Systemic chemotherapy after cranial irradiation in patients with brain metastases from non-small cell lung cancer: A retrospective study

Response of brain metastasis from lung cancer patients to an oral nutraceutical product containing silibinin

Despite multimodal treatment approaches, the prognosis of brain metastases (BM) from non-small cell lung cancer (NSCLC) remains poor. Untreated patients with BM have a median survival of about 1 month, with almost all patients dying from neurological causes. We herein present the first report describing the response of BM from NSCLC patients to an oral nutraceutical product containing silibinin, a flavonoid extracted from the seeds of the milk thistle. We present evidence of how the use of the silibinin-based nutraceutical Legasil^® resulted in significant clinical and radiological improvement of BM from NSCLC patients with poor performance status that progressed after whole brain radiotherapy and chemotherapy. The suppressive effects of silibinin on progressive BM, which involved a marked reduction of the peritumoral brain edema, occurred without affecting the primary lung tumor outgrowth in NSCLC patients. Because BM patients have an impaired survival prognosis and are in need for an immediate tumor control, the combination of brain radiotherapy with silibinin-based nutraceuticals might not only alleviate BM edema but also prove local control and time for either classical chemotherapeutics with immunostimulatory effects or new immunotherapeutic agents such as checkpoint blockers to reveal their full therapeutic potential in NSCLC BM patients. New studies aimed to illuminate the mechanistic aspects underlying the regulatory effects of silibinin on the cellular and molecular pathobiology of BM might expedite the entry of new formulations of silibinin into clinical testing for progressive BM from lung cancer patients.

Analyses of prognostic factors in cases of non-small cell lung cancer with multiple brain metastases

AIM

To observe the therapeutic efficacy and prognostic factors that influence survival rates in non-small cell lung cancer (NSCLC) patients with multiple brain metastases (BMs), (more than three and less than ten).

METHODS

Retrospective analyses were conducted on the clinical data of 209 NSCLC patients with multiple BMs and were admitted to our hospital between March 2007 and November 2012. All BM patients received whole-brain radiotherapy. Two hundred patients received combined chemotherapy during the treatment process; 99 received targeted drug therapy; and nine got only symptomatic and supportive treatment. Survival time was defined as the period from the start of BM therapy to the patient's death or end of the follow-up period. The Kaplan-Meier method was used to calculate the median survival time, and the 6-month, 1-, and 2-year cumulative survival rates, as well as to plot the survival curves. The patients' cultural background included their socioeconomic status, level of education, their understanding of the disease, and the degree of care and support they received from their family members. Log-rank test was employed to test the differences in the survival rates between the subgroups. Cox multivariate regression analyses were used to analyze the various factors influencing the prognoses of NSCLC with multiple BMs.

RESULTS

The follow-up duration was between 1 and 87 months. The median survival time for all BM patients was 12.1 months (95% confidence interval 9.37-14.83). The 6-month, 1-, and 2-year cumulative survival rates were 80%, 50.2%, and 10.7%, respectively. Univariate analyses revealed that the independent factors influencing survival prognoses included Karnofsky Performance Status score, control of the primary lung tumor, interval between the confirmed diagnoses of lung cancer and BM, presence of extracranial metastasis, number of chemotherapy cycles undergone, Graded Prognostic Assessment class, administration of combined targeted drug therapy, the pathological type, and the cultural backgrounds of the patients. Multivariate analyses indicated that the number of chemotherapy cycles, administration of combined drug therapy, and patients' cultural background were key independent factors influencing survival prognoses.

CONCLUSION

Active treatment of NSCLC with multiple BMs was beneficial, and the patients' cultural background had a strong influence on survival prognoses. Chemotherapy combined with targeted drug therapy could increase the patients' median and overall survival rates. The number of chemotherapy cycles undergone, administration of combined targeted drug therapy, and the cultural backgrounds of the patients had significant effects on the patients' survival prognoses.

Non-small cell lung cancer histological subtype has prognostic impact in patients with brain metastases

In patients with brain metastases from non-small cell lung cancer, the prognostic impact of primary tumour histology, a feature with increasing implications for choice of systemic therapy, is not well defined. Therefore, a multi-institutional analysis was performed: retrospective uni- and multivariate analyses in 209 patients treated with different approaches including surgery and radiosurgery. While squamous cell and large cell carcinoma patients had comparable survival, those with adenocarcinoma survived significantly longer. In multivariate models, adenocarcinoma histology was confirmed as independent prognostic factor, which complements both recursive partitioning analysis (RPA) classes and diagnosis-specific graded prognostic assessment (GPA). When evaluated together with primary tumour control, extracranial metastases, number of brain metastases, age and performance status as individual covariates rather than RPA or GPA score, adenocarcinoma histology again emerged as significant prognostic factor. A significant but small survival advantage for patients with adenocarcinoma was evident already in the time period before drugs such as pemetrexed and epidermal growth factor receptor tyrosine kinase inhibitors were available. However, the gap has widened in recently treated patients. Comparable to patients without brain metastases, primary tumour histology should be taken into account when assessing patients' prognosis and recommending treatment strategy.

Modern multidisciplinary management of brain metastases

Ideal management of brain metastases (BMs) requires simultaneous control of the existing brain metastasis (local brain control), prevention of future BMs (distant brain control), and control of the systemic cancer (systemic control). Available tools include whole brain radiation therapy (WBRT), surgery, stereotactic radiosurgery (SRS), and systemic therapies, such as chemotherapies, biologic agents, and radiosensitizing agents. Selecting the combination of these tools is highly individualized and is impacted by numerous factors involving the tumor, patient, provider, and evolving evidence. Historically, patients received WBRT, either alone or with local treatments (surgery or SRS). However, concern about the effects of WBRT, coupled with improvements in local control and survival in select patients, with the combination treatment, has led to a reconsideration of the role of WBRT. Additionally, there have been advancements in the efficacy and tolerance of systemic therapies and clarification regarding the relative risks and symptoms of tumor recurrence versus treatment complications. Thankfully, individualizing modern multidisciplinary management for patients with BMs is being aided by numerous recently completed, ongoing, and planned prospective series.