoclonal antibodies have also shown good efficacy, and adoptive cell therapies, such as CAR-T, exhibit strong tumour killing ability and good safety, and thus, these therapies may comprise a new strategy for the treatment of breast cancer. These breakthrough successes have promoted the achievement of "individualized" breast cancer treatment. Moreover, a recent study showed that patients with various cancer types with a higher tumour mutational burden (TMB) are more likely to benefit from immunotherapy. As research progresses, TMB may also demonstrate a certain clinical significance in the treatment of breast cancer. This paper reviews the latest research progress on breast cancer immunotherapy and the predictive value and application status of TMB in immunotherapy regimens for breast cancer patients to provide a reference for further in-depth studies of breast cancer immunotherapy.
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Affiliation(s)
- Kangsheng Liu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi’an Jiaotong UniversityXi’an 710061, Shannxi, P. R. China
- Department of Clinical Laboratory, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care HospitalNanjing 210029, Jiangsu, P. R. China
| | - Xiaodong Mao
- Department of Endocrinology, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese MedicineNanjing 210028, Jiangsu, P. R. China
| | - Taiping Li
- Department of Neuro-Psychiatric Institute, The Affiliated Brain Hospital of Nanjing Medical UniversityNanjing 210029, Jiangsu, P. R. China
| | - Zhirong Xu
- Department of Clinical Laboratory, The First Affiliated Hospital of Soochow UniversitySuzhou 215006, Jiangsu, P. R. China
| | - Ruifang An
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi’an Jiaotong UniversityXi’an 710061, Shannxi, P. R. China
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Mireștean CC, Iancu RI, Iancu DPT. An Underestimated Toxicity Radiation-Induced Hypothyroidism in Patients Multimodally Treated for Breast Cancer. J Clin Med 2021; 10:jcm10235503. [PMID: 34884204 PMCID: PMC8658069 DOI: 10.3390/jcm10235503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/15/2021] [Accepted: 11/20/2021] [Indexed: 11/16/2022] Open
Abstract
Radiation therapy is part of the therapeutic arsenal for breast cancer, whether it is adjuvant treatment after lumpectomy or radical mastectomy, or it is used as a palliative option in the case of metastatic or recurrent disease. Significant advances in diagnostic and therapeutic stratification of breast cancers have significantly prolonged survival, even in the metastatic stage. Exposure of patients during the course of the disease in a multidisciplinary therapeutic approach including chemotherapy, hormone therapy, targeted anti-HER therapies or CDK4/6 inhibitors had led to improved survival but with the price of additional toxicity. Among them, hypothyroidism is a well-known consequence of external radiation therapy, especially in the case of cervical region irradiation, including supraclavicular and infra-clavicular nodal levels. In this situation, the thyroid gland is considered as an organ at risk (OAR) and receives a significant dose of radiation. Subclinical hypothyroidism is a common endocrine disorder characterized by elevated TSH levels with normal levels of FT4 (free T4) and FT3 (free T3), and as a late effect, primary hypothyroidism is one of the late effects that significantly affects the quality of life for patients with breast cancer receiving multimodal treatment. Hypothyroidism has a significant impact on quality of life, most often occurring as late clinical toxicity, secondary to thyroid irradiation at doses between 30 and 70 Gy. Dose-volume parameters of irradiation, gland function at the beginning of the treatment and associated systemic therapies may be factors that alter thyroid radio-sensitivity and affect thyroid gland tolerance. In the case of head and neck tumor pathology, in which doses of >50 Gy are routinely used, the thyroid gland is generally considered as an OAR, the rate of radio-induced hypothyroidism being estimated at rates of between 20% and 52%. For breast cancer, the thyroid is often neglected in terms of dosimetry protection, the rate of late dysfunction being 6–21%.
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Affiliation(s)
- Camil Ciprian Mireștean
- Department of Oncology and Radiotherapy, University of Medicine and Pharmacy Craiova, 200349 Craiova, Romania;
- Department of Surgery, Railways Clinical Hospital Iasi, 700506 Iași, Romania
| | - Roxana Irina Iancu
- Oral Pathology Department, Faculty of Dental Medicine, “Gr. T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
- Department of Clinical Laboratory, “St. Spiridon” Emergency Universitary Hospital, 700111 Iași, Romania
- Correspondence: ; Tel.: +40-232-301-603
| | - Dragoș Petru Teodor Iancu
- Oncology and Radiotherapy Department, Faculty of Medicine, “Gr. T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania;
- Department of Radiation Oncology, Regional Institute of Oncology, 700483 Iași, Romania
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10
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Joe NS, Hodgdon C, Kraemer L, Redmond KJ, Stearns V, Gilkes DM. A common goal to CARE: Cancer Advocates, Researchers, and Clinicians Explore current treatments and clinical trials for breast cancer brain metastases. NPJ Breast Cancer 2021; 7:121. [PMID: 34521857 PMCID: PMC8440644 DOI: 10.1038/s41523-021-00326-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 08/09/2021] [Indexed: 02/08/2023] Open
Abstract
Breast cancer is the most commonly diagnosed cancer in women worldwide. Approximately one-tenth of all patients with advanced breast cancer develop brain metastases resulting in an overall survival rate of fewer than 2 years. The challenges lie in developing new approaches to treat, monitor, and prevent breast cancer brain metastasis (BCBM). This review will provide an overview of BCBM from the integrated perspective of clinicians, researchers, and patient advocates. We will summarize the current management of BCBM, including diagnosis, treatment, and monitoring. We will highlight ongoing translational research for BCBM, including clinical trials and improved detection methods that can become the mainstay for BCBM treatment if they demonstrate efficacy. We will discuss preclinical BCBM research that focuses on the intrinsic properties of breast cancer cells and the influence of the brain microenvironment. Finally, we will spotlight emerging studies and future research needs to improve survival outcomes and preserve the quality of life for patients with BCBM.
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Affiliation(s)
- Natalie S Joe
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Cellular and Molecular Medicine Program, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christine Hodgdon
- INSPIRE (Influencing Science through Patient-Informed Research & Education) Advocacy Program, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vered Stearns
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- INSPIRE (Influencing Science through Patient-Informed Research & Education) Advocacy Program, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniele M Gilkes
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Cellular and Molecular Medicine Program, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- INSPIRE (Influencing Science through Patient-Informed Research & Education) Advocacy Program, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Chemical and Biomolecular Engineering, The Johns Hopkins University, Baltimore, MD, USA.
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11
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Witt JS, Wisinski KB, Anderson BM. Concurrent Radiation and Modern Systemic Therapies for Breast Cancer: An Ever-Expanding Frontier. Clin Breast Cancer 2021; 21:120-127. [PMID: 34030859 DOI: 10.1016/j.clbc.2020.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/28/2020] [Indexed: 11/29/2022]
Abstract
Radiotherapy is a critical tool for reducing locoregional recurrence, extending survival, and palliating symptoms in patients with breast cancer. With an ever-expanding armamentarium of systemic agents available, and an increasing trend toward the use of hypofractionated radiation regimens, it can be difficult to determine the safety of concurrent therapy. In particular, new targeted agents in both the adjuvant and metastatic setting have limited prospective or long-term data demonstrating safety when delivered concurrently with radiotherapy. Other systemic agents, including chemotherapy and endocrine therapy, are also important components of the overall treatment strategy for localized and metastatic breast cancer, and are often delivered concurrently with radiation in certain clinical scenarios. This review explores the safety, efficacy, and pitfalls of delivering radiation in conjunction with systemic therapies for breast cancer.
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Affiliation(s)
- Jacob S Witt
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Kari B Wisinski
- Division of Hematology, Medical Oncology, and Palliative Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; Carbone Cancer Center, University of Wisconsin, Madison, WI
| | - Bethany M Anderson
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison, WI; Carbone Cancer Center, University of Wisconsin, Madison, WI.
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12
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Mills MN, Walker C, Thawani C, Naz A, Figura NB, Kushchayev S, Etame A, Yu HHM, Robinson TJ, Liu J, Vogelbaum MA, Forsyth PA, Czerniecki BJ, Soliman HH, Han HS, Ahmed KA. Trastuzumab Emtansine (T-DM1) and stereotactic radiation in the management of HER2+ breast cancer brain metastases. BMC Cancer 2021; 21:223. [PMID: 33663447 PMCID: PMC7934378 DOI: 10.1186/s12885-021-07971-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/24/2021] [Indexed: 12/21/2022] Open
Abstract
Background Due to recent concerns about the toxicity of trastuzumab emtansine (T-DM1) with stereotactic radiation, we assessed our institutional outcomes treating HER2-positive breast cancer brain metastases (BCBM) with T-DM1 and stereotactic radiation. Methods This is a single institution series of 16 patients with HER2-positive breast cancer who underwent 18 stereotactic sessions to 40 BCBM from 2013 to 2019 with T-DM1 delivered within 6 months. The Kaplan-Meier method was used to calculate overall survival (OS), local control (LC), distant intracranial control (DIC), and systemic progression-free survival (sPFS) from the date of SRS. A neuro-radiologist independently reviewed follow-up imaging. Results One patient had invasive lobular carcinoma, and 15 patients had invasive ductal carcinoma. All cases were HER2-positive, while 10 were hormone receptor (HR) positive. Twenty-four lesions were treated with stereotactic radiosurgery (SRS) to a median dose of 21 Gy (14–24 Gy). Sixteen lesions were treated with fractionated stereotactic radiation (FSRT) with a median dose of 25 Gy (20-30Gy) delivered in 3 to 5 fractions. Stereotactic radiation was delivered concurrently with T-DM1 in 19 lesions (48%). Median follow up time was 13.2 months from stereotactic radiation. The 1-year LC, DIC, sPFS, and OS were 75, 50, 30, and 67%, respectively. There was 1 case of leptomeningeal progression and 1 case (3%) of symptomatic radionecrosis. Conclusions We demonstrate that stereotactic radiation and T-DM1 is well-tolerated and effective for patients with HER2-positive BCBM. An increased risk for symptomatic radiation necrosis was not noted in our series.
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Affiliation(s)
- Matthew N Mills
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA.
| | - Chelsea Walker
- University of South Florida, Morsani College of Medicine, Tampa, FL, 33612, USA
| | - Chetna Thawani
- University of South Florida, Morsani College of Medicine, Tampa, FL, 33612, USA
| | - Afrin Naz
- University of South Florida, Morsani College of Medicine, Tampa, FL, 33612, USA
| | - Nicholas B Figura
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA
| | - Sergiy Kushchayev
- Departments of Radiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Arnold Etame
- Departments of Neuro Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Hsiang-Hsuan Michael Yu
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA
| | - Timothy J Robinson
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA
| | - James Liu
- Departments of Neuro Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Michael A Vogelbaum
- Departments of Neuro Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Peter A Forsyth
- Departments of Neuro Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Brian J Czerniecki
- Departments of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Hatem H Soliman
- Departments of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Hyo S Han
- Departments of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Kamran A Ahmed
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA
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13
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Higashiyama N, Nangia J, Shafaee MN, Chen N, Michael BL, Rimawi M, Hoyos V. Dose-reduced trastuzumab deruxtecan can be safely used in liver failure and active leptomeningeal metastases. CURRENT PROBLEMS IN CANCER: CASE REPORTS 2020; 2. [PMID: 34505091 PMCID: PMC8425325 DOI: 10.1016/j.cpccr.2020.100034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Trastuzumab deruxtecan has been shown to have responses in heavily pretreated patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer. However, the safety of this medication in patients with severe liver dysfunction and untreated or symptomatic central nervous system metastases is unknown. We describe a patient with metastatic HER2-positive breast cancer with liver failure and leptomeningeal metastases who was treated with dose-reduced trastuzumab deruxtecan. With treatment, the patient’s hyperbilirubinemia resolved and she demonstrated a response on imaging. She was dose-escalated to full dose with minimal adverse events.
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Affiliation(s)
- Nicole Higashiyama
- Baylor College of Medicine, Department of Internal Medicine, Section of Hematology-Oncology, One Baylor Plaza, Houston, TX, United States
| | - Julie Nangia
- Baylor College of Medicine, Department of Internal Medicine, Section of Hematology-Oncology, One Baylor Plaza, Houston, TX, United States.,Baylor College of Medicine, Lester and Sue Smith Breast Center, Dan L. Duncan Comprehensive Cancer Center, 7200 Cambridge St. 7th Floor, Houston, TX, United States
| | - Maryam Nemati Shafaee
- Baylor College of Medicine, Department of Internal Medicine, Section of Hematology-Oncology, One Baylor Plaza, Houston, TX, United States.,Baylor College of Medicine, Lester and Sue Smith Breast Center, Dan L. Duncan Comprehensive Cancer Center, 7200 Cambridge St. 7th Floor, Houston, TX, United States
| | - Nan Chen
- Baylor College of Medicine, Department of Internal Medicine, Section of Hematology-Oncology, One Baylor Plaza, Houston, TX, United States
| | - Binu Liz Michael
- Baylor College of Medicine, Department of Internal Medicine, Section of Hematology-Oncology, One Baylor Plaza, Houston, TX, United States.,Baylor College of Medicine, Lester and Sue Smith Breast Center, Dan L. Duncan Comprehensive Cancer Center, 7200 Cambridge St. 7th Floor, Houston, TX, United States
| | - Mothaffar Rimawi
- Baylor College of Medicine, Department of Internal Medicine, Section of Hematology-Oncology, One Baylor Plaza, Houston, TX, United States.,Baylor College of Medicine, Lester and Sue Smith Breast Center, Dan L. Duncan Comprehensive Cancer Center, 7200 Cambridge St. 7th Floor, Houston, TX, United States
| | - Valentina Hoyos
- Baylor College of Medicine, Department of Internal Medicine, Section of Hematology-Oncology, One Baylor Plaza, Houston, TX, United States.,Baylor College of Medicine, Lester and Sue Smith Breast Center, Dan L. Duncan Comprehensive Cancer Center, 7200 Cambridge St. 7th Floor, Houston, TX, United States.,Baylor College of Medicine, Center for Cell and Gene Therapy, One Baylor Plaza, Room N1002, Houston, TX, United States
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14
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Kofron CP, Chapman A. Breast Cancer With Brain Metastases: Perspective From a Long-Term Survivor. Integr Cancer Ther 2020; 19:1534735419890017. [PMID: 31906724 PMCID: PMC6947880 DOI: 10.1177/1534735419890017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The purpose of this essay is to inform others that it is possible to survive breast cancer with brain metastases. The second author is the subject patient and a long-term survivor of systemic metastatic breast cancer with numerous brain metastases (corresponding to 8% survivor group). We credit her survival to a combination of (1) medicine as practiced by an excellent oncologist with whom we developed a partnership to manage the patient’s health, (2) our informed exploration of the available scientific knowledge including a review of scientific research articles that go beyond conventional care, and (3) the patient’s supplementation with numerous repurposed drugs and other substances reported to have antitumor properties. Alongside her conventional treatment (the medical standard of care), it seems likely that this supplementation has been a key factor in the patient’s long-term survival. We also point out that the lack of follow-up magnetic resonance imaging brain scans for early detection of brain metastases poses substantial risks for patients with HER2+ metastatic breast cancer in non–central nervous system locations. Thus, we suggest that research be conducted on such early detection for possible inclusion in the recommendations for the medical standard of care. Finally, medical doctors and also patients with backgrounds in biological science may wish to consider potential options and advantages of repurposed drugs and other substances reported in scientific publications when the medical standard of care has limited options for advanced cancer and other severe chronic health conditions. However, any efforts along this line by patients should be in collaboration with their medical doctors.
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Affiliation(s)
| | - Angela Chapman
- Biology Program, California State University Channel Islands, Camarillo, CA, USA
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15
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Fecci PE, Champion CD, Hoj J, McKernan CM, Goodwin CR, Kirkpatrick JP, Anders CK, Pendergast AM, Sampson JH. The Evolving Modern Management of Brain Metastasis. Clin Cancer Res 2019; 25:6570-6580. [PMID: 31213459 PMCID: PMC8258430 DOI: 10.1158/1078-0432.ccr-18-1624] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/23/2019] [Accepted: 06/13/2019] [Indexed: 12/11/2022]
Abstract
The incidence of brain metastases is increasing as cancer therapies improve and patients live longer, providing new challenges to the multidisciplinary teams that care for these patients. Brain metastatic cancer cells possess unique characteristics that allow them to penetrate the blood-brain barrier, colonize the brain parenchyma, and persist in the intracranial environment. In addition, brain metastases subvert the innate and adaptive immune system, permitting evasion of the antitumor immune response. Better understanding of the above mechanisms will allow for development and delivery of more effective therapies for brain metastases. In this review, we outline the molecular mechanisms underlying development, survival, and immunosuppression of brain metastases. We also discuss current and emerging treatment strategies, including surgery, radiation, disease-specific and mutation-targeted systemic therapy, and immunotherapy.
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Affiliation(s)
- Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
- Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
| | - Cosette D Champion
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
- Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
| | - Jacob Hoj
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
| | - Courtney M McKernan
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
- Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
| | - John P Kirkpatrick
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
- Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Carey K Anders
- Duke Cancer Institute, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Ann Marie Pendergast
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
| | - John H Sampson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina.
- Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
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16
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Pegram MD, Miles D, Tsui CK, Zong Y. HER2-Overexpressing/Amplified Breast Cancer as a Testing Ground for Antibody-Drug Conjugate Drug Development in Solid Tumors. Clin Cancer Res 2019; 26:775-786. [PMID: 31582515 DOI: 10.1158/1078-0432.ccr-18-1976] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/17/2019] [Accepted: 09/30/2019] [Indexed: 11/16/2022]
Abstract
Efficacy data from the KATHERINE clinical trial, comparing the HER2-directed antibody-drug conjugate (ADC) ado-trastuzumab emtansine (T-DM1) to trastuzumab in patients with early-stage HER2-amplified/overexpressing breast cancer with residual disease after neoadjuvant therapy, demonstrates superiority of T-DM1 (HR for invasive disease or death, 0.50; P < 0.001). This establishes foundational precedent for ADCs as effective therapy for treatment of subclinical micrometastasis in an adjuvant (or post-neoadjuvant) early-stage solid tumor setting. Despite this achievement, general principles from proposed systems pharmacokinetic modeling for intracellular processing of ADCs indicate potential shortcomings of T-DM1: (i) C max limited by toxicities; (ii) slow internalization rate; (iii) resistance mechanisms due to defects in intracellular trafficking [loss of lysosomal transporter solute carrier family 46 member 3, (SLC46A3)], and increased expression of drug transporters MDR1 and MRP1; and (iv) lack of payload bystander effects limiting utility in tumors with heterogeneous HER2 expression. These handicaps may explain the inferiority of T-DM1-based therapy in the neoadjuvant and first-line metastatic HER2+ breast cancer settings, and lack of superiority to chemotherapy in HER2+ advanced gastric cancer. In this review, we discuss how each of these limitations is being addressed by manipulating internalization and trafficking using HER2:HER2 bispecific or biparatopic antibody backbones, using site-specific, fixed DAR conjugation chemistry, and payload swapping to exploit alternative intracellular targets and to promote bystander effects. Newer HER2-directed ADCs have impressive clinical activity even against tumors with lower levels of HER2 receptor expression. Finally, we highlight ongoing clinical efforts to combine HER2 ADCs with other treatment modalities, including chemotherapy, molecularly targeted therapies, and immunotherapy.
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Affiliation(s)
- Mark D Pegram
- Stanford Comprehensive Cancer Institute, Stanford University School of Medicine, Stanford, California.
| | - David Miles
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, London, United Kingdom
| | - C Kimberly Tsui
- Department of Genetics, Stanford University School of Medicine, Stanford, California
| | - Yu Zong
- Stanford Comprehensive Cancer Institute, Stanford University School of Medicine, Stanford, California
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17
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Systemic therapy for brain metastases. Crit Rev Oncol Hematol 2019; 142:44-50. [PMID: 31357143 DOI: 10.1016/j.critrevonc.2019.07.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 06/30/2019] [Accepted: 07/14/2019] [Indexed: 02/07/2023] Open
Abstract
Metastases from cells outside of the central nervous system are the most common cancer found in the brain and are commonly associated with poor prognosis. Although cancer treatment is improving overall, central nervous system metastases are becoming more prevalent and require finesse to properly treat. Physicians must consider the biology of the primary tumor and the complex neurological environment that the metastasis resides in. This can be further complicated by the fact that the practice of cancer management is constantly evolving and therapy that works outside of the blood-brain barrier may not be effective inside of it. Therefore, this review seeks to update the reader on recent advancements made on the three most common sources of brain metastases: lung cancer, breast cancer, and melanoma. Each of these malignancies has been the subject of intriguing and novel avenues of therapy which are reviewed here.
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18
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Phase II study of irinotecan and temozolomide in breast cancer patients with progressing central nervous system disease. Breast Cancer Res Treat 2019; 177:401-408. [PMID: 31172405 DOI: 10.1007/s10549-019-05309-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 05/29/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Breast cancer patients with progressing central nervous system (CNS) disease have limited treatment options. Few chemotherapy drugs with activity in breast cancer have well-documented CNS penetration. This phase 2 trial evaluated efficacy and safety of irinotecan 125 mg/m2 on days 1 and 15 with temozolomide 100 mg/m2 days 1-7 and days 15-21 of a 28 day cycle. METHODS Breast cancer patients of any biological subtype and progressing brain metastases and/or leptomeningeal disease (LMD) were eligible. The primary endpoint was CNS response rate. Secondary endpoints were clinical benefit rate (CBR), time to progression (TTP), and overall survival (OS). Imaging studies evaluating intracranial and extracranial response were performed every 8 weeks. RESULTS Thirty patients were evaluable for safety and efficacy. The most common hematologic and non-hematologic adverse events were neutropenia, and nausea and fatigue, respectively. There were two confirmed CNS partial responses (PR) and five patients with stable disease in the CNS ≥ 16 weeks, resulting in a 7% PR and 23% CBR. Median TTP was 2.3 months (range 13-444 days), and median OS from treatment initiation until death was 4.9 months (range 20-1023 days). Excluding patients with LMD, median TTP and OS were 3.1 and 5.6 months, respectively. Only one patient progressed systemically before CNS progression. CONCLUSIONS The combination of irinotecan and temozolomide was well tolerated, demonstrated some clinical activity across multiple breast cancer subtypes with progressing CNS disease, and offers a reasonable option for patients who are not candidates for further radiation or clinical trials.
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19
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Production and Evaluation of an Avian IgY Immunotoxin against CD133+ for Treatment of Carcinogenic Stem Cells in Malignant Glioma: IgY Immunotoxin for the Treatment of Glioblastoma. JOURNAL OF ONCOLOGY 2019; 2019:2563092. [PMID: 31275378 PMCID: PMC6582814 DOI: 10.1155/2019/2563092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/25/2019] [Accepted: 05/09/2019] [Indexed: 02/07/2023]
Abstract
Background Glioblastoma is the most common malignant tumor of Central Nervous System. Despite the research in therapeutics, the prognosis is dismal. Malignant glioma stem cells (MGSCs) are a major cause of treatment failure and increasing tumor recurrence. In general, cancer stem cells (CSCs) express prominin-1 (CD133), considered as a potential therapeutic target. In this study, we produced an avian immunotoxin directed against the subpopulation of CD133+ CSCs within a malignant glioma. We used the avian IgY because it has various advantages as increased affinity to mammal antigens and inexpensive obtention of large amounts of specific antibodies (approximately 1 mg/per egg). The design, production, purification and use of IgY anti CD133 immunotoxin constitute an original goal of this research. Methods The immunodominant peptide of CD133 was designed to immunize hens; also, the extracellular domain of CD133 was cloned to probe the IgY antibodies. In parallel, a recombinant abrin A chain was produced in E. coli in order to join it to the Fc domain of the anti-CD133 IgY to conform the immunotoxin. This anti-CD133 IgY anti-tumor immunotoxin was tested in vitro and in vivo. Results. The cytotoxicity of the immunotoxin in vitro showed that IgY-abrin immunotoxin reduced 55% cell viability. After subcutaneous MGSCs implantation, the animals treated intraperitoneally or intratumorally with the IgY-abrin immunotoxin showed more than 50% decrease of tumor volume. Conclusion Results showed that the IgY-abrin immunotoxin had cytotoxic activity against CD133+ MGSCs and provides a novel approach for the immunotherapy of glioblastoma.
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20
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Tripathy D, Tolaney SM, Seidman AD, Anders CK, Ibrahim N, Rugo HS, Twelves C, Dieras V, Müller V, Tagliaferri M, Hannah AL, Cortés J. ATTAIN: Phase III study of etirinotecan pegol versus treatment of physician's choice in patients with metastatic breast cancer and brain metastases. Future Oncol 2019; 15:2211-2225. [PMID: 31074641 DOI: 10.2217/fon-2019-0180] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The increasing incidence of breast cancer brain metastases is a major clinical problem with its associated poor prognosis and limited treatment options. The long-acting topoisomerase-1 inhibitor, etirinotecan pegol, was designed to preferentially accumulate in tumor tissue including brain metastases, providing sustained cytotoxic SN38 levels. Motivated by improved survival findings from subgroup analyses from the Phase III BEACON trial, this ongoing randomized, Phase III trial compares etirinotecan pegol to drugs commonly used for advanced breast cancer in patients with stable, treated breast cancer brain metastases who have been previously treated with an anthracycline, taxane and capecitabine. The primary end point is overall survival. Secondary end points include objective response rate, progression-free survival and time to CNS disease progression or recurrence in patients with/without CNS lesions present at study entry. Trial registration number: NCT02915744.
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Affiliation(s)
- Debu Tripathy
- The University of Texas MD Anderson Cancer Center, Department of Breast Medical Oncology, Houston, TX 77030, USA
| | - Sara M Tolaney
- Dana-Farber Cancer Institute, Center for Women's Cancers, Boston, MA 02215, USA
| | - Andrew D Seidman
- Memorial Sloan-Kettering Cancer Center, Bobst International Center, New York, NY 10065, USA
| | - Carey K Anders
- University of North Carolina School of Medicine, Duke Cancer Center, Chapel Hill, NC 27710, USA
| | - Nuhad Ibrahim
- The University of Texas MD Anderson Cancer Center, Department of Breast Medical Oncology, Houston, TX 77030, USA
| | - Hope S Rugo
- University of California San Francisco, Department of Medicine (Hematology/Oncology), San Francisco, CA 94115, USA
| | - Chris Twelves
- University of Leeds, Leeds Institute of Cancer and Pathology (LICAP), Leeds, LS2 9JT, UK.,St James' University Hospital, Institute of Oncology, Leeds, LS9 7BE, UK
| | - Veronique Dieras
- Institut Curie, Oncological Medicine Department, 75248, Paris, France
| | - Volkmar Müller
- University Medical Center Hamburg-Eppendorf, Department of Obstetrics and Gynecology, 20246 Hamburg, Germany
| | | | | | - Javier Cortés
- IOB Institute of Oncology, Quironsalud Group, 28034 Madrid & 08023 Barcelona, Spain.,Vall d'Hebron Institute of Oncology (VHIO), Breast Cancer and Melanoma Group, 08035 Barcelona, Spain
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21
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El Shafie RA, Böhm K, Weber D, Lang K, Schlaich F, Adeberg S, Paul A, Haefner MF, Katayama S, Hörner-Rieber J, Hoegen P, Löw S, Debus J, Rieken S, Bernhardt D. Palliative Radiotherapy for Leptomeningeal Carcinomatosis-Analysis of Outcome, Prognostic Factors, and Symptom Response. Front Oncol 2019; 8:641. [PMID: 30671384 PMCID: PMC6331444 DOI: 10.3389/fonc.2018.00641] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 12/06/2018] [Indexed: 12/18/2022] Open
Abstract
Introduction: The purpose of this article is to report our institution's 10-year experience on palliative radiotherapy for the treatment of leptomeningeal carcinomatosis (LC), assessing survival, neurologic outcome, and prognostic factors. Patients and methods: We retrospectively analyzed 110 patients who received palliative radiotherapy for LC between 2008 and 2018. The most common histologies were breast cancer (n = 43, 39.1%) and non-small cell lung cancer (NSCLC) (n = 31, 28.2%). Radiotherapy was administered as whole-brain radiotherapy (WBRT) (n = 51, 46.4%), focal spinal RT (n = 11, 10.0%) or both (n = 47, 42.7%). Twenty-five patients (22.7%) were selected for craniospinal irradiation. Clinical performance and neurologic function were quantified on the neurologic function scale (NFS) before and in response to therapy. A Cox Proportional Hazards model with univariate and multivariate analysis was fitted for survival. Results: Ninety-eight patients (89.1%) died and 12 (10.9%) were alive at the time of analysis. Median OS from LC diagnosis and from the beginning of RT was 13.9 weeks (IQR: 7.1-34.0) and 9.9 weeks (IQR: 5.3-26.3), respectively. In univariate analysis, prognostic of longer OS were a Karnofsky performance scale index (KPI) of ≥70% (HR 0.20, 95%-CI: [0.13; 0.32], p < 0.001), initially moderate neurological deficits (NFS ≤2) (HR 0.32, 95% CI: [0.19; 0.52], p < 0.001), symptom response to RT (HR 0.41, 95%-CI: [0.26; 0.67], p < 0.001) and the administration of systemic therapy (HR 0.51, 95%-CI: [0.33; 0.78], p = 0.002). Prognostic of inferior OS were high-grade myelosuppression (HR 1.78, 95% CI: [1.06; 3.00], p = 0.03) and serum LDH levels >500 U/l (HR 3.62, 95% CI: [1.76; 7.44], p < 0.001). Clinical performance, symptom response and serum LDH stayed independently prognostic for survival in multivariate analysis. RT was well-tolerated and except for grade III myelosuppression in 19 cases (17.3%), no high-grade acute toxicities were observed. Neurologic symptom stabilization was achieved in 83 cases (75.5%) and a sizeable improvement in 39 cases (35.5%). Conclusion: Radiotherapy is a well-tolerated and efficacious means of providing symptom palliation for patients with LC, delaying neurologic deterioration while probably not directly influencing survival. Prognostic factors such as clinical performance, neurologic response and serum LDH can be used for patient stratification to facilitate treatment decisions.
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Affiliation(s)
- Rami A. El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Karina Böhm
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Dorothea Weber
- Institute of Medical Biometry and Informatics, Heidelberg University Hospital, Heidelberg, Germany
| | - Kristin Lang
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Fabian Schlaich
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Angela Paul
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias F. Haefner
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Sonja Katayama
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Philipp Hoegen
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Sarah Löw
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology (E050), German Cancer Research Center (DKFZ), Heidelberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
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22
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Hassanieh I, Hilal L, Al Feghali KA, Khalifeh I, Youssef B. Trastuzumab Emtansine for the Treatment of HER-2 Positive Carcinoma Ex-pleomorphic Adenoma Metastatic to the Brain: A Case Report. Front Oncol 2018; 8:274. [PMID: 30087853 PMCID: PMC6066556 DOI: 10.3389/fonc.2018.00274] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 07/02/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Carcinoma Ex-pleomorphic adenoma is a malignant transformation of the common benign neoplasm of the salivary glands, “pleomorphic adenoma.” Only two cases were ever reported with brain metastases, with absence of good evidence guiding management of such cases. Case Presentation: A 61-year-old woman presenting with facial paralysis was found to have carcinoma ex-pleomorphic adenoma of the parotid gland. Twenty months after local treatment, she developed brain metastases, treated with whole brain radiation therapy. The patient then had progressive intracranial disease after the end of radiation therapy in addition to the appearance of liver metastases. Pathology showed overexpression of HER2, so she was treated with Trastuzumab Emtansine (TDM1). Follow-up imaging revealed significant decrease in the number and size of the metastatic brain lesions in keeping with a good response to TDM1 treatment. Conclusion: Prognosis of metastatic carcinoma ex-pleomorphic adenoma is very poor, and there is no clear management for such cases. We present a case of carcinoma ex-pleomorphic adenoma with brain and liver metastases with a very good response to TDM1 treatment.
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Affiliation(s)
- Ihab Hassanieh
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon.,Department of Pathology, American University of Beirut, Beirut, Lebanon
| | - Lara Hilal
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon.,Department of Pathology, American University of Beirut, Beirut, Lebanon
| | - Karine A Al Feghali
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon.,Department of Pathology, American University of Beirut, Beirut, Lebanon
| | - Ibrahim Khalifeh
- Department of Pathology, American University of Beirut, Beirut, Lebanon
| | - Bassem Youssef
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon.,Department of Pathology, American University of Beirut, Beirut, Lebanon
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23
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Fabi A, Alesini D, Valle E, Moscetti L, Caputo R, Caruso M, Carbognin L, Ciccarese M, La Verde N, Arpino G, Cannita K, Paris I, Santini D, Montemurro F, Russillo M, Ferretti G, Filippelli G, Rossello R, Fabbri A, Zambelli A, Leonardi V, D'Ottavio AM, Nisticò C, Stani S, Giampaglia M, Scandurra G, Catania G, Malaguti P, Giannarelli D, Cognetti F. T-DM1 and brain metastases: Clinical outcome in HER2-positive metastatic breast cancer. Breast 2018; 41:137-143. [PMID: 30092500 DOI: 10.1016/j.breast.2018.07.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/11/2018] [Accepted: 07/11/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND We reported the results of an Italian large retrospective analysis that evaluated the effectiveness and safety of T-DM1 in 'field-practice' breast cancer patients. We performed a sub-analysis to investigate the clinical activity of T-DM1 in patients with brain metastases (BMs). METHODS The records of 87 adult women with HER2-positive breast cancer and BMs treated with T-DM1 were reviewed. Their clinical outcomes were compared with those of 216 patients without central nervous system (CNS) involvement. RESULTS Response to T-DM1 treatment in BMs was available for 53 patients in the BM group (60.9%): two patients reported a complete response (3.8%), 11 patients obtained partial response (20.7%; overall response rate: 24.5%), 16 patients had a stable disease (30.1%). Regarding extracranial disease, a total of 77 and 191 patients were evaluable for response in BM group and non-BM group, respectively. The overall response rate was 35.1% in the BM group and 38.3% in the non-BM group; disease control rate was 53.3% and 66.6%, respectively. At a median follow-up of 16 months (range: 1-55), median cumulative progression-free survival (PFS) was 7 months (95% CI: 5.4-8.6) in the BM group and 8 months (95% CI: 5.7-10.3) in the non-BM group. In the second-line setting, PFS was 5 (95% CI: 3.1-6.9) versus 11 (95% CI: 7.1-14.9) months (p = 0.01). Overall survival was 14 months (95% CI: 12.2-15.8) in the BM group and 32 months (95% CI: 24.4-39.6) in the non-BM group (p < 0.0001). CONCLUSIONS T-DM1 is active in breast cancer patients with BMs.
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Affiliation(s)
- Alessandra Fabi
- Oncologia Medica 1, Istituto Nazionale Tumori "Regina Elena", Roma, Italy.
| | - Daniele Alesini
- Oncologia Medica 1, Istituto Nazionale Tumori "Regina Elena", Roma, Italy
| | | | | | | | | | | | | | - Nicla La Verde
- Oncologia Medica, PO Fatebenefratelli e Oftalmico, Milano, Italy
| | - Grazia Arpino
- Oncologia Medica, Università Federico II, Napoli, Italy
| | - Katia Cannita
- Oncologia Medica, Ospedale S. Salvatore, Università dell'Aquila, Italy
| | - Ida Paris
- Oncologia e Ginecologica Polo Donna, Policlinico A.Gemelli, Roma, Italy
| | - Daniele Santini
- Oncologia Medica, Campus Bio-medico Universitario, Roma, Italy
| | - Filippo Montemurro
- Investigative Clinical Oncology, Cancer Institute-FPO, IRCCS, Candiolo, Torino, Italy
| | | | - Gianluigi Ferretti
- Oncologia Medica 1, Istituto Nazionale Tumori "Regina Elena", Roma, Italy
| | | | - Rosalba Rossello
- Oncologia Medica, Ospedale S. Vincenzo, Taormina, Messina, Italy
| | | | | | | | | | - Cecilia Nisticò
- Oncologia Medica 1, Istituto Nazionale Tumori "Regina Elena", Roma, Italy
| | | | | | - Giusy Scandurra
- Oncologia Medica, Ospedale per le Emergenze Cannizzaro, Catania, Italy
| | - Giovanna Catania
- Oncologia Medica 1, Istituto Nazionale Tumori "Regina Elena", Roma, Italy
| | - Paola Malaguti
- Oncologia Medica 1, Istituto Nazionale Tumori "Regina Elena", Roma, Italy
| | - Diana Giannarelli
- Unità di Biostatistica, Istituto Nazionale Tumori "Regina Elena", Roma, Italy
| | - Francesco Cognetti
- Oncologia Medica 1, Istituto Nazionale Tumori "Regina Elena", Roma, Italy
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24
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LCCC 1025: a phase II study of everolimus, trastuzumab, and vinorelbine to treat progressive HER2-positive breast cancer brain metastases. Breast Cancer Res Treat 2018; 171:637-648. [PMID: 29938395 DOI: 10.1007/s10549-018-4852-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 06/07/2018] [Indexed: 01/09/2023]
Abstract
PURPOSE HER2 + breast cancer (BC) is an aggressive subtype with high rates of brain metastases (BCBM). Two-thirds of HER2 + BCBM demonstrate activation of the PI3K/mTOR pathway driving resistance to anti-HER2 therapy. This phase II study evaluated everolimus (E), a brain-permeable mTOR inhibitor, trastuzumab (T), and vinorelbine (V) in patients with HER2 + BCBM. PATIENTS AND METHODS Eligible patients had progressive HER2 + BCBM. The primary endpoint was intracranial response rate (RR); secondary objectives were CNS clinical benefit rate (CBR), extracranial RR, time to progression (TTP), overall survival (OS), and targeted sequencing of tumors from enrolled patients. A two-stage design distinguished intracranial RR of 5% versus 20%. RESULTS 32 patients were evaluable for toxicity, 26 for efficacy. Intracranial RR was 4% (1 PR). CNS CBR at 6 mos was 27%; at 3 mos 65%. Median intracranial TTP was 3.9 mos (95% CI 2.2-5). OS was 12.2 mos (95% CI 0.6-20.2). Grade 3-4 toxicities included neutropenia (41%), anemia (16%), and stomatitis (16%). Mutations in TP53 and PIK3CA were common in BCBM. Mutations in the PI3K/mTOR pathway were not associated with response. ERBB2 amplification was higher in BCBM compared to primary BC; ERBB2 amplification in the primary BC trended toward worse OS. CONCLUSION While intracranial RR to ETV was low in HER2 + BCBM patients, one-third achieved CNS CBR; TTP/OS was similar to historical control. No new toxicity signals were observed. Further analysis of the genomic underpinnings of BCBM to identify tractable prognostic and/or predictive biomarkers is warranted. CLINICAL TRIAL (NCT01305941).
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25
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Shah N, Mohammad AS, Saralkar P, Sprowls SA, Vickers SD, John D, Tallman RM, Lucke-Wold BP, Jarrell KE, Pinti M, Nolan RL, Lockman PR. Investigational chemotherapy and novel pharmacokinetic mechanisms for the treatment of breast cancer brain metastases. Pharmacol Res 2018; 132:47-68. [PMID: 29604436 PMCID: PMC5997530 DOI: 10.1016/j.phrs.2018.03.021] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 03/26/2018] [Accepted: 03/27/2018] [Indexed: 02/08/2023]
Abstract
In women, breast cancer is the most common cancer diagnosis and second most common cause of cancer death. More than half of breast cancer patients will develop metastases to the bone, liver, lung, or brain. Breast cancer brain metastases (BCBM) confers a poor prognosis, as current therapeutic options of surgery, radiation, and chemotherapy rarely significantly extend life and are considered palliative. Within the realm of chemotherapy, the last decade has seen an explosion of novel chemotherapeutics involving targeting agents and unique dosage forms. We provide a historical overview of BCBM chemotherapy, review the mechanisms of new agents such as poly-ADP ribose polymerase inhibitors, cyclin-dependent kinase 4/6 inhibitors, phosphatidyl inositol 3-kinaseinhibitors, estrogen pathway antagonists for hormone-receptor positive BCBM; tyrosine kinase inhibitors, antibodies, and conjugates for HER2+ BCBM; repurposed cytotoxic chemotherapy for triple negative BCBM; and the utilization of these new agents and formulations in ongoing clinical trials. The mechanisms of novel dosage formulations such as nanoparticles, liposomes, pegylation, the concepts of enhanced permeation and retention, and drugs utilizing these concepts involved in clinical trials are also discussed. These new treatments provide a promising outlook in the treatment of BCBM.
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Affiliation(s)
- Neal Shah
- West Virginia University, Health Sciences Center, School of Pharmacy, Department of Basic Pharmaceutical Sciences, Morgantown, WV 26506, USA.
| | - Afroz S Mohammad
- West Virginia University, Health Sciences Center, School of Pharmacy, Department of Basic Pharmaceutical Sciences, Morgantown, WV 26506, USA.
| | - Pushkar Saralkar
- West Virginia University, Health Sciences Center, School of Pharmacy, Department of Basic Pharmaceutical Sciences, Morgantown, WV 26506, USA.
| | - Samuel A Sprowls
- West Virginia University, Health Sciences Center, School of Pharmacy, Department of Basic Pharmaceutical Sciences, Morgantown, WV 26506, USA.
| | - Schuyler D Vickers
- West Virginia University, Health Sciences Center, School of Pharmacy, Department of Basic Pharmaceutical Sciences, Morgantown, WV 26506, USA.
| | - Devin John
- West Virginia University, Health Sciences Center, School of Pharmacy, Department of Basic Pharmaceutical Sciences, Morgantown, WV 26506, USA.
| | - Rachel M Tallman
- West Virginia University, Health Sciences Center, School of Pharmacy, Department of Basic Pharmaceutical Sciences, Morgantown, WV 26506, USA.
| | - Brandon P Lucke-Wold
- West Virginia University, Health Sciences Center, School of Pharmacy, Department of Basic Pharmaceutical Sciences, Morgantown, WV 26506, USA.
| | - Katherine E Jarrell
- West Virginia University, Health Sciences Center, School of Pharmacy, Department of Basic Pharmaceutical Sciences, Morgantown, WV 26506, USA.
| | - Mark Pinti
- West Virginia University, Health Sciences Center, School of Pharmacy, Department of Basic Pharmaceutical Sciences, Morgantown, WV 26506, USA.
| | - Richard L Nolan
- West Virginia University, Health Sciences Center, School of Pharmacy, Department of Basic Pharmaceutical Sciences, Morgantown, WV 26506, USA.
| | - Paul R Lockman
- West Virginia University, Health Sciences Center, School of Pharmacy, Department of Basic Pharmaceutical Sciences, Morgantown, WV 26506, USA.
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26
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Ricciardi GRR, Russo A, Franchina T, Schifano S, Mastroeni G, Santacaterina A, Adamo V. Efficacy of T-DM1 for leptomeningeal and brain metastases in a HER2 positive metastatic breast cancer patient: new directions for systemic therapy - a case report and literature review. BMC Cancer 2018; 18:97. [PMID: 29370839 PMCID: PMC5784540 DOI: 10.1186/s12885-018-3994-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 01/16/2018] [Indexed: 11/10/2022] Open
Abstract
Background Herein, we report a complete response after whole brain radiotherapy (WBRT) and concomitant T-DM1 in a patient with HER2-positive metastatic breast cancer (MBC) and extensive brain and leptomeningeal involvement. Case presentation A 46 years old Caucasian woman with HER2-positive MBC and no baseline CNS involvement, started in August 2015 1st line therapy with Pertuzumab-Trastuzumab-Docetaxel, with partial response. However, in April 2016 the patient eventually progressed with emergence of brain and leptomeningeal metastases. Hence, she started in May 2016 2nd line therapy with T-DM1 and concomitant WBRT, with complete response (CR) after 3 courses of therapy, with complete resolution of neurological symptoms and no relevant toxicities. The CR is lasting over 13 months and the patient is out of corticosteroid use. Conclusions To the best of our knowledge, this is the first case reporting interesting antitumor activity of T-DM1 and concomitant WBRT in both brain and leptomeningeal metastases, with a favorable safety profile and prolonged extracranial disease control. Further prospective studies should confirm these findings.
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Affiliation(s)
| | - Alessandro Russo
- Medical Oncology Unit, A.O. Papardo & Department of Human Pathology University of Messina, Messina, Italy
| | - Tindara Franchina
- Medical Oncology Unit, A.O. Papardo & Department of Human Pathology University of Messina, Messina, Italy
| | - Silvia Schifano
- Medical Oncology Unit, A.O. Papardo & Department of Human Pathology University of Messina, Messina, Italy
| | | | | | - Vincenzo Adamo
- Medical Oncology Unit, A.O. Papardo & Department of Human Pathology University of Messina, Messina, Italy.
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27
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Morikawa A, Wang R, Patil S, Diab A, Yang J, Hudis CA, McArthur HL, Beal K, Seidman AD. Characteristics and Prognostic Factors for Patients With HER2-overexpressing Breast Cancer and Brain Metastases in the Era of HER2-targeted Therapy: An Argument for Earlier Detection. Clin Breast Cancer 2017; 18:353-361. [PMID: 29337140 DOI: 10.1016/j.clbc.2017.12.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 11/24/2017] [Accepted: 12/17/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Although brain metastases (BM) are associated with poor prognosis, patients with human epidermal growth factor receptor 2 (HER2) overexpressing (HER2+) breast cancer (BC) with BM who are treated with anti-HER2 therapy have a relatively longer survival after BM diagnosis compared with other subtypes and HER2+ patients previously untreated with anti-HER2 therapy. It is unclear if previously reported prognostic factors are applicable to patients with HER2+ BC in the era of HER2-targeted therapy. PATIENTS AND METHODS We evaluated 100 consecutive patients with HER2+ BC with BM who underwent radiation therapy as primary BM treatment from January 2001 to December 2011 at Memorial Sloan Kettering Cancer Center by retrospective review. Patient characteristics at the time of BM diagnosis and their associations with time from BM to death were evaluated by Kaplan-Meier curves, log-rank tests, and Cox proportional hazard models. RESULTS Significantly better survival from BM was noted for patients with higher performance status, fewer BM lesions, continued use of HER2-targeted therapy after BM diagnosis, and better controlled extracranial metastatic disease. Absence of neurologic symptoms at BM diagnosis was significantly associated with fewer lesions, decreased use of whole brain radiotherapy, and longer survival in univariate and multivariate analysis (multivariate hazard ratio, 3.69; 95% confidence interval, 1.69-8.07). CONCLUSION Our finding supports the continued use of HER2-targeted therapy after BM diagnosis. In addition, future research on the clinical impact of detecting asymptomatic BM in patients with HER2+ BC, in terms of improving prognosis, quality of life, and avoidance of whole brain radiotherapy, is warranted.
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Affiliation(s)
- Aki Morikawa
- Breast Cancer Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rui Wang
- Breast Cancer Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sujata Patil
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Adi Diab
- Breast Cancer Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonathan Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Clifford A Hudis
- Breast Cancer Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Heather L McArthur
- Breast Cancer Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew D Seidman
- Breast Cancer Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY.
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28
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Lin NU, Gaspar LE, Soffietti R. Breast Cancer in the Central Nervous System: Multidisciplinary Considerations and Management. Am Soc Clin Oncol Educ Book 2017; 37:45-56. [PMID: 28561683 DOI: 10.1200/edbk_175338] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Breast cancer is the second most common primary tumor associated with central nervous system (CNS) metastases. Patients with metastatic HER2-positive or triple-negative (estrogen receptor (ER)-negative, progesterone receptor (PR)-negative, HER2-negative) breast cancer are at the highest risk of developing parenchymal brain metastases. Leptomeningeal disease is less frequent but is distributed across breast cancer subtypes, including lobular breast cancer. Initial treatment strategies can include surgery, radiation, intravenous or intrathecal chemotherapy, and/or targeted approaches. In this article, we review the epidemiology of breast cancer brain metastases, differences in clinical behavior and natural history by tumor subtype, and important considerations in the multidisciplinary treatment of these patients. We will highlight new findings that impact current standards of care, clinical controversies, and notable investigational approaches in clinical testing.
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Affiliation(s)
- Nancy U Lin
- From the Breast Oncology Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO; Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, Turin, Italy
| | - Laurie E Gaspar
- From the Breast Oncology Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO; Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, Turin, Italy
| | - Riccardo Soffietti
- From the Breast Oncology Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO; Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, Turin, Italy
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29
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Chao YL, Anders CK. Systemic Therapy in the Setting of Central Nervous System (CNS) Metastases in Breast Cancer. CURRENT BREAST CANCER REPORTS 2017. [DOI: 10.1007/s12609-017-0253-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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30
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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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31
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Trastuzumab distribution in an in-vivo and in-vitro model of brain metastases of breast cancer. Oncotarget 2017; 8:83734-83744. [PMID: 29137378 PMCID: PMC5663550 DOI: 10.18632/oncotarget.19634] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/03/2017] [Indexed: 11/25/2022] Open
Abstract
Background Drug and antibody delivery to brain metastases has been highly debated in the literature. The blood-tumor barrier (BTB) is more permeable than the blood-brain barrier (BBB), and has shown to have highly functioning efflux transporters and barrier properties, which limits delivery of targeted therapies. Methods We characterized the permeability of 125I-trastuzumab in an in-vivo, and fluorescent trastuzumab-Rhodamine123 (t-Rho123) in a novel microfluidic in-vitro, BBB and BTB brain metastases of breast cancer model. In-vivo: Human MDA-MB-231-HER2+ metastatic breast cancer cells were grown and maintained under static conditions. Cells were harvested at 80% confluency and prepped for intra-cardiac injection into 20 homozygous female Nu/Nu mice. In-vitro: In a microfluidic device (SynVivo), human umbilical vein endothelial cells were grown and maintained under shear stress conditions in the outer compartment and co-cultured with CTX-TNA2 rat brain astrocytes (BBB) or Met-1 metastatic HER2+ murine breast cancer cells (BTB), which were maintained in the central compartment under static conditions. Results Tissue distribution of 125I-trastuzumab revealed only ~3% of injected dose reached normal brain, with ~5% of injected dose reaching brain tumors. No clear correlation was observed between size of metastases and the amount of 125I-trastuzumab localized in-vivo. This heterogeneity was paralleled in-vitro, where the distribution of t-Rho123 from the outer chamber to the central chamber of the microfluidic device was qualitatively and quantitatively analyzed over time. The rate of t-Rho123 linear uptake in the BBB (0.27 ± 0.33 × 104) and BTB (1.29 ± 0.93 × 104) showed to be significantly greater than 0 (p < 0.05). The BTB devices showed significant heterogenetic tendencies, as seen in in-vivo. Conclusions This study is one of the first studies to measure antibody movement across the blood-brain and blood-tumor barriers, and demonstrates that, though in small and most likely not efficacious quantities, trastuzumab does cross the blood-brain and blood-tumor barriers.
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32
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Le Rhun E, Weller M, Brandsma D, Van den Bent M, de Azambuja E, Henriksson R, Boulanger T, Peters S, Watts C, Wick W, Wesseling P, Rudà R, Preusser M. EANO-ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up of patients with leptomeningeal metastasis from solid tumours. Ann Oncol 2017; 28:iv84-iv99. [PMID: 28881917 DOI: 10.1093/annonc/mdx221] [Citation(s) in RCA: 236] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- E Le Rhun
- Neuro-Oncology, Department of Neurosurgery, Lille University Hospital, Lille
- Neurology, Medical Oncology Department, Oscar Lambret Center, Lille
- Lille University, Inserm U-1192, Villeneuve d'Ascq, France
| | - M Weller
- Department of Neurology and Brain Tumour Center, University Hospital, Zurich, Switzerland
| | - D Brandsma
- Department of Neuro-Oncology, Netherlands Cancer Institute, Amsterdam
| | - M Van den Bent
- The Brain Tumour Center at the Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - E de Azambuja
- Medical Oncology Department, Institut Jules Bordet and L'Université Libre de Bruxelles (U.L.B), Brussels, Belgium
| | - R Henriksson
- Regional Cancer Center, Stockholm
- Department of Radiation Sciences and Oncology, University, Umea, Sweden
| | - T Boulanger
- Neuroradiology, Imaging Department, Oscar Lambret Center, Lille, France
| | - S Peters
- Department of Oncology, University Hospital, Lausanne, Switzerland
| | - C Watts
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - W Wick
- Neurology Clinic, Heidelberg University Hospital, Heidelberg
- Clinical Cooperation Unit Neuro-Oncology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - P Wesseling
- Department of Pathology, VU University Medical Centre and Brain Tumour Center, Amsterdam
- Department of Pathology, Princess Máxima Center for Paediatric Oncology and University Medical Centre Utrecht, Utrecht, The Netherlands
| | - R Rudà
- Department of Neuro-Oncology, City of Health and Science Hospital, University of Turin, Turin, Italy
| | - M Preusser
- Clinical Division of Oncology, Department of Medicine 1, CNS Unit Comprehensive Cancer Centre (CCC-CNS), Medical University, Vienna, Austria
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Miller JA, Kotecha R, Ahluwalia MS, Mohammadi AM, Chao ST, Barnett GH, Murphy ES, Vogelbaum MA, Angelov L, Peereboom DM, Suh JH. Overall survival and the response to radiotherapy among molecular subtypes of breast cancer brain metastases treated with targeted therapies. Cancer 2017; 123:2283-2293. [PMID: 28192598 DOI: 10.1002/cncr.30616] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 12/08/2016] [Accepted: 01/18/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND The current study was conducted to investigate survival and the response to radiotherapy among patients with molecular subtypes of breast cancer brain metastases treated with or without targeted therapies. METHODS Patients diagnosed with breast cancer brain metastases at a single tertiary care institution were included. The primary outcome was overall survival, whereas secondary outcomes included the cumulative incidences of distant intracranial failure, local failure, and radiation necrosis. Competing risks regression was used to model secondary outcomes. RESULTS Within the study period, 547 patients presented with 3224 brain metastases and met inclusion criteria. Among patients with human epidermal growth factor receptor 2 (HER2)-amplified disease, 80% received HER2 antibodies and 38% received HER2/epidermal growth factor receptor tyrosine kinase inhibitors (TKIs). The median survival was significantly shorter in the basal cohort (8.4 months), and progressively increased in the luminal A (12.3 months), HER2-positive (15.4 months), and luminal B (18.8 months) cohorts (P<.001). Among patients with HER2-amplified disease, the median survival was extended with the use of both HER2 antibodies (17.9 months vs 15.1 months; P = .04) and TKIs (21.1 months vs 15.4 months; P = .03). The 12-month cumulative incidences of local failure among molecular subtypes were 6.0% in the luminal A cohort, 10.3% in the luminal B cohort, 15.4% in the HER2-positive cohort, and 9.9% in the basal cohort (P = .01). Concurrent HER2/epidermal growth factor receptor TKIs with stereotactic radiosurgery significantly decreased the 12-month cumulative incidence of local failure from 15.1% to 5.7% (P<.001). CONCLUSIONS Molecular subtypes appear to be prognostic for survival and predictive of the response to radiotherapy. TKIs were found to improve survival and local control, and may decrease the rate of distant failure. To preserve neurocognition, these results support a paradigm of upfront radiosurgery and HER2-directed therapy in the HER2-amplified population, reserving whole-brain radiotherapy for salvage. Cancer 2017;123:2283-2293. © 2017 American Cancer Society.
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Affiliation(s)
- Jacob A Miller
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Rupesh Kotecha
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manmeet S Ahluwalia
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alireza M Mohammadi
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samuel T Chao
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Erin S Murphy
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Vogelbaum
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - David M Peereboom
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - John H Suh
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
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