Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy Oncology Group (RTOG) brain metastases trials

A magnetic resonance imaging (MRI)-based deep learning radiomics model predicts recurrence-free survival in lung cancer patients after surgical resection of brain metastases

AIM

To develop and validate a magnetic resonance imaging (MRI)-based deep learning radiomics model (DLRM) to predict recurrence-free survival (RFS) in lung cancer patients after surgical resection of brain metastases (BrMs).

MATERIALS AND METHODS

A total of 215 lung cancer patients with BrMs confirmed by surgical pathology were retrospectively included in five centres, 167 patients were assigned to the training cohort, and 48 to the external test cohort. All patients underwent regular follow-up brain MRIs. Clinical and morphological MRI models for predicting RFS were built using univariate and multivariate Cox regressions, respectively. Handcrafted and deep learning (DL) signatures were constructed from BrMs pretreatment MR images using the least absolute shrinkage and selection operator (LASSO) method, respectively. A DLRM was established by integrating the clinical and morphological MRI predictors, handcrafted and DL signatures based on the multivariate Cox regression coefficients. The Harrell C-index, area under the receiver operating characteristic curve (AUC), and Kaplan-Meier's survival analysis were used to evaluate model performance.

RESULTS

The DLRM showed satisfactory performance in predicting RFS and 6- to 18-month intracranial recurrence in lung cancer patients after BrMs resection, achieving a C-index of 0.79 and AUCs of 0.84-0.90 in the training set and a C-index of 0.74 and AUCs of 0.71-0.85 in the external test set. The DLRM outperformed the clinical model, morphological MRI model, handcrafted signature, DL signature, and clinical-morphological MRI model in predicting RFS (P < 0.05). The DLRM successfully classified patients into high-risk and low-risk intracranial recurrence groups (P < 0.001).

CONCLUSION

This MRI-based DLRM could predict RFS in lung cancer patients after surgical resection of BrMs.

Upfront frameless hypofractionated gamma knife radiosurgery for large posterior Fossa metastases

The management of large metastatic brain tumors (METs), particularly those in the posterior fossa (pf-METs), is challenging. While surgery can alleviate symptoms, it carries the risk of complications such as leptomeningeal disease (LMD). Upfront hypofractionated Gamma Knife radiosurgery (hf-GKRS) has shown promise as an alternative approach for managing large METs. This study assesses the efficacy and safety of upfront hf-GKRS for treatment-naïve large pf-METs. In this retrospective, single-center study, 40 patients with 42 pf-METs received hf-GKRS from October 2017 to June 2024. Patients eligible for the study were 18 years or older, had histologically confirmed malignancy, large pf-METs (> 4 cm3), and a minimum of two follow-up MRI scans. The primary outcome was local control (LC), with secondary assessments of distant intracranial failure (DICF), intracranial progression-free survival (PFS), overall survival (OS), and toxicity. LC was achieved in 88.1% of pf-METs over a median follow-up of 6 months (mean: 13.7 months). LC rates at 6, 12, and 24 months were 95.8%, 95.8%, and 74.5%, respectively. Local failure (LF) occurred in 11.9% of cases, with a median recurrence time of 12 months. DICF was noted in 35% of patients, while no cases of LMD were reported. Intracranial PFS rates at 6, 12, and 24 months were 54.1%, 39.0%, and 16.7%, respectively, with a median PFS of 8 months. Symptomatic hydrocephalus developed in one patient (2.5%). Controlled primary tumor status (HR: 0.17, p = 0.036) was significantly associated with lower risk of death, while no other parameters were predictive of LC, DICF, or intracranial PFS. hf-GKRS demonstrates strong efficacy and safety as a primary treatment for selected, treatment-naïve large pf-METs over a relatively short follow-up duration. Further studies are warranted to refine patient selection, fractionation, and dosing strategies for this challenging population.

Biomarkers in lung cancer treatment

Lung carcinoma (LC) is the primary cause of millions of deaths worldwide. As LC is typically diagnosed at a later stage, its prevention and treatment are difficult. The pathological basis of both types of LC, namely non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC), is highly determined. The only treatments available for LC are surgical resection and chemotherapy, which require sophisticated new treatments. Biomarkers are promising treatment options, because they can be used for both diagnosis and treatment. Typical signaling molecules known as biomarkers identify abnormalities in cellular activity and serve as prognostic and diagnostic indicators. Biomarkers show great promise in clinical decision making, early and quick diagnosis, recurrence of illness, and tracking the effectiveness of cancer treatments. This review provides an overview of biomarkers, their benefits, and future directions for those new to the field of biomarker research in LC therapy.

Hybrid Deep Learning for Survival Prediction in Brain Metastases Using Multimodal MRI and Clinical Data

Background: Survival prediction in patients with brain metastases remains a major clinical challenge, where timely and individualized prognostic estimates are critical for guiding treatment strategies and patient counseling. Methods: We propose a novel hybrid deep learning framework that integrates volumetric MRI-derived imaging biomarkers with structured clinical and demographic data to predict overall survival time. Our dataset includes 148 patients from three institutions, featuring expert-annotated segmentations of enhancing tumors, necrosis, and peritumoral edema. Two convolutional neural network backbones-ResNet-50 and EfficientNet-B0-were fused with fully connected layers processing tabular data. Models were trained using mean squared error loss and evaluated through stratified cross-validation and an independent held-out test set. Results: The hybrid model based on EfficientNet-B0 achieved state-of-the-art performance, attaining an R2 score of 0.970 and a mean absolute error of 3.05 days on the test set. Permutation feature importance highlighted edema-to-tumor ratio and enhancing tumor volume as the most informative predictors. Grad-CAM visualizations confirmed the model's attention to anatomically and clinically relevant regions. Performance consistency across validation folds confirmed the framework's robustness and generalizability. Conclusions: This study demonstrates that multimodal deep learning can deliver accurate, explainable, and clinically actionable survival predictions in brain metastases. The proposed framework offers a promising foundation for integration into real-world oncology workflows to support personalized prognosis and informed therapeutic decision-making.

Anti‑HER2‑targeted therapies for the treatment of advanced HER2‑positive breast cancer with brain metastases (Review)

Compared with other metastatic sites, breast cancer brain metastases (BCBMs) are associated with the shortest survival time. In addition, human epidermal growth factor receptor 2 (HER2) is observed to be amplified in 20-25% of breast cancer cases where it is a poor prognostic factor for brain metastases. Various anti-HER2 targeted therapies have brought both new opportunities and challenges to patients with HER2-positive BCBM over the past decade. However, prolonging survival time and improving quality of life of patients have become controversial issues in the field of clinical research on BCBMs. On the basis of the latest literature, the present review documents the anti-HER2 targeted drugs applied in patients with HER2-positive BCBM. Further studies on the efficacy and safety of novel HER2-targeted drugs and combined or sequential therapy in clinical treatment are expected to provide more effective strategies for the treatment of patients with HER2-positive BCBM.

Integrated analysis of molecular and clinical features associated with overall survival in melanoma patients with brain metastasis

Melanoma brain metastases (MBMs) are diagnosed in up to 60% of metastatic melanoma patients. Previous studies have identified clinical factors that correlate with overall survival (OS) after MBM diagnosis. However, molecular and immune features associated with OS are poorly understood. An improved understanding of the molecular and immune correlates of OS could provide insights into MBM patient outcomes and guide therapeutic development. Thus, we analyzed clinical features and outcomes of 74 melanoma patients who underwent surgical resection (via craniotomy) between 1991 and 2015 at our institution with RNA-seq data generated from their MBMs. The median post-operative OS was 8.6 months (range 0.6-146.9). On univariate analysis (UVA), the expression of multiple immune gene signatures was associated with improved OS, including IFN-γ Index, T cell-inflamed and the Expanded Immune Genes. The gene expression signatures of several immune cell types (i.e., T cells, CD8 T cells, cytotoxic lymphocytes, NK cells, monocytes) positively correlated with OS, whereas higher neutrophil gene expression correlated with shorter OS. UVA of clinical features identified low Karnofsky performance score (KPS), elevated serum lactate dehydrogenase (LDH), presence of extracranial metastases (ECMs), and uncontrolled (versus controlled) ECMs as clinical predictors of shorter survival. Multivariate analyses (MVA) were performed with significant clinical factors and all immune features without any redundant highly correlated variables in the model. After backward selection, multivariable coxPH model identified low KPS, low T cell signature, and low monocytic lineage signature as independent predictors of shorter survival. Finally, comparative analysis of MBMs from patients with MBMs only showed that these tumors were characterized by decreased oxidative phosphorylation (OXPHOS) and increased immune infiltration signature versus MBMs from patients with concurrent ECMs. Together these results support the clinical significance of specific immune features of MBMs and suggest their potential use as prognostic biomarkers.

Neurological Manifestations of Patients With CNS Metastases: Experience From a Single Center in an Upper-Middle-Income Country

PURPOSE

This study aimed to report the neurological manifestations of patients with CNS metastases (CNSm) and to determine their association with survival in patients with brain metastases (BrMs).

MATERIALS AND METHODS

A retrospective analysis of patients with CNSms (BrMs or neoplastic meningitis) seen at two referral centers between 2010 and 2022. The neurological manifestations and their association with survival were measured and presented.

RESULTS

Among 822 patients with CNSms, the most common neurological manifestations were headache, focal weakness, visual disorders, nausea/vomiting, seizures, and altered mental status (53%, 35%, 24%, 23%, 22%, and 18%, respectively). In patients with BrMs, neurological manifestations associated with survival were asymptomatic (hazard ratio [HR], 0.48 [95% CI, 0.31 to 0.73]; P = .001), focal weakness (HR, 1.26 [95% CI, 1.02 to 1.54]; P = .027), or visual disorders (HR, 1.26 [95% CI, 1.01 to 1.58]; P = .045).

CONCLUSION

Neurological manifestations in patients with BrMs are associated with survival and can aid in prognostic stratification.

Future directions in the evaluation and management of newly diagnosed metastatic cancer

There is much debate regarding optimal selection in patients with metastatic cancer who should undergo local treatment (surgery or radiation treatment) to the primary tumor and/or metastases. Additionally, the optimal treatment of newly diagnosed metastatic cancer is largely unclear. Current prognostication systems to best inform these clinical scenarios are limited, as all metastatic patients are grouped together as having Stage IV disease without further incorporation of patient and disease-specific covariates that significantly impact patient outcomes. Therefore, improving current prognostic scoring systems and incorporation of these covariates is essential to best individualize treatment for patients with metastatic cancer. In this narrative review article, we provide a detailed review of prognostication systems that can be used for both the site of metastasis and primary site to best tailor treatment in these patients. Additionally, we discuss the incorporation and ongoing developments in radiographic, genomic, and biostatistical techniques that can be used as prognostication tools.

Systemic inflammation response index predicts overall survival in patients undergoing stereotactic radiosurgery for brain metastasis from non-small cell lung cancer

This study aimed to evaluate the prognostic value of pre-treatment blood cell counts in patients with brain metastasis (BM) from non-small cell lung cancer (NSCLC) who were treated using linear accelerator (linac)-based stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (fSRT) with a micro-multileaf collimator. Between January 2011 and November 2022, 271 consecutive patients underwent linac-based SRS/fSRT for BM from NSCLC. Thirty patients with insufficient blood test data during this period were excluded from this analysis. Thirty-five patients with steroid intake at the time point of the blood test and 18 patients with higher C-reactive protein were excluded. Thus, 188 patients were eventually enrolled in this study. The median follow-up period after SRS/fSRT was 21 months (range: 0-121 months), and the median survival time after SRS/fSRT was 19 months. Neutrophil-lymphocyte ratio ≥ 1.90, lymphocyte-monocyte ratio ≤ 1.67 and systemic inflammation response index (SIRI) ≥ 2.95 were unfavorable predictors of prognosis for patients who underwent SRS/fSRT for BM from NSCLC. Cox proportional-hazard multivariate analysis revealed that the SIRI was independent prognostic factors for increased risk of death. Thus, simple, less expensive, and routinely performed pre-treatment blood cell count measurements such as SIRI can predict the overall survival of patients treated with SRS/fSRT for BM from NSCLC.

The METACER national cohort study of brain metastases in gastrointestinal cancers prospectively establishes prognostic factors

PURPOSE

Availability data are scarce and primarily retrospective in patients with brain metastasis (BM) from gastrointestinal (GI) cancers. The objective of this cohort was to determine prognostic factors for survival outcomes in patients with BM from GI cancers.

METHODS

METACER is a national multicentric prospective cohort study which included patients with BM diagnosis during a histologically proven digestive cancer follow-up between 2010 and 2014. The primary endpoint was overall survival (OS). The secondary endpoints were Progression-Free survival (PFS), prognostic factors, and BM-free survival as time from disease diagnosis to BM diagnosis.

RESULTS

METACER included 130 patients, with colorectal cancer (CRC) (N = 105) and eso-gastric (N = 25) cancer (EGC). The median OS was 6.6 months: 7.1 months (95%CI: 4.7-9.7) in CRC patients and 5.2 months, (95%CI: 1.9-7.6) in EG patients (p = 0.827). In multivariate analysis, cerebral BM location (versus cerebellar), BM surgery, performance status (0-1 versus 2), and a unique BM were significantly associated with prolonged OS. BM-free survival were 30.8 months (95%CI:25.2-36.9) in CRC patients and 7.8 months (95%CI:3.8-13.6) in EGC patients (p < 0.001). In synchronous metastatic disease, BM-free survival were 18.6 months (95%CI:13.1-25.2) in CRC patients and 3.7 months (95%CI:0.03-7.8) in EGC patients (p < 0.001).

CONCLUSION

BM in GI cancers are of poor prognosis. BM surgery should be considered in case of unique brain lesion. In metastatic settings, EGC patients have shorter BM-free survival than CRC patients.

The velocity of temporalis muscle wasting in cerebral metastasis is prognostic for poor survival

Purpose

Recently, the temporalis muscle thickness on cranial CT scan was proposed as a surrogate marker for patients' baseline frailty that correlates with outcome in primary and metastatic brain tumor patients. In this study, we investigated whether the velocity of temporalis muscle atrophy (TMA) affects the outcome of patients with cerebral metastases.

Methods

We analyzed radiological and clinical data sets of 96 patients who received craniotomy for cerebral metastasis resection in our institution. We then correlated the radiological data with clinical course and outcome after stratification for the velocity of temporalis muscle atrophy.

Results

The median velocity of TMA was 0.0016 mm/day. In patients with a slow TMA rate, the median overall survival was significantly longer than in patients with a fast TMA rate (37.7 months versus 22.9, p = 0.0007). Furthermore, patients with slow TMA had longer progression-free survival postoperatively (7.6 versus 4.38 months, p <0.0001). The overall survival postoperatively (OS-PO) was also significantly longer in patients with slow TMA (8.9 months versus 5.1, p=0002).

Conclusion

Based on this study, the velocity of temporalis muscle atrophy may represent an objective and dynamic index with potential for survival prognostication for patients with cerebral metastases.

Cerebellar re-irradiation after whole brain radiotherapy significant symptom relief with minimal toxicity in metastatic brain patients

Whole-brain radiotherapy (WBRT) remains a standard treatment for extensive brain metastases, providing symptom relief and improved progression-free survival (PFS). Re-irradiation is often necessary for recurrent disease, particularly in the cerebellum, which accounts for 10-20% of cases. Cerebellar metastases are associated with distinct symptoms and poorer prognoses compared to supratentorial lesions. This study evaluates the outcomes of cerebellar-only re-irradiation for brain metastases, with or without stereotactic radiosurgery (SRS) for supratentorial lesions. A retrospective analysis of 56 patients treated between 2017 and 2023 was conducted. Patients received cerebellar-only re-irradiation after WBRT. Symptom improvement was assessed three months post-treatment. Statistical analyses included t-tests, Mann-Whitney U tests, and multivariable logistic regression. The cohort's median age was 53 years, with breast cancer being the most prevalent histology (71%). Symptom improvement occurred in 75% of patients, with relief rates of 84.6% for nausea, 80% for headache, and 58.3% for dizziness. Dexamethasone use decreased in 76.3% of cases. Median PFS was 39.2%, with a six-month overall survival of 50%. Only 1.7% of patients developed symptomatic radiation necrosis. Factors associated with symptom improvement included younger age, extended intervals between WBRT and re-irradiation, and higher equivalent dose in 2 Gy fractions (EQD2). Cerebellar-only re-irradiation is an effective, low-toxicity option for recurrent cerebellar metastases. This approach warrants further validation in prospective studies, particularly in comparison to SRS.

Survival and quality of life after first-time diagnosis of brain metastases: a multicenter, prospective, observational study

Background

A major concern in anticancer treatment (ACT) of brain metastases (BM) is exposing patients with short expected survival to treatments that negatively impact on quality of life (QoL). Such futile ACT at the end of life is time-consuming and burdensome for patients and their families and entails unnecessary healthcare costs. Refraining from ACT is challenging for both physicians and patients. This study aimed to provide real-life data on survival after BM diagnosis and patient reported outcomes (PROs) after ACT to identify risk factors for futile treatment and to support BM treatment decisions.

Methods

This multi-center, prospective, observational study recruited consecutive patients with first-time BM from November 2017 to March 2021. Patients were followed until death or study end (October 1st, 2023). Clinical factors associated with survival were analyzed by the Cox' proportional hazards model. Changes in PROs after BM treatment were described according to Eastern Cooperative Oncology Group (ECOG) performance status, survival, and treatment groups.

Findings

For the total cohort (N = 912), median overall survival (mOS) after BM diagnosis was 5.9 months (95% confidence interval [CI] 5.2-6.7). ECOG 2-4, uncontrolled extracranial metastases, and ≥5 BM were associated with short survival. In patients treated with radiotherapy, survival for patients with ECOG 2 and those with ECOG 3-4 was similar and particularly short for the whole brain radiotherapy (WBRT) group (ECOG 2: 2.9 months [95% CI 2.3-3.5]; ECOG 3-4: 2.1 [1.5-2.7]). Patients surviving <6 months after BM diagnosis reported worse QoL scores two months after ACT; patients surviving >6 months reported stable scores over time.

Interpretation

Patients with ECOG 2-4, especially those with uncontrolled extracranial metastases and ≥5 BM, are at risk for futile ACT. BM treatment guidelines should strongly caution against ACT to patients with expected survival <6 months and specifically advise against WBRT.

Funding

The South-Eastern Norway Regional Health Authority; The Norwegian Cancer Society.

Prognostication of Brain-Metastasized Patients Receiving Subsequent Systemic Therapy: A Single-Center Long-Term Follow-Up

BACKGROUND

Survival of patients with brain metastases (BMs) is poor. It has become clear that targeted therapy has an effect on BMs and patient' prognosis. The question remains which patients benefit from additional systemic therapy. This assumption was evaluated in a large single-center cohort.

METHODS

Patients consecutively planned to undergo local radiotherapy for their BMs in 2006-2017 were selected (n = 200). Prognosis, using CERENAL, disease-specific graded prognostic assessment (DS-GPA), and Radiation Therapy Oncology Group recursive partitioning analysis (RTOG RPA), was evaluated.

RESULTS

Ninety-three (46.5%) patients received at least one additional line of systemic therapy subsequent to the diagnosis of their BMs. The median overall survival (OS) was 6.3 months. Having received subsequent systemic therapy resulted in a more favorable OS (10.4 versus 3.9 months). Interestingly, using dichotomized scores, CERENAL showed prognostic properties in all patients for disease-specific survival on multivariate analysis, whereas RTOG RPA and DS-GPA were not withheld in the model. Lastly, only having a favorable DS-GPA resulted in prolonged progression-free survival for first systemic therapy following BM diagnosis.

CONCLUSIONS

Receiving subsequent systemic therapy has a profound influence on outcome in patients with BMs, indicating the effect of systemic therapy on BMs. Use of the CERENAL brain prognostic score shows potential for further prognostication of patients with more favorable outcomes.

A novel prognostic score (HAMP) for head and neck cancer patients with single and multiple SBRT-treated lung metastases derived from retrospective analyses of survival outcome

BACKGROUND

We report on the characterization and introduction of a novel prognostic score for patients undergoing stereotactic body radiotherapy (SBRT) for the treatment of single and multiple pulmonary metastases (PMs) derived from head and neck cancer (HNC).

METHODS

In this retrospective study, we examined selected factors associated with progression-free survival (PFS) and overall survival (OS) among 59 patients with HNC treated with SBRT for a total of 118 PMs, between 2009 and 2023. Factors related to survival were included in the prognostic scoring system.

RESULTS

Prognostic factors including histology, age, number of metastases, and performance status at first SBRT were weighted differently depending on the strength of correlation to PFS and OS. Total prognostic scores (HAMP) ranged from 13 to 24 points, with a cut-off total score of ≤18 scoring points for patients in a high-risk (HR) subcohort, and of ≥19 scoring points for patients in a low-risk group (LR). Median PFS (23.8 vs. 5.5 months, p < 0.001) and OS (61.3 vs. 16.4 months, p < 0.001) were significantly longer in the low-risk group compared to the high-risk group.

CONCLUSION

The HAMP score might be a convenient tool to facilitate individualized treatment decisions and appropriate follow-up. The accuracy and reliability of the score requires further evaluation in prospective studies.

Upfront Stereotactic Radiosurgery or Fractionated Stereotactic Radiotherapy in Elderly Patients with Brain Metastases from Non-Small Cell Lung Cancer: A Retrospective Analysis of a 10-Year Bi-institutional Experience

PURPOSE

Stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT) are increasingly used as initial therapies for brain metastases (BM). We aimed to assess the outcomes of SRS/FSRT in patients aged ≥ 65 years who had 1-10 BM from non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

We retrospectively reviewed 91 elderly NSCLC patients with 222 BM who were treated with SRS/FSRT at two institutions between 2010 and 2020. The primary endpoint was overall survival (OS) after SRS/FSRT. In addition, in-field local control (IFLC) within the treated field was evaluated. Statistical analysis was performed to identify the prognostic factors affecting OS and IFLC.

RESULTS

During a median follow-up of 18 months, the median OS was 32 months. The 1- and 2-year survival rates were 69.8% and 56.1%, respectively. In multivariate analysis, the NSCLC-specific graded prognostic assessment (GPA) score (p=0.007) and administration of systemic therapy (p=0.039) were defined as prognosticators affecting OS. The median IFLC period was 31 months, and the 1- and 2-year IFLC rates were 75.9% and 57.6%, respectively. The total BM volume (p=0.042) significantly affected IFLC. No severe adverse events were reported after SRS/FSRT.

CONCLUSION

SRS/FSRT is an effective upfront treatment option for BM arising from NSCLC in elderly patients, with a good OS without severe side effects. Higher GPA score and active systemic treatment were associated with improved OS, indicating that elderly patients are significant candidates for SRS/FSRT.

High expression of SULF1 is associated with adverse prognosis in breast cancer brain metastasis

BACKGROUND

Breast cancer is the most common cancer in women, and in advanced stages, it often metastasizes to the brain. However, research on the biological mechanisms of breast cancer brain metastasis and potential therapeutic targets are limited.

METHODS

Differential gene expression analysis (DEGs) for the datasets GSE43837 and GSE125989 from the GEO database was performed using online analysis tools such as GEO2R and Sangerbox. Further investigation related to SULF1 was conducted using online databases such as Kaplan-Meier Plotter and cBioPortal. Thus, expression levels, variations, associations with HER2, biological processes, and pathways involving SULF1 could be analyzed using UALCAN, cBioPortal, GEPIA2, and LinkedOmics databases. Moreover, the sensitivity of SULF1 to existing drugs was explored using drug databases such as RNAactDrug and CADSP.

RESULTS

High expression of SULF1 was associated with poor prognosis in advanced breast cancer brain metastasis and was positively correlated with the expression of HER2. In the metastatic breast cancer population, SULF1 ranked top among the 16 DEGs with the highest mutation rate, reaching 11%, primarily due to amplification. KEGG and GSEA analyses revealed that the genes co-expressed with SULF1 were positively enriched in the 'ECM-receptor interaction' gene set and negatively enriched in the 'Ribosome' gene set. Currently, docetaxel and vinorelbine can act as treatment options if the expression of SULF1 is high.

CONCLUSIONS

This study, through bioinformatics analysis, unveiled SULF1 as a potential target for treating breast cancer brain metastasis (BM).

Validation of the graded prognostic assessment and recursive partitioning analysis as prognostic tools using a modern cohort of patients with brain metastases

Background

Prognostic indices for patients with brain metastases (BM) are needed to individualize treatment and stratify clinical trials. Two frequently used tools to estimate survival in patients with BM are the recursive partitioning analysis (RPA) and the diagnosis-specific graded prognostic assessment (DS-GPA). Given recent advances in therapies and improved survival for patients with BM, this study aims to validate and analyze these 2 models in a modern cohort.

Methods

Patients diagnosed with BM were identified via our institution's Tumor Board meetings. Data were retrospectively collected from the date of diagnosis with BM. The concordance of the RPA and GPA was calculated using Harrell's C index. A Cox proportional hazards model with backwards elimination was used to generate a parsimonious model predictive of survival.

Results

Our study consisted of 206 patients diagnosed with BM between 2010 and 2019. The RPA had a prediction performance characterized by Harrell's C index of 0.588. The DS-GPA demonstrated a Harrell's C index of 0.630. A Cox proportional hazards model assessing the effect of age, presence of lung, or liver metastases, and Eastern Cooperative Oncology Group (ECOG) performance status score of 3/4 on survival yielded a Harrell's C index of 0.616. Revising the analysis with an uncategorized ECOG demonstrated a C index of 0.648.

Conclusions

We found that the performance of the RPA remains unchanged from previous validation studies a decade earlier. The DS-GPA outperformed the RPA in predicting overall survival in our modern cohort. Analyzing variables shared by the RPA and DS-GPA produced a model that performed analogously to the DS-GPA.

Real-World Experience in Hispanic Patients With Breast Cancer and Brain Metastases Using Different Prognostic Tools

PURPOSE

Only a small percentage of Hispanic patients have been included in studies that developed prognostic models for breast cancer and brain metastases. Therefore, there is a clear need for tools tailored to this demographic. This study assesses the efficacy of common prognostic tools in a Hispanic population.

METHODS AND MATERIALS

We retrospectively analyzed a data set of Hispanic patients with breast cancer and newly diagnosed brain metastases from 2009 to 2023 at a single referral center. For each prognostic tool, Kaplan-Meier curves were built. The performances of the models were compared using the area under the curve (AUC), C-statistic, and Akaike information criteria (AIC).

RESULTS

Of 492 patients, the median time from breast cancer to brain metastasis diagnosis was 22.7 months (IQR, 12.1-53.3). The median overall survival was 11.6 months (95% CI, 9.9-13.4). All models were validated as prognostic tools (P < .001). The model with the better performance was the breast graded prognostic assessment (GPA; AIC, 402; AUC, 0.65), followed by the modified GPA (AIC, 406; AUC, 0.64), the disease-specific GPA (AIC, 407; AUC, 0.62), recursive partitioning analysis (AIC, 421; AUC, 0.62), and GPA (AIC, 422; AUC, 0.60).

CONCLUSIONS

The breast GPA demonstrated superior accuracy in prognosticating outcomes for Hispanic patients with breast cancer and brain metastases. This underscores the critical importance of incorporating racial and ethnic diversity in creating and validating medical prognostic tools.

Surgical resection versus stereotactic radiosurgery for the treatment of brain metastases in the motor cortex; a meta-analysis and systematic review

Brain metastasis in the motor cortex is a challenging condition to treat. Surgical resection or stereotactic radiosurgery (SRS)/hypofractionated stereotactic radiotherapy (hypoSRT) are valuable options up to now. Due to its unique location and potential for neurologic deficits, neither treatment is entirely satisfactory. There is still a lack of data on the treatment result of motor cortex metastasis. This study provides a comprehensive review and meta-analysis comparing surgery and SRS/hypoSRT for treating brain metastasis in the motor cortex. Core databases, including PubMed, Embase, and the Cochrane Library, were systematically searched for brain metastasis in the motor cortex, demonstrating the clinical outcomes of both surgery and SRS/hypoSRT. Motor power outcome and treatment-associated complication rates were thoroughly evaluated. Twenty-five articles were listed for full-text review. Among them, 13 articles were eligible for inclusion criteria: retrospective cohort studies comparing surgery and SRS/hypoSRT. There are 323 patients in the surgery group and 220 in the SRS/hypoSRT group. The motor outcome is better in surgery group, but without statistical significance (0.49 vs 0.37, p = 0.3937) and treatment-related complication is lower in surgery group with statistical significance (0.09 vs 0.26, p = 0.0218). Treatment modality should be tailored by the patient's performance status, history of radiation, presence of ongoing chemotherapy, or extracranial progression status.

Is Whole-Brain Radiotherapy for Brain Metastases an Overestimated Therapy? A Retrospective Study of Real-World Data Using Landmark Analyses

BACKGROUND

The role of whole-brain radiotherapy for patients with brain metastases is changing as immunotherapy and molecularly targeted therapies advance. However, whole-brain radiotherapy continues to be part of the multimodal concept.

METHODS

This retrospective study included 285 patients who received whole-brain radiotherapy for brain metastases, using a median dose of 30 Gy. The study analyzed prognostic factors for survival using Cox regression analyses, while two landmark analyses, reflecting a minimum survival of 60 and 90 days, accounted for early deaths. Neurological symptoms were compared before and after treatment using the McNemar test.

RESULTS

The median patient age was 62 years. Non-small cell lung cancer (n = 95), breast cancer (n = 53), and small cell lung cancer (n = 48) were the most frequent cancer types. Median survival was 4.3 months (interquartile range 1.8-11.1). In the multivariable Cox regression model, patients who received additional immunotherapy/molecularly targeted therapy had a higher chance of survival than others. Overall survival was influenced by control of primary cancer, extracranial metastases, age, Karnofsky performance status, and number of brain metastases. The 90-day landmark analysis included 181 patients who survived at least 90 days, reflecting that 104 patients (36.5%) died within the first 90 days. The 90-day landmark analysis confirmed all predictive variables for survival. Patients who died before the 90-day landmark endpoint had more brain metastases, lower Karnofsky performance status, higher age, and were less frequently treated with immunotherapy/molecularly targeted therapy than those surviving at least 90 days. The treatment significantly improved neurological symptoms.

CONCLUSION

These results indicate an insufficient patient selection, as one-third of patients treated with whole-brain radiotherapy died within 90 days. However, neurological symptoms improved, and the addition of immunotherapy and/or molecularly targeted therapy to whole-brain radiotherapy was associated with better survival. Patients receiving whole-brain irradiation should be more carefully selected.

TRIAL REGISTRATION

ClinicalTrials: 24-3626-104.

Limitations of outcome prediction based on interfractional volume changes of large (≥ 10cm3) brain metastases during fractionated gamma knife radiosurgery

PURPOSE

This study investigated the interfractional volume changes of large (≥ 10 cm3) brain metastases (BMs) during fractionated gamma knife radiosurgery (FGKRS) to assess its predictive value for tumor control outcomes.

METHODS

The patients who underwent FGKRS for large BMs between January 2017 and December 2022 in our center were reviewed. The interfractional volume change was defined as the disparity in tumor volume (TV) measured between the magnetic resonance images acquired on the first treatment day and those obtained after 2 or 3 fractions during the course of FGKRS.

RESULTS

A total of 73 lesions in 70 patients with various primary pathologies were included. Over a median follow-up period of 11 months (range 1-77), the tumor control rate was 63%. Initial TV (cm3) was associated with progression free survival (PFS) and overall survival (OS) in both univariate and multivariate analyses (p = 0.01). Interfractional TV changes revealed an increase in 13 (17.8%) lesions, no change in 14 (19.2%) lesions, and a decrease in 46 (63.0%) lesions, with a mean volume reduction of 5% ± 0.12. Three cut-offs (5%, 10% and 15% volume decrement) were established and patients were divided into two groups based on each reference point. However, there were no significant differences in PFS and OS between the two groups, irrespective of the chosen cut-off value used.

CONCLUSION

Interfractional volume changes of large BMs were not found to be associated with tumor control outcomes. Neither significant interfractional volume reduction nor significant volume increase necessarily predicts the tumor control, making early close monitoring essential after FGKRS.

Whole brain radiation therapy for patients with brain metastases: survival outcomes and prognostic factors in a contemporary institutional series

PURPOSE

To study survival outcomes and prognostic factors in patients undergoing whole brain radiation therapy (WBRT) for brain metastases in the contemporary setting.

METHODS

Patients undergoing WBRT from 2013-2021 were retrospectively included in an ethics-approved institutional database. Patient and treatment characteristics were assessed, including patient age, primary tumor histology, Karnofsky Performance Status (KPS), extracranial disease, as well as WBRT dose. Overall survival (OS) was calculated from onset of WBRT using the Kaplan-Meier method.

RESULTS

A total of 328 patients (median age 63 years) were included. Most patients (52%) had ≥ 10 brain metastases, and 17% had leptomeningeal disease. WBRT was delivered with 10 × 3 Gy (64%), 5 × 4 Gy (25%), or other regimens (11%). Median follow-up was 4.4 months (range, 0.1-154.3), and median OS was 4.7 months (95%CI, 3.8-6.0). OS differed between histologies (p = 0.01), with the longest survival seen in breast cancer (median 7.7 months). Patients with KPS of 90-100 survived for a median of 8.3 months, compared to 4.1 months with KPS 70-80, and 1.7 months with KPS < 70 (p < 0.01). Multivariate analyses revealed that KPS had the largest impact on survival. Patients who received a WBRT dose of ≥ 30 Gy also had a reduced risk of death (HR 0.45; p < 0.001). Survival differed between subgroups reclassified according to the Rades scoring system (p < 0.01).

CONCLUSION

Survival outcomes of patients undergoing WBRT in the contemporary era appear comparable to historical cohorts, although individual patient factors need to be considered. Patients with otherwise favorable prognostic factors may benefit from longer-course WBRT.

Surgical Resection Followed by Stereotactic Radiosurgery (S+SRS) Versus SRS Alone for Large Posterior Fossa Brain Metastases: A Comparative Analysis of Outcomes and Factors Guiding Treatment Modality Selection

BACKGROUND/OBJECTIVES

Around 20% of cancer patients will develop brain metastases (BrMs), with 15-25% occurring in the posterior fossa (PF). Although the effectiveness of systemic therapies is increasing, surgery followed by stereotactic radiosurgery (S+SRS) versus definitive SRS remains the mainstay of treatment. Given the space restrictions within the PF, patients with BrMs in this location are at higher risk of brainstem compression, hydrocephalus, herniation, coma, and death. However, the criteria for treating large PF BrMs with S+SRS versus definitive SRS remains unclear.

METHODS

We reviewed a prospective registry database (2009 to 2020) and identified 64 patients with large PF BrMs (≥4 cc) treated with SRS or S+SRS. Clinical and radiological parameters were analyzed. The two endpoints were overall survival (OS) and local failure (LF).

RESULTS

Patients in the S+SRS group were more highly symptomatic than patients in the SRS group. Gait imbalance and intracranial pressure symptoms were 97% and 80%, and 47% and 35% for S+SRS and SRS, respectively. Radiologically, there were significant differences in the mean volume of the lesions [6.7 cm3 in SRS vs. 29.8 cm3 in the S+SRS cohort, (p < 0.001)]; compression of the fourth ventricle [47% in SRS vs. 96% in S+SRS cohort, (p < 0.001)]; and hydrocephalus [0% in SRS vs. 29% in S+SRS cohort, (p < 0.001)]. Patients treated with S+SRS had a higher Graded Prognostic Assessment (GPA). LF was 12 and 17 months for SRS and S+SRS, respectively. Moreover, the S+SRS group had improved OS (12 vs. 26 months, p = 0.001).

CONCLUSIONS

A higher proportion of patients treated with S+SRS presented with hydrocephalus, fourth-ventricle compression, and larger lesion volumes. SRS-alone patients had a lower KPS, a lower GPA, and more brain metastases. S+SRS correlated with improved OS, suggesting that it should be seriously considered for patients with large PF-BrM.

Blood-brain barrier and blood-brain tumor barrier penetrating peptide-drug conjugate as targeted therapy for the treatment of lung cancer brain metastasis

Lung cancer is the leading cause of cancer deaths worldwide. Brain metastasis of lung cancer, which counts for nearly 50% of late-stage lung cancer patients, is a sign of a really poor prognosis. However, the presence of blood-brain barrier (BBB) and blood-brain tumor barrier (BBTB) limits the penetration of drugs from the blood into the brain and thus restricts their accumulation in brain tumors. Systematic delivery of drugs into brain and brain tumor lesion using BBB and BBTB penetrating vehicles represents a promising strategy to overcome the BBB and BBTB limitations. Hence, we validated one of our previously identified BBB/BBTB penetrating peptide and its drug conjugate form for the treatment of lung cancer brain metastasis. With in vitro experiment, we first validated that the receptor LRP1, which mediated the peptide penetration of the BBB, was expressed on lung cancer cells and thus can be targeted by the peptide to overcome BBTB. With this delivery peptide, we constructed peptide-paclitaxel conjugate (the PDC) and in vitro validation showed that the PDC can across the BBB and efficiently kill lung cancer cells. We therefore constructed mouse lung cancer brain metastasis xenograft. In vivo anti-tumor validations showed that the PDC efficiently inhibited the proliferation of the brain resident lung cancer cells and significantly expanded the survival of the mouse xenograft, with no visible damages to the organs. Overall, our study provided potential therapeutic drugs for the treatment of lung cancer brain metastasis that may be clinically effective in the near future.

Breast Cancer Brain Metastasis: A Comprehensive Review

The mechanisms underlying breast cancer brain metastasis (BCBM) development are complex, and its clinical presentation varies depending on the number, location, and size of brain metastases. Common symptoms include headache, neurologic deficits, and seizures. Diagnosis of BCBM typically relies on neuroimaging techniques, such as magnetic resonance imaging and computed tomography scans. Local therapies, such as surgery and stereotactic radiosurgery, can be used to control tumor growth and relieve symptoms. Whole-brain radiotherapy has been a mainstay of treatment for BCBM, but its use has been associated with cognitive decline. Systemic therapy with chemotherapy and targeted agents plays an increasingly important role in the management of BCBM. Novel agents, such as human epidermal growth factor receptor 2 (HER2)-targeted therapies and tyrosine kinase inhibitors, have shown promising results in improving survival for patients with HER2-positive and triple-negative BCBM. This comprehensive review synthesizes current knowledge, clinical insights, and evolving paradigms to provide a robust understanding and roadmap for optimizing the diagnosis and management of BCBM.

Stereotactic radiosurgery for brain metastases from human epidermal receptor 2 positive breast Cancer: an international, multi-center study

PURPOSE

To report patient outcomes and local tumor control rates in a cohort of patients with biopsy-proven HER-2 positive breast cancer treated with stereotactic radiosurgery (SRS) for brain metastases (BM).

METHODS

This international, retrospective, multicenter study, included 195 female patients with 1706 SRS-treated BM. Radiologic and clinical outcomes after SRS were determined and prognostic factors identified.

RESULTS

At SRS, median patient age was 55 years [interquartile range (IQR) 47.6-62.0], and 156 (80%) patients had KPS ≥ 80. The median tumor volume was 0.1 cm3 (IQR 0.1-0.5) and the median prescription dose was 16 Gy (IQR 16-18). Local tumor control (LTC) rate was 98%, 94%, 93%, 90%, and 88% at six-, 12-, 24-, 36- and 60-months post-SRS, respectively. On multivariate analysis, tumor volume (p = < 0.001) and concurrent pertuzumab (p = 0.02) improved LTC. Overall survival (OS) rates at six-, 12-, 24-, 36-, 48-, and 60-months were 90%, 69%, 46%, 27%, 22%, and 18%, respectively. Concurrent pertuzumab improved OS (p = 0.032). In this patient subgroup, GPA scores ≥ 2.5 (p = 0.038 and p = 0.003) and rare primary tumor histologies (p = 0.01) were associated with increased and decreased OS, respectively. Asymptomatic adverse radiation events (ARE) occurred in 27 (14.0%) and symptomatic ARE in five (2.6%) patients. Invasive lobular carcinoma primary (p = 0.042) and concurrent pertuzumab (p < 0.001) conferred an increased risk for overall but not for symptomatic ARE.

CONCLUSION

SRS affords effective LTC for selected patients with BM from HER-2 positive breast cancer. Concurrent pertuzumab improved LTC and OS but at the same time increased the risk for overall, but not symptomatic, ARE.

Lymphopenia associated with whole-brain radiotherapy and its effects on clinical outcomes of patients with brain metastases

There is increasing awareness of radiotherapy's potential side effects, such as lymphopenia. Therefore, this study aimed to establish the association between WBRT and the development of lymphopenia in patients with brain metastases undergoing brain radiotherapy (RT), along with evaluating the corresponding clinical outcomes. Including 116 patients with brain metastases undergoing brain radiotherapy, the study collected the absolute lymphocyte counts (ALC) within 2 weeks before brain radiotherapy (pre-radiotherapy, pre-RT), as well as ones at 1 and 2 months after completing RT (post-RT). Univariate and multivariate analyses were performed to identify associations between radiation modality and post-RT ALC. The relationships between post-RT ALC and overall survival were evaluated with Kaplan-Meier analysis and a multivariate Cox regression model. The median ALC definitely decreased at 1 month post-RT, but at 2 months post-RT, gradually rose but not to the pre-RT ALC. The multivariate analysis identified WBRT and lower pre-RT ALC as independent risk factors associated with the decrease in post-RT ALC at 1 month. It also revealed more than 4 brain metastases, G3-4 lymphopenia at 1 month and lower post-RT ALC at 2 months exhibited significantly worse prognosis regardless of the radiation modality. However, there was indeed an independent correlation between radiation modality and the outcome of intracranial progression-free survival (PFS). To approach the feasibility and reasonableness of treatment, clinicians should carefully consider various factors to achieve long-term survival of patients.

Radiomics-based prediction of local control in patients with brain metastases following postoperative stereotactic radiotherapy

BACKGROUND

Surgical resection is the standard of care for patients with large or symptomatic brain metastases (BMs). Despite improved local control after adjuvant stereotactic radiotherapy, the risk of local failure (LF) persists. Therefore, we aimed to develop and externally validate a pre-therapeutic radiomics-based prediction tool to identify patients at high LF risk.

METHODS

Data were collected from A Multicenter Analysis of Stereotactic Radiotherapy to the Resection Cavity of BMs (AURORA) retrospective study (training cohort: 253 patients from 2 centers; external test cohort: 99 patients from 5 centers). Radiomic features were extracted from the contrast-enhancing BM (T1-CE MRI sequence) and the surrounding edema (T2-FLAIR sequence). Different combinations of radiomic and clinical features were compared. The final models were trained on the entire training cohort with the best parameter set previously determined by internal 5-fold cross-validation and tested on the external test set.

RESULTS

The best performance in the external test was achieved by an elastic net regression model trained with a combination of radiomic and clinical features with a concordance index (CI) of 0.77, outperforming any clinical model (best CI: 0.70). The model effectively stratified patients by LF risk in a Kaplan-Meier analysis (P < .001) and demonstrated an incremental net clinical benefit. At 24 months, we found LF in 9% and 74% of the low and high-risk groups, respectively.

CONCLUSIONS

A combination of clinical and radiomic features predicted freedom from LF better than any clinical feature set alone. Patients at high risk for LF may benefit from stricter follow-up routines or intensified therapy.

Exposed Phosphatidylserine as a Biomarker for Clear Identification of Breast Cancer Brain Metastases in Mouse Models

Brain metastasis is the most common intracranial malignancy in adults. The prognosis is extremely poor, partly because most patients have more than one brain lesion, and the currently available therapies are nonspecific or inaccessible to those occult metastases due to an impermeable blood-tumor barrier (BTB). Phosphatidylserine (PS) is externalized on the surface of viable endothelial cells (ECs) in tumor blood vessels. In this study, we have applied a PS-targeting antibody to assess brain metastases in mouse models. Fluorescence microscopic imaging revealed that extensive PS exposure was found exclusively on vascular ECs of brain metastases. The highly sensitive and specific binding of the PS antibody enables individual metastases, even micrometastases containing an intact BTB, to be clearly delineated. Furthermore, the conjugation of the PS antibody with a fluorescence dye, IRDye 800CW, or a radioisotope, 125I, allowed the clear visualization of individual brain metastases by optical imaging and autoradiography, respectively. In conclusion, we demonstrated a novel strategy for targeting brain metastases based on our finding that abundant PS exposure occurs on blood vessels of brain metastases but not on normal brain, which may be useful for the development of imaging and targeted therapeutics for brain metastases.

Validity test of small cell lung cancer (SCLC) graded prognostic assessment and proposal of a new index for patients with brain metastases from SCLC

Background and purpose

We performed a validity test of a recently-reported, small cell lung cancer (SCLC) graded prognostic assessment (GPA) system for SCLC patients with brain metastases (BMs). Thereafter, we created a new prognostic index, the SCLC Grade, for such patients.

Materials and methods

We studied 508 SCLC patients selected from among nearly 7000 consecutive patients undergoing gamma knife SRS for BMs since 1998.

Results

In the SCLC GPA, there were no median survival time (MST) differences among pairs of the neighboring subgroups. Therefore, the 508 patients were randomly divided into the two series, i.e., a test (340 patients) and a validity (168) series. In the test series, five factors were identified by univariable analyses as favoring longer survival (rounded lower 95 % CI of the HR was at least 1.3): Sex, Karnofsky Performance Status, tumor numbers, primary tumor status and extracerebral metastases. This new index is the sum of scores (0 and 1) of these five factors: SCLC-Grade 4-6 (score of 4, 5 or 6), 2-3 (2 or 3), and 0-1 (0 or 1). This new system showed highly statistically significant MST differences among subclasses. Next, this SCLC-Grade was applied to the verification series. Consistent results were obtained, i.e., there were highly statistically significant MST differences among subclasses.

Conclusions

Our validity test results for the SCLC GPA demonstrated this system to not precisely reflect the outcomes of SCLC patients with BMs. Our results suggest the herein-proposed SCLC-Grade to have superior prognostic value.

Diagnostic and prognostic risk factors analysis for distant metastasis in melanoma: a population-based study

BACKGROUND

We aimed to develop tools that could predict the occurrence of distant metastases in melanoma and its prognosis based on clinical and pathological characteristics.

MATERIALS AND METHODS

We obtained data from the Surveillance, Epidemiology, and End Results (SEER) database of melanoma patients diagnosed between 2010 and 2019. Logistic analyses were performed to identify independent risk factors associated with distant metastasis. Additionally, multivariate Cox analyses were conducted to determine independent prognostic factors for patients with distant metastasis. Two nomograms were established and evaluated with the receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA). Furthermore, we performed a retrospective analysis of melanoma with distant metastasis from our institute between March 2018 and June 2022.

RESULTS

Of the total 19 396 melanoma patients, 352 (1.8%) had distant metastases at the time of diagnosis. The following clinical and pathological characteristics were identified as independent risk factors for distant metastasis in melanoma: N stage, tumor size, ulceration, mitosis, primary tumor site, and pathological subtype. Furthermore, tumor size, pathological subtype, and radiotherapy were identified as independent prognostic factors. The results of the training and validation cohorts' ROC curves, calibration, DCA, and Kaplan-Meier survival curves demonstrate the effectiveness of the two nomograms. The retrospective study results from our center supported the results from the SEER database.

CONCLUSION

The clinical and pathological characteristics of melanoma can predict a patient's risk of metastasis and prognosis, and the two nomograms are expected to be effective tools to guide therapy decisions.

Neurosurgical resection of multiple brain metastases: outcomes, complications, and survival rates in a retrospective analysis

PURPOSE

This study investigates the outcomes of microsurgical resection of multiple brain metastasis (BMs).

METHODS

This retrospective, monocentric analysis included clinical data from all consecutive BM patients, who underwent simultaneous resection of ≥ 2 BMs between January 2018 and May 2023. Postoperative neurological and functional outcomes, along with perioperative complications, as well as survival data were evaluated.

RESULTS

A total of 47 patients, with a median age of 61 years (IQR 48-69), underwent 73 craniotomies (median 2; range 1-3) for resection of 104 BMs. Among patients, 80.8% presented with symptomatic BMs, causing focal neurological deficits in 53% of cases. Gross total resection was achieved in 87.2% of BMs. Karnofsky Performance Scale (KPS) scores improved in 42.6% of patients, remained unchanged in 46.8%, and worsened in 10.6% after surgery. Perioperative complications were observed in 29.8% of cases, with transient complications occurring in 19.2% and permanent deficits in 10.6%. The 30-days mortality rate was 2.1%. Logistic regression identified eloquent localization (p = 0.036) and infratentorial craniotomy (p = 0.018) as significant predictors of postoperative complications. Concerning overall prognosis, patients with permanent neurological deficits post-surgery (HR 11.34, p = 0.007) or progressive extracranial disease (HR: 4.649; p = 0.006) exhibited inferior survival.

CONCLUSION

Microsurgical resection of multiple BMs leads to clinical stabilization or functional improvement in most patients. Although transient complications do not affect overall survival, the presence of persistent neurological deficits (> 3 months post-surgery) and progressive extracranial disease negatively impact overall survival. This highlights the importance of careful patient selection for resection of multiple BMs.

The indication of palliative whole-brain radiotherapy for patients with brain metastases: a simple prognostic scoring system in the era of stereotactic radiosurgery

BACKGROUND

Stereotactic irradiation has become the mainstay treatment for brain metastases (BM), and whole-brain radiotherapy (WBRT) is often used for symptom palliation. However, the survival time of patients with BM undergoing palliative WBRT (pWBRT) is limited, making it difficult to select patients who should receive treatment.

METHODS

We collected patient data from 2016 to 2022 at the Shizuoka Cancer Center and retrospectively analyzed the factors related to survival time. Overall survival (OS) was defined as the survival time after WBRT.

RESULTS

A total of 301 patients (median age, 66 years) who underwent pWBRT were included. The primary cancers were lung, breast, gastrointestinal tract, and other cancers in 203 (67%), 38 (13%), 33 (11%), and 27 (9%) patients, respectively. Median OS of all patients was 4.1 months. In the multivariate analysis, male sex (hazard ratio [HR]:1.4), Karnofsky Performance Status (KPS) ≤ 60 (HR:1.7), presence of extracranial metastasis (ECM) (HR:1.6), neutrophil-lymphocyte ratio (NLR) ≥ 5 (HR:1.6), and lactate dehydrogenase (LDH) ≥ upper limit of normal (ULN) (HR:1.3) were significantly associated with shorter OS (all P < 0.05). To predict the OS, we created a prognostic scoring system (PSS). We gave one point to each independent prognostic factor. Median OS for patients with scores of 0-2, 3, and 4-5 were 9.0, 3.5 and 1.7 months, respectively (P < 0.001).

CONCLUSIONS

Male sex, KPS ≤ 60, presence of ECM, NLR ≥ 5, and LDH ≥ ULN were poor prognostic factors for patients with BM undergoing pWBRT. By PSS combining these factors, it may be possible to select patients who should undergo pWBRT.

Individualized trajectories in postradiotherapy neurocognitive functioning of patients with brain metastases

Background

The increasing incidence of brain metastases (BMs) and improved survival rates underscore the necessity to investigate the effects of treatments on individuals. The aim of this study was to evaluate the individual trajectories of subjective and objective cognitive performance after radiotherapy in patients with BMs.

Methods

The study population consisted of adult patients with BMs referred for radiotherapy. A semi-structured interview and comprehensive neurocognitive assessment (NCA) were used to assess both subjective and objective cognitive performance before, 3 months and ≥ 11 months after radiotherapy. Reliable change indices were used to identify individual, clinically meaningful changes.

Results

Thirty-six patients completed the 3-month follow-up, and 14 patients completed the ≥ 11-months follow-up. Depending on the domain, subjective cognitive decline was reported by 11-22% of patients. In total, 50% of patients reported subjective decline in at least one cognitive domain. Intracranial progression 3 months postradiotherapy was a risk-factor for self-reported deterioration (P = .031). Objective changes were observed across all domains, with a particular vulnerability for decline in memory at 3 months postradiotherapy. The majority of patients (81%) experienced both a deterioration as well as improvement (eg, mixed response) in objective cognitive functioning. Results were similar for the long-term follow-up (3 to ≥11 months). No risk factors for objective cognitive change 3 months postradiotherapy were identified.

Conclusions

Our study revealed that the majority of patients with BMs will show a mixed cognitive response following radiotherapy, reflecting the complex impact. This underscores the importance of patient-tailored NCAs 3 months postradiotherapy to guide optimal rehabilitation strategies.

Intraoperative radiotherapy after neurosurgical resection of brain metastases as institutional standard treatment- update of the oncological outcome form a single center cohort after 117 procedures

PURPOSE

Stereotactic radiotherapy (SRT) is the predominant method for the irradiation of resection cavities after resection of brain metastases (BM). Intraoperative radiotherapy (IORT) with 50 kV x-rays is an alternative way to irradiate the resection cavity focally. We have already reported the outcome of our first 40 IORT patients treated until 2020. Since then, IORT has become the predominant cavity treatment in our center due to patients´ choice.

METHODS

We retrospectively analyzed the outcomes of all patients who underwent resection of BM and IORT between 2013 and August 2023 at Augsburg University Medical Center (UKA).

RESULTS

We identified 105 patients with 117 resected BM treated with 50 kV x-ray IORT. Median diameter of the resected metastases was 3.1 cm (range 1.3 - 7.0 cm). Median applied dose was 20 Gy. All patients received standardized follow-up (FU) including three-monthly MRI of the brain. Mean FU was 14 months, with a median MRI FU for patients alive of nine months. Median overall survival (OS) of all treated patients was 18.2 months (estimated 1-year OS 57.7%). The observed local control (LC) rate of the resection cavity was 90.5% (estimated 1-year LC 84.2%). Distant brain control (DC) was 61.9% (estimated 1-year DC 47.9%). Only 16.2% of all patients needed WBI in the further course of disease. The observed radio necrosis rate was 2.6%.

CONCLUSION

After 117 procedures IORT still appears to be a safe and appealing way to perform cavity RT after neurosurgical resection of BM with low toxicity and excellent LC.

Risk factors and prognostic factors of brain metastasis of triple-negative breast cancer: A single-center retrospective study

OBJECTIVE

This retrospective study is to explore the risk factors and prognostic factors of brain metastases of triple-negative breast cancer (TNBC) in a single center.

METHODS

Clinical data of patients with stages I-III TNBC were collected. The Kaplan-Meier method, log-rank test, and stepwise COX regression were performed.

RESULTS

The 437 patients with stages I-III TNBC were followed up for five years. Among them, 89 cases (20.4%) developed brain metastases, and they were followed up for 2 years after brain metastasis. The cumulative brain metastasis rates of TNBC patients at six months, one year, two years, three years, and five years were 1.38%, 5.75%, 12.94%, 17.63%, and 21.26%, respectively. Multivariate analysis suggested that the first diagnosis age ≤35 years old, advanced pathological stage, lymph node metastasis, and Ki-67 ≥30% represented the risk factors for brain metastasis. In contrast, the surgical method was a protective factor for brain metastasis. The median survival time after brain metastasis was 4.87 months. The survival rates at one, three, six, 12, and 24 months were 84.27%, 60.67%, 34.83%, 15.69%, and 6.64%, respectively. The age >60 years at first diagnosis, Ki-67 ≥30%, local recurrence, and distant metastasis were closely related to the poor prognosis of TNBC patients with brain metastases, while radiotherapy alone, systemic therapy, and combined chemotherapy and radiotherapy represented the prognostic protective factors.

CONCLUSIONS

Patient age, Ki-67 level, metastasis, and treatment methods are the risk factors and prognostic factors for brain metastasis of TNBC. Surgical resection of the primary lesion during the first treatment is essential to reduce the incidence of brain metastases. Close postoperative follow-up (such as brain magnetic resonance imaging [MRI]) within 2-3 years after surgery is recommended to improve the prognosis.

Initial Age and Performans Status: Predicators for Re-Irradiation Ability in Patients with Relapsed Brain Metastasis after Initial Stereotactic Radiotherapy

BACKGROUND

Brain metastases (BMs) frequently occur in cancer patients, and stereotactic radiation therapy (SRT) is a preferred treatment option. In this retrospective study, we analyzed patients treated by SRT for a single BM during their first SRT session and we compared two subgroups: "Cohort 1" with patients did not undergo cerebral re-irradiation and "Cohort 2" with patients received at least one subsequent SRT session for cerebral recurrence.

METHODS

We included patients who received SRT for a single BM between January 2010 and June 2020. Cohort 1 comprised 152 patients, and Cohort 2 had 46 patients.

RESULTS

Cohort 2 exhibited younger patients with higher Karnofsky performance status (KPS). Median overall survival was considerably longer in Cohort 2 (21.8 months) compared to Cohort 1 (6.1 months). Local and cerebral recurrence rates were significantly higher in Cohort 2 (p < 0.001), attributed to patient selection and longer survival. The combined score of age and KPS proved to be a predictive factor for survival, with patients under 65 years of age and KPS > 80 showing the best survival rates in the overall population.

CONCLUSION

This retrospective study highlights that the combined score of age and KPS can predict better survival, especially for patients under 65 years with a KPS score above 80. Further research involving larger and more diverse populations is essential to validate and expand upon these findings.

Discontinuation of Palliative Brain Radiotherapy in Patients with Brain Metastases: A Case-Control Study

Background: Discontinuation of radiotherapy is rarely discussed in the scientific literature. The goal of this study was, therefore, to estimate the frequency of and reasons for treatment discontinuations in patients receiving radiotherapy for brain metastases from solid tumors and to identify factors predicting said discontinuations. Methods: All patients treated for brain metastases from solid tumors between 2010 and 2020 at our institution were retrospectively reviewed. In addition to collecting relevant patient characteristics, the Recursive Partitioning Analysis (RPA) and disease-specific Graded Prognostic Assessment (GPA) groups for each patient were calculated to assess the performance of these scores in predicting treatment discontinuations. Results: Out of 468 patients who underwent cranial radiotherapy, 35 treatments (7.5%) were discontinued. The most frequent reason was clinical deterioration, which was documented in 26 (74.3%) of discontinued treatments. Patients whose radiotherapy was discontinued had, on average, more leptomeningeal disease (20.0% vs. 12.6%), worse ECOG performance status (mean ECOG performance status 1.86 vs. 1.39), and more uncontrolled extracranial metastases (85.3% vs. 70.8%). The frequencies of treatment discontinuation increased with worse prognosis and differed significantly across RPA groups (p = 0.037) but not across GPA groups (p = 0.612). Conclusions: Treatment discontinuation occurred in 7.5% of cases, mostly due to clinical deterioration. Poor performance status, as well as more advanced disease and, in turn, poor prognosis, were associated with higher discontinuation rates.

Preoperative Blood Counts Predict Overall Survival in Patients Undergoing Surgical Removal of Brain Metastasis

OBJECTIVE

The prognosis for patients with cancer with brain metastasis (BM) requiring surgical removal is quite limited. Preoperative prognostic factors can provide meaningful information to surgeons, oncologists, and patients. This study evaluated the preoperative blood counts in patients with BM who were treated with surgical removal.

METHODS

Between January 2011 and November 2021, 221 consecutive surgeries were conducted on 198 patients with BM. Among the 198 patients, 188 patients with sufficient blood test data and follow-up were analyzed in this study. The tumors originated from the lungs (n = 102, 54.3%), colon (n = 26, 13.3%), breast (n = 13, 6.9%), kidney (n = 8, 4.3%), stomach (n = 6, 3.2%), and others (n = 33, 17.6%). The blood test data included neutrophils, lymphocytes, monocytes, eosinophils, basophils, red blood cell count, hemoglobin, and albumin.

RESULTS

The median follow-up and median survival times were both 11 months (range: 0-139 months). Higher neutrophil-lymphocyte ratio ≥ 3.17, platelet-lymphocyte ratio ≥112.7, systemic immune-inflammation index ≥594.4, systemic inflammation response index ≥1.25 were unfavorable predictors of prognosis for the patients treated with surgical removal for BM (P < 0.001). Furthermore, lower lymphocyte-monocyte ratio < 2.33 and prognostic nutritional index < 48.5 were unfavorable predictors.

CONCLUSIONS

Simple, less expensive, routinely ordered preoperative blood count assessments, such as the neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, lymphocyte-monocyte ratio, systemic immune-inflammation index, systemic inflammation response index, and prognostic nutritional index, can predict the overall survival of patients treated with surgical removal for BM.

Navigating the Complexities of Brain Metastases Management

The management of brain metastases, a potentially devastating complication of advanced cancers, has become increasingly complex with advancements in local and systemic therapies. Improved outcomes and extended survival for patients with metastatic solid tumors have led to a surge in the prevalence and possibly incidence of brain metastases, affecting up to 40% of individuals with solid tumors. Enhanced imaging technologies contribute to more accurate and early detection, shaping the understanding of the intricate landscape of this condition. Traditionally, surgery and radiation stood as the mainstays of treatment because of the limited efficacy of systemic therapies within the brain. However, emerging clinical data, particularly in melanoma, lung, and breast cancers, reveal promising results with novel systemic treatments such as immunotherapy and targeted therapies. Despite the historical exclusion of patients with active brain metastases from clinical trials, a shift is occurring toward a more inclusive approach. This chapter delves into the multifaceted challenges associated with managing brain metastases, with a focus on the evolving landscape of systemic approaches as well as the intricacies of shared decision making, providing a comprehensive overview of the current state and future directions in navigating the complexities of brain metastases management.

Predicting Survival with Brain Metastases in the Stereotactic Radiosurgery Era: are Existing Prognostic Scores Still Relevant? Or Can we do Better?

Predicting survival is essential to tailoring treatment for patients diagnosed with brain metastases. We have evaluated the performance of widely used, validated prognostic scoring systems (Graded Prognostic Assessment and diagnosis-specific Graded Prognostic Assessment) in over 1000 'real-world' patients treated with stereotactic radiosurgery to the brain, selected according to National Health Service commissioning criteria. Survival outcomes from our dataset were consistent with those predicted by the prognostic systems, but with certain cancer subtypes showing a significantly better survival than predicted. Although performance status remains the simplest tool for prediction, total brain tumour volume emerges as an independent prognostic factor, and a new, improved, prognostic scoring system incorporating this has been developed.

A new updated prognostic index for patients with brain metastases (BMs) treated with palliative whole brain radiotherapy (WBRT) in the era of precision oncology. METASNCore project

INTRODUCTION

Palliative WBRT is the main treatment for multiple BMs. Recent studies report no benefit in survival after WBRT compared to palliative supportive care in patients (pts) with poor prognosis. A new era of systemic treatment strategies based on targeted therapies are improving the prognosis of patients with BMs. The purpose of this study is to develop a prognostic score in palliative pts with BMs who undergo WBRT in this new setting.

METHODS

239 pts with BMs who received palliative WBRT between 2013-2022 in our center were analyzed retrospectively. The score was designed according to the value of the β coefficient of each variable with statistical significance in the multivariate model using Cox regression. Once the score was established, a comparison was performed according to Kaplan-Meier and was analyzed by log-rank test.

RESULTS

149 pts (62.3%) were male and median (m) age was 60 years. 139 (58,2%) were lung cancer and 35 (14,6%) breast cancer. All patients received 30Gys in 10 sessions. m overall survival (OS) was 3,74 months (ms). 37 pts (15,5%) had a specific target mutation. We found that 62 pts were in group < 4 points with mOS 6,89 ms (CI 95% 3,18-10,62), 84 in group 4-7 points with mOS 4,01 ms (CI 95% 3,40-4,62) and 92 pts in group > 7 points with mOS 2,72 ms (CI 95% 1,93-3,52) (p < 0,001).

CONCLUSIONS

METASNCore items are associated with OS and they could be useful to select palliative pts to receive WBRT. More studies are necessary to corroborate our findings.

Prognostic Factors and Impact of Therapeutic Intervention in Patients With Brain Metastases at the Initial Presentation

Background Studies investigating the normative characteristics and prognosis of patients diagnosed with brain metastases (BMs) at the onset of cancer are scarce. Therefore, we analyzed real-world treatment options. Methodology This retrospective study enrolled 112 patients newly diagnosed with BM between May 2006 and October 2021. The variables examined included patients' age, sex, recurrence split analysis, Glasgow prognostic score (GPS), number of lesions, tumor size, peripheral brain tumor edema, targeted therapy, supportive care, chemotherapy, and date of onset. Prognostic factors were assessed using recursive partitioning analysis (RPA), graded prognostic assessment (GPA) scores, and GPS scoring, with magnetic resonance imaging (MRI) and computed tomography (CT) studies. Primary treatment comprised whole-brain radiotherapy (WBRT), with regular follow-up. Results Data from 112 survivors were analyzed, revealing a median overall survival time (MST) of 7.7 months, with some patients surviving beyond 24 months post-WBRT. Univariate analysis revealed associations between MST and RPA class, GPS, and treatment modalities (including targeted therapy and chemotherapy). RPA class 2, GPS of 0, and targeted therapy were identified as predictors of better prognosis in the multivariate analysis. In the subgroup not receiving chemotherapy, no significant difference in prognosis was seen between groups with or without WBRT. Conclusions Alongside RPA, scores indicating chronic inflammatory changes, including GPS, were confirmed as crucial prognostic factors. Moreover, treatment with molecularly targeted drugs correlated with favorable prognoses. The treatment-naïve group exhibited poorer prognoses, and WBRT was not deemed a significant prognostic factor in the chemotherapy group.

Survival prediction in patients with gynecological cancer irradiated for brain metastases

BACKGROUND AND PURPOSE

This large population-based, retrospective, single-center study aimed to identify prognostic factors in patients with brain metastases (BM) from gynecological cancers.

MATERIAL AND METHODS

One hundred and forty four patients with BM from gynecological cancer treated with radiotherapy (RT) were identified. Primary cancer diagnosis, age, performance status, number of BM, presence of extracranial disease, and type of BM treatment were assessed. Overall survival (OS) was calculated using the Kaplan-Meier method and the Cox proportional hazards regression model was used for multivariable analysis. A prognostic index (PI) was developed based on scores from independent predictors of OS.

RESULTS

Median OS for the entire study population was 6.2 months. Forty per cent of patients died within 3 months after start of RT. Primary cancer with the origin in cervix or vulva (p = 0.001),  Eastern Cooperative Oncology Group (ECOG) 3-4 (p < 0.001), and the presence of extracranial disease (p = 0.001) were associated with significantly shorter OS. The developed PI based on these factors, categorized patients into three risk groups with a median OS of 13.5, 4.0, and 2.4 months for the good, intermediate, and poor prognosis group, respectively.

INTERPRETATION

Patients with BM from gynecological cancers carry a poor prognosis. We identified prognostic factors and developed a scoring tool to select patients with better or worse prognosis. Patients in the high-risk group have a particular poor prognosis, and omission of RT could be considered.

Overall Survival after Radiotherapy for Brain Metastases According to ECOG Status-A Prospective Study of 294 NSCLC Patients

Up to 40% of non-smallcell lung cancer (NSCLC) patients develop brain metastases (BMs). The potential benefits of radiotherapy (RT) in patients with poor performance status (PS) are questionable, with considerable risk for futile treatment. We analyzed overall survival after initial radiotherapy in NSCLC patients with BMs, focusing on the relationship between PS and survival after RT. This study reports a prospective observational study including consecutive 294 NSCLC patients with first-time BMs. Overall survival (OS) was calculated from the start of RT to death or last follow-up (1 June 2023). Overall, in the 294 included patients (median age 69 years), the median OS was 4.6 months; 2.5 months after WBRT (n = 141), and 7.5 months after SRT (n = 153). After WBRT, mOS was equally poor for patients with ECOG 2 (1.9 months) and ECOG 3-4 (1.2 months). After SRT, mOS for patients with ECOG 2 was 4.1 months; for ECOG 3 patients, mOS was 4 1.6 months. For NSCLC patients with ECOG 2 diagnosed with BMs who are not candidates for surgery or SRT, WBRT should be questioned due to short survival.

The therapeutic effect of radiotherapy combined with systemic therapy compared to radiotherapy alone in patients with simple brain metastasis after first-line treatment of limited-stage small cell lung cancer: a retrospective study

PURPOSE

We aimed to compare the therapeutic effect of radiotherapy (RT) plus systemic therapy (ST) with RT alone in patients with simple brain metastasis (BM) after first-line treatment of limited-stage small cell lung cancer (LS-SCLC).

METHODS

The patients were treated at a single center from January 2011 to January 2022. BM only without metastases to other organs was defined as simple BM. The eligible patients were divided into RT alone (monotherapy arm) and RT plus ST (combined therapy arm). Univariate and multivariate Cox proportional hazards analyses were used to examine factors associated with increased risk of extracranial progression. After 1:1 propensity score matching analysis, two groups were compared for extracranial progression-free survival (ePFS), PFS, overall survival (OS), and intracranial PFS (iPFS).

RESULTS

133 patients were identified and 100 were analyzed (monotherapy arm: n = 50, combined therapy arm: n = 50). The ePFS of the combined therapy was significantly longer than that of the monotherapy, with a median ePFS of 13.2 months (95% CI, 6.6-19.8) in combined therapy and 8.2 months (95% CI, 5.7-10.7) in monotherapy (P = 0.04). There were no statistically significant differences in PFS (P = 0.057), OS (P = 0.309), or iPFS (P = 0.448). Multifactorial analysis showed that combined therapy was independently associated with better ePFS compared with monotherapy (HR = 0.617, P = 0.034); more than 5 BMs were associated with worse ePFS compared with 1-5 BMs (HR = 1.808, P = 0.012).

CONCLUSIONS

Compared with RT alone, combined therapy improves ePFS in patients with simple BM after first-line treatment of LS-SCLC. Combined therapy and 1-5 BMs reduce the risk of extracranial recurrence.

Comparative study of dynamic conformal arc therapy and volumetric modulated arc therapy for treating single brain metastases: A retrospective analysis of dosimetric and clinical outcomes

Background and purpose

Stereotactic radiation therapy (SRT) is commonly used to treat brain metastases (BMs). This retrospective study compared two SRT techniques, dynamic conformal arc therapy (DCAT) and volumetric modulated arc therapy (VMAT), for single BM treatments.

Material and methods

Data of patients treated between January 2010 and June 2020 were considered. Patients with multiple BMs, resected BMs, reirradiation, whole-brain radiation therapy and brainstem metastases were excluded. We focused our analysis on 97 patients who received 23.1 Gy in three fractions. Acute toxicities and follow-up outcomes were recorded. Dosimetric data were analyzed in two subgroups (PTV ≤ 10 cc and PTV > 10 cc).

Results

DCAT and VMAT were used in 70 (72.2 %) and 27 (27.8 %) patients, respectively. Acute toxicities were not significantly different between groups (p = 0.259), and no difference was detected in the incidence rate of radionecrosis, local recurrence and cerebral recurrence (p > 0.999, p > 0.999 and p = 0.682, respectively). PTV coverage was better with DCAT for small volumes (PTV ≤ 10 cc). Mean conformity index (CI) was significantly higher with VMAT and mean gradient index (GI) was significantly lower with DCAT whatever volume subgroups (p < 0.001). DCAT had more heterogeneous plans and VMAT required more monitor units. DCAT resulted in reduced low and intermediate doses, whereas VMAT led to decreased high doses.

Conclusion

DCAT and VMAT are two effective and safe SRT techniques for BMs treatment. In the era of re-irradiation, it is important to reduce the doses delivered to healthy tissues. Further prospective studies are needed to validate these findings.

The dosimetric parameters impact on local recurrence in stereotactic radiotherapy for brain metastases

OBJECTIVES

Stereotactic radiotherapy (SRT) for brain metastases (BM) allows very good local control (LC). However, approximately 20%-30% of these lesions will recur. The objective of this retrospective study was to evaluate the impact of dosimetric parameters on LC in cerebral SRT.

METHODS

Patients treated with SRT for 1-3 BM between January 2015 and December 2018 were retrospectively included. A total of 349 patients with 538 lesions were included. The median gross tumour volume (GTV) was 2 cm3 (IQR, 0-7). The median biological effective dose with α/β = 10 (BED10) was 60 Gy (IQR, 32-82). The median prescription isodose was 71% (IQR, 70-80). Correlations with LC were examined using the Cox regression model.

RESULTS

The median follow-up period was 55 months (min-max, 7-85). Median overall survival was 17.8 months (IQR, 15.2-21.9). There were 95 recurrences and LC at 1 and 2 years was 87.1% (95% CI, 84-90) and 78.1% (95% CI, 73.9-82.4), respectively. Univariate analysis showed that systemic treatment, dose to 2% and 50% of the planning target volume (PTV), BED10 > 50 Gy, and low PTV and GTV volume were significantly correlated with better LC. In the multivariate analysis, GTV volume, isodose, and BED10 were significantly associated with LC.

CONCLUSION

These results show the importance of a BED10 > 50 Gy associated with a prescription isodose <80% to optimize LC during SRT for BM.

ADVANCES IN KNOWLEDGE

Isodose, BED, and GTV volume were significantly associated with LC. A low isodose improves LC without increasing the risk of radionecrosis.