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Chen M, Li R, Kong Y, Shi L, Wang J, Wang Y, Xu Y, Ji Y, Hu X. Rational and design of prophylactic cranial irradiation (PCI) and brain MRI surveillance versus brain MRI surveillance alone in patients with limited-stage small cell lung cancer achieving complete remission (CR) of tumor after chemoradiotherapy: a multicenter prospective randomized study. BMC Cancer 2024; 24:429. [PMID: 38589800 PMCID: PMC11000402 DOI: 10.1186/s12885-024-12123-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 03/14/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Prophylactic cranial irradiation (PCI) is part of standard care in limited-stage small cell lung cancer (SCLC) at present. As evidence from retrospective studies increases, the benefits of PCI for limited-stage SCLC are being challenged. METHODS A multicenter, prospective, randomized controlled study was designed. The key inclusion criteria were: histologically or cytologically confirmed small cell carcinoma, age ≥ 18 years, KPS ≥ 80, limited-stage is defined as tumor confined to one side of the chest including ipsilateral hilar, bilateral mediastinum and supraclavicular lymph nodes, patients have received definitive thoracic radiotherapy (regardless of the dose-fractionation of radiotherapy used) and chemotherapy, evaluated as complete remission (CR) of tumor 4-6 weeks after the completion of chemo-radiotherapy. Eligible patients will be randomly assigned to two arms: (1) PCI and brain MRI surveillance arm, receiving PCI (2.5 Gy qd to a total dose of 25 Gy in two weeks) followed by brain MRI surveillance once every three months for two years; (2) brain MRI surveillance alone arm, undergoing brain MRI surveillance once every three months for two years. The primary objective is to compare the 2-year brain metastasis-free survival (BMFS) rates between the two arms. Secondary objectives include 2-year overall survival (OS) rates, intra-cranial failure patterns, 2-year progression-free survival rates and neurotoxicity. In case of brain metastasis (BM) detect during follow-up, stereotactic radiosurgery (SRS) will be recommended if patients meet the eligibility criteria. DISCUSSION Based on our post-hoc analysis of a prospective study, we hypothesize that in limited-stage SCLC patients with CR after definitive chemoradiotherapy, and ruling out of BM by MRI, it would be feasible to use brain MRI surveillance and omit PCI in these patients. If BM is detected during follow-up, treatment with SRS or whole brain radiotherapy does not appear to have a detrimental effect on OS. Additionally, this approach may reduce potential neurotoxicity associated with PCI.
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Affiliation(s)
- Mengyuan Chen
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China
| | - Runhua Li
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China
| | - Yue Kong
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China
| | - Lei Shi
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China
| | - Jing Wang
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China
| | - Yuezhen Wang
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China
| | - Yujin Xu
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China
| | - Yongling Ji
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China
| | - Xiao Hu
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China.
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Okada Y, Zama T, Itonaga T, Mikami R, Okubo M, Sugahara S, Nakai M, Abe K, Yoshimura M, Saito K. Association between PET-CT accumulation in the hypothalamic/pituitary regions and neuron-specific enolase/primary tumor in limited-stage small cell lung cancer: a case-controlled retrospective study. EJNMMI REPORTS 2024; 8:4. [PMID: 38748049 PMCID: PMC10962629 DOI: 10.1186/s41824-024-00190-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/06/2023] [Indexed: 05/19/2024]
Abstract
BACKGROUND Research on the relationship between neuron-specific enolase (NSE) levels and normal organs, particularly the central nervous system, in small cell lung cancer is limited. Therefore, this study aimed to investigate the relationship between positron emission tomography-computed tomography (PET-CT) accumulation at hypothalamic/pituitary regions, tumor activity, and NSE level in limited-stage small cell lung cancer. We retrospectively analyzed patients who were diagnosed with limited-stage small cell lung cancer at Tokyo Medical University Hospital between July 1, 2019, and May 31, 2023, and were treated with chemoradiotherapy or radiotherapy. Leukocytes, erythrocytes, hemoglobin, platelets, total protein, albumin, NSE, and carcinoembryonic antigen were measured in blood samples obtained before treatment initiation. The maximum standardized uptake value (SUVmax), volume, and total lesion glycolysis (TLG) of each hypothalamic /pituitary region, primary tumor, and lymph node metastases were extracted from PET-CT images. The total tumor volume (primary tumor volume plus lymph node metastases volume) and total TLG (primary tumor TLG plus lymph node metastases TLG) were calculated. RESULTS This study included 19 patients (mean age, 70.1 ± 8.8 years; 13 men and 6 women); the pathology in all patients was small cell lung cancer. Patients were classified into two groups according to the NSE reference value (16.3 ng/mL): six patients having NSE level below the reference value and 13 having NSE level above the reference value. The SUVmax in the hypothalamic/pituitary region was 2.95 in the NSE < 16.3 ng/mL group and 4.10 in the NSE > 16.3 ng/mL group, with a statistically significant difference (p = 0.03). The total tumor volume was 17.8 mL in the NSE < 16.3 ng/mL group and 98.9 mL in the NSE > 16.3 ng/mL group, with a statistically significant difference (p < 0.01). A correlation coefficient of r = 0.458 (p = 0.0486) was observed between SUVmax in the hypothalamus/pituitary and NSE level. A correlation coefficient of r = 0.647 (p < 0.01) was also observed between total tumor volume and NSE level. Finally, a correlation coefficient of r = 0.53 (p = 0.01) was observed between hypothalamic/pituitary TLG and primary tumor TLG. CONCLUSIONS The findings demonstrated a correlation between hypothalamic/pituitary activity and tumor activity, suggesting the prognostic significance of NSE.
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Affiliation(s)
- Yukinori Okada
- Department of Radiology, Tokyo Medical University, Tokyo, Japan.
| | - Tatsuhiko Zama
- Department of Radiology, Tokyo Medical University, Tokyo, Japan
| | | | - Ryuji Mikami
- Department of Radiology, Tokyo Medical University, Tokyo, Japan
| | - Mitsuru Okubo
- Department of Radiology, Tokyo Medical University, Tokyo, Japan
| | - Shinji Sugahara
- Department of Radiology, Tokyo Medical University, Tokyo, Japan
| | - Motoki Nakai
- Department of Radiology, Tokyo Medical University, Tokyo, Japan
| | - Koichiro Abe
- Department of Radiology, Tokyo Medical University, Tokyo, Japan
| | - Mana Yoshimura
- Department of Radiology, Tokyo Medical University, Tokyo, Japan
| | - Kazuhiro Saito
- Department of Radiology, Tokyo Medical University, Tokyo, Japan
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Gatto L, Di Nunno V, Tosoni A, Bartolini S, Ranieri L, Franceschi E. Vorasidenib in IDH1/2-mutant low-grade glioma: the grey zone of patient's selection. Front Oncol 2024; 13:1339266. [PMID: 38273856 PMCID: PMC10809174 DOI: 10.3389/fonc.2023.1339266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 12/29/2023] [Indexed: 01/27/2024] Open
Affiliation(s)
- Lidia Gatto
- Department of Oncology, Azienda Unità Sanitaria Locale (AUSL) Bologna, Bologna, Italy
| | - Vincenzo Di Nunno
- Nervous System Medical Oncology Department, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Alicia Tosoni
- Nervous System Medical Oncology Department, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Stefania Bartolini
- Nervous System Medical Oncology Department, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Lucia Ranieri
- Nervous System Medical Oncology Department, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Enrico Franceschi
- Nervous System Medical Oncology Department, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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Rossi S, Pagliaro A, Michelini A, Navarria P, Clerici E, Franceschini D, Toschi L, Finocchiaro G, Scorsetti M, Santoro A. The Era of Immunotherapy in Small-Cell Lung Cancer: More Shadows Than Light? Cancers (Basel) 2023; 15:5761. [PMID: 38136306 PMCID: PMC10741846 DOI: 10.3390/cancers15245761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/10/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
Small-cell lung cancer is an extremely chemo-sensitive disease; the addition of immunotherapy to chemotherapy has demonstrated a slight clinical benefit in pivotal trials, even with a statistically significant difference in terms of survival outcomes when compared to chemotherapy alone. In this scenario, the role of radiotherapy as a consolidation treatment in thoracic disease or as a prophylactic therapy in the brain should be clarified. In addition, due to the frailty and the poor prognostic characteristics of these patients, the need for predictive biomarkers that could support the use of immunotherapy is crucial. PD-L1 and TMB are not actually considered definitive biomarkers due to the heterogeneity of results in the literature. A new molecular classification of small-cell lung cancer based on the expression of key transcription factors seems to clarify the disease behavior, but the knowledge of this molecular subtype is still insufficient and the application in clinical practice far from reality; this classification could lead to a better understanding of SCLC disease and could provide the right direction for more personalized treatment. The aim of this review is to investigate the current knowledge in this field, evaluating whether there are predictive biomarkers and clinical patient characteristics that could help us to identify those patients who are more likely to respond to immunotherapy.
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Affiliation(s)
- Sabrina Rossi
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.P.); (A.M.); (L.T.); (G.F.); (A.S.)
| | - Arianna Pagliaro
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.P.); (A.M.); (L.T.); (G.F.); (A.S.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy;
| | - Angelica Michelini
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.P.); (A.M.); (L.T.); (G.F.); (A.S.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy;
| | - Pierina Navarria
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (P.N.); (E.C.); (D.F.)
| | - Elena Clerici
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (P.N.); (E.C.); (D.F.)
| | - Davide Franceschini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (P.N.); (E.C.); (D.F.)
| | - Luca Toschi
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.P.); (A.M.); (L.T.); (G.F.); (A.S.)
| | - Giovanna Finocchiaro
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.P.); (A.M.); (L.T.); (G.F.); (A.S.)
| | - Marta Scorsetti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy;
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (P.N.); (E.C.); (D.F.)
| | - Armando Santoro
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.P.); (A.M.); (L.T.); (G.F.); (A.S.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy;
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Vojtíšek R. What is the current role of prophylactic cranial irradiation in the treatment algorithm for small cell lung cancer? Rep Pract Oncol Radiother 2023; 28:698-706. [PMID: 38179287 PMCID: PMC10764050 DOI: 10.5603/rpor.97432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 09/04/2023] [Indexed: 01/06/2024] Open
Abstract
Prophylactic cranial irradiation (PCI) is considered an important technological advance made in oncology in an effort to reduce the incidence of brain metastases (BM) and improve overall survival (OS) of patients with small cell lung cancer (SCLC). Although it is often reported that PCI improves the therapeutic potential in limited-stage (LS) SCLC, no randomised trial has ever conclusively confirmed this. Nevertheless, PCI has been considered the standard of care for LS-SCLC since the late 1990s. The data supporting the use of PCI in LS-SCLC are based on an analysis of work performed prior to the current approach to staging [brain magnetic resonance imaging (MRI), positron emission tomography (PET)/computed tomography (CT)]. The evidence for the rationale and feasibility of this approach in the modern diagnostic era should be demonstrated. The situation with extensive stage (ES) SCLC is seemingly easier because, unlike LS-SCLC, we have data from two randomised trials. Unfortunately, their results are in direct conflict with each other. Although it is generally assumed that good control of brain disease leads to better quality of life, this has never been prospectively demonstrated. In fact, PCI is associated not only with increased treatment costs and some patient discomfort, but also with non-negligible potential toxicity. For this reason, efforts have been made to preserve cognitive function by sparing the hippocampus. This concept is called hippocampal avoidance. The optimal fractionation regimen is currently less controversial than the optimal integration of PCI into the treatment algorithm. A dose of 25 Gy administered in 10 fractions should remain the standard for the eventual use of PCI in patients with SCLC. In summary, PCI is not a conditio sine qua non in any indication. Neither in patients with LS-SCLC nor in patients with ES-SCLC has a clear improvement in OS been demonstrated at follow-up using current imaging modalities.
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Affiliation(s)
- Radovan Vojtíšek
- Department of Oncology and Radiotherapy, University Hospital in Pilsen, Czech Republic
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Moss TT, Stavem K, Aandahl A, Gløersen AS, Grønberg BH, Neumann K, Vedeler CA, Lundqvist C. Case Report: Limbic encephalitis following treatment with durvalumab for small-cell lung cancer. Front Immunol 2023; 14:1278761. [PMID: 37908347 PMCID: PMC10613972 DOI: 10.3389/fimmu.2023.1278761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 09/29/2023] [Indexed: 11/02/2023] Open
Abstract
Background Durvalumab is an immune checkpoint Inhibitor (ICIs) that is used in the treatment of malignant tumors, such as lung cancer and melanoma. ICIs are associated with immune-related adverse events including autoimmune encephalitis, although both paraneoplastic phenomena and ICI treatment may lead to autoimmunity. Case presentation We describe a 72-year old male patient with small-cell lung cancer, who during adjuvant treatment with Durvalumab developed GABABR1 and GAD65 antibodies and both diabetes and autoimmune limbic encephalitis. Because he was followed prospectively as part of a treatment study, we had access to repeated serum samples and cognitive assessments over time prior to developing encephalitis and diabetes, in addition to later assessments. A high titer of GABABR1 antibodies appeared early, while GAD65 antibodies appeared later with a lower titer in parallel with the development of diabetes. As he subsequently developed clinical signs of encephalitis, verified by EEG and brain MRI, he also had CSF GABABR1 antibodies. Durvalumab was discontinued and steroid treatment with subsequent plasmapheresis were started, resulting in reduction of both CSF and serum antibody levels. Clinical signs of encephalitis gradually improved. Conclusion This case illustrates the importance of being aware of possible serious autoimmune adverse reactions, including neurological syndromes such as encephalitis, when treating patients with high risk of para-neoplasia with ICIs. In addition, the case shows the development of autoantibodies over time.
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Affiliation(s)
- Thomas T. Moss
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Knut Stavem
- Pulmonary Department, Akershus University Hospital, Lørenskog, Norway
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Astrid Aandahl
- Department of Immunology and Transfusion Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Anne S. Gløersen
- Pulmonary Department, Akershus University Hospital, Lørenskog, Norway
| | - Bjørn H. Grønberg
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Oncology, St. Olavs Hospital, Trondheim, Norway
| | - Kirill Neumann
- Pulmonary Department, Akershus University Hospital, Lørenskog, Norway
| | - Christian A. Vedeler
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christofer Lundqvist
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Fujiwara M, Tada H. Perihippocampal Meningeal Carcinomatosis Following Hippocampal Avoidance Prophylactic Cranial Irradiation in Small Cell Lung Cancer: A Case Report. Cureus 2023; 15:e46499. [PMID: 37927701 PMCID: PMC10624598 DOI: 10.7759/cureus.46499] [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: 10/04/2023] [Indexed: 11/07/2023] Open
Abstract
Prophylactic cranial irradiation (PCI) for limited disease small cell lung cancer is the standard of care for curative treatment of this disease. However, neurocognitive dysfunction is one of the late adverse events of PCI and is often problematic. Recently, hippocampal avoidance prophylactic cranial irradiation (HA-PCI) is sometimes performed to prevent neurocognitive dysfunction after PCI. In HA-PCI, the question is whether or not metastases appear around the hippocampus that were not irradiated. We have experienced a case of perihippocampal meningeal carcinomatosis after HA-PCI. We also draw attention to the potential risks of performing HA-PCI based on this experience.
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Affiliation(s)
- Masateru Fujiwara
- Radiation Oncology, Osaka University Graduate School of Medicine, Suita, JPN
- Radiation Oncology, Suita Tokushukai Hospital, Suita, JPN
| | - Hirohito Tada
- Thoracic Surgery, Suita Tokushukai Hospital, Suita, JPN
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Rammohan N, Ho A, Besson P, Kruser TJ, Bandt SK. Whole-brain radiotherapy associated with structural changes resembling aging as determined by anatomic surface-based deep learning. Neuro Oncol 2023; 25:1323-1330. [PMID: 36734195 PMCID: PMC10326473 DOI: 10.1093/neuonc/noad029] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Brain metastases are the most common intracranial tumors in adults and are associated with significant morbidity and mortality. Whole-brain radiotherapy (WBRT) is used frequently in patients for palliation, but can result in neurocognitive deficits. While dose-dependent injury to individual areas such as the hippocampus has been demonstrated, global structural shape changes after WBRT remain to be studied. METHODS We studied healthy controls and patients with brain metastases and examined MRI brain anatomic surface data before and after WBRT. We implemented a validated graph convolutional neural network model to estimate patient's "brain age". We further developed a mixed-effects linear model to compare the estimated age of the whole brain and substructures before and after WBRT. RESULTS 4220 subjects were analyzed (4148 healthy controls and 72 patients). The median radiation dose was 30 Gy (range 25-37.5 Gy). The whole brain and substructures underwent structural change resembling rapid aging in radiated patients compared to healthy controls; the whole brain "aged" 9.32 times faster, the cortex 8.05 times faster, the subcortical structures 12.57 times faster, and the hippocampus 10.14 times faster. In a subset analysis, the hippocampus "aged" 8.88 times faster in patients after conventional WBRT versus after hippocampal avoidance (HA)-WBRT. CONCLUSIONS Our findings suggest that WBRT causes the brain and its substructures to undergo structural changes at a pace up to 13x of the normal aging pace, where hippocampal avoidance offers focal structural protection. Correlating these structural imaging changes with neurocognitive outcomes following WBRT or HA-WBRT would benefit from future analysis.
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Affiliation(s)
- Nikhil Rammohan
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alexander Ho
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Pierre Besson
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Tim J Kruser
- SSM Health Dean Medical Group, Turville Bay Radiation Oncology Center, Madison, WI, USA
| | - S Kathleen Bandt
- Department of Neurologic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Leskinen S, Shah HA, Yaffe B, Schneider SJ, Ben-Shalom N, Boockvar JA, D'Amico RS, Wernicke AG. Hippocampal avoidance in whole brain radiotherapy and prophylactic cranial irradiation: a systematic review and meta-analysis. J Neurooncol 2023; 163:515-527. [PMID: 37395975 DOI: 10.1007/s11060-023-04384-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/26/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE We systematically reviewed the current landscape of hippocampal-avoidance radiotherapy, focusing specifically on rates of hippocampal tumor recurrence and changes in neurocognitive function. METHODS PubMed was queried for studies involving hippocampal-avoidance radiation therapy and results were screened using PRISMA guidelines. Results were analyzed for median overall survival, progression-free survival, hippocampal relapse rates, and neurocognitive function testing. RESULTS Of 3709 search results, 19 articles were included and a total of 1611 patients analyzed. Of these studies, 7 were randomized controlled trials, 4 prospective cohort studies, and 8 retrospective cohort studies. All studies evaluated hippocampal-avoidance whole brain radiation treatment (WBRT) and/or prophylactic cranial irradiation (PCI) in patients with brain metastases. Hippocampal relapse rates were low (overall effect size = 0.04; 95% confidence interval [0.03, 0.05]) and there was no significant difference in risk of relapse between the five studies that compared HA-WBRT/HA-PCI and WBRT/PCI groups (risk difference = 0.01; 95% confidence interval [- 0.02, 0.03]; p = 0.63). 11 out of 19 studies included neurocognitive function testing. Significant differences were reported in overall cognitive function and memory and verbal learning 3-24 months post-RT. Differences in executive function were reported by one study, Brown et al., at 4 months. No studies reported differences in verbal fluency, visual learning, concentration, processing speed, and psychomotor speed at any timepoint. CONCLUSION Current studies in HA-WBRT/HA-PCI showed low hippocampal relapse or metastasis rates. Significant differences in neurocognitive testing were most prominent in overall cognitive function, memory, and verbal learning. Studies were hampered by loss to follow-up.
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Affiliation(s)
- Sandra Leskinen
- State University of New York Downstate Medical Center, Brooklyn, NY, USA
| | - Harshal A Shah
- Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Beril Yaffe
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA
| | - Shonna J Schneider
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA
| | - Netanel Ben-Shalom
- Department of Neurological Surgery, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA
| | - John A Boockvar
- Department of Neurological Surgery, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA
| | - A Gabriella Wernicke
- Department of Radiation Oncology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA.
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Li W, Ding C, Sheng W, Wan Q, Cui Z, Qi G, Liu Y. Development and validation of a nomogram for the prediction of brain metastases in small cell lung cancer. THE CLINICAL RESPIRATORY JOURNAL 2023; 17:456-467. [PMID: 37071990 DOI: 10.1111/crj.13615] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/29/2023] [Indexed: 04/20/2023]
Abstract
INTRODUCTION The aim was to develop and validate a nomogram for the prediction of brain metastases (BM) in small cell lung cancer (SCLC), to explore the risk factors and assist clinical decision-making. METHODS We reviewed the clinical data of SCLC patients between 2015 and 2021. Patients between 2015 and 2019 were included to develop, whereas patients between 2020 and 2021 were used for external validation. Clinical indices were analysed by using the least absolute shrinkage and selection operator (LASSO) logistic regression analyses. The final nomogram was constructed and validated by bootstrap resampling. RESULTS A total of 631 SCLC patients between 2015 and 2019 were included to construct model. Gender, T stage, N stage, Eastern Cooperative Oncology Group (ECOG), haemoglobin (HGB), the absolute value of lymphocyte (LYMPH #), platelet (PLT), retinol-binding protein (RBP), carcinoembryonic antigen (CEA) and neuron-specific enolase (NSE) were identified as risk factors and included into the model. The C-indices were 0.830 and 0.788 in the internal validation by 1000 bootstrap resamples. The calibration plot revealed excellent agreement between the predicted and the actual probability. Decision curve analysis (DCA) showed better net benefits with a wider range of threshold probability (net clinical benefit was 1%-58%). The model was further externally validated in patients between 2020 and 2021 with a C-index of 0.818. CONCLUSIONS We developed and validated a nomogram to predict the risk of BM in SCLC patients, which could help clinicians to rationally schedule follow-ups and promptly implement interventions.
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Affiliation(s)
- Weiwei Li
- Department of Pulmonary and Critical Care Medicine, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, 250021, China
- Shandong Key Laboratory of Infections Respiratory Disease, Medical Science and Technology Innovation Center, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China
- Department of Critical Care Medicine, The 960th Hospital of the PLA (People's Liberation Army) Joint Logistics Support Force, Jinan, Shandong, 250012, China
| | - Can Ding
- Department of Pulmonary and Critical Care Medicine, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250013, China
| | - Wei Sheng
- Cancer Centre, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Qiang Wan
- Center of Cell Metabolism and Disease, Jinan Central Hospital, Shandong University, Jinan, Shandong, 250013, China
| | - Zhengguo Cui
- Department of Environmental Health, University of Fukui School of Medical Science, Fukui, Japan
| | - Guiye Qi
- Department of Medical Engineering Management, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Yi Liu
- Department of Pulmonary and Critical Care Medicine, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, 250021, China
- Shandong Key Laboratory of Infections Respiratory Disease, Medical Science and Technology Innovation Center, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China
- Department of Allergy, Department of Pulmonary and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
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11
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Risk factors for cognitive impairment in radically treated stage III NSCLC: Secondary findings of the NVALT-11 study. Radiother Oncol 2023; 183:109627. [PMID: 36934893 DOI: 10.1016/j.radonc.2023.109627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/07/2023] [Accepted: 03/12/2023] [Indexed: 03/19/2023]
Abstract
AIM To identify risk factors for self-reported cognitive impairment in radically treated stage III non-small cell lung cancer (NSCLC). METHODS Cognitive functioning was assessed using the EORTC-QLQ-C30 at seven pre-specified time points in the phase III NVALT-11 trial (observation versus prophylactic cranial irradiation [PCI] in stage III NSCLC treated with chemo-radiotherapy±surgery). Cognition was analyzed as binary (impairment or not) and continuous outcome, respectively, using generalized estimating equation (GEE) before and after multiple imputation. A score <75 was defined as cognitive impairment. A mean difference by <10, 10-<20, ≥ 20 points was regarded as no, moderate, and large clinical effect, respectively. We categorized the cognitive impairment into four types based on changes over time: sustained, reversible, recurring, and alternating. RESULTS In the no-PCI arm, 43/84 [51.2%] reported cognitive impairment at least once, of which 31.4% were sustained, 25.7% reversible, 28.6% recurring, and 14.3% alternating. Results were similar in the PCI arm. Cognitive functioning at baseline was comparable in two arms and a score <75 was a significant risk factor with large effect for subsequent cognitive impairment (no-PCI: β = -22.30, p<0.001; PCI arm: β = -22.34, p<0.001; All: β = -23.47, p<0.001). Younger age (≤ 60y), squamous histology, and PCI were risk factors without clinical relevance (β > -10, p<0.05). Cognitive functioning declined over time (β = -0.26, p=0.001) except for patients with cognitive impairment at baseline (β=0.141, p=0.33). CONCLUSION Cognitive impairment is dynamic over time with four types. Baseline cognitive impairment (score <75) is the most important risk factor for subsequent cognitive impairment in stage III NSCLC. Note: This work has been partly reported as an oral presentation at the ESTRO 2021 meeting (OC-0176).
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12
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Sun A, Abdulkarim B, Blais N, Greenland J, Louie AV, Melosky B, Schellenberg D, Snow S, Liu G. Use of radiation therapy among patients with Extensive-stage Small-cell lung cancer receiving Immunotherapy: Canadian consensus recommendations. Lung Cancer 2023; 179:107166. [PMID: 36944282 DOI: 10.1016/j.lungcan.2023.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/23/2023] [Accepted: 03/06/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVES Thoracic radiation therapy (TRT) and prophylactic cranial irradiation (PCI) are commonly used in the management of extensive-stage small-cell lung cancer (ES-SCLC); however, Phase III trials of first-line immunotherapy often excluded these options. Guidance is needed regarding appropriate use of TRT, PCI, and magnetic resonance imaging (MRI) surveillance while new data are awaited. MATERIALS AND METHODS In two web-based meetings, a pan-Canadian expert working group of five radiation oncologists and four medical oncologists addressed eight clinical questions regarding use of radiation therapy (RT) and MRI surveillance among patients with ES-SCLC receiving immunotherapy. A targeted literature review was conducted using PubMed and conference proceedings to identify recent (January 2019-April 2022) publications in this setting. Fifteen recommendations were developed; online voting was conducted to gauge agreement with each recommendation. RESULTS After considering recently available evidence across lung cancer populations and clinical experience, the experts recommended that all patients with a response to chemo-immunotherapy, good performance status (PS), and limited metastases be considered for consolidation TRT (e.g., 30 Gy in 10 fractions). When considered appropriate after multidisciplinary team discussion, TRT can be initiated during maintenance immunotherapy. All patients who respond to concurrent chemo-immunotherapy should undergo restaging with brain MRI to guide decision-making regarding PCI versus MRI surveillance alone. MRI surveillance should be conducted for two years after response to initial therapy. PCI (e.g., 25 Gy in 10 fractions or 20 Gy in 5 fractions) can be considered for patients without central nervous system involvement who have a response to chemo-immunotherapy and good PS. Concurrent treatment with PCI and immunotherapy or with TRT, PCI, and immunotherapy is appropriate after completion of initial therapy. All recommendations were agreed upon unanimously. CONCLUSIONS These consensus recommendations provide practical guidance regarding appropriate use of RT and immunotherapy in ES-SCLC while awaiting new clinical trial data.
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Affiliation(s)
- Alexander Sun
- Princess Margaret Cancer Centre, 700 University Avenue, Toronto, ON M5G 1Z5, Canada.
| | - Bassam Abdulkarim
- McGill University Health Centre, McGill University, 1001 Decarie Boulevard, Montréal, QC H4A 3J1, Canada.
| | - Normand Blais
- Centre Hospitalier de l'Université de Montréal, University of Montréal, 1051 Rue Sanguinet, Montréal, QC H2X 3E4, Canada.
| | - Jonathan Greenland
- Eastern Health, 300 Prince Philip Drive, St. John's, NL A1B 3V6, Canada.
| | - Alexander V Louie
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada.
| | - Barbara Melosky
- BC Cancer-Vancouver Centre, 600 W 10th Avenue, Vancouver, BC V5Z 4E6, Canada.
| | | | - Stephanie Snow
- QEII Health Sciences Centre, Dalhousie University, 5788 University Avenue, Halifax, NS B3H 1V8, Canada.
| | - Geoffrey Liu
- Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON M5G 2M9, Canada.
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13
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Chu X, Gong J, Yang X, Ni J, Gu Y, Zhu Z. A "Seed-and-Soil" Radiomics Model Predicts Brain Metastasis Development in Lung Cancer: Implications for Risk-Stratified Prophylactic Cranial Irradiation. Cancers (Basel) 2023; 15:cancers15010307. [PMID: 36612303 PMCID: PMC9818608 DOI: 10.3390/cancers15010307] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 12/26/2022] [Accepted: 12/28/2022] [Indexed: 01/09/2023] Open
Abstract
Introduction: Brain is a major site of metastasis for lung cancer, and effective therapy for developed brain metastasis (BM) is limited. Prophylactic cranial irradiation (PCI) has been shown to reduce BM rate and improve survival in small cell lung cancer, but this result was not replicated in unselected non-small cell lung cancer (NSCLC) and had the risk of inducing neurocognitive dysfunctions. We aimed to develop a radiomics BM prediction model for BM risk stratification in NSCLC patients. Methods: 256 NSCLC patients with no BM at baseline brain magnetic resonance imaging (MRI) were selected; 128 patients developed BM within three years after diagnosis and 128 remained BM-free. For radiomics analysis, both the BM and non-BM groups were randomly distributed into training and testing datasets at an 70%:30% ratio. Both brain MRI (representing the soil) and chest computed tomography (CT, representing the seed) radiomic features were extracted to develop the BM prediction models. We first developed the radiomic models using the training dataset (89 non-BM and 90 BM cases) and subsequently validated the models in the testing dataset (39 non-BM and 38 BM cases). A radiomics BM score (RadBM score) was generated, and BM-free survival were compared between RadBM score-high and RadBM score-low groups. Results: The radiomics model developed from baseline brain MRI features alone can predict BM development in NSCLC patients. A fusion model integrating brain MRI features with primary tumor CT features (seed-and-soil model) provided synergetic effect and was more efficient in predicting BM (areas under the receiver operating characteristic curve 0.84 (95% confidence interval: 0.80−0.89) and 0.80 (95% confidence interval: 0.71−0.88) in the training and testing datasets, respectively). BM-free survival was significantly shorter in the RadBM score-high group versus the RadBM score-low group (Log-rank, p < 0.001). Hazard ratios for BM were 1.056 (95% confidence interval: 1.044−1.068) per 0.01 increment in RadBM score. Cumulative BM rates at three years were 75.8% and 24.2% for the RadBM score-high and RadBM score-low groups, respectively. Only 1.2% (7/565) of the BM lesions were located within the hippocampal avoidance region. Conclusion: The results demonstrated that intrinsic features of a non-metastatic brain exert a significant impact on BM development, which is first-in-class in metastasis prediction studies. A radiomics BM prediction model utilizing both primary tumor and pre-metastatic brain features might provide a useful tool for individualized PCI administration in NSCLC patients more prone to develop BM.
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Affiliation(s)
- Xiao Chu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai 200032, China
| | - Jing Gong
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Xi Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai 200032, China
| | - Jianjiao Ni
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai 200032, China
| | - Yajia Gu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Correspondence: (Y.G.); (Z.Z.); Tel.: +86-18017312040 (Y.G.); +86-18017312901 (Z.Z.); Fax: +86-21-64175242 (Y.G. & Z.Z.)
| | - Zhengfei Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai 200032, China
- Correspondence: (Y.G.); (Z.Z.); Tel.: +86-18017312040 (Y.G.); +86-18017312901 (Z.Z.); Fax: +86-21-64175242 (Y.G. & Z.Z.)
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14
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Chu X, Zhu Z. Prophylactic cranial irradiation in small cell lung cancer: an update. Curr Opin Oncol 2023; 35:61-67. [PMID: 36421007 DOI: 10.1097/cco.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The current review presents recent updates in the seminal literature of research on prophylactic cranial irradiation (PCI) in small cell lung cancer (SCLC). RECENT FINDINGS Brain MRI restaging before the administration of PCI reveals a substantial proportion of brain metastasis in baseline brain metastasis free extensive-stage SCLC (ES-SCLC) and limited-stage SCLC (LS-SCLC). Posthoc analyses from the CASPIAN and IMpower133 trials revealed decreases in brain metastasis rates in ES-SCLC treated with chemoimmunotherapy relative to the brain metastasis rates in ES-SCLC treated with chemotherapy alone. A recent meta-analysis of literature published after the landmark 1999 Auperin meta-analysis confirmed the survival benefit of PCI in LS-SCLC patients. A recent study employing PET before and after PCI demonstrated that hippocampal avoidance -PCI (HA-PCI) preserved the metabolic activity of the hippocampi compared with regular PCI. Two phase III trials evaluating neurocognitive functions after HA-PCI versus PCI have yielded conflicting results. Ongoing clinical trials (MAVERICK, PRIMALung, NRG CC003, NCT04535739, NCT04829708 and NCT03514849) regarding PCI versus MRI surveillance and HA-PCI versus PCI were also discussed. SUMMARY Currently, the indications for PCI in SCLC are under question in the modern MRI era. Result from prospective phase III, MRI staged and MRI monitored RCTs are expected to elucidate the role of PCI in LS-SCLC and ES-SCLC. Preliminary results indicated that adding immunotherapy to chemotherapy may reduce brain metastasis rate in SCLC. Further data to this aspect are warranted to determine the role of PCI in the immuno-chemotherapy era. The future direction for PCI should be the comprehensive integration of personalized patient selection, HA-PCI utilization and potential employment of other neurocognitive preservation strategies.
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Affiliation(s)
- Xiao Chu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center
- Department of Oncology, Shanghai Medical College, Fudan University
- Shanghai Clinical Research Center for Radiation Oncology
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Zhengfei Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center
- Department of Oncology, Shanghai Medical College, Fudan University
- Shanghai Clinical Research Center for Radiation Oncology
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
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15
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Kirkman MA, Day J, Gehring K, Zienius K, Grosshans D, Taphoorn M, Li J, Brown PD. Interventions for preventing and ameliorating cognitive deficits in adults treated with cranial irradiation. Cochrane Database Syst Rev 2022; 11:CD011335. [PMID: 36427235 PMCID: PMC9697842 DOI: 10.1002/14651858.cd011335.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cognitive deficits are common in people who have received cranial irradiation and have a serious impact on daily functioning and quality of life. The benefit of pharmacological and non-pharmacological treatment of cognitive deficits in this population is unclear. This is an updated version of the original Cochrane Review published in Issue 12, 2014. OBJECTIVES To assess the effectiveness of interventions for preventing or ameliorating cognitive deficits in adults treated with cranial irradiation. SEARCH METHODS For this review update we searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE via Ovid, Embase via Ovid, and PsycInfo via Ovid to 12 September 2022. SELECTION CRITERIA We included randomised controlled (RCTs) trials that evaluated pharmacological or non-pharmacological interventions in cranial irradiated adults, with objective cognitive functioning as a primary or secondary outcome measure. DATA COLLECTION AND ANALYSIS Two review authors (MK, JD) independently extracted data from selected studies and carried out a risk of bias assessment. Cognitive function, fatigue and mood outcomes were reported. No data were pooled. MAIN RESULTS Eight studies met the inclusion criteria and were included in this updated review. Six were from the original version of the review, and two more were added when the search was updated. Nineteen further studies were assessed as part of this update but did not fulfil the inclusion criteria. Of the eight included studies, four studies investigated "prevention" of cognitive problems (during radiotherapy and follow-up) and four studies investigated "amelioration" (interventions to treat cognitive impairment as a late complication of radiotherapy). There were five pharmacological studies (two studies on prevention and three in amelioration) and three non-pharmacological studies (two on prevention and one in amelioration). Due to differences between studies in the interventions being evaluated, a meta-analysis was not possible. Studies in early radiotherapy treatment phase (five studies) Pharmacological studies in the "early radiotherapy treatment phase" were designed to prevent or ameliorate cognitive deficits and included drugs used in dementia (memantine) and fatigue (d-threo-methylphenidate hydrochloride). Non-pharmacological studies in the "early radiotherapy treatment phase" included a ketogenic diet and a two-week cognitive rehabilitation and problem-solving programme. In the memantine study, the primary cognitive outcome of memory at six months did not reach significance, but there was significant improvement in overall cognitive function compared to placebo, with similar adverse events across groups. The d-threo-methylphenidate hydrochloride study found no statistically significant difference between arms, with few adverse events. The study of a calorie-restricted ketogenic diet found no effect, although a lower than expected calorie intake in the control group complicates interpretation of the results. The study investigating the utility of a rehabilitation program did not carry out a statistical comparison of cognitive performance between groups. Studies in delayed radiation or late effect phase (four studies) The "amelioration" pharmacological studies to treat cognitive complications of radiotherapy included drugs used in dementia (donepezil) or psychostimulants (methylphenidate and modafinil). Non-pharmacological measures included cognitive rehabilitation and problem solving (Goal Management Training). These studies included patients with cognitive problems at entry who had "stable" brain cancer. The donepezil study did not find an improvement in the primary cognitive outcome of overall cognitive performance, but did find improvement in an individual test of memory, compared to placebo; adverse events were not reported. A study comparing methylphenidate with modafinil found improvements in cognitive function in both the methylphenidate and modafinil arms; few adverse events were reported. Another study comparing two different doses of modafinil combined treatment arms and found improvements across all cognitive tests, however, a number of adverse events were reported. Both studies were limited by a small sample size. The Goal Management Training study suggested a benefit of the intervention, a behavioural intervention that combined mindfulness and strategy training, on executive function and processing speed. There were a number of limitations across studies and few were without high risks of bias. AUTHORS' CONCLUSIONS In this update, limited additional evidence was found for the treatment or amelioration of cognitive deficits in adults treated with cranial irradiation. As concluded in the original review, there is supportive evidence that memantine may help prevent cognitive deficits for adults with brain metastases receiving cranial irradiation. There is supportive evidence that donepezil, methylphenidate and modafinil may have a role in treating cognitive deficits in adults with brain tumours who have been treated with cranial irradiation; patient withdrawal affected the statistical power of these studies. Further research that tries to minimise the withdrawal of consent, and subsequently reduce the requirement for imputation procedures, may offer a higher certainty of evidence. There is evidence from only a single small study to support non-pharmacological interventions in the amelioration of cognitive deficits. Further research is required.
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Affiliation(s)
- Matthew A Kirkman
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Julia Day
- Community Rehabilitation and Brain Injury Service (CRABIS), Strathbrock Partnership Centre, West Lothian, UK
| | - Karin Gehring
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, Netherlands
| | - Karolis Zienius
- Edinburgh Centre for Neuro-Oncology (ECNO), Western General Hospital, Edinburgh, UK
| | - David Grosshans
- Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Martin Taphoorn
- Department of Neurology, Haaglanden Medical Center, PO Box 432, Netherlands
| | - Jing Li
- Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Paul D Brown
- Radiation Oncology, Mayo Clinic, Rochester, MN, USA
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16
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Zhao W, Zhou W, Rong L, Sun M, Lin X, Wang L, Wang S, Wang Y, Hui Z. Epidermal growth factor receptor mutations and brain metastases in non-small cell lung cancer. Front Oncol 2022; 12:912505. [PMID: 36457515 PMCID: PMC9707620 DOI: 10.3389/fonc.2022.912505] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 10/20/2022] [Indexed: 10/07/2023] Open
Abstract
Studies have revealed that non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) mutations has a high incidence of brain metastases (BMs). However, the association between EGFR mutations and BMs remains unknown. This review summarizes detailed information about the incidence of BMs, clinical and imaging characteristics of BMs, brain surveillance strategies, influence of treatments on BMs, prognosis after BMs, and differences in EGFR mutations between paired primary tumors and BMs in EGFR-mutated NSCLC. The prognostic results demonstrate that patients with mutated EGFR have a higher incidence of BMs, EGFR tyrosine kinase inhibitors (EGFR-TKIs) (afatinib and osimertinib) delay the development of BMs, and patients with mutated EGFR with synchronous or early BMs have better overall survival after BMs than those with wild-type EGFR. The EGFR mutation status of BM sites is not always in accordance with the primary tumors, which indicates that there is heterogeneity in EGFR gene status between paired primary tumors and BMs. However, the EGFR gene status of the primary site can largely represent that of BM sites. Among patients developing synchronous BMs, patients with mutated EGFR are less likely to have central nervous system (CNS) symptoms than patients with wild-type EGFR. However, the possibility of neuro-symptoms is high in patients with metachronous BMs. Patients with mutated EGFR tend to have multiple BMs as compared to patients with wild-type EGFR. Regarding very early-stage NSCLC patients without neuro-symptoms, regular neuroimaging follow-up is not recommended. Among advanced NSCLC patients with EGFR mutation, liberal brain imaging follow-up in the first several years showed more advantages in terms of cost.
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Affiliation(s)
- Wei Zhao
- Department of Radiation Oncology, Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital, Chongqing, China
| | - Wei Zhou
- Department of Radiation Oncology, Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital, Chongqing, China
| | - Li Rong
- Department of Gastroenterology, Bishan Hospital of Chongqing medical university/Bishan Hospital of Chongqing, Chongqing, China
| | - Mao Sun
- Department of Radiation Oncology, Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital, Chongqing, China
| | - Xing Lin
- Department of Radiation Oncology, Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital, Chongqing, China
| | - Lulu Wang
- Department of Radiation Oncology, Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital, Chongqing, China
| | - Shiqiang Wang
- Department of Neurosurgery, Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital, Chongqing, China
| | - Ying Wang
- Department of Radiation Oncology, Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital, Chongqing, China
| | - Zhouguang Hui
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of VIP Medical Services, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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17
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Merie R, Gee H, Hau E, Vinod S. An Overview of the Role of Radiotherapy in the Treatment of Small Cell Lung Cancer - A Mainstay of Treatment or a Modality in Decline? Clin Oncol (R Coll Radiol) 2022; 34:741-752. [PMID: 36064636 DOI: 10.1016/j.clon.2022.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/16/2022] [Accepted: 08/10/2022] [Indexed: 01/31/2023]
Abstract
AIMS Small cell lung cancer (SCLC) accounts for about 15% of all lung cancers. Chemotherapy, immunotherapy and radiotherapy all play important roles in the management of SCLC. The aim of this study was to provide a comprehensive overview of the role and evidence of radiotherapy in the cure and palliation of SCLC. MATERIALS AND METHODS The search strategy included a search of the PubMed database, hand searches, reference lists of relevant review articles and relevant published abstracts. CLINICALTRIALS gov was also queried for relevant trials. RESULTS Thoracic radiotherapy improves overall survival in limited stage SCLC, but the timing and dose remain controversial. The role of thoracic radiotherapy in extensive stage SCLC with immunotherapy is the subject of several ongoing trials. Current evidence supports the use of prophylactic cranial irradiation (PCI) for limited stage SCLC but the evidence is equivocal in extensive stage SCLC. Whole brain radiotherapy is well established for the treatment of brain metastases but evidence is rapidly accumulating for the use of stereotactic radiosurgery. Further studies will define the role of PCI, whole brain radiotherapy and hippocampal avoidant PCI in the immunotherapy era. CONCLUSION Radiotherapy is an essential component in the multimodality management of SCLC. Technological advances have allowed safer delivery of radiotherapy with reduced toxicities. Discussion at multidisciplinary team meetings is important to ensure radiotherapy is considered and offered in appropriate patients.
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Affiliation(s)
- R Merie
- Icon Cancer Centre, Concord Repatriation General Hospital, Concord, NSW, Australia; South West Sydney Clinical Campuses, University of NSW, Liverpool, NSW, Australia.
| | - H Gee
- Sydney West Radiation Oncology Network (SWRON), Sydney, NSW, Australia; Sydney Medical School, Westmead Hospital, University of Sydney, Sydney, NSW, Australia; Children's Medical Research Institute (CMRI), University of Sydney, Sydney, NSW, Australia
| | - E Hau
- Sydney West Radiation Oncology Network (SWRON), Sydney, NSW, Australia; Sydney Medical School, Westmead Hospital, University of Sydney, Sydney, NSW, Australia; The Westmead Institute for Medical Research (WIMR), Westmead, NSW, Australia
| | - S Vinod
- South West Sydney Clinical Campuses, University of NSW, Liverpool, NSW, Australia; Cancer Therapy Centre, Liverpool Hospital, Liverpool, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
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18
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Chen Y, Wang Y, Ren F, Huang Z, Tan B, Zhao Z, Yu X, Dong P, Yu J, Meng X. Prophylactic cranial irradiation (PCI) versus active surveillance in patients with limited-stage small cell lung cancer: a retrospective, multicentre study. Respir Res 2022; 23:274. [PMID: 36184624 PMCID: PMC9526908 DOI: 10.1186/s12931-022-02196-2] [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: 04/26/2022] [Accepted: 09/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background The recommendation of PCI for limited-stage small cell lung cancer (LS-SCLC) is primarily based on evidence from the pre-magnetic resonance imaging (MRI) era. However, as MRI accuracy improves and stereotactic radiosurgery advances, the role of PCI for LS-SCLC has become uncertain. This study aims to compare the contemporary survival outcomes of patients with LS-SCLC treated with PCI versus active surveillance. Methods We conducted a retrospective cohort study in which 1068 patients with LS-SCLC who achieved a good response to first-line chemoradiotherapy were consecutively enrolled from 5 tertiary medical centres between June 2009 and June 2019. Of these patients, 440 received PCI, while 628 received surveillance without PCI. Propensity score matching with a 1:1 ratio was performed to balance the baseline characteristics of the two cohorts. The endpoints were overall survival (OS) and the incidence of brain metastasis (BM). Results In total, 648 patients were matched. The baseline characteristics were generally well balanced. At a median follow-up of 64.5 months (range 2–190), patients who underwent PCI had a significantly lower risk for BM than those who underwent surveillance. The 3-year cumulative incidence rate of BM was 28.2% (95% CI 22.5–33.8%) in the PCI cohort and 38.5% (32.6–44.5%) in the surveillance cohort (Gray’s p = 0.002). However, the lower incidence of BM in the PCI cohort did not translate into a significant extension of OS. The median OS was 35.8 months (95% CI 27.6–44.0 months) in the PCI cohort versus 32 months (26.4–37.6 months) in the surveillance cohort (HR 0.90, 95% CI 0.74–1.10, p = 0.29). Multivariable analysis showed that disease stage, chemoradiotherapy sequence, and response to chemoradiotherapy were independent prognostic factors for BM or OS. Conclusions Overall, PCI reduces the risk for BM but does not substantially prolong OS compared with active surveillance. A phase 3, prospective clinical trial (NCT04829708) we initiated is currently underway, which is expected to corroborate our results.
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Affiliation(s)
- Yu Chen
- Shandong University Cancer Center, Jinan, Shandong, China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, 250117, Shandong, China
| | - Yao Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, 250117, Shandong, China
| | - Fei Ren
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, 250117, Shandong, China
| | - Zhaoqin Huang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Bingxu Tan
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Zhonghua Zhao
- Department of Oncology, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Xinshuang Yu
- Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Department of Oncology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Lung Cancer Institute, Jinan, Shandong, China
| | - Peng Dong
- Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Department of Oncology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Lung Cancer Institute, Jinan, Shandong, China
| | - Jinming Yu
- Shandong University Cancer Center, Jinan, Shandong, China.,Shandong Provincial Key Laboratory of Radiation Oncology, Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China.,8Research Unit of Radiation Oncology, Chinese Academy of Medical Sciences, Jinan, Shandong, China
| | - Xiangjiao Meng
- Shandong University Cancer Center, Jinan, Shandong, China. .,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, 250117, Shandong, China.
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Dinkel JG, Lahmer G, Mennecke A, Hock SW, Richter-Schmidinger T, Fietkau R, Distel L, Putz F, Dörfler A, Schmidt MA. Effects of Hippocampal Sparing Radiotherapy on Brain Microstructure-A Diffusion Tensor Imaging Analysis. Brain Sci 2022; 12:brainsci12070879. [PMID: 35884686 PMCID: PMC9312994 DOI: 10.3390/brainsci12070879] [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: 05/18/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 11/16/2022] Open
Abstract
Hippocampal-sparing radiotherapy (HSR) is a promising approach to alleviate cognitive side effects following cranial radiotherapy. Microstructural brain changes after irradiation have been demonstrated using Diffusion Tensor Imaging (DTI). However, evidence is conflicting for certain parameters and anatomic structures. This study examines the effects of radiation on white matter and hippocampal microstructure using DTI and evaluates whether these may be mitigated using HSR. A total of 35 tumor patients undergoing a prospective randomized controlled trial receiving either conventional or HSR underwent DTI before as well as 6, 12, 18, 24, and 30 (±3) months after radiotherapy. Fractional Anisotropy (FA), Mean Diffusivity (MD), Axial Diffusivity (AD), and Radial Diffusivity (RD) were measured in the hippocampus (CA), temporal, and frontal lobe white matter (TL, FL), and corpus callosum (CC). Longitudinal analysis was performed using linear mixed models. Analysis of the entire patient collective demonstrated an overall FACC decrease and RDCC increase compared to baseline in all follow-ups; ADCC decreased after 6 months, and MDCC increased after 12 months (p ≤ 0.001, 0.001, 0.007, 0.018). ADTL decreased after 24 and 30 months (p ≤ 0.004, 0.009). Hippocampal FA increased after 6 and 12 months, driven by a distinct increase in ADCA and MDCA, with RDCA not increasing until 30 months after radiotherapy (p ≤ 0.011, 0.039, 0.005, 0.040, 0.019). Mean radiation dose correlated positively with hippocampal FA (p < 0.001). These findings may indicate complex pathophysiological changes in cerebral microstructures after radiation, insufficiently explained by conventional DTI models. Hippocampal microstructure differed between patients undergoing HSR and conventional cranial radiotherapy after 6 months with a higher ADCA in the HSR subgroup (p ≤ 0.034).
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Affiliation(s)
- Johannes G. Dinkel
- Neuroradiologisches Institut des Universitätsklinikums Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (J.G.D.); (A.M.); (S.W.H.); (A.D.)
| | - Godehard Lahmer
- Strahlenklinik des Universitätsklinikums Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (G.L.); (R.F.); (L.D.); (F.P.)
| | - Angelika Mennecke
- Neuroradiologisches Institut des Universitätsklinikums Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (J.G.D.); (A.M.); (S.W.H.); (A.D.)
| | - Stefan W. Hock
- Neuroradiologisches Institut des Universitätsklinikums Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (J.G.D.); (A.M.); (S.W.H.); (A.D.)
| | - Tanja Richter-Schmidinger
- Psychiatrische und Psychotherapeutische Klinik des Universitätsklinikums Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany;
| | - Rainer Fietkau
- Strahlenklinik des Universitätsklinikums Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (G.L.); (R.F.); (L.D.); (F.P.)
| | - Luitpold Distel
- Strahlenklinik des Universitätsklinikums Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (G.L.); (R.F.); (L.D.); (F.P.)
| | - Florian Putz
- Strahlenklinik des Universitätsklinikums Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (G.L.); (R.F.); (L.D.); (F.P.)
| | - Arnd Dörfler
- Neuroradiologisches Institut des Universitätsklinikums Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (J.G.D.); (A.M.); (S.W.H.); (A.D.)
| | - Manuel A. Schmidt
- Neuroradiologisches Institut des Universitätsklinikums Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (J.G.D.); (A.M.); (S.W.H.); (A.D.)
- Correspondence:
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20
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Pangua C, Rogado J, Serrano-Montero G, Belda-Sanchís J, Álvarez Rodríguez B, Torrado L, Rodríguez De Dios N, Mielgo-Rubio X, Trujillo JC, Couñago F. New perspectives in the management of small cell lung cancer. World J Clin Oncol 2022; 13:429-447. [PMID: 35949427 PMCID: PMC9244973 DOI: 10.5306/wjco.v13.i6.429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 09/05/2021] [Accepted: 05/23/2022] [Indexed: 02/06/2023] Open
Abstract
The treatment of small cell lung cancer (SCLC) is a challenge for all specialists involved. New treatments have been added to the therapeutic armamentarium in recent months, but efforts must continue to improve both survival and quality of life. Advances in surgery and radiotherapy have resulted in prolonged survival times and fewer complications, while more careful patient selection has led to increased staging accuracy. Developments in the field of systemic therapy have resulted in changes to clinical guidelines and the management of patients with advanced disease, mainly with the introduction of immunotherapy. In this article, we describe recent improvements in the management of patients with SCLC, review current treatments, and discuss future lines of research.
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Affiliation(s)
- Cristina Pangua
- Department of Medical Oncology, Hospital Universitario Infanta Leonor, Madrid 28031, Spain
| | - Jacobo Rogado
- Department of Medical Oncology, Hospital Universitario Infanta Leonor, Madrid 28031, Spain
| | - Gloria Serrano-Montero
- Department of Medical Oncology, Hospital Universitario Infanta Leonor, Madrid 28031, Spain
| | - José Belda-Sanchís
- Department of Thoracic Surgery, Hospital de la Santa Creu i Sant Pau & Hospital de Mar, Universitat Autònoma de Barcelona, Barcelona 08041, Catalonia, Spain
| | - Beatriz Álvarez Rodríguez
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, HM CIOCC Centro Integral Oncológico Clara Campal, Madrid 28050, Spain
| | - Laura Torrado
- Department of Radiation Oncology, Hospital Universitario Lucus Augusti & Instituto de Investigación Sanitaria Santiago de Compostela (IDIS), Lugo 27003, Spain
| | - Nuria Rodríguez De Dios
- Department of Radiation Oncology, Hospital Del Mar & Hospital Del Mar Medical Research Institute (IMIM) & Pompeu Fabra University, Barcelona 08003, Catalonia, Spain
| | - Xabier Mielgo-Rubio
- Department of Medical Oncology, Alcorcón Foundation University Hospital, Alcorcón 28922, Madrid, Spain
| | - Juan Carlos Trujillo
- Department of Thoracic Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona 08029, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid, Hospital La Luz, Universidad Europea de Madrid, Madrid 28223, Spain
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21
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Batra U, Chufal KS, Nathany S, Ahmad I, Chowdhary RL, Sharma M, Jain P, Gairola M. Immunotherapy in advanced non-small-cell lung cancer (NSCLC) after progression on chemotherapy: real-world results from a prospective institutional cohort. Immunotherapy 2022; 14:851-858. [PMID: 35698820 DOI: 10.2217/imt-2021-0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objective: To analyze the outcomes of patients receiving immunotherapy (IO) with advanced non-driver mutated non-small-cell lung cancer (NSCLC) after progression on systemic treatment. Methods: The overall survival (OS), progression-free survival (PFS) and best response to IO of 64 patients who met our inclusion criteria were analyzed. Results: Median follow-up, OS and PFS were 35.9, 7.1 and 3.2 months, respectively. On uni- and multi-variable analysis, better ECOG PS and fewer extra-thoracic metastases were associated with prolonged OS and PFS. Response to IO was associated with prolonged OS, while thoracic radiotherapy and isolated CNS involvement were associated with prolonged PFS. ECOG PS, thoracic radiotherapy and PDL1 status significantly influenced the likelihood of response to IO. Overall, 30% patients experienced any grade toxicity. Conclusion: Our results are concordant with reported trial outcomes and support the application of IO in Indian patients.
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Affiliation(s)
- Ullas Batra
- Department of Medical Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, 110085, India
| | - Kundan Singh Chufal
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, 110085, India
| | - Shrinidhi Nathany
- Department of Molecular Diagnostics, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, 110085, India
| | - Irfan Ahmad
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, 110085, India
| | - Rahul Lal Chowdhary
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, 110085, India
| | - Mansi Sharma
- Department of Medical Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, 110085, India
| | - Praveen Jain
- Department of Medical Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, 110085, India
| | - Munish Gairola
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, 110085, India
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22
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Memantine in the Prevention of Radiation-Induced Brain Damage: A Narrative Review. Cancers (Basel) 2022; 14:cancers14112736. [PMID: 35681716 PMCID: PMC9179311 DOI: 10.3390/cancers14112736] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 12/03/2022] Open
Abstract
Simple Summary Decline in cognitive function is a major problem for patients undergoing whole-brain radiotherapy (WBRT). Scientific interest has increased due to the high dropout rate of patients in the first months after WBRT and the early onset of cognitive decline. Therefore, the study of antiglutamatergic pharmacological prophylaxis and hippocampal-sparing WBRT techniques has been deepened based on the knowledge of the mechanisms of hyperglutamatergic neurotoxicity and the role of some hippocampal areas in cognitive decline. In order to provide a summary of the evidence in this field, and to foster future research in this setting, this literature review presents current evidence on the prevention of radiation-induced cognitive decline and particularly on the role of memantine. Abstract Preserving cognitive functions is a priority for most patients with brain metastases. Knowing the mechanisms of hyperglutamatergic neurotoxicity and the role of some hippocampal areas in cognitive decline (CD) led to testing both the antiglutamatergic pharmacological prophylaxis and hippocampal-sparing whole-brain radiotherapy (WBRT) techniques. These studies showed a relative reduction in CD four to six months after WBRT. However, the failure to achieve statistical significance in one study that tested memantine alone (RTOG 0614) led to widespread skepticism about this drug in the WBRT setting. Moreover, interest grew in the reasons for the strong patient dropout rates in the first few months after WBRT and for early CD onset. In fact, the latter can only partially be explained by subclinical tumor progression. An emerging interpretation of the (not only) cognitive impairment during and immediately after WBRT is the dysfunction of the limbic and hypothalamic system with its immune and hormonal consequences. This new understanding of WBRT-induced toxicity may represent the basis for further innovative trials. These studies should aim to: (i) evaluate in greater detail the cognitive effects and, more generally, the quality of life impairment during and immediately after WBRT; (ii) study the mechanisms producing these early effects; (iii) test in clinical studies, the modern and advanced WBRT techniques based on both hippocampal-sparing and hypothalamic-pituitary-sparing, currently evaluated only in planning studies; (iv) test new timings of antiglutamatergic drugs administration aimed at preventing not only late toxicity but also acute effects.
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23
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Tohidinezhad F, Di Perri D, Zegers CML, Dijkstra J, Anten M, Dekker A, Van Elmpt W, Eekers DBP, Traverso A. Prediction Models for Radiation-Induced Neurocognitive Decline in Adult Patients With Primary or Secondary Brain Tumors: A Systematic Review. Front Psychol 2022; 13:853472. [PMID: 35432113 PMCID: PMC9009149 DOI: 10.3389/fpsyg.2022.853472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/07/2022] [Indexed: 12/25/2022] Open
Abstract
Purpose Although an increasing body of literature suggests a relationship between brain irradiation and deterioration of neurocognitive function, it remains as the standard therapeutic and prophylactic modality in patients with brain tumors. This review was aimed to abstract and evaluate the prediction models for radiation-induced neurocognitive decline in patients with primary or secondary brain tumors. Methods MEDLINE was searched on October 31, 2021 for publications containing relevant truncation and MeSH terms related to “radiotherapy,” “brain,” “prediction model,” and “neurocognitive impairments.” Risk of bias was assessed using the Prediction model Risk Of Bias ASsessment Tool. Results Of 3,580 studies reviewed, 23 prediction models were identified. Age, tumor location, education level, baseline neurocognitive score, and radiation dose to the hippocampus were the most common predictors in the models. The Hopkins verbal learning (n = 7) and the trail making tests (n = 4) were the most frequent outcome assessment tools. All studies used regression (n = 14 linear, n = 8 logistic, and n = 4 Cox) as machine learning method. All models were judged to have a high risk of bias mainly due to issues in the analysis. Conclusion Existing models have limited quality and are at high risk of bias. Following recommendations are outlined in this review to improve future models: developing cognitive assessment instruments taking into account the peculiar traits of the different brain tumors and radiation modalities; adherence to model development and validation guidelines; careful choice of candidate predictors according to the literature and domain expert consensus; and considering radiation dose to brain substructures as they can provide important information on specific neurocognitive impairments.
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Affiliation(s)
- Fariba Tohidinezhad
- Department of Radiation Oncology (Maastro Clinic), School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, Netherlands
| | - Dario Di Perri
- Department of Radiation Oncology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Catharina M L Zegers
- Department of Radiation Oncology (Maastro Clinic), School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, Netherlands
| | - Jeanette Dijkstra
- Department of Medical Psychology, School for Mental Health and Neurosciences (MHeNS), Maastricht University Medical Center, Maastricht, Netherlands
| | - Monique Anten
- Department of Neurology, School for Mental Health and Neuroscience (MHeNS), Maastricht University Medical Center, Maastricht, Netherlands
| | - Andre Dekker
- Department of Radiation Oncology (Maastro Clinic), School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, Netherlands
| | - Wouter Van Elmpt
- Department of Radiation Oncology (Maastro Clinic), School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, Netherlands
| | - Daniëlle B P Eekers
- Department of Radiation Oncology (Maastro Clinic), School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, Netherlands
| | - Alberto Traverso
- Department of Radiation Oncology (Maastro Clinic), School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, Netherlands
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24
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Belluomini L, Calvetti L, Inno A, Pasello G, Roca E, Vattemi E, Veccia A, Menis J, Pilotto S. SCLC Treatment in the Immuno-Oncology Era: Current Evidence and Unmet Needs. Front Oncol 2022; 12:840783. [PMID: 35494084 PMCID: PMC9047718 DOI: 10.3389/fonc.2022.840783] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/21/2022] [Indexed: 12/20/2022] Open
Abstract
Small cell lung cancer (SCLC) represents about 13%–15% of all lung cancers. It has a particularly unfavorable prognosis and in about 70% of cases occurs in the advanced stage (extended disease). Three phase III studies tested the combination of immunotherapy (atezolizumab, durvalumab with or without tremelimumab, and pembrolizumab) with double platinum chemotherapy, with practice-changing results. However, despite the high tumor mutational load and the chronic pro-inflammatory state induced by prolonged exposure to cigarette smoke, the benefit observed with immunotherapy is very modest and most patients experience disease recurrence. Unfortunately, biological, clinical, or molecular factors that can predict this risk have not yet been identified. Thanks to these clinically meaningful steps forward, SCLC is no longer considered an “orphan” disease. Innovative treatment strategies and combinations are currently under investigation to further improve the expected prognosis of patients with SCLC. Following the recent therapeutic innovations, we have reviewed the available literature data about SCLC management, with a focus on current unmet needs and potential predictive factors. In detail, the role of radiotherapy; fragile populations, such as elderly or low-performance status patients (ECOG PS 2), usually excluded from randomized studies; predictive factors of response useful to optimize and guide therapeutic choices; and new molecular targets and future combinations have been explored and revised.
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Affiliation(s)
- Lorenzo Belluomini
- Medical Oncology, Department of Medicine, University of Verona, Verona, Italy
| | | | - Alessandro Inno
- Medical Oncology, IRCCS Sacro Cuore Don Calabria Hospital, Verona, Italy
| | - Giulia Pasello
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Medical Oncology 2, Istituto Oncologico Veneto IRCCS, Padua, Italy
| | - Elisa Roca
- Thoracic Oncology, Lung Unit, P. Pederzoli Hospital, Peschiera del Garda, Italy
| | - Emanuela Vattemi
- Medical Oncology, Azienda Sanitaria dell’Alto Adige, Bolzano, Italy
| | | | - Jessica Menis
- Medical Oncology, Department of Medicine, University of Verona, Verona, Italy
| | - Sara Pilotto
- Medical Oncology, Department of Medicine, University of Verona, Verona, Italy
- *Correspondence: Sara Pilotto,
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25
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Qi C, Li W, Li H, Wen F, Zhou L, Sun X, Yu H. Benefits of Prophylactic Cranial Irradiation in the MRI Era for Patients With Limited Stage Small Cell Lung Cancer. Front Oncol 2022; 12:833478. [PMID: 35296010 PMCID: PMC8918584 DOI: 10.3389/fonc.2022.833478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 02/07/2022] [Indexed: 01/22/2023] Open
Abstract
PurposePrevious studies have shown that prophylactic cranial irradiation (PCI) can improve the survival of patients with limited-stage small cell lung cancer (LS-SCLC). PCI is recommended for patients who respond well to chemoradiotherapy. However, whether PCI could be extrapolated to the LS-SCLC patients in the modern era of MRI is unknown. This study aimed to explore the value of PCI in patients with LS-SCLC in the era of brain MRI.MethodsThis study included 306 patients with LS-SCLC at the Cancer Hospital of China Medical University. All patients received brain MRI at diagnosis and after radiochemotherapy to exclude brain metastases. A propensity score matching was performed to reduce the influence of potential confounders. Overall survival (OS), progression-free survival (PFS), and recurrence failure types were compared between PCI and non-PCI groups.ResultsAmong the 306 eligible patients, 81 underwent PCI, and 225 did not. After propensity score matching, there was no statistical difference in baseline data between the two groups, with 75 patients in each group. PCI did not achieve OS (median OS: 35 vs. 28 months, p = 0.128) or PFS (median PFS: 15 vs. 10 months, p = 0.186) benefits. During follow-up, 30 patients (20.0%) developed brain metastases, including 13 patients (17.3%) in the PCI group and 17 patients (22.7%) in the non-PCI group. Regarding death as a competitive risk, patients who received PCI had a lower cumulative incidence of brain metastasis than those who did not (3 years: 14.7% vs. 22.7%; Gray’s test, p = 0.007).ConclusionsWhen brain MRI was performed at diagnosis and pre-PCI, PCI could reduce the cumulative rate of brain metastases, but it did not achieve survival benefits for LS-SCLC patients.
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Affiliation(s)
- Chao Qi
- School of Graduate, Dalian Medical University, Dalian, China
| | - Wang Li
- Department of Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, China
| | - Hanming Li
- School of Graduate, Dalian Medical University, Dalian, China
| | - Fengyun Wen
- Department of Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, China
| | - Lu Zhou
- Department of Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, China
| | - Xiaohu Sun
- Department of Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, China
| | - Hong Yu
- Department of Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, China
- *Correspondence: Hong Yu,
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26
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Yu NY, Sio TT, Ernani V, Savvides P, Schild SE. Role of Prophylactic Cranial Irradiation in Extensive-Stage Small Cell Lung Cancer. J Natl Compr Canc Netw 2021; 19:1465-1469. [PMID: 34902829 DOI: 10.6004/jnccn.2021.7105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/21/2021] [Indexed: 11/17/2022]
Abstract
Patients with small cell lung cancer (SCLC) are at significant risk of developing brain metastases during their disease course. Prophylactic cranial irradiation (PCI) has been incorporated into SCLC treatment guidelines to diminish the risk of developing brain metastases. In 2007, a randomized trial suggested that PCI decreases the incidence of brain metastases and prolongs overall survival (OS) in patients with extensive-stage SCLC (ES-SCLC) who have responded to initial therapy. However, this study did not include modern central nervous system imaging with CT or MRI prior to randomization. A more recent Japanese trial with MRI staging and surveillance demonstrated that PCI diminished the incidence of brain metastases but did not improve survival. This review examines the largest clinical studies, controversies, and future directions of PCI in patients with ES-SCLC.
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Affiliation(s)
| | | | - Vinicius Ernani
- Division of Hematology and Medical Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - Panayiotis Savvides
- Division of Hematology and Medical Oncology, Mayo Clinic Hospital, Phoenix, Arizona
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27
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Rittberg R, Banerji S, Kim JO, Rathod S, Dawe DE. Treatment and Prevention of Brain Metastases in Small Cell Lung Cancer. Am J Clin Oncol 2021; 44:629-638. [PMID: 34628433 DOI: 10.1097/coc.0000000000000867] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Central nervous system (CNS) metastasis will develop in 50% of small cell lung cancer (SCLC) patients throughout disease course. Development of CNS metastasis poses a particular treatment dilemma due to the accompanied cognitive changes, poor permeability of the blood-brain barrier to systemic therapy and relatively advanced state of disease. Survival of patients with untreated SCLC brain metastases is generally <3 months with whole brain radiotherapy used as first-line management in most SCLC patients. To prevent development of CNS metastasis prophylactic cranial irradiation (PCI) is recommended in limited stage disease, after response to chemotherapy and radiation, while PCI may be considered in extensive stage disease after favorable response to upfront treatment. Neurocognitive toxicity with whole brain radiotherapy and PCI is a concern and remains difficult to predict. The mechanism of toxicity is likely multifactorial, but a potential mechanism of injury to the hippocampus has led to hippocampal sparing radiation techniques. Treatment of established non-small cell lung cancer CNS metastases has increasingly focused on using stereotactic radiotherapy (SRS) and it is tempting to extrapolate these results to SCLC. In this review, we explore the evidence surrounding the prediction, prevention, detection, and treatment of CNS metastases in SCLC. We further review whether existing evidence supports extrapolating less toxic treatments to SCLC patients with CNS metastases and discuss trials that may shed more light on this question.
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Affiliation(s)
- Rebekah Rittberg
- Department of Internal Medicine, University of Manitoba
- Departments of Hematology and Medical Oncology
| | - Shantanu Banerji
- Department of Internal Medicine, University of Manitoba
- Departments of Hematology and Medical Oncology
- Research Institute in Oncology and Hematology at CancerCare Manitoba, Winnipeg, MB, Canada
| | | | | | - David E Dawe
- Department of Internal Medicine, University of Manitoba
- Departments of Hematology and Medical Oncology
- Research Institute in Oncology and Hematology at CancerCare Manitoba, Winnipeg, MB, Canada
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28
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Rahimy E, Dudley SA, von Eyben R, Pollom EL, Seiger K, Modlin L, Wynne J, Fujimoto D, Jacobs LR, Chang SD, Gibbs IC, Hancock SL, Adler JR, Li G, Choi CYH, Soltys SG. Phase I/II Dose-Escalation Trial of 3-Fraction Stereotactic Radiosurgery for Resection Cavities From Large Brain Metastases: Health-related Quality of Life Outcomes. Am J Clin Oncol 2021; 44:588-595. [PMID: 34670228 DOI: 10.1097/coc.0000000000000868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We investigated differences in quality of life (QoL) in patients enrolled on a phase I/II dose-escalation study of 3-fraction resection cavity stereotactic radiosurgery (SRS) for large brain metastases. METHODS Eligible patients had 1 to 4 brain metastases, one of which was a resection cavity 4.2 to 33.5 cm3. European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaires core-30 (QLQ-30) and brain cancer specific module (QLQ-BN20) were obtained before SRS and at each follow-up. Nine scales were analyzed (global health status; physical, social, and emotional functioning; motor dysfunction, communication deficit, fatigue, insomnia, and future uncertainty). QoL was assessed with mixed effects models. Differences ≥10 points with q-value (adjusted P-value to account for multiplicity of testing) <0.10 were considered significant. RESULTS Between 2009 and 2014, 50 enrolled patients completed 277 QoL questionnaires. Median questionnaire follow-up was 11.8 months. After SRS, insomnia demonstrated significant improvement (q=0.032, -17.7 points at 15 mo post-SRS), and future uncertainty demonstrated significant worsening (q=0.018, +9.9 points at 15 mo post-SRS). Following intracranial progression and salvage SRS, there were no significant QoL changes. The impact of salvage whole brain radiotherapy could not be assessed because of limited data (n=4 patients). In the 28% of patients that had adverse radiation effect, QoL had significant worsening in 3 metrics (physical functioning, q=0.024, emotional functioning q=0.001, and future uncertainty, q=0.004). CONCLUSIONS For patients treated with 3-fraction SRS for large brain metastasis cavities, 8 of 9 QoL metrics were unchanged or improved after initial SRS. Intracranial tumor progression and salvage SRS did not impact QoL. Adverse radiation effect may be associated with at least short-term QoL impairments, but requires further investigation.
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Affiliation(s)
| | - Sara A Dudley
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD
| | | | | | - Kira Seiger
- Department of Dermatology, University of California, San Francisco
| | - Leslie Modlin
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, NY
| | - Jacob Wynne
- Department of Radiation Oncology, Emory University, Atlanta, GA
| | - Dylann Fujimoto
- University of California, Irvine, School of Medicine, Irvine
| | - Lisa R Jacobs
- Department of Pediatrics, University of California, Los Angeles
| | | | | | | | | | - Gordon Li
- Neurosurgery, Stanford University, Stanford
| | - Clara Y H Choi
- Department of Radiation Oncology, Santa Clara Valley Medical Center, San Jose, CA
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Witlox WJA, Ramaekers BLT, Lacas B, Pechoux CL, Sun A, Wang SY, Hu C, Redman M, van der Noort V, Li N, Guckenberger M, van Tinteren H, Groen HJM, Joore MA, De Ruysscher DKM. Association of different fractionation schedules for prophylactic cranial irradiation with toxicity and brain metastases-free survival in stage III non-small cell lung cancer: A pooled analysis of individual patient data from three randomized trials. Radiother Oncol 2021; 164:163-166. [PMID: 34619235 DOI: 10.1016/j.radonc.2021.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/07/2021] [Accepted: 09/24/2021] [Indexed: 11/19/2022]
Abstract
We assessed the impact of different PCI fractionation schedules (30 Gy in 10 versus 15 fractions) on brain metastases-free survival (BMFS) and toxicity in stage III NSCLC. Our results suggest that 30 Gy in 10 fractions is associated with increased toxicity, while no conclusive evidence of improving BMFS was seen with this schedule.
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Affiliation(s)
- Willem J A Witlox
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC), The Netherlands; Department of Radiation Oncology (Maastro Clinic), Maastricht University Medical Centre (MUMC), The Netherlands.
| | - Bram L T Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC), The Netherlands
| | - Benjamin Lacas
- Department of Biostatistics and Epidemiology, Gustave Roussy, University Paris-Saclay, Villejuif, France; Oncostat U1018, Inserm, University Paris-Saclay, labeled Ligue Contre le Cancer, Villejuif, France
| | - Cecile Le Pechoux
- Department of Radiation Oncology, Gustave Roussy, Paris-Saclay University, Villejuif, France
| | - Alexander Sun
- Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Canada
| | - Si-Yu Wang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Chen Hu
- NRG Oncology Statistics and Data Management Center, Philadelphia, United States; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Mary Redman
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, United States
| | - Vincent van der Noort
- Department of Biometrics, Netherlands Cancer Institute (NKI), Amsterdam, The Netherlands
| | - Ning Li
- Department of Experimental Research, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Harm van Tinteren
- Trial and Data Center, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Harry J M Groen
- Department of Pulmonary Diseases, University of Groningen and University Medical Center Groningen, The Netherlands
| | - Manuela A Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC), The Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, The Netherlands
| | - Dirk K M De Ruysscher
- Department of Radiation Oncology (Maastro Clinic), Maastricht University Medical Centre (MUMC), The Netherlands
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30
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Rodríguez de Dios N, Couñago F, Murcia-Mejía M, Rico-Oses M, Calvo-Crespo P, Samper P, Vallejo C, Luna J, Trueba I, Sotoca A, Cigarral C, Farré N, Manero RM, Durán X, Gispert JD, Sánchez-Benavides G, Rognoni T, Torrente M, Capellades J, Jiménez M, Cabada T, Blanco M, Alonso A, Martínez-San Millán J, Escribano J, González B, López-Guerra JL. Randomized Phase III Trial of Prophylactic Cranial Irradiation With or Without Hippocampal Avoidance for Small-Cell Lung Cancer (PREMER): A GICOR-GOECP-SEOR Study. J Clin Oncol 2021; 39:3118-3127. [PMID: 34379442 DOI: 10.1200/jco.21.00639] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Radiation dose received by the neural stem cells of the hippocampus during whole-brain radiotherapy has been associated with neurocognitive decline. The key concern using hippocampal avoidance-prophylactic cranial irradiation (HA-PCI) in patients with small-cell lung cancer (SCLC) is the incidence of brain metastasis within the hippocampal avoidance zone. METHODS This phase III trial enrolled 150 patients with SCLC (71.3% with limited disease) to standard prophylactic cranial irradiation (PCI; 25 Gy in 10 fractions) or HA-PCI. The primary objective was the delayed free recall (DFR) on the Free and Cued Selective Reminding Test (FCSRT) at 3 months; a decrease of 3 points or greater from baseline was considered a decline. Secondary end points included other FCSRT scores, quality of life (QoL), evaluation of the incidence and location of brain metastases, and overall survival (OS). Data were recorded at baseline, and 3, 6, 12, and 24 months after PCI. RESULTS Participants' baseline characteristics were well balanced between the two groups. The median follow-up time for living patients was 40.4 months. Decline on DFR from baseline to 3 months was lower in the HA-PCI arm (5.8%) compared with the PCI arm (23.5%; odds ratio, 5; 95% CI, 1.57 to 15.86; P = .003). Analysis of all FCSRT scores showed a decline on the total recall (TR; 8.7% v 20.6%) at 3 months; DFR (11.1% v 33.3%), TR (20.3% v 38.9%), and total free recall (14.8% v 31.5%) at 6 months, and TR (14.2% v 47.6%) at 24 months. The incidence of brain metastases, OS, and QoL were not significantly different. CONCLUSION Sparing the hippocampus during PCI better preserves cognitive function in patients with SCLC. No differences were observed with regard to brain failure, OS, and QoL compared with standard PCI.
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Affiliation(s)
- Núria Rodríguez de Dios
- Radiation Oncology, Hospital del Mar, Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Pompeu Fabra University, Barcelona, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud, Madrid, Spain
| | - Mauricio Murcia-Mejía
- Department of Radiation Oncology, Hospital Universitario Sant Joan de Reus, Reus, Tarragona, Spain
| | - Mikel Rico-Oses
- Department of Radiation Oncology, Complejo Hospitalario Navarra, Pamplona, Spain
| | - Patricia Calvo-Crespo
- Department of Radiation Oncology, Hospital Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Pilar Samper
- Department of Radiation Oncology, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
| | - Carmen Vallejo
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Javier Luna
- Department of Radiation Oncology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Itziar Trueba
- Department of Radiation Oncology, Hospital Universitario de Álava-sede Txagorritxu.Vitoria-Gasteiz, Spain
| | - Amalia Sotoca
- Department of Radiation Oncology, Hospital Ruber Internacional, Madrid, Spain
| | - Cristina Cigarral
- Department of Radiation Oncology, Hospital Clínico de Salamanca, Salamanca, Spain
| | - Núria Farré
- Department of Radiation Oncology, Hospital Universitario Santa Creu i Sant Pau, Barcelona, Spain
| | - Rosa M Manero
- Department of Neurology, Hospital del Mar, Barcelona, Spain
| | - Xavier Durán
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Juan Domigo Gispert
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Pompeu Fabra University, Barcelona, Spain.,BarcelonaBeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Madrid, Spain
| | - Gonzalo Sánchez-Benavides
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,BarcelonaBeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, Spain
| | - Teresa Rognoni
- Department of Neurology, Clínica Universidad de Navarrra, Madrid, Spain
| | - Margarita Torrente
- Department of Psychology, School of Educational Sciences and Psychology, Rovira i Virgili University, Tarragona, Spain.,Laboratory of Toxicology and Environmental Health, School of Medicine, IISPV, Rovira i Virgili University, Tarragona, Spain
| | | | - Mar Jiménez
- Department of Radiology, Hospital Universitario Quirónsalud, Madrid, Spain
| | - Teresa Cabada
- Department of Radiology, Complejo Hospitalario Navarra, Pamplona, Spain
| | - Miguel Blanco
- Department of Radiology, Hospital Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Ana Alonso
- Department of Radiology, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
| | | | - José Escribano
- Department of Radiology, Hospital Ruber Internacional, Madrid, Spain
| | - Beatriz González
- Department of Radiation Oncology, Hospital Clínico de Salamanca, Salamanca, Spain
| | - José Luis López-Guerra
- Department of Radiation Oncology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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31
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Yan M, Toh TS, Lindsay PE, Weiss J, Hueniken K, Yeung C, Sugumar V, Pinto D, Tadic T, Sun A, Bezjak A, Cho J, Raman S, Giuliani M, Moraes FY, Liu G, Hope AJ, Lok BH. Limited-stage small cell lung cancer: Outcomes associated with prophylactic cranial irradiation over a 20-year period at the Princess Margaret Cancer Centre. Clin Transl Radiat Oncol 2021; 30:43-49. [PMID: 34296000 PMCID: PMC8282904 DOI: 10.1016/j.ctro.2021.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 06/27/2021] [Indexed: 11/25/2022] Open
Abstract
Prophylactic cranial irradiation (PCI) was more commonly used in younger patients. PCI utilization rates did not change throughout our 20-year institutional experience. PCI was associated with improved OS and lower brain metastasis risk, independent of MRI follow-up or era of treatment. For LS-SCLC patients with good thoracic response, PCI remains the standard-of-care.
Background & purpose Prophylactic cranial irradiation (PCI) is recommended for limited-stage small-cell lung cancer (LS-SCLC) patients with good response to concurrent chemoradiation. We report our institution’s 20-year experience with this patient population and associated clinical outcomes. Materials & methods A retrospective cohort of consecutive LS-SCLC patients treated with curative intent chemoradiation at our institution (1997–2018) was reviewed. Overall survival (OS) was calculated using the Kaplan-Meier method, and significant covariates determined by the Cox proportional hazards model. Covariates predictive of PCI were determined using Fisher's exact test and the Mann-Whitney test. Brain failure risk (BFR) was calculated using the cumulative incidence method treating death as a competing event. Treatment cohorts (historic vs. contemporary) were stratified by the median year of diagnosis (2005). Results A total of 369 patients with LS-SCLC were identified, of which 278 patients were notionally PCI eligible. PCI was given to 196 patients (71%). Younger age was associated with PCI utilization (p < 0.001). PCI utilization rates did not change between the historic and contemporary treatment era (p = 0.11), whereas magnetic resonance imaging (MRI) use at baseline and follow-up became more prevalent in the contemporary era (p = <0.001). On multivariable analysis, PCI utilization was associated with improved OS (HR 1.88, 95% CI 1.32–2.69) and decreased BFR (HR 4.66, 95% CI 2.58–8.40). Patients who had MRI follow-up had a higher incidence of BFR (HR 0.35, 95% CI 0.18–0.66) in multivariable analyses. Conclusions For LS-SCLC patients at our institution, PCI is more frequently utilized in younger patients, and the utilization rate did not change significantly over the past 20 years. PCI was independently associated with improved OS and lower BFR. Omission of PCI in LS-SCLC patients should not be routinely practiced in the absence of further prospective data.
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Affiliation(s)
- Michael Yan
- Department of Oncology, Cancer Centre of Southeastern Ontario, Queen's University, Kingston, ON, Canada
| | - Tzen S Toh
- The Medical School, University of Sheffield, Sheffield, United Kingdom.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Patricia E Lindsay
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Jessica Weiss
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Katrina Hueniken
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Christy Yeung
- Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, ON, Canada
| | - Vijithan Sugumar
- Department of Physiology and Pharmacology, Western University, London, ON, Canada
| | - Dixon Pinto
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Tony Tadic
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Alexander Sun
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Andrea Bezjak
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - John Cho
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Srinivas Raman
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Meredith Giuliani
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Fabio Ynoe Moraes
- Department of Oncology, Cancer Centre of Southeastern Ontario, Queen's University, Kingston, ON, Canada
| | - Geoffrey Liu
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Andrew J Hope
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Benjamin H Lok
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
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32
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Bartels F, Wandrey MM, Aigner A, Strönisch T, Farmer K, Rentzsch K, Tessmer A, Grohé C, Finke C. Association Between Neuronal Autoantibodies and Cognitive Impairment in Patients With Lung Cancer. JAMA Oncol 2021; 7:1302-1310. [PMID: 34196651 DOI: 10.1001/jamaoncol.2021.2049] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Paraneoplastic neurological syndromes are associated with neuronal autoantibodies, and some of these autoantibodies are associated with neuropsychological symptoms. The most common underlying tumor is lung cancer. The association of neuronal autoantibodies with cognitive deficits has not been systematically investigated in patients with small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). Objective To assess the frequency of neuronal autoantibodies in patients with lung cancer and analyze their association with cognitive function. Design, Setting, and Participants This prospective, cross-sectional study included 167 patients with lung cancer (both SCLC and NSCLC) recruited at a single lung cancer center in Berlin, Germany, between June 2015 and April 2016. Detailed neuropsychological testing was performed in a carefully selected subgroup of 97 patients (from which patients with potential confounding factors were excluded). Investigators were blinded to patients' autoantibody status and cognitive test results. Data were analyzed from May 2016 to December 2019. Main Outcomes and Measures Prevalence of neuronal autoantibodies and their association with cognitive impairment. The evaluation of autoantibodies as potential risk factors for cognitive impairment was performed using bayesian logistic regression models. Results Among 167 patients with lung cancer (median age, 66.0 years [interquartile range, 59.0-72.0 years]; 105 men [62.9%]), 127 had NSCLC, and 40 had SCLC. Brain-directed autoantibodies were detected in 61 of 167 patients (36.5%); 33 patients (19.8%) had known autoantibodies and 28 patients (16.8%) had autoantibodies against currently unknown antigens that were detected through immunohistochemical analysis. Cognitive impairment was found in 65 of 97 patients (67.0%). Among patients with SCLC, the odds of cognitive impairment for those with any autoantibodies was 11-fold higher (odds ratio [OR], 11.0; 95% credible interval [CrI], 1.2-103.6) than that of autoantibody-negative patients, and the increased odds were independent of age, sex, and neurological deficit. Among patients with NSCLC, those with immunoglobin A autoantibodies targeting the N-methyl-d-aspartate receptor had a relevantly increased odds of verbal memory deficits (OR, 182.8; 95% CrI, 3.1-10 852.4). Autoantibodies against currently unknown antigens were also associated with increased odds of cognitive impairment (OR, 2.8; 95% CrI, 0.6-12.1). Conclusions and Relevance In this prospective, cross-sectional study, more than one-third of patients with lung cancer had neuronal autoantibodies that were found to be associated with cognitive impairment. These autoantibodies might represent a potentially treatable mechanism of immune-mediated cognitive impairment among patients with lung cancer.
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Affiliation(s)
- Frederik Bartels
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Mona-Marie Wandrey
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Annette Aigner
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Timo Strönisch
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kimberley Farmer
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kristin Rentzsch
- Institute of Experimental Immunology, EUROIMMUN, Lübeck, Germany
| | - Antje Tessmer
- Department of Respiratory Diseases, Evangelische Lungenklinik Berlin, Berlin, Germany
| | - Christian Grohé
- Department of Respiratory Diseases, Evangelische Lungenklinik Berlin, Berlin, Germany
| | - Carsten Finke
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
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33
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Kim H, Keller A, Beriwal S, Smith KJ, Vargo JA. Cost-Effectiveness of Prophylactic Cranial Irradiation Versus MRI Surveillance for Extensive-Stage Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2021; 111:1186-1194. [PMID: 33984410 DOI: 10.1016/j.ijrobp.2021.04.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 01/30/2023]
Abstract
PURPOSE Owing to conflicting prospective data, controversy exists regarding prophylactic cranial irradiation (PCI) in extensive-stage small cell lung cancer (ES-SCLC). We evaluated the cost-effectiveness of PCI versus magnetic resonance imaging (MRI) surveillance for patients with ES-SCLC based on currently available evidence and in the context of the proposed Centers for Medicare & Medicaid Services alternative payment model. METHODS AND MATERIALS A Markov state transition model was constructed to perform a cost-effectiveness analysis comparing MRI surveillance alone with PCI for ES-SCLC. Clinical parameters were obtained from clinical trial data, and cost data were based on 2019 Medicare reimbursement. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with effectiveness in quality-adjusted life years (QALYs) and evaluated with a willingness-to-pay threshold of $100,000 per QALY gained. One-way and probabilistic sensitivity analyses were performed to consider model uncertainty. RESULTS In the base-case scenario, PCI was not cost-effective in this model, with an ICER of $168,456 per QALY gained compared with MRI surveillance alone, assuming that overall survival was 10 months for MRI surveillance alone and 12.5 months for PCI. One-way sensitivity analysis showed that results were most sensitive to the variation of overall survival and cognitive decline rates between the 2 groups. In a scenario analysis in which all patients received hippocampal-avoidance PCI, the model results became nearly cost-effective with PCI. CONCLUSIONS PCI was not found to be cost-effective within this model compared with MRI surveillance alone, owing to the neurocognition decline effect of PCI based on available evidence. Hippocampal-avoidance PCI may be a potential cost-effective strategy for ES-SCLC, with confirmation expected after an ongoing prospective clinical trial (The Southwest Oncolology Group MRI Brain Surveillance Alone Versus MRI Surveillance And Prophylactic Cranial Irradiation [MAVERICK]), which includes assessments of cognitive function.
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Affiliation(s)
- Hayeon Kim
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Andrew Keller
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Kenneth J Smith
- Clinical and Translational Science and Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John A Vargo
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania.
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34
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Maldonado F, Gonzalez-Ling A, Oñate-Ocaña LF, Cabrera-Miranda LA, Zatarain-Barrón ZL, Turcott JG, Flores-Estrada D, Lozano-Ruiz F, Cacho-Díaz B, Arrieta O. Prophylactic Cranial Irradiation in Patients With High-Risk Metastatic Non-Small Cell Lung Cancer: Quality of Life and Neurocognitive Analysis of a Randomized Phase II Study. Int J Radiat Oncol Biol Phys 2021; 111:81-92. [PMID: 33915217 DOI: 10.1016/j.ijrobp.2021.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/31/2021] [Accepted: 04/14/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE To this date, studies regarding the use of prophylactic cranial irradiation (PCI) versus standard of care (SoC) for patients with non-small cell lung cancer have shown limited benefit in survival outcomes, in addition to the potential effects on quality of life (QoL) and neurocognitive function (NCF). This randomized, phase II study evaluated the role of PCI in QoL and NCF, in a population comprised of subjects at a high risk for development of brain metastases (BM). METHODS AND MATERIALS Eligible patients had histologically confirmed non-small cell lung cancer without baseline BM, harboring epidermal growth factor receptor mutations, anaplastic lymphoma kinase rearrangements, or elevated carcinoembryonic antigen (CEA) at diagnosis. Participants were assigned to receive SoC or SoC plus PCI (25 Gy in 10 fractions). Primary endpoint was BM at 24 months (BM-24), for which the study was powered. Secondary endpoints included QoL assessed using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30) and the Lung Cancer module (LC13) and NCF assessed using the Mini Mental State Examination (MMSE). Patients were followed every 3 months for a year for QoL and NCF. RESULTS From May 2012 to December 2017, 84 patients were enrolled in the study, 41 were allocated to PCI while 43 received SoC. Efficacy outcomes are discussed in a separate article. The global health-QoL scores were similar at 3, 6, 9, and 12 months after randomization between both study arms, with no significant differences when comparing by groups. At 1-year postrandomization, median global health QoL scores were 83 (p25-p75: 75-83) and 83 (p25-p75: 75-83) in the control and experimental arms, respectively. There were no significant changes in terms of the mean differences between subjects in either study arm when analyzing the change between baseline and 12-month scores (16.4 ± 19.9 vs 12.9 ± 14.7; P = .385). Seventeen patients were alive at database lockdown in February 2020, without significant differences in median MMSE (30 [p25-75: 29-30] vs 30 [p25-75: 28-30]) or QLQ-C30 scores (75.0 [p25-75: 50-87.2] vs 67.0 [p25-75: 50.0-100.0]). CONCLUSIONS Among a selected high-risk population for developing BM, PCI did not significantly decrease QoL or neurocognitive function as assessed using the MMSE. Future studies are warranted to assess this observation, using more varied and sensitive tools available to date.
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35
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Ghanta S, Keller A, Rodríguez-López JL, Patel A, Beriwal S. Utility of Prophylactic Cranial Irradiation for Limited Stage Small Cell Lung Cancer in the Modern Era with Magnetic Resonance Imaging Surveillance. Clin Oncol (R Coll Radiol) 2021; 33:e323-e330. [PMID: 33888381 DOI: 10.1016/j.clon.2021.03.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/03/2021] [Accepted: 03/23/2021] [Indexed: 02/07/2023]
Abstract
AIMS To retrospectively analyse the impact of prophylactic cranial irradiation (PCI) on survival and intracranial progression in patients with limited stage small cell lung cancer (LS-SCLC) in the modern era of widespread magnetic resonance imaging brain screening. MATERIALS AND METHODS Patients with LS-SCLC treated within our network between 2009 and 2020 who responded to initial therapy were stratified by receipt of PCI and stage of disease. A propensity score match analysis was carried out for stage II-III patients. Overall and neurological survival were defined as time to death and presumed death due to uncontrolled intracranial disease, respectively. Brain metastasis-free survival and symptomatic brain metastasis-free survival were defined as freedom from intracranial progression and symptomatic intracranial progression, respectively. The effect of PCI on these outcomes was assessed using Kaplan-Meier and Cox proportional hazards models. RESULTS In total, 243 (69.6%) of 349 patients received PCI. On multivariate analysis in the propensity matched stage II-III cohort, PCI was a significant predictor of improved neurological survival (hazard ratio 0.23, 95% confidence interval 0.08-0.65; P = 0.01), brain metastasis-free survival (hazard ratio 0.25, 95% confidence interval 0.12-0.51; P < 0.01) and symptomatic brain metastasis-free survival (hazard ratio 0.21, 95% confidence interval 0.08-0.55; P < 0.01), but not improved overall survival. Two-year neurological survival estimates within the propensity matched cohort were 96.8% (95% confidence interval 87.6-99.2%) with PCI and 77.2% (95% confidence interval 63.0-86.4%) without PCI and 1- and 2-year estimates of incidence of brain metastases were 3.9% (95% confidence interval 1.3-11.7%) and 11.7% (95% confidence interval 5.6-23.5%) in the PCI group and 31.6% (95% confidence interval 22.1-43.9%) and 40.4% (95% confidence interval 29.2-54.0%) in the no PCI group, respectively. CONCLUSIONS In the modern era of magnetic resonance imaging screening, PCI was associated with reduced incidence of intracranial progression in patients with stage II-III LS-SCLC who respond to initial therapy. This, importantly, translated to a decreased risk of neurological death within our propensity matched cohort, without significant improvement in overall survival.
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Affiliation(s)
- S Ghanta
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - A Keller
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - J L Rodríguez-López
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - A Patel
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - S Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA.
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Nishie K, Yamamoto S, Yamaga T, Horita N, Mori R, Gouda MA, Hanaoka M. Prophylactic cranial irradiation for extensive-stage small cell lung cancer. Hippokratia 2021. [DOI: 10.1002/14651858.cd014559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Kenichi Nishie
- Department of Respiratory Medicine; Iida Municipal Hospital; Iida Japan
| | - Shuhei Yamamoto
- Department of Rehabilitation; Shinshu University Hospital; Matsumoto Japan
| | - Takayoshi Yamaga
- Department of Occupational Therapy; Health Science University; Fujikawaguchiko-machi Japan
| | - Nobuyuki Horita
- Department of Pulmonology; Yokohama City University Graduate School of Medicine; Yokohama Japan
| | - Rintaro Mori
- Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Mohamed A Gouda
- Department of Clinical Oncology; Faculty of Medicine, Menoufia University; Shebin Al-Kom Egypt
| | - Masayuki Hanaoka
- The First Department of Internal Medicine of Japan; Shinshu University School of Medicine; Matsumoto Japan
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Chammah SE, Allenbach G, Jumeau R, Boughdad S, Prior JO, Nicod Lalonde M, Schaefer N, Meyer M. Impact of prophylactic cranial irradiation and hippocampal sparing on 18F-FDG brain metabolism in small cell lung cancer patients. Radiother Oncol 2021; 158:200-206. [PMID: 33667589 DOI: 10.1016/j.radonc.2021.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/09/2021] [Accepted: 02/13/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Prophylactic cranial irradiation (PCI) in small-cell lung cancer (SCLC) patients improves survival. However, it is also associated with cognitive impairment, although the underlying mechanisms remain poorly understood. Our study aims to evaluate the impact of PCI and potential benefit of hippocampal sparing (HS) on brain metabolism assessed by 18F-Fluoro-Deoxy-Glucose Positron Emission Tomography/Computed Tomography (18F-FDG PET/CT). MATERIALS AND METHODS We retrospectively included 22 SCLC patients. 50% had hippocampal-sparing (HS) PCI. 18F-FDG PET/CT was performed 144.5 ± 73 days before and 383 ± 451 days after PCI. Brain 18F-FDG PET scans were automatically segmented in 12 regions using Combined-AAL Atlas from MI-Neurology Software (Syngo.Via, Siemens Healthineers). For all atlas regions, we computed SUV Ratio using brainstem as a reference region (SUVR = SUVmean/Brainstem SUVmean) and compared SUVR before and after PCI, using a Wilcoxon test, with a level of significance of p < 0.05. RESULTS We found significant decreases in 18F-FDG brain metabolism after PCI in the basal ganglia (p = 0.004), central regions (p = 0.001), cingulate cortex (p < 0.001), corpus striata (p = 0.003), frontal cortex (p < 0.001), parietal cortex (p = 0.001), the occipital cortex (p = 0.002), precuneus (p = 0.001), lateral temporal cortex (p = 0.001) and cerebellum (p < 0.001). Conversely, there were no significant changes in the mesial temporal cortex (MTC) which includes the hippocampi (p = 0.089). The subgroup who received standard PCI showed a significant decrease in metabolism of the hippocampi (p = 0.033). Contrastingly, the subgroup of patients who underwent HS-PCI showed no significant variation in metabolism of the hippocampi (p = 0.783). CONCLUSION PCI induced a diffuse decrease in 18F-FDG brain metabolism. HS-PCI preserves metabolic activity of the hippocampi.
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Affiliation(s)
| | - Gilles Allenbach
- Nuclear Medicine and Molecular Imaging Department, CHUV, Lausanne, Switzerland
| | | | - Sarah Boughdad
- Nuclear Medicine and Molecular Imaging Department, CHUV, Lausanne, Switzerland
| | - John O Prior
- Nuclear Medicine and Molecular Imaging Department, CHUV, Lausanne, Switzerland
| | - Marie Nicod Lalonde
- Nuclear Medicine and Molecular Imaging Department, CHUV, Lausanne, Switzerland
| | - Niklaus Schaefer
- Nuclear Medicine and Molecular Imaging Department, CHUV, Lausanne, Switzerland.
| | - Marie Meyer
- Nuclear Medicine and Molecular Imaging Department, CHUV, Lausanne, Switzerland
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Predictors of survival following surgical resection of limited-stage small cell lung cancer. J Thorac Cardiovasc Surg 2020; 161:760-771.e2. [PMID: 33349449 DOI: 10.1016/j.jtcvs.2020.10.148] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/20/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Adjuvant chemotherapy, postoperative radiation (PORT), and prophylactic cranial irradiation (PCI) have been individually examined in limited-stage small cell lung cancer (SCLC). There is a paucity of data on the effectiveness of each adjuvant treatment modality when used in combination after surgical resection of SCLC. METHODS Data were collected from 5 cancer centers on all patients with limited-stage SCLC who underwent surgical resection between 1986 and 2019. Univariate and multivariable models were conducted to identify predictors of long-term outcomes, focusing on freedom from recurrence and survival benefit of adjuvant chemotherapy, PORT, and PCI. RESULTS A total of 164 patients were analyzed. Multivariable Cox regression analysis did not identify any adjuvant therapies to significantly influence recurrence in this cohort. Specifically, PORT was not associated with a significant influence on locoregional recurrence and PCI was not significantly associated with intracranial outcomes. Adjuvant chemotherapy improved survival in all stage I through III disease (hazard ratio, 0.49; 95% confidence interval, 0.29-0.81; P = .005) and even in pathologically node negative patients (hazard ratio, 0.49; 95% confidence interval, 0.27-0.91; P = .024). Although PCI was found to improve survival in univariate analysis, it was not significant in a multivariable model. PORT was not found to affect survival on either univariate or multivariable analysis. CONCLUSIONS This is among the largest multi-institutional studies on surgically resected limited-stage SCLC. Our results highlight survival benefit of adjuvant chemotherapy, but did not identify a statistically significant influence from mediastinal PORT or PCI in our cohort. Larger prospective studies are needed to determine the benefit of PORT or PCI in a surgically resected limited-stage SCLC population.
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Chan M, Ferguson D, Ni Mhurchu E, Yuan R, Gondara L, McKenzie M, Olson R, Thiessen B, Lalani N, Ma R, Nichol A. Patients with pretreatment leukoencephalopathy and older patients have more cognitive decline after whole brain radiotherapy. Radiat Oncol 2020; 15:271. [PMID: 33239056 PMCID: PMC7687765 DOI: 10.1186/s13014-020-01717-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/13/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose To investigate predictors of cognitive decline after whole brain radiotherapy (WBRT) for brain metastases. Methods A secondary analysis of a phase 2 clinical trial was conducted in patients who received stereotactic radiosurgery for 1–10 brain metastases and WBRT (NCT01046123). The Montreal Cognitive Assessment (MoCA) was performed at baseline and every 3 months after WBRT. Baseline T2-weighted fluid attenuation inversion recovery magnetic resonance imaging was independently assessed by two neuroradiologists for the presence of white matter hyperintensities (WMH) using the Fazekas visual rating scale. WMH were also manually segmented for volumetric analysis. Univariable and multivariable logistic regression were used to test the association between baseline variables and MoCA score decline.
Results Forty-six patients survived ≥ 3 months after treatment. Age (OR 1.12 (1.04–1.21), p < 0.01), baseline WMH volume (OR 1.20, 95% CI 1.06–1.52, p = 0.02) and baseline Fazekas score ≥ 3/6 (OR 6.4, 95% CI 1.7–24.7, p < 0.01) were predictive of MoCA score decline. In multivariable analysis, age was the only significant predictor of MoCA decline. However, all three patients with pre-treatment leukoencephalopathy (Fazekas score = 6/6) had notable adverse outcomes due to cognitive impairment: one required full-time home nursing support and two were institutionalized. Conclusion A greater decline in cognition after WBRT was observed in older patients and patients with a higher baseline WMH burden. Although this study is small and hypothesis-generating, we propose that radiation oncologists should exercise caution in prescribing WBRT if leukoencephalopathy is present on pre-treatment imaging. Trial Registration: clinicaltrials.gov identifier NCT01046123. First posted January 11, 2010. https://clinicaltrials.gov/ct2/show/NCT01046123
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Affiliation(s)
- Matthew Chan
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, 600 West 10th Ave, Vancouver, BC, V5Z 4E6, Canada
| | - David Ferguson
- Department of Radiology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Elaine Ni Mhurchu
- Department of Radiology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Ren Yuan
- Department of Radiology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Lovedeep Gondara
- Department of Population Oncology, BC Cancer - Vancouver Centre, Vancouver, BC, Canada
| | - Michael McKenzie
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, 600 West 10th Ave, Vancouver, BC, V5Z 4E6, Canada
| | - Robert Olson
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Prince George, Prince George, BC, Canada
| | - Brian Thiessen
- Department of Medical Oncology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Nafisha Lalani
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, 600 West 10th Ave, Vancouver, BC, V5Z 4E6, Canada
| | - Roy Ma
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, 600 West 10th Ave, Vancouver, BC, V5Z 4E6, Canada
| | - Alan Nichol
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada. .,Department of Radiation Oncology, BC Cancer - Vancouver, 600 West 10th Ave, Vancouver, BC, V5Z 4E6, Canada.
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Taylor JM, Rusthoven CG, Moghanaki D. Prophylactic cranial irradiation or MRI surveillance for extensive stage small cell lung cancer. J Thorac Dis 2020; 12:6225-6233. [PMID: 33209461 PMCID: PMC7656401 DOI: 10.21037/jtd.2020.03.80] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The treatment paradigm for extensive stage small cell lung cancer (ES-SCLC) is evolving. Prophylactic cranial irradiation (PCI) has long been considered a component of standard treatment in patients with extensive stage disease who respond to chemotherapy. However, in the modern era of magnetic resonance imaging, the role of PCI has become an area of controversy following conflicting level I evidence. Due to conflicting data and toxicity concerns, the routine use of PCI has declined. Recent improvements in systemic disease control with the use of immunotherapy and reductions in the toxicity attributable to PCI with hippocampal avoidance and memantine have reignited the discussion. As such, we present here a narrative review of PCI with a focus on historical milestones, randomized data, risk mitigation and future directions.
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Affiliation(s)
- James M Taylor
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, PA, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado-Denver, Aurora, CO, USA
| | - Drew Moghanaki
- Department of Radiation Oncology, Atlanta VA Health Care System, Emory University School of Medicine, Atlanta, GA, USA
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Rusthoven CG, Camidge DR, Robin TP, Brown PD. Radiosurgery for Small-Cell Brain Metastases: Challenging the Last Bastion of Preferential Whole-Brain Radiotherapy Delivery. J Clin Oncol 2020; 38:3587-3591. [PMID: 32776807 DOI: 10.1200/jco.20.01823] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - D Ross Camidge
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Tyler P Robin
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MD
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Cheng C, Zhuang H. [Treatment for Brain Metastases from EGFR Mutations NSCLC Patients: How Should We Choose in Clinical Practice?]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2020; 23:631-637. [PMID: 32746605 PMCID: PMC7467988 DOI: 10.3779/j.issn.1009-3419.2020.101.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Brain metastasis of epidermal growth factor receptor (EGFR) sensitive mutations is a hot and difficult point in targeted era of non-small cell lung cancer (NSCLC) treatment, meanwhile it is also the central issue of controversy in the field of lung cancer treatment. Different results of different studies and different understanding of different disciplines, this field of treatment has been accompanied by different voices, patients without clinical symptoms can use targeted therapy first, and then start local radiotherapy with clinical symptoms or disease progression. It is a major model of the medical oncology. That is to say, taking symptoms and progress as indication and standard of local treatment intervention. In the absence of symptoms, local radiotherapy may increase patients' pain, which belongs to overtreatment. However, the perspective of radiotherapy is that brain metastases need to be treated clinically as early as possible, if not, it may affect the survival of patients. Early treatment of local lesions and increasing the depth of treatment are helpful to prolong the survival time of patients. This article refers to relevant literatures and summarizes the discussion from the perspective of pursuing the truth of disease treatment and problem solving in order to provide reference for patients' clinical practice.
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Affiliation(s)
- Cheng Cheng
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China
| | - Hongqing Zhuang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China
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43
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Ding C, Li J, Wang S, Yang C, Zhang R, Bai W, Liu M, Zhen C, Qiao X. Prognostic factors for patients with limited-stage small-cell lung cancer without receiving prophylactic cranial irradiation. RADIATION MEDICINE AND PROTECTION 2020. [DOI: 10.1016/j.radmp.2020.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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44
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Zeng H, Hendriks LEL, van Geffen WH, Witlox WJA, Eekers DBP, De Ruysscher DKM. Risk factors for neurocognitive decline in lung cancer patients treated with prophylactic cranial irradiation: A systematic review. Cancer Treat Rev 2020; 88:102025. [PMID: 32512415 DOI: 10.1016/j.ctrv.2020.102025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/21/2020] [Accepted: 04/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prophylactic cranial irradiation (PCI) reduces brain metastasis incidence in lung cancer, however with risk of neurocognitive decline. Nevertheless, risk factors for neurocognitive decline after PCI remain unclear. METHODS We systematically reviewed the PubMed database according to the PRISMA guideline. Inclusion criteria were: randomized clinical trials (RCTs) and observational/single arm trials evaluating PCI, including ≥20 patients, reporting neurocognitive test results for lung cancer. Primary aim: evaluate risk factors associated with neurocognitive decline after PCI. RESULTS Twenty records were eligible (8 different RCTs, 8 observational studies), including 3553 patients in total (858 NSCLC, 2695 SCLC) of which 73.6% received PCI. Incidence of mild/moderate cognitive decline after PCI varied from 8 to 89% (grading not always provided); for those without PCI, this was 3.4-42%. Interestingly, 23-95% had baseline cognitive impairment. Risk factors were often not reported. In one trial, both age (>60 years) and higher PCI dose (36 Gy) including twice-daily PCI were associated with a higher risk of cognitive decline. In one trial, white matter abnormalities were more frequent in the concurrent or sandwiched PCI arm, but without significant neuropsychological differences. One trial identified hippocampal sparing PCI to limit the neurocognitive toxicities of PCI and another reported an association between hippocampal dose volume effects and memory decline. As neurocognition was a secondary endpoint in most RCTs, and was assessed by various instruments with often poor/moderate compliance, high-quality data is lacking. CONCLUSIONS Age, PCI dose, regimen and timing might be associated with cognitive impairment after PCI in lung cancer patients, but high-quality data is lacking. Future PCI trials should collect and evaluate possible risk factors systematically.
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Affiliation(s)
- Haiyan Zeng
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.
| | - Lizza E L Hendriks
- Department of Pulmonary Diseases, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands.
| | - Wouter H van Geffen
- Department of Respiratory Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands.
| | - Willem J A Witlox
- Department of Clinical Epidemiology and Medical Technology Assessment, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands.
| | - Danielle B P Eekers
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.
| | - Dirk K M De Ruysscher
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.
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Abstract
PURPOSE OF REVIEW The current article reviews the state of art of prevention strategies for brain metastases from solid tumors and touches both old pivotal studies and new directions of personalized molecular approaches. RECENT FINDINGS Prophylactic cranial irradiation (PCI) has a definite role in the prevention of relapse into the brain for patients with small cell lung cancer (SCLC) responding to chemotherapy and radiotherapy as it prolongs overall survival (OS). However, the risk of late cognitive deficit following whole brain radiotherapy (WBRT) in this patient population is still not well known. Conversely, PCI significantly reduces the incidence of brain metastases and prolongs the disease-free interval in patients with non-SCLC (NSCLC), but does not improve OS thus far. Pharmacologic prevention is a new concept driven by the efficacy of targeted agents on macrometastases from specific molecular subgroups. SUMMARY The future challenges for prevention of brain metastases are represented by the identification of subgroups of patients at higher risk of relapse into the brain coupled with either new WBRT strategies to better preserve cognition or effective molecular agents to target micrometastases.
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Affiliation(s)
- Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
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46
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Pezzi TA, Fang P, Gjyshi O, Feng L, Liu S, Komaki R, Lin SH. Rates of Overall Survival and Intracranial Control in the Magnetic Resonance Imaging Era for Patients With Limited-Stage Small Cell Lung Cancer With and Without Prophylactic Cranial Irradiation. JAMA Netw Open 2020; 3:e201929. [PMID: 32236532 PMCID: PMC7113726 DOI: 10.1001/jamanetworkopen.2020.1929] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/02/2020] [Indexed: 12/18/2022] Open
Abstract
Importance Historical data suggest that there is an overall survival benefit associated with prophylactic cranial irradiation (PCI) in patients with small cell lung cancer (SCLC). However, as the fidelity of magnetic resonance imaging (MRI) of the brain continues to improve, this idea is now being questioned, with recent research showing no survival benefit associated with PCI in extensive-stage SCLC; however, the role for PCI is not clear in patients with limited-stage SCLC (LS-SCLC). Objective To report the overall survival and rates of intracranial control for patients with LS-SCLC, all staged with MRI, who either did or did not undergo PCI. Design, Setting, and Participants This cohort study included 297 patients with LS-SCLC at a large US academic cancer center. Patients were treated with thoracic radiation; 205 also underwent PCI and 92 did not. All patients underwent at least baseline MRI, with restaging brain MRI and/or computed tomography; they did not have disease progression after thoracic radiation treatment. A propensity score-matching analysis was undertaken in an attempt to adjust for potential bias. Of the 297 patients who met the inclusion criteria, the propensity score was calculated for 295 patients, using patient, tumor, and treatment characteristics. Data were analyzed in October 2019. Intervention Prophylactic cranial irradiation in patients with LS-SCLC. Main Outcomes and Measures The rate of overall survival and intracranial control. Results Of the 297 patients, 162 (54.5%) were men. The median age was 62.2 years (range, 27.0-85.0 years) for patients who underwent PCI and 68.6 years (range, 40.0-86.0 years) for those who did not undergo PCI. The 3-year cumulative incidence rate of brain metastases was higher in the no-PCI group vs the PCI group, when counting death as a competing risk, but the difference was not statistically significant (20.40% [95% CI, 12.45%-29.67%] vs 11.20% [95% CI, 5.40%-19.20%]; P = .10). The use of PCI was not associated with a difference in overall survival between the patient groups (hazard ratio, 0.844; 95% CI, 0.604-1.180; P = .32). Conclusions and Relevance These findings suggest that patients with LS-SCLC staged with MRI who undergo PCI after thoracic radiation treatment were not associated with a decreased risk of developing new brain metastases compared with patients who do not undergo PCI. The use of PCI was not associated with an overall survival benefit for such patients.
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Affiliation(s)
- Todd A. Pezzi
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Penny Fang
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Olsi Gjyshi
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Lei Feng
- Division of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Suyu Liu
- Division of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Ritsuko Komaki
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Steven H. Lin
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
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Grigg CM, Boselli D, Livasy C, Symanowski J, McHaffie DR, Riggs S, Clark PE, Beano H, Raghavan D, Burgess EF. Limited Stage Small Cell Bladder Cancer: Outcomes of a Contemporary Cohort. Bladder Cancer 2020. [DOI: 10.3233/blc-190259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Limited stage small cell bladder cancer is curable with multi-modality therapy using external beam radiotherapy or radical cystectomy. The optimal management strategy for this rare disease is still debated, yet few case series have described patients treated after 2010. OBJECTIVE: To analyze outcomes from a contemporary cohort of patients undergoing definitive treatment. METHODS: Patients diagnosed with small cell bladder cancer after January 1, 2010 were identified from an institutional database. Clinical histories were collected by chart review. Survival outcomes were analyzed in patients who received curative-intent therapy consisting of bladder radiotherapy or cystectomy. RESULTS: Thirty patients with limited stage disease that received definitive therapy were identified. Seventeen patients received primary radiotherapy, and thirteen underwent cystectomy. Median age was 70 years. Median follow up was 39.6 months (range 7.2–95.8). The median overall survival of patients undergoing radiotherapy or cystectomy were 36.8 and 30.6 months, respectively (hazard ratio 0.99, 95% confidence interval 0.35–2.85). The median metastasis free survival for patients receiving radiotherapy was not reached, and 18.9 months in the cystectomy group (hazard ratio 0.94, 95% confidence interval 0.34–2.61). The most common sites of relapse were lymph node (n = 6) and bone (n = 5). Brain metastases were less common (n = 3). CONCLUSIONS: Patients receiving cystectomy or radiotherapy had similar outcomes in this contemporary series, but definitive comparisons are limited by the cohort size and high censoring rate (53%). Survival in our cohort is improved compared with older reports, though outcomes remain poor, reiterating the need for better therapeutic options.
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Affiliation(s)
- Claud M. Grigg
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | - Chad Livasy
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | | | - Stephen Riggs
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Peter E. Clark
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Hamza Beano
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Derek Raghavan
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
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Zhang Q, Cai XW, Feng W, Yu W, Fu XL. Risk factors of brain metastases as initial failure in completely resected stage IIIA(N2) non-small cell lung cancer. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:374. [PMID: 32355818 PMCID: PMC7186613 DOI: 10.21037/atm.2020.02.72] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background This study aimed to identify the risk factors of brain metastases (BM) as the initial site of failure in patients with completely resected stage IIIA (N2) non-small-cell lung cancer (NSCLC). Methods From January 2005 and June 2012, the clinical data of 357 patients with completely resected stage IIIA (N2) NSCLC were reviewed in this study. Kaplan-Meier analysis was used to identify the incidence of BM as the initial site of failure and survival. To assess the risk factors of BM, the log-rank test and Cox regression were used for univariate analysis and multivariate analysis, separately. Result Seventy-three (20.4%) patients developed BM; 60 patients had BM as their initial site of failure. The 1-, 3-, and 5-year risk for patients developing BM as the initial site of failure was 9.1%, 27.4% and 35.4%, respectively. Univariate analysis showed adenocarcinoma histology (P=0.000), number of regional LN >4 (P=0.018), multiple N2 stations (P=0.027), multiple region of LN involvement (P=0.010) were significantly associated with an increased risk of developing BM as the initial site of failure. Multivariate analysis showed adenocarcinoma (P=0.001; HR =0.150; 95% CI, 0.047–0.479), multiple regions of LN involvement (P=0.015; HR =2.010; 95% CI, 1.146–3.524) were significantly associated with the high risk of developing BM as the initial site of failure. In patients with adenocarcinoma and multiple regions of LN involvement, the 5-year actuarial risk of BM as the initial failure was 47.6%, respectively. Conclusions Adenocarcinoma and multiple regions of LN involvement were independent risk factors for BM as the initial failure in completely resected stage IIIA (N2) NSCLC. Prospective clinical trials are needed to verify the effect of PCI in the highest-risk subset we identified.
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Affiliation(s)
- Qin Zhang
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China.,Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Xu-Wei Cai
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China.,Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Wen Feng
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China.,Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Wen Yu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China.,Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Xiao-Long Fu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China.,Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
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Sun A, Hu C, Wong SJ, Gore E, Videtic G, Dutta S, Suntharalingam M, Chen Y, Gaspar LE, Choy H. Prophylactic Cranial Irradiation vs Observation in Patients With Locally Advanced Non-Small Cell Lung Cancer: A Long-term Update of the NRG Oncology/RTOG 0214 Phase 3 Randomized Clinical Trial. JAMA Oncol 2020; 5:847-855. [PMID: 30869743 DOI: 10.1001/jamaoncol.2018.7220] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Brain metastasis (BM) rates are high in locally advanced non-small cell lung cancer (LA-NSCLC), approaching rates seen in small cell lung cancer, where prophylactic cranial irradiation (PCI) is standard of care. Although PCI decreases the incidence of BM in LA-NSCLC, a survival advantage has not yet been shown. Objective To determine if PCI improves survival in LA-NSCLC. Design, Setting, and Participants Radiation Therapy Oncology Group (RTOG) 0214 was a randomized phase 3 clinical trial in stage III NSCLC stratified by stage (IIIA vs IIIB), histologic characteristics (nonsquamous vs squamous) and therapy (no surgery vs surgery). The study took place at 291 institutions in the United States, Canada, and internationally. Of 356 patients with stage III NSCLC entered onto this study, 16 were ineligible; therefore, 340 patients were randomized. Intervention for Clinical Trials Observation vs PCI. Main Outcomes and Measures The primary outcome was overall survival (OS). The secondary end points were disease-free survival (DFS) and incidence of BM. Results Of the 340 total participants, mean (SD) age was 61 years; 213 of the participants were men and 127 were women. The median follow-up time was 2.1 years for all patients, and 9.2 years for living patients. The OS for PCI was not significantly better than observation (hazard ratio [HR], 0.82; 95% CI, 0.63-1.06; P = .12; 5- and 10-year rates, 24.7% and 17.6% vs 26.0% and 13.3%, respectively), while the DFS (HR, 0.76; 95% CI, 0.59-0.97; P = .03; 5- and 10-year rates, 19.0% and 12.6% vs 16.1% and 7.5% for PCI vs observation) and BM (HR, 0.43; 95% CI, 0.24-0.77; P = .003; 5- and 10-year rates, 16.7% vs 28.3% for PCI vs observation) were significantly different. Patients in the PCI arm were 57% less likely to develop BM than those in the observation arm. Younger patients (<60 years) and patients with nonsquamous disease developed more BM. On multivariable analysis, PCI was associated with decreased BM and improved DFS, but not improved OS. Multivariable analysis within the nonsurgical arm suggests that PCI effectively prolongs OS, DFS, and BM. Conclusions and Relevance In patients with stage III LA-NSCLC without progression of disease after therapy, PCI decreased the 5- and 10-year rate of BM and improved 5- and 10-year DFS, but did not improve OS. Although this study did not meet its primary end point, the long-term results reveal many important findings that will benefit future trials. Identifying the appropriate patient population and a safe intervention is critical. Trial Registration ClinicalTrials.gov identifier: NCT00048997.
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Affiliation(s)
- Alexander Sun
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Chen Hu
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania.,Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | - Swati Dutta
- Michigan Cancer Research Consortium CCOP, Ann Arbor
| | | | | | | | - Hak Choy
- University of Texas Southwestern Medical Center, Dallas
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Meta-analysis of prophylactic cranial irradiation or not in treatment of extensive-stage small-cell lung cancer: The dilemma remains. Cancer Radiother 2020; 24:44-52. [PMID: 32044160 DOI: 10.1016/j.canrad.2019.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 10/25/2019] [Accepted: 10/29/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE The role of prophylactic cranial irradiation (PCI) in treatment of extensive-stage small-cell lung cancer (SCLC) is controversial. The aim of this study was to systematically evaluate the efficacy and safety of using PCI in the treatment of extensive-stage SCLC. In the present study, we examined whether PCI was essential for the optimal treatment of extensive-disease small-cell lung cancer. MATERIAL AND METHODS We searched the PubMed, Embase, Medline, and China National Knowledge Infrastructure databases to identify articles that assessed the efficacy of PCI in treating extensive-stage small-cell lung cancer patients. RESULTS We identified 8 studies that involved a total of 982 patients who received PCI (PCI group) and a total of 4509 patients who did not receive PCI (control group). The results showed that PCI significantly improved the 1-year overall survival rate (HR=1.50; 95% CI: 1.23-1.82; I2=67%; P<0.0001) and reduced the incidence of brain metastasis (HR=0.46; 95% CI: 0.37-0.58; I2=6%; P<0.00001). CONCLUSION PCI improves the 1-year overall survival rate and reduces the risk of brain metastasis in patients with extensive-stage SCLC.
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