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Roberge D, Brown PD, Whitton A, O'Callaghan C, Leis A, Greenspoon J, Smith GL, Hu JJ, Nichol A, Winch C, Chan MD. The Future Is Now-Prospective Study of Radiosurgery for More Than 4 Brain Metastases to Start in 2018! Front Oncol 2018; 8:380. [PMID: 30271753 PMCID: PMC6146211 DOI: 10.3389/fonc.2018.00380] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/23/2018] [Indexed: 12/25/2022] Open
Abstract
Stereotactic radiosurgery (SRS) has replaced whole brain radiotherapy (WBRT) as standard therapy for most patients with four or fewer brain metastases due to improved cognitive outcomes and more favorable health related quality of life (QoL). Whether SRS or WBRT is the optimal radiation modality for patients with five to fifteen brain metastases remains an open question. Efforts are underway to develop prospective evidence to answer this question. One of the planned trials is a Canadian Cancer Trials Group (CCTG)-lead North American intergroup trial. In general cancer treatments must have two basic aims: prolonging and improving QoL. In this vein, the selection of overall survival and QoL metrics as outcomes appear obvious. Potential secondary outcomes are numerous: patient/disease related, treatment related, economic, translational, imaging, and dosimetric. In designing a trial, one must also ponder what is standard WBRT—specifically, whether it should be associated with memantine. With the rapid accrual of an intergroup trial of hippocampal-sparing WBRT, we may find that the standard WBRT regimen changes in the course of planned trials. As up-front radiosurgery is increasingly used for more than 4 brain metastases without high level evidence, we have a window of opportunity to develop high quality evidence which will help guide our future clinical and policy decisions.
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Affiliation(s)
- David Roberge
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Anthony Whitton
- Division of Radiation Oncology, Juravinski Cancer Centre, Hamilton, ON, Canada
| | | | - Anne Leis
- Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Jeffrey Greenspoon
- Division of Radiation Oncology, Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Grace Li Smith
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - Jennifer J Hu
- Department of Public Health Sciences, University of Miami School of Medicine, Miami, FL, United States
| | - Alan Nichol
- BC Cancer Agency, Vancouver Centre, Vancouver, BC, Canada
| | - Chad Winch
- Canadian Cancer Trials Group, Kingston, ON, Canada
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
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Vouk K, Benter U, Amonkar MM, Marocco A, Stapelkamp C, Pfersch S, Benjamin L. Cost and economic burden of adverse events associated with metastatic melanoma treatments in five countries. J Med Econ 2016; 19:900-12. [PMID: 27123564 DOI: 10.1080/13696998.2016.1184155] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To estimate per-event cost and economic burden associated with managing the most common and/or severe metastatic melanoma (MM) treatment-related adverse events (AEs) in Australia, France, Germany, Italy, and the UK. METHODS AEs associated with chemotherapy (dacarbazine, paclitaxel, fotemustine), immunotherapy (ipilimumab), and targeted therapy (vemurafenib) were identified by literature review. Medical resource use data associated with managing AEs were collected through two blinded Delphi panel cycles in each of the five countries. Published costs were used to estimate per-event costs and combined with AEs incidence, treatment usage, and MM prevalence to estimate the economic burden for each country. RESULTS The costliest AEs were grade 3/4 events due to immunotherapy (Australia/France: colitis; UK: diarrhea) and chemotherapy (Germany/Italy: neutropenia/leukopenia). Treatment of AEs specific to chemotherapy (Australia/Germany/Italy/France: neutropenia/leukopenia) and targeted therapy (UK: squamous cell carcinoma) contributed heavily to country-specific economic burden. LIMITATIONS Economic burden was estimated assuming that each patient experienced an AE only once. In addition, the context of settings was heterogeneous and the number of Delphi panel experts was limited. CONCLUSIONS Management costs for MM treatment-associated AEs can be substantial. Results could be incorporated in economic models that support reimbursement dossiers. With the availability of newer treatments, establishment of a baseline measure of the economic burden of AEs will be crucial for assessing their impact on patients and regional healthcare systems.
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Affiliation(s)
| | | | | | | | | | - Sylvie Pfersch
- e Novartis Pharma S.A.S. , Rueil-Malmaison Cedex , France
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Nowak-Sadzikowska J, Walasek T, Jakubowicz J, Blecharz P, Reinfuss M. Current treatment options of brain metastases and outcomes in patients with malignant melanoma. Rep Pract Oncol Radiother 2015; 21:271-7. [PMID: 27601961 DOI: 10.1016/j.rpor.2015.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/31/2015] [Accepted: 12/01/2015] [Indexed: 10/22/2022] Open
Abstract
The prognosis for patients with melanoma who have brain metastases is poor, a median survival does not exceed 4-6 months. There are no uniform standards of treatment for patients with melanoma brain metastases (MBMs). The most preferred treatment approaches include local therapy - surgical resection and/or stereotactic radiosurgery (SRS). The role of whole brain radiotherapy (WBRT) as an adjuvant to local therapy is controversial. WBRT remains a palliative approach for those patients who have multiple MBMs with contraindications for surgery or SRS, or/and poor performance status, or/and very widespread extracranial metastases. Corticosteroids have been used in palliative treatment of MBMs as relief from symptoms related to intracranial pressure and edema. In recent years, the development of new systemic therapeutic strategies has been observed. Various modalities of systemic treatment include chemotherapy, immunotherapy and targeted therapy. Also, multimodality management in different combinations is a common strategy. Decisions regarding the use of specific treatment modalities are dependent on patient's performance status, and the extent of both intracranial and extracranial disease. This review summarizes current treatment options, indications and outcomes in patients with brain metastases from melanoma.
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Affiliation(s)
- Jadwiga Nowak-Sadzikowska
- Oncology Clinic, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Kraków, Poland
| | - Tomasz Walasek
- Radiotherapy Department, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Kraków, Poland
| | - Jerzy Jakubowicz
- Oncology Clinic, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Kraków, Poland
| | - Paweł Blecharz
- Gynecologic Oncology Clinic, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Kraków, Poland
| | - Marian Reinfuss
- Radiotherapy Department, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Kraków, Poland
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Lubrano V, Derrey S, Truc G, Mirabel X, Thariat J, Cupissol D, Sassolas B, Combemale P, Modiano P, Bedane C, Dygai-Cochet I, Lamant L, Mourrégot A, Rougé Bugat MÈ, Siegrist S, Tiffet O, Mazeau-Woynar V, Verdoni L, Planchamp F, Leccia MT. [Locoregional treatments of brain metastases for patients with metastatic cutaneous melanoma: French national guidelines]. Neurochirurgie 2014; 60:269-75. [PMID: 25241016 DOI: 10.1016/j.neuchi.2014.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 05/12/2014] [Accepted: 05/21/2014] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The management of metastatic cutaneous melanoma is changing, marked by innovative therapies. However, their respective use and place in the therapeutic strategy continue to be debated by healthcare professionals. OBJECTIVE The French national cancer institute has led a national clinical practice guideline project since 2008. It has carried out a review of these modalities of treatment and established recommendations. METHODS The clinical practice guidelines development process is based on systematic literature review and critical appraisal by experts. The recommendations are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines are reviewed by independent practitioners in cancer care delivery. RESULTS This article presents the results of bibliographic search, the conclusions of the literature and the recommendations concerning locoregional treatments of brain metastases for patients with metastatic cutaneous melanoma.
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Affiliation(s)
- V Lubrano
- Service de neurochirurgie, hôpital de Rangueil, CHU de Toulouse, 1, avenue du Professeur-Jean-Poulhès, TSA 50032, 31059 Toulouse, France
| | - S Derrey
- Département de neurochirurgie, hôpital Charles-Nicolle, 1, rue de Germont, 76000 Rouen, France
| | - G Truc
- Département de radiothérapie, centre Georges-François-Leclerc, 1, rue du Professeur-Marion, BP 77980, 21079 Dijon, France
| | - X Mirabel
- Département de radiothérapie-curiethérapie, centre Oscar-Lambret, 3, rue Frédéric-Combemale, BP 307, 59020 Lille, France
| | - J Thariat
- Pôle de radiothérapie, centre Antoine-Lacassagne, 33, avenue de Valombrose, 06189 Nice, France
| | - D Cupissol
- Service d'oncologie médicale, ICM, institut du cancer de Montpellier Val-d'Aurelle, 208, avenue des Apothicaires, parc Euromédecine, 34298 Montpellier, France
| | - B Sassolas
- Service de dermatologie, hôpital Cavale-Blanche, boulevard Tanguy-Prigent, 29609 Brest, France
| | - P Combemale
- Unité onco-dermatologie, centre Léon Bérard, 28, rue Laennec, 69008 Lyon, France
| | - P Modiano
- Service de dermatologie, hôpital Saint-Vincent-de-Paul, boulevard de Belfort, BP 387, 59020 Lille, France
| | - C Bedane
- Service de dermatologie, hôpital Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges, France
| | - I Dygai-Cochet
- Service de médecine nucléaire, centre Georges-François-Leclerc, 1, rue du Professeur-Marion, BP 77980, 21079 Dijon, France
| | - L Lamant
- Service d'anatomie pathologique, hôpital Purpan, place Baylac, 31059 Toulouse, France
| | - A Mourrégot
- Service de chirurgie oncologique, ICM, institut du cancer de Montpellier Val-d'Aurelle, 208, avenue des Apothicaires, parc Euromédecine, 34298 Montpellier, France
| | - M-È Rougé Bugat
- Cabinet médical, 59, rue de la Providence, 31500 Toulouse, France
| | - S Siegrist
- Cabinet médical, 3, rue Saint-Sigisbert, 57050 le Ban-Saint-Martin, France
| | - O Tiffet
- Service de chirurgie générale et thoracique, centre hospitalier universitaire, 42055 Saint-Étienne, France
| | - V Mazeau-Woynar
- Direction des recommandations et de la qualité de l'expertise, Institut national du cancer, 52, avenue André-Morizet, 92513 Boulogne-Billancourt, France
| | - L Verdoni
- Direction des recommandations et de la qualité de l'expertise, Institut national du cancer, 52, avenue André-Morizet, 92513 Boulogne-Billancourt, France
| | - F Planchamp
- Direction des recommandations et de la qualité de l'expertise, Institut national du cancer, 52, avenue André-Morizet, 92513 Boulogne-Billancourt, France.
| | - M-T Leccia
- Clinique de dermatolo-vénéréologie, photobiologie et allergologie, pôle pluridisciplinaire de médecine, hôpital Michallon, 38043 Grenoble, France
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Abstract
Melanoma spreads to the CNS with an incidence of 4 to 20%. Metastases from cancer of the colorectal and genitourinary tract, as well as sarcoma, are less frequent (1%). Surgery should be considered for single brain metastases in patients with controllable disease. Stereotactic needle biopsy may still be worthwhile to confirm diagnosis, and also in patients whose tumors are considered unresectable. Whole-brain radiotherapy is the treatment of choice for most brain metastases, since more than 70% of patients have multiple metastases at the time of diagnosis. Radiosurgery is particularly useful for patients unable to tolerate surgery and for patients with lesions inaccessible to surgery. Chemotherapy could be useful in patients with asymptomatic brain metastases and uncontrolled extracranial disease, depending on performance status and previous chemotherapy received.
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Affiliation(s)
- Alicia Tosoni
- Department of Medical Oncology, Azienda Ospedale, University of Padova, Italy.
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McWilliams RR, Rao RD, Buckner JC, Link MJ, Markovic S, Brown PD. Melanoma-induced brain metastases. Expert Rev Anticancer Ther 2014; 8:743-55. [DOI: 10.1586/14737140.8.5.743] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
PURPOSE OF REVIEW To summarize developments in the management of brain metastases over the past decade. RECENT FINDINGS A few randomized trials have been published during the past decade examining the use of whole brain radiotherapy (WBRT) and radiosurgery (SRS) boost versus WBRT alone. Other recent trials have been published examining the use of SRS alone versus SRS and WBRT.There continues to be neither a role for the routine use of chemotherapy (excluding patients with metastatic seminoma to brain) nor radiosensitizers in the management of patients with brain metastases. SUMMARY The management options for selected patients with brain metastases today include steroids (to treat brain edema), anticonvulsants (to treat seizures), WBRT, surgery (for single brain metastasis) and radiosurgery (SRS), either alone or in combination. Survival, local metastasis control, overall brain control, and neuro-cognitive outcomes should influence management. New therapeutic areas of research for brain metastases include defining the role of conventional and novel chemotherapy and targeted agents, radiation sensitizers, and stem cell-associated therapies either alone or in combination with various forms of radiation, as well as decreasing radiation morbidities, using drugs or technology.
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Tsao MN, Rades D, Wirth A, Lo SS, Danielson BL, Gaspar LE, Sperduto PW, Vogelbaum MA, Radawski JD, Wang JZ, Gillin MT, Mohideen N, Hahn CA, Chang EL. Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es): An American Society for Radiation Oncology evidence-based guideline. Pract Radiat Oncol 2012; 2:210-225. [PMID: 25925626 PMCID: PMC3808749 DOI: 10.1016/j.prro.2011.12.004] [Citation(s) in RCA: 412] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 12/09/2011] [Accepted: 12/15/2011] [Indexed: 12/25/2022]
Abstract
Purpose To systematically review the evidence for the radiotherapeutic and surgical management of patients newly diagnosed with intraparenchymal brain metastases. Methods and Materials Key clinical questions to be addressed in this evidence-based Guideline were identified. Fully published randomized controlled trials dealing with the management of newly diagnosed intraparenchymal brain metastases were searched systematically and reviewed. The U.S. Preventative Services Task Force levels of evidence were used to classify various options of management. Results The choice of management in patients with newly diagnosed single or multiple brain metastases depends on estimated prognosis and the aims of treatment (survival, local treated lesion control, distant brain control, neurocognitive preservation). Single brain metastasis and good prognosis (expected survival 3 months or more): For a single brain metastasis larger than 3 to 4 cm and amenable to safe complete resection, whole brain radiotherapy (WBRT) and surgery (level 1) should be considered. Another alternative is surgery and radiosurgery/radiation boost to the resection cavity (level 3). For single metastasis less than 3 to 4 cm, radiosurgery alone or WBRT and radiosurgery or WBRT and surgery (all based on level 1 evidence) should be considered. Another alternative is surgery and radiosurgery or radiation boost to the resection cavity (level 3). For single brain metastasis (less than 3 to 4 cm) that is not resectable or incompletely resected, WBRT and radiosurgery, or radiosurgery alone should be considered (level 1). For nonresectable single brain metastasis (larger than 3 to 4 cm), WBRT should be considered (level 3). Multiple brain metastases and good prognosis (expected survival 3 months or more): For selected patients with multiple brain metastases (all less than 3 to 4 cm), radiosurgery alone, WBRT and radiosurgery, or WBRT alone should be considered, based on level 1 evidence. Safe resection of a brain metastasis or metastases causing significant mass effect and postoperative WBRT may also be considered (level 3). Patients with poor prognosis (expected survival less than 3 months): Patients with either single or multiple brain metastases with poor prognosis should be considered for palliative care with or without WBRT (level 3). It should be recognized, however, that there are limitations in the ability of physicians to accurately predict patient survival. Prognostic systems such as recursive partitioning analysis, and diagnosis-specific graded prognostic assessment may be helpful. Conclusions Radiotherapeutic intervention (WBRT or radiosurgery) is associated with improved brain control. In selected patients with single brain metastasis, radiosurgery or surgery has been found to improve survival and locally treated metastasis control (compared with WBRT alone).
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Affiliation(s)
- May N Tsao
- Department of Radiation Oncology, University of Toronto, Odette Cancer Centre, Toronto, Ontario, Canada.
| | - Dirk Rades
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Luebeck, Germany (ESTRO representative)
| | - Andrew Wirth
- Peter MacCallum Cancer Center, Trans Tasman Radiation Oncology Group (TROG), East Melbourne, Australia
| | - Simon S Lo
- Department of Radiation Oncology, Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Brita L Danielson
- Department of Radiation Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Canada (CARO representative)
| | - Laurie E Gaspar
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Paul W Sperduto
- University of Minnesota Gamma Knife Center and Minneapolis Radiation Oncology, Minneapolis, Minnesota
| | | | | | - Jian Z Wang
- Department of Radiation Oncology, Ohio State University, Columbus, Ohio (deceased)
| | - Michael T Gillin
- Department of Radiation Oncology, M.D. Anderson Cancer Center, Houston, Texas
| | - Najeeb Mohideen
- Department of Radiation Oncology, Northwest Community Hospital, Arlington Heights, Illinois
| | - Carol A Hahn
- Department of Radiation Oncology, Duke University Medical School, Durham, North Carolina
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, California
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Rades D, Panzner A, Dziggel L, Haatanen T, Lohynska R, Schild SE. Dose-escalation of whole-brain radiotherapy for brain metastasis in patients with a favorable survival prognosis. Cancer 2011; 118:3852-9. [PMID: 22170514 DOI: 10.1002/cncr.26680] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 09/19/2011] [Accepted: 10/06/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patients with brain metastases who have a favorable survival prognosis may benefit from intensive treatments, including neurosurgery and radiosurgery. However, many patients cannot receive such treatments, and whole-brain radiotherapy (WBRT) alone is their only option. The most common WBRT schedule is 30 grays (Gy) in 10 fractions. In this retrospective study, the authors investigated whether these patients benefit from a dose escalation beyond 30 Gy. METHODS Data from 109 patients who received 30 Gy in 10 fractions were compared with 75 patients who received 40 Gy in 20 fractions. All patients had a favorable survival prognosis. Both groups were compared for local control (LC) and overall survival (OS). Subgroup analyses were performed for patients who had less radiosensitive tumors (N = 27) and for other patients (N = 157). RESULTS The LC rate at 1 year was 28% after 30 Gy and 44% after 40 Gy (P = .064). On multivariate analysis, the 40 Gy dose was associated with improved LC (P = .047). The survival rate at 1 year was 50% after 30 Gy and 61% after 40 Gy (P = .007). On multivariate analysis, the 40 Gy dose was associated with improved OS (P = .008). On subgroup analysis of patients who had less radiosensitive tumors, the 1-year LC rate was 7% after 30 Gy and 38% after 40 Gy (P = .031); and the 1-year OS rate was 40% and 73%, respectively (P = .008). On subgroup analysis of patients who had other tumor types, the 1-year LC rate was 31% after 30 Gy and 45% after 40 Gy (P = .26); and the 1-year OS rate was 52% and 59%, respectively (P = .08). CONCLUSIONS Escalation of the WBRT dose beyond 30 Gy resulted in better outcomes, particularly for patients who had less radiosensitive tumors.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lubeck, Ratzeburger Allee 160, Lubeck, Germany.
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Mendivil AA, Rettenmaier MA, Cox C, Abaid LN, Brown III JV, Micha JP, Lopez KL, Goldstein BH. Acute and Delayed Complications from Surgery and Adjuvant Radiotherapy in the Treatment of High-Risk Endometrial Cancer. Oncology 2011; 81:79-83. [DOI: 10.1159/000330821] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 07/01/2011] [Indexed: 12/12/2022]
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Radioactive EGFR antibody cetuximab in multimodal cancer treatment: stability and synergistic effects with radiotherapy. Int J Radiat Oncol Biol Phys 2009; 75:1226-31. [PMID: 19356858 DOI: 10.1016/j.ijrobp.2008.12.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2008] [Revised: 12/05/2008] [Accepted: 12/11/2008] [Indexed: 11/21/2022]
Abstract
PURPOSE Systemic therapies when added to whole brain radiotherapy have failed to improve the survival of patients with multiple brain metastases. The epidermal growth factor receptor antibody cetuximab is an attractive option, if it is able to cross the blood-brain barrier. This might be proven with molecular imaging if the radiolabeled antibody is stable long enough to be effective. This study investigated the stability of radiolabeled cetuximab (Erbitux) ((131)I-Erbi) and potential synergistic effects with radiotherapy in vitro. METHODS AND MATERIALS Two cell lines were investigated, A431 with numerous epidermal growth factor receptors, and JIMT without epidermal growth factor receptors. We labeled 0.4 mg cetuximab with 50 MBq of [(131)I] iodide. Stability was determined for 72 h. The cell cultures were incubated with (131)I-Erbi or cold cetuximab for 72 h. Uptake and cell proliferation were measured every 24 h after no radiotherapy or irradiation with 2, 4, or 10 Gy. RESULTS The radiolabeling yield of (131)I-Erbi was always >80%. The radiochemical purity was still 93.6% after 72 h. A431 cells showed a (131)I-Erbi uptake about 100-fold greater than the JIMT controls. After 48 h, the A431 cultures showed significantly decreased proliferation. At 72 h after irradiation, (131)I-Erbi resulted in more pronounced inhibition of cell proliferation than the cold antibody in all radiation dose groups. CONCLUSION (131)I-Erbi was stable for <or=72 h. Radiotherapy led to increased tumor cell uptake of (131)I-Erbi. Radiotherapy and (131)I-Erbi synergistically inhibited tumor cell proliferation. These results provide the prerequisite data for a planned in vivo study of whole brain radiotherapy plus cetuximab for brain metastases.
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Xu KC, Niu LZ, Hu YZ, He WB, He YS, Zuo JS. Cryosurgery with combination of (125)iodine seed implantation for the treatment of locally advanced pancreatic cancer. J Dig Dis 2008; 9:32-40. [PMID: 18251792 DOI: 10.1111/j.1443-9573.2007.00322.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To study the therapeutic value of cryosurgery with combination of (125)iodine seed implantation for locally advanced pancreatic cancer. METHODS Thirty-eight patients with locally advanced pancreatic cancer were enrolled in this study. The diagnosis was confirmed by pathology in 31 patients. Ten patients had metastases of the peripancreatic lymph node and eight had liver metastases. The therapy included cryosurgery, which was performed intra-operatively or percutaneously under guidance of ultrasound and/or computed tomography (CT), and (125)iodine seed implantation, which was performed during cryosurgery process or post-cryosurgery under the guidance of ultrasound and/or CT. RESULTS Eleven patients received intra-operative cryosurgery and 27 received percutaneous cryosurgery. Fourteen patients underwent two procedures of cryosurgery and three underwent three procedures of cryosurgery. (125)Iodine seed implantation was performed during the freezing procedure in 29 patients and within 3-7 days after cryosurgery in nine patients under ultrasound and CT guidance. Fifteen patients, of whom 13 had metastases of peripancreatic lymph nodes or liver received regional chemotherapy. At 3 months after therapy, a CT follow-up was performed to estimate the tumor response to therapy. Most of the patients had varying degrees of tumor necrosis. A complete response of the tumor was seen in 23.6% of patients, a partial response in 42.1%, stable disease in 26.3% and progressive disease in 7.9%. The adverse effects associated with cryosurgery mainly included pain of the upper abdomen and increased serum amylase activity. Acute pancreatitis was seen in five patients, one of whom presented a severe type of pancreatitis. During the followed-up of a median of 16 months (range of 5-37) median overall survival was 12 months, 19 patients (50.0%) survived for 12 months or longer and four survived for 24 months or longer. CONCLUSION As it is far less invasive than conventional pancreas resection and entails a low rate of adverse effects, cryosurgery should be the choice modality for most patients with locally advanced pancreatic cancer. (125)Iodine seed implantation can destroy residue survival cancer cells after cryosurgery. Hence, combination of both modalities has a complementary effect.
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Affiliation(s)
- Ke Cheng Xu
- Cryosurgery Center for Cancer, Fuda Cancer Hospital Guangzhou, Guangzhou, China.
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15
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Rades D, Haatanen T, Schild SE, Dunst J. Dose escalation beyond 30 grays in 10 fractions for patients with multiple brain metastases. Cancer 2007; 110:1345-50. [PMID: 17639588 DOI: 10.1002/cncr.22906] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Whole-brain radiotherapy (WBRT) to 30 grays (Gy) in 10 fractions is the standard treatment in patients with multiple brain metastases in the majority of treatment centers worldwide. The current study investigated the potential benefit of dose escalation beyond 30 Gy. METHODS Data regarding 416 patients who were treated with WBRT for multiple brain metastases were evaluated retrospectively. Survival and freedom from recurrent brain metastasis (local control) of 257 patients who were treated with 10 fractions of 3 Gy each for 2 weeks were compared with those of 159 patients treated with 45 Gy in 15 fractions for 3 weeks or 40 Gy in 20 fractions for 4 weeks. Eight additional potential prognostic factors were investigated including age, gender, Karnofsky performance score (KPS), tumor type, interval between tumor diagnosis and RT, number of metastases, extracranial metastases, and Recursive Partitioning Analysis (RPA) class. RESULTS On multivariate analysis, improved survival was found to be associated with lower RPA class (P < .001), age <60 years (P = .026), KPS >or=70 (P < .001), and absence of extracranial metastases (P = .003). A trend was observed for number of metastases (2-3 vs >or=4; P = .07). Improved local control was associated with a KPS >or=70 (P < .001) and breast cancer (P < .001). A trend was observed for number of metastases (P = .059). The RT schedule did not appear to have any significant impact on survival (P = .86) or local control (P = .61). The subgroup analyses, performed for each of the 3 RPA classes, did not demonstrate a significantly better outcome with dose escalation. CONCLUSIONS Dose escalation beyond 30 Gy in 10 fractions does not appear to improve survival or local control in patients with multiple brain metastases but does increase the treatment time and cost of therapy.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Luebeck, Germany.
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McWilliams RR, Rao RD, Brown PD, Link MJ, Buckner JC. Treatment options for brain metastases from melanoma. Expert Rev Anticancer Ther 2006; 5:809-20. [PMID: 16221051 DOI: 10.1586/14737140.5.5.809] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Brain metastases are a common complication of metastatic malignant melanoma, conferring an exceedingly poor prognosis. Diagnosis of brain metastasis often has significant implications for duration and quality of life, and management can be difficult due to rapid progression of disease and resistance to conventional therapies. This review focuses primarily on the published evidence for treatment modalities for brain metastases from melanoma, emerging technologies and outlines future directions for research. In summary, external-beam radiation alone appears effective in palliating symptoms. Surgical management of solitary or acutely symptomatic lesions appears to alleviate symptoms and provide the possibility of local control of disease. Stereotactic radiosurgery is an increasingly utilized technique for patients with a limited number of metastases and presents a less-invasive alternative to craniotomy. Chemotherapy alone is relatively ineffective, although combined chemotherapy with external-beam radiation is being investigated. Future directions include combined modality therapy, the incorporation of novel agents and careful consideration of the structure of clinical trials for this disease.
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Affiliation(s)
- Robert R McWilliams
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, MN 55905, USA.
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Tsao MN, Lloyd NS, Wong RKS, Rakovitch E, Chow E, Laperriere N. Radiotherapeutic management of brain metastases: A systematic review and meta-analysis. Cancer Treat Rev 2005; 31:256-73. [PMID: 15951117 DOI: 10.1016/j.ctrv.2005.04.007] [Citation(s) in RCA: 141] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The management of brain metastases is a significant health care problem. An estimated 20-40% of cancer patients will develop metastatic cancer to the brain during the course of their illness. METHODS A systematic review of randomized trials on adult cancer patients with single or multiple brain metastases from cancer of any histology was conducted. Eligible studies investigated external beam radiotherapy or radiosurgery in one of the study arms. Outcomes of interest included survival, intracranial progression-free duration, response of brain metastases to therapy, quality of life, symptom control, neurological function, and toxicity. RESULTS Twenty-seven trials were included in this systematic review of the evidence. Pooled results from three randomized trials of surgical excision combined with whole brain radiotherapy (WBRT) showed no improvement in overall survival as compared to WBRT alone in patients with single brain metastasis. One randomized study of postoperative WBRT following excision of a single brain metastasis versus surgery alone detected a significant reduction in intracranial tumour recurrence rates but no corresponding difference in overall survival. Nine trials of altered dose-fractionation schedules compared to a standard control fractionation schedule (3000 cGy in 10 fractions) of WBRT showed no difference in probability of survival at 6 months. The addition of radiosensitizers, as assessed in five trials, did not confer additional benefit to WBRT in terms of overall survival or the frequency of brain metastases response. Three trials examined the use of WBRT and radiosurgery boost versus WBRT alone in selected patients with brain metastases. Overall survival did not improve for patients with multiple brain metastases. However, one trial reported an improvement in survival for patients with single brain metastasis treated with WBRT and radiosurgery boost. One older randomized trial examined the use of WBRT versus supportive care alone (using oral prednisone). Results were not conclusive. CONCLUSION For patients with a single brain metastasis, good performance status, and minimal or no evidence of extracranial disease, surgical excision and postoperative WBRT improves survival (as compared to WBRT alone). There may be a small survival advantage associated with the use of radiosurgery boost and WBRT as compared to WBRT alone in selected patients with a single brain metastasis. There is no difference in overall survival or in neurologic function improvement with the use of altered whole brain dose-fractionation schedules as compared to standard fractionation schedules (3000 cGy in 10 fractions or 2000 cGy in 5 fractions). There is no survival benefit associated with the use of radiosurgery boost and WBRT versus WBRT alone in patients with multiple brain metastases. Currently, neither chemotherapy nor radiosensitizers show a clear benefit in the objective parameters of survival and progression-free survival. For patients with poor performance status and active extracranial disease, steroids and supportive care are an option.
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Affiliation(s)
- May N Tsao
- Department of Radiation Oncology, Toronto-Sunnybrook Regional Cancer Centre, 2075 Bayview Avenue, Toronto, Ont., Canada M4N 3M5.
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Tosoni A, Ermani M, Brandes AA. The pathogenesis and treatment of brain metastases: a comprehensive review. Crit Rev Oncol Hematol 2004; 52:199-215. [PMID: 15582786 DOI: 10.1016/j.critrevonc.2004.08.006] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2004] [Indexed: 12/22/2022] Open
Abstract
Brain metastases are the most common intracranial tumors and their incidence is increasing. Untreated brain metastases are associated with a poor prognosis and a poor performance status. The role of surgery in the management of multiple brain metastases is still controversial. As more than 70% of patients have multiple metastases at the time of diagnosis, whole brain radiotherapy is the treatment of choice in most cases. Brain metastases are an ideal target for stereotactic radiosurgery, as they are better circumscribed than primary brain tumors. Currently, chemotherapy has a limited role in the treatment of most brain metastases. Several new therapies, with a good penetration through the blood brain barrier, such as temozolomide, have been used in brain metastases with different results depending on the histology of the primary tumor. A better understanding of the complex processes underlying the development of brain metastasis will enable us to develop more satisfactory targeted treatments.
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Affiliation(s)
- Alicia Tosoni
- Department of Medical Oncology, University Hospital of Padova, Ospedale Busonera, Via Gattamelata 64, 35100 Padova, Italy
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Morris SL, Low SH, A'Hern RP, Eisen TG, Gore ME, Nutting CM, Harrington KJ. A prognostic index that predicts outcome following palliative whole brain radiotherapy for patients with metastatic malignant melanoma. Br J Cancer 2004; 91:829-33. [PMID: 15305201 PMCID: PMC2409881 DOI: 10.1038/sj.bjc.6602018] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
To determine the outcome of patients with metastatic malignant melanoma (MMM) treated with palliative whole brain radiotherapy (WBRT) and to identify factors that predict treatment outcome to assist future trial design, a retrospective study was performed on patients with MMM who received WBRT at the Royal Marsden Hospital between 1998 and 2003. Data regarding patient factors, tumour factors and survival were collected. A total of 112 patients were identified and full data were available for 102 patients. The median age was 53 years (range 25–81 years), 66.7% were male and 33.3% female. The median dose prescribed was 20 Gy in five fractions as a mid-plane dose. The median survival after WBRT for the whole group was 51 days (range 3–1386). In an attempt to define prognostic groups, we used the validated RTOG recursive partitioning analysis (RPA) classification for brain metastasis (class 1: Karnofsky Performance Score (KPS) ⩾70%, age <65 years with no extracranial metastasis; class 3: KPS <70%; class 2: all others). The median survivals were 151, 71 and 21 days for RPA class 1, 2 and 3, respectively (P<0.001). Multivariate analysis showed that RPA class, leptomeningeal involvement, presence and number of extracranial metastatic sites and progressive disease in the brain on imaging before WBRT are important independent predictive factors. A prognostic index was derived from these factors that allowed identification of patients unlikely to benefit from WBRT. In conclusion, the RTOG RPA classification is valid when applied to patients with MMM. Patients in RPA class 1 and good prognosis class 2 are likely to benefit from palliative WBRT and should be considered for entry into trials that aim to improve duration of response. We identified that patients with RPA class 3, leptomeningeal involvement or RPA class 2 with poor prognostic index are unlikely to benefit from palliative WBRT.
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Affiliation(s)
- S L Morris
- Melanoma Unit, The Royal Marsden Hospital NHS Trust, 203 Fulham Road, London SW3 6JJ, UK
| | - S H Low
- Melanoma Unit, The Royal Marsden Hospital NHS Trust, 203 Fulham Road, London SW3 6JJ, UK
| | - R P A'Hern
- Melanoma Unit, The Royal Marsden Hospital NHS Trust, 203 Fulham Road, London SW3 6JJ, UK
| | - T G Eisen
- Melanoma Unit, The Royal Marsden Hospital NHS Trust, 203 Fulham Road, London SW3 6JJ, UK
- Institute of Cancer Research, 237 Fulham Road, London SW3 6JB, UK
| | - M E Gore
- Melanoma Unit, The Royal Marsden Hospital NHS Trust, 203 Fulham Road, London SW3 6JJ, UK
- Institute of Cancer Research, 237 Fulham Road, London SW3 6JB, UK
| | - C M Nutting
- Melanoma Unit, The Royal Marsden Hospital NHS Trust, 203 Fulham Road, London SW3 6JJ, UK
- Institute of Cancer Research, 237 Fulham Road, London SW3 6JB, UK
| | - K J Harrington
- Melanoma Unit, The Royal Marsden Hospital NHS Trust, 203 Fulham Road, London SW3 6JJ, UK
- Institute of Cancer Research, 237 Fulham Road, London SW3 6JB, UK
- Institute of Cancer Research, 237 Fulham Road, London SW3 6JB, UK. E-mail:
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Abstract
Brain metastases from malignant melanoma have a poor prognosis, and treatment can be difficult because of rapid progression of the disease. To help define the treatment of this disease, we reviewed the published literature on brain metastases from melanoma. If a solitary metastasis is present, surgery might be beneficial, especially if systemic disease is absent. Stereotactic radiosurgery is a less invasive, attractive option for solitary or oligometastatic (up to 6) lesions. External beam whole-brain radiation therapy can produce responses and frequently palliates symptoms, but as the sole therapy, it is unlikely to eradicate brain metastases. Chemotherapy may be gaining a role with newer agents that penetrate the blood-brain barrier. Combined modality therapy appears to be the future direction of treatment of multiple metastases.
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Affiliation(s)
- Robert R McWilliams
- Division of Medical Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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