Post-operative stereotactic radiosurgery versus observation for completely resected brain metastases: a single-centre, randomised, controlled, phase 3 trial

Efficacy of disitamab vedotin (RC48) for previously treated human epidermal growth factor receptor 2-positive breast cancer with symptomatic brain metastases: a case report and review of the literature

Local radiotherapy or surgery is the standard of care for treating brain metastases among patients with breast cancer. However, affected by tumor subtype, more than 50% of human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer and brain metastases will still develop local recurrence or new brain lesions within 1 year after radiotherapy. As systemic therapies demonstrate higher and clinically relevant levels of intracranial activity and longer survival, there is limited evidence to guide how to weigh the options of radiotherapy versus systemic therapy (and deferral of radiation) in patients with progressive brain metastases, particularly those that are symptomatic. This study presents a case of progressive symptomatic HER2-positive brain metastases in a patient previously treated with whole brain radiotherapy and various targeted therapies. Due to limited access to novel HER2-targeted drugs, a new antibody-drug conjugate drug, disitamab vedotin (RC48) monotherapy, was chosen for postprogression treatment. The patient experienced rapid relief of neurological symptoms, partial regression of the brain tumor, and sustained disease remission for over 12 months without any treatment-related toxicity, also avoided reirradiation exposure and potential neurocognitive decline. The treatment of brain metastasis has been a topic of ongoing discussion. Our experience may offer valuable insights into managing HER2-positive progressive symptomatic brain metastases.

A hybrid [18F]fluoropivalate PET-multiparametric MRI to detect and characterise brain tumour metastases based on a permissive environment for monocarboxylate transport

The incidence of Intracranial Metastatic Disease (IMD) continues to increase in part due to improvements in systemic therapy resulting in durable control of extra-cranial disease (ECD). Contrast-enhanced Magnetic Resonance Imaging (CE-MRI) is the preferred method for imaging IMD, but has limitations particularly in follow-up surveillance scans to optimise patient care. We investigate a new diagnostic approach of hybrid ([18]F]fluoropivalate (FPIA) Positron Emission Tomography-multiparametric MRI (PET-mpMRI), in 12 treatment-naïve and 10 stereotactic radiosurgery (SRS)-treated patients (± combination therapy within 4-8 weeks). High FPIA uptake was seen in all IMD compared to contralateral white matter, regardless of ECD tumour-of-origin (p = 0.0001) and FPIA-PET volumes extended beyond CE-MRI volumes in treatment-naïve but not SRS-treated tumours. Patients with maximum PET Standardised Uptake Value, (SUVmax) ≥ 2.0 showed particularly short overall-survival (median 4 v 15 months, p = 0.0136), while CE-MRI was uninformative regarding outcome; a PET-mpMRI grade-measure also provided non-invasive prediction of overall-survival, warranting larger studies of PET-mpMRI. Independent metabolomics analyses were consistent with shared adaptation of IMD to utilise or accumulate monocarboxylates and acylcarnitines, respectively, providing a common phenotypic basis to FPIA-PET. Reprogrammed monocarboxylate metabolism-related FPIA-PET provides new insights into annotating IMD, to be expounded in future opportunities for therapy decisions for the growing number of cancer patients with IMD [Trial registration reference: Clinicaltrials.gov NCT04807582; 3rd November 2021, retrospectively registered].

A feasibility trial of delayed resection for brain metastases following pre-operative stereotactic radiosurgery

PURPOSE

Pre-operative stereotactic radiosurgery (SRS) for brain metastases (BrM), an emerging alternative to post-operative SRS, is typically performed 1-2 days before resection. However, a longer period of the irradiated tumour in situ may confer anti-tumour immunological benefits. We conducted the first clinical trial to evaluate the feasibility of planned delayed resection after pre-operative SRS.

METHODS

In this single-arm trial, patients with suspected BrM suitable for pre-operative SRS and surgery were eligible. The primary endpoint was feasibility of resection 7-21 days after SRS, with a pre-defined feasibility threshold of 66% receiving this. Secondary endpoints included 6-month adverse events (AE) and local control (LC) rates. Tumour volume change was assessed from SRS- and neurosurgery-planning MRI's.

RESULT

78 patients were screened and the target accrual of 15 patients was met. Common reasons for pre-operative SRS ineligibility were lack of existing cancer diagnosis (44%) and tumour size/peri-tumoural oedema (18%). Two patients declined resection after SRS. The median SRS-to-surgery interval was 8 days (range 0-15). Nine tumours in 8 patients (56%) received delayed resection. Reasons for earlier resection were predominantly non-medical. There were no Grade > 2 AE. The 6-month BrM LC was 100%. At a median follow-up of 13.8 months, the only BrM local failure after SRS and resection occurred with a 0-day SRS-to-surgery interval. No histopathological diagnosis issues were encountered with delayed resection. An increased SRS-to-surgery interval correlated with greater tumour shrinkage.

CONCLUSIONS

The pre-defined feasibility threshold for delayed resection was not met, but more than half of patients received delayed resection without safety concerns.

TRIAL REGISTRATION NUMBER

ACTRN12622001372774 (Registered 26/10/2022).

ENDOCAN-TUTHYREF guidelines. Locoregional therapies for locally advanced and/or metastatic thyroid cancer

This article presents consensus recommendations by a multidisciplinary panel of endocrinologists, medical oncologists, pathologists, radiation oncologists, surgeons and nuclear medicine physicians. The recommendations specifically address iodine-refractory well-differentiated thyroid carcinoma and locally advanced and/or metastatic medullary thyroid carcinoma. Treatment algorithms based on risk-benefit assessments of various multimodal therapeutic approaches are proposed for each clinical scenario. Given the limited data available on the management of these rare but aggressive forms of thyroid cancer, these consensus recommendations provide essential guidance for multidisciplinary teams to ensure optimal care for patients with these complex thyroid carcinomas.

New imaging findings of tumor invasion into brain tissue: "Peritumoral Hyperintense Enhancement Sign"

Introduction

This study investigated the MRI characteristics of meningiomas and brain metastases, exploring the relationship between the "Peritumoral Hyperintense Enhancement Sign" and brain invasion, and its clinical implications for treatment planning.

Methods

A multicenter retrospective analysis was conducted on 24 cases (17 brain metastases and 7 meningiomas), examining the MRI features of the "Peritumoral Hyperintense Enhancement Sign" and corresponding histopathological characteristics.

Results

All cases demonstrated peritumoral enhancement: 8 cases exhibited flame-shaped enhancement, 12 showed crescentic enhancement, and 4 displayed both patterns. Histopathological analysis confirmed brain invasion in regions showing abnormal enhancement.

Conclusion

The "Peritumoral Hyperintense Enhancement Sign" not only serves as a valuable indicator of brain invasion and provides guidance for clinical target delineation in treatment planning, but also facilitates more precise treatment planning and may contribute to improved prognostic assessment and reduced recurrence risk.

Patterns of Recurrence After Postoperative Stereotactic Radiotherapy for Brain Metastases

BACKGROUND/OBJECTIVES

Neurosurgical resection is the standard treatment for large brain metastases (BMs). Postoperative stereotactic radiotherapy (SRT) is used to reduce local recurrence (LR) but does not always prevent leptomeningeal disease (LMD). This study aims to analyze patterns of tumor recurrence and to identify opportunities for the further improvement of treatment efficacy.

METHODS

We included 147 patients who underwent resection and SRT for BMs. The distance between the resection cavity target volume and the new tumor growth was calculated. Cox regression analyses were used to assess associations of LMD with various patient characteristics.

RESULTS

Median survival after postoperative SRT was 14 months (IQR 6-30) with a 3-year actuarial survival rate of 21%. LR occurred in 20/147 patients (14%). After total resection, LR occurred in 21% of patients after 3 years of follow-up compared to 36% after subtotal resection. Marginal LR occurred in 5/147 patients (3%). LMD was found in 21/147 patients (14%; 3-year actuarial rate, 26%), and it was found more commonly in patients with resected cerebellar metastases (23%; 3-year actuarial rate, 46%) compared to those with cerebral metastases (11%; 3-year actuarial rate 17%) (HR 2.54, 95% CI 1.07-6.04, p = 0.034).

CONCLUSIONS

This study examined patterns of recurrence after postoperative radiotherapy and its implications for radiation dose, radiation field size, and treatment sequence. Local control was high after total resection. Radiation field size appeared adequate given the low incidence of marginal recurrences. Patients with cerebellar metastases showed an increased risk of LMD, underscoring the need for preventive measures, particularly preoperative SRT.

Enhancing radiotherapy techniques for Triple-Negative breast cancer treatment

Breast cancer is the most prevalent cancer among women worldwide, with various subtypes that require distinct treatment approaches. Among these, Triple-Negative Breast Bancer (TNBC) is recognized as the most aggressive form, often associated with poor prognosis due to its lack of targeted therapeutic options. This review specifically focuses on Radiotherapy (RT) as a treatment modality for TNBC, evaluating recent advancements and ongoing challenges, particularly the issue of radioresistance. RT remains an essential part in the management of breast cancer, including TNBC. Over the years, multiple improvements have been made to enhance RT effectiveness and minimize resistance. The introduction of advanced techniques such as Stereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS) has significantly improved precision and reduced toxicity. More recently, proton radiation therapy, a novel RT modality, has been introduced, offering enhanced dose distribution and reducing damage to surrounding healthy tissues. Despite these technological advancements, a subset of TNBC patients continues to exhibit resistance to RT, leading to recurrence and poor treatment outcomes. To overcome radioresistance, there is an increasing interest in combining RT with targeted therapeutic agents that sensitize cancer cells to radiation. Radiosensitizing drugs have been explored to enhance the efficacy of RT by making cancer cells more susceptible to radiation-induced damage. Potential candidates include DNA damage repair inhibitors, immune checkpoint inhibitors, and small-molecule targeted therapies that interfere with key survival pathways in TNBC cells. In conclusion, while RT remains a crucial modality for TNBC treatment, radioresistance remains a significant challenge. Future research should focus on optimizing RT techniques while integrating radiosensitizing agents to improve treatment efficacy. By combining RT with targeted drug therapy, a more effective and personalized treatment approach can be developed, ultimately improving patient outcomes and reducing recurrence rates in TNBC.

Stereotactic radiosurgery for patients with brain metastases: current principles, expanding indications and opportunities for multidisciplinary care

The management of brain metastases is challenging and should ideally be coordinated through a multidisciplinary approach. Stereotactic radiosurgery (SRS) has been the cornerstone of management for most patients with oligometastatic central nervous system involvement (one to four brain metastases), and several technological and therapeutic advances over the past decade have broadened the indications for SRS to include polymetastatic central nervous system involvement (>4 brain metastases), preoperative application and fractionated SRS, as well as combinatorial approaches with targeted therapy and immune-checkpoint inhibitors. For example, improved imaging and frameless head-immobilization technologies have facilitated fractionated SRS for large brain metastases or postsurgical cavities, or lesions in proximity to organs at risk. However, these opportunities come with new challenges and questions, including the implications of tumour histology as well as the role and sequencing of concurrent systemic treatments. In this Review, we discuss these advances and associated challenges in the context of ongoing clinical trials, with insights from a global group of experts, including recommendations for current clinical practice and future investigations. The updates provided herein are meaningful for all practitioners in clinical oncology.

Post-operative hypofractionated stereotactic radiotherapy for brain metastases from lung and breast cancer in patients without prior WBRT: a retrospective dose escalation study

This study investigated hypofractionated stereotactic radiotherapy (HSRT) for resected brain metastases and how the dose-fractionation affects local control (LC) and radionecrosis (RN). We retrospectively evaluated patients with brain metastases who were treated between 2010 and 2023. Post-operative HSRT was delivered in three or five fractions. The primary objective was to determine the effect of dose escalation and fractionation on LC. Secondary objectives included identifying factors associated with RN. Statistical analyses were conducted using Chi-square or Fisher's exact tests for categorical data and Mann-Whitney U tests for continuous variables (significance level: p < 0.05). After a median follow-up of 19 months, 34 patients out of 212 (16%) had local recurrence. A biologically effective dose (BED10) > 28.8 Gy was associated with better LC (p = 0.002), but no benefit was found for a BED10 > 48 Gy. RN developed in 34 patients (16%). A prescription BED10 > 48 Gy was associated with an increased incidence of symptomatic RN (p = 0.002). For HSRT in three fractions, a CTV D99% ≥ 29 Gy significantly improved the LC (p = 0.04), and V30Gy, V23.1 Gy, and V18Gy were significantly associated with an increased risk of RN. The fractionation was not found to affect the LC or RN. This large, retrospective cohort study on post-operative HSRT indicates that a BED10 of 40.9-48 Gy (3 × 7,7 Gy or 5 × 6 Gy) to the planning target volume results in excellent LC while limiting the risk of RN. No difference in LC or RN was found for different fractionations.

Factors associated with local failure after stereotactic radiation to the surgical bed of patients with a single breast cancer metastasis

INTRODUCTION

Breast cancer brain metastases (BCBM) are increasingly common due to improved systemic therapies prolonging survival. This study evaluates local control and factors influencing outcomes in patients with resected BCBM treated with postoperative stereotactic radiotherapy (SRT).

METHODS

A retrospective review included single resected BCBM treated with postoperative SRT from 2010 to 2022. The median follow-up was 28 months (range, 14-43). Variables analyzed included tumor size, biology, surgical corridor inclusion, radiation dose, and timing of SRT. Multivariable analysis was conducted using Cox regression.

RESULTS

62 patients were analyzed in multivariable analysis, HER2-positive status was associated with improved local control (HR: 0.76, 95% CI: 0.36-0.88, p = 0.032), as was a higher biologically effective dose (BED > 40 Gy, HR: 0.65, 95% CI: 0.45-0.89, p = 0.028). In contrast, tumor size > 5 cm (HR: 2.1, 95% CI: 1.7-4.6, p = 0.021) and delayed initiation of SRT beyond 28 days post-surgery (HR: 2.7, 95% CI: 1.9-4.7, p = 0.015) were associated with worse outcomes. Age, cystic metastases, inclusion of surgical corridor, and tumor location were not significantly related to local control. Radiation necrosis occurred in 13% of patients, predominantly asymptomatic.

CONCLUSION

Postoperative SRT provides effective local control in resected BCBM. In multivariable analysis, HER2 positivity, higher BED, and timely SRT significantly influenced outcomes, while larger tumor size and delayed treatment were negative prognostic factors. Future research should optimize dosimetric strategies and integrate systemic therapy to improve local and intracranial control.

Current Treatment Paradigms for Advanced Melanoma with Brain Metastases

The therapeutic management of melanoma brain metastases has undergone a profound revolution during recent decades. Optimal integration of systemic therapies with local treatments seems to represent the strategy to pursue in order to maximize clinical outcomes, stressing the need for real multidisciplinary care in this setting of patients. However, the current approach in the clinics does not necessarily reflect what the current guidelines state, and several pending issues are present, from the ideal therapeutic sequence between stereotactic radiosurgery (SRS) and drug administration to the current role of surgery and whole brain radiotherapy (WBRT), all of which need to be addressed. This narrative review aims to provide practical help for navigating the current controversies, with an eye towards possible future advancements in the field, which could help to obtain a comprehensive molecular characterization of the tumor and a more personalized patient-centered therapeutic approach.

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.

Neoadjuvant Stereotactic Radiosurgery for Large Brain Metastases: An International, Multicenter, Single-Arm Phase II Trial

BACKGROUND AND OBJECTIVES

Previous reports have suggested that neoadjuvant stereotactic radiosurgery (SRS) for brain metastases (BrMets) mitigates the elevated risks of radiation necrosis (RN) and meningeal recurrence associated with adjuvant SRS. We report treatment outcomes from a multicenter phase II trial (NCT03368625) of single-fraction neoadjuvant SRS for large BrMets.

METHODS

Patients with 1 index BrMet requiring resection and up to 9 nonindex BrMets not requiring resection were recruited across 3 centers and treated with single-fraction SRS (14-21 Gy) targeting the index lesion with a 2-mm margin, followed by surgical resection. Nonindex lesions were targeted with definitive SRS. The primary end point was 1-year rate of grade 2+ RN affecting the index lesion. Secondary end points included median overall survival, 2-year intracranial progression-free survival, and 1-year rates of local failure (LF) affecting the index lesion, leptomeningeal disease, and pachymeningeal disease.

RESULTS

Between April 2018 and November 2022, 35 patients were enrolled; the median follow-up period was 11.8 months (IQR: 6.14, 15.9). No patients developed grade 2+ RN. Six patients experienced LF (1-year rate: 18.0% [95% CI: 7.03, 32.9]); 1 patient developed classic leptomeningeal disease (1-year rate: 2.9% [95% CI: 0.21, 12.9]), and 1 patient developed pachymeningeal disease (1-year rate: 3.2% [95% CI: 0.22, 14.6]). The median overall survival was 13.8 months (95% CI: 8.15, 22.4), and the 2-year intracranial progression-free survival was 29.5% (95% CI: 13.8, 63.1).

CONCLUSION

In this study, no patients experienced symptomatic RN and the incidence of meningeal failure was lower than historical rates associated with postoperative SRS. However, the high 1-year rate of LF suggests a potential benefit for higher or fractionated radiation doses or larger clinical target volume margins.

Clinical outcome analysis of different first‑ and second‑generation EGFR‑tyrosine kinase inhibitors in untreated patients with EGFR‑mutated non‑small cell lung cancer with baseline brain metastasis

Currently, the clinical outcomes of patients with epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NSCLC) with baseline brain metastasis receiving first- and second-generation EGFR-tyrosine kinase inhibitors (TKIs) are not clear. The present study aimed to assess the clinical outcomes of patients with EGFR-mutated NSCLC with baseline brain metastasis who received first-line first- and second-generation EGFR-TKIs. In the present study, a retrospective analysis of clinical charts was performed to investigate first- and second-generation EGFR-TKIs in patients with EGFR-mutated NSCLC with baseline brain metastasis. Data from 197 patients with EGFR-mutated NSCLC with baseline brain metastasis who received first-line gefitinib, erlotinib or afatinib between May 2013 and January 2020 were retrieved from the Cancer Center database of Chang Gung Memorial Hospital at Linkou for analysis. The systemic objective response rate and intracranial response rate to first-line EGFR-TKIs were 75.1 and 76.1%, respectively. The median progression-free survival (PFS) with first-line EGFR-TKIs, brain metastasis PFS (BMPFS) and overall survival (OS) of all the included patients were 13.07 [95% confidence interval (CI), 11.43-14.70], 24.63 (95% CI, 20.98-28.28) and 28.13 months (95% CI, 23.53-32.74), respectively. According to multivariate analysis, a greater number of brain metastases (>3) and the presence of leptomeningeal carcinomatosis (LMC) were independent predictors of a shorter PFS. Patients with a greater number of brain metastases or LMC also had markedly shorter BMPFS and OS than those with fewer brain metastases or no LMC. First- and second-generation EGFR-TKIs were effective for treating previously untreated patients with EGFR-mutated NSCLC with baseline brain metastasis. In conclusion, for patients whose unfavorable factors [a greater number of brain metastases (>3) and LMCs] are associated with worse clinical outcomes, upfront osimertinib therapy, alone or in combination with other therapeutic strategies and procedures, should be considered.

Phase 1/2 Dose Escalation Trial of 3-Fraction Stereotactic Radiosurgery for Resection Cavities from Large Brain Metastases

PURPOSE

We performed a dose escalation trial of hypofractionated stereotactic radiosurgery (SRS) to determine the maximum tolerated dose (MTD) of 3-fraction SRS for brain metastases resection cavities.

METHODS AND MATERIALS

Following surgical resection of a brain metastasis, patients were enrolled by SRS treatment volume onto 2 arms: arm 1 = 4.2-14.1 cm3, approximating a 2 to 3 cm diameter sphere, and arm 2 = 14.2-33.5 cm3 or a 3 to 4 cm sphere equivalent. Dose escalation levels were 24, 27, 30, and 33 Gy in 3 consecutive-day fractions, with 6 patients at each dose level in a 6 + 6 trial design. Dose-limiting toxicity was defined as either acute (within 30 days of SRS) grade 3 to 5 central nervous system toxicity and/or late grade 3 to 5 radiation necrosis occurring at any subsequent timepoint. The MTD was defined as the highest dose where 0 to 1 out of 6 or 0 to 3 out of 12 had a dose-limiting toxicity.

RESULTS

From 2009 to 2014, 48 evaluable patients were enrolled. One (2%) patient had acute G3 toxicity; dose escalation proceeded to 33 Gy. No MTD was reached. Overall, 14 (29%) of 48 patients had G1-4 late radiation necrosis; G1 in 4 (8%), G2 in 6 (13%), G3 in 2 (4%), and G4 in 2 (4%). At the 33 Gy dose level, any grade necrosis was 58% in all 12 patients, 83% in the 6 patients on the larger volume arm 2; no G3-4 necrosis occurred in smaller arm 1 targets. With a median overall survival of 24 months (95% CI, 18-35), the 1-year cumulative incidence rates were: 10% (95% CI, 3.8-21) for local progression, 48% (95% CI, 33-61) for distant intracranial progression, and 13% (95% CI, 5-24) for radiation necrosis. Nodular meningeal disease occurred in 15% (7 of 48) of patients.

CONCLUSIONS

Grade 3 to 4 toxicity was 8% and no MTD was reached with dose escalation to 33 Gy in 3 fractions. However, with a 58% incidence of G1-4 radiation necrosis at the 33 Gy level and 33% G3-4 necrosis at 30 Gy on arm 2, a 3-fraction dose of 27-30 Gy for targets 2 to 3 cm and 27 Gy for targets 3 to 4 cm may provide the optimal balance between toxicity and tumor control. A dose of 33 Gy is reserved for cavities <3 cm where tumor control may benefit from higher doses.

Risk Factors of Developing Leptomeningeal Seeding After Resection of Brain Metastasis in Patients With Breast Cancer: Defining the Indication for Preoperative SRS

BACKGROUND/AIM

This study aimed to identify the incidence and risk factors for leptomeningeal seeding (LMS) in patients with breast cancer following brain metastasis resection and radiotherapy (RT) and to determine potential candidates for preoperative stereotactic radiosurgery (SRS).

PATIENTS AND METHODS

Between 2012 and 2022, 33 patients with breast cancer underwent surgical resection and postoperative RT for newly detected brain metastases. Twenty-one patients received whole-brain RT, while 12 patients were treated with SRS. Survival and incidence of LMS development were retrospectively analyzed. Several risk factors for the development of LMS were identified.

RESULTS

After a median follow-up of 25.3 months, the 1- and 3-year overall survival (OS) rates were 81.2% and 58.1%, respectively. Development of LMS was the only significant factor affecting OS in multivariate analysis (Hazard ratio=3.08). Significant risk factors for LMS included age ≤45 years, triple-negative breast cancer (TNBC), and piecemeal resection. The 1-year LMS risk was 85.7% for younger patients, 46.2% for those with TNBC or piecemeal resection, and 11.1% for older patients without TNBC undergoing en-bloc resection.

CONCLUSION

Patients with breast cancer brain metastases who were ≤45 years old, had TNBC, or underwent piecemeal resection were at high risk of developing LMS, regardless of the postoperative RT technique used. Patients with these risk factors are essential candidates for alternative treatment approaches, such as preoperative SRS.

Survival improvements in patients with melanoma brain metastases and leptomeningeal disease in the modern era: Insights from a nationwide study (2015-2022)

INTRODUCTION

Advances in modern therapies have improved outcomes for patients with melanoma brain metastases (MBM), though prognosis remains poor. The optimal treatment strategy for patients who do not meet clinical trial inclusion criteria is unclear.

METHODS

This study included all patients with MBM diagnosed in Denmark between 2015 and 2022, identified through the Danish Metastatic Melanoma Database (DAMMED) and local surgical and radiotherapy records. Data were collected from electronic patient records.

RESULTS

A total of 838 patients were included, with a median overall survival (OS) of 9.0 months. Of these, 112 (19.4 %) survived beyond 3 years post-diagnosis. Patients treated with immune checkpoint inhibitors (ICI) as first line treatment, specifically ipilimumab + nivolumab, demonstrated an intracranial overall response rate (icORR) of 46 % and a 2-year OS of 49 %. Those treated with BRAF/MEK inhibitors (BRAF/MEKi) had an icORR of 56 % but a 2-year OS of 20 %. Patients with leptomeningeal disease (LMD, n = 67) had a median OS of 8.4 months. Systemic therapy was associated with a superior OS for patients with LMD, though no survival benefit was seen with ICI compared to BRAF/MEKi. Among the 230 patients who underwent surgery, 30 received postoperative stereotactic radiosurgery (SRS); however, there was no difference in OS or intracranial progression-free survival between the groups.

CONCLUSION

A considerable proportion of patients with brain metastases diagnosed after 2015 survived more than 3 years. Patients with LMD appeared to obtain limited benefit of ICI with only few patients alive > 3 years post-diagnosis.

Re-irradiation followed by resection for recurrent brain metastases after initial stereotactic radiosurgery: illustrative cases

BACKGROUND

The management of recurrent brain metastases after initial stereotactic radiosurgery (SRS) remains challenging, with high local recurrence rates following salvage surgery. While preoperative SRS has shown promise for newly diagnosed metastases, its application in post-SRS recurrences is largely unexplored.

OBSERVATIONS

The authors treated three patients with recurrent brain metastases using preoperative re-irradiation followed by resection. Gamma Knife SRS was performed at marginal doses of 16-18 Gy, followed by resection within 24-48 hours. Local control was achieved in all patients without radiation-related complications. Histopathological examination confirmed the presence of viable tumor cells and radiation-induced changes. Follow-up magnetic resonance imaging revealed no evidence of tumor recurrence or adverse effects. Two patients remained alive at 35 and 19 months, whereas one died of primary cancer progression at 20 months.

LESSONS

Preoperative re-irradiation followed by resection for recurrent brain metastases after initial SRS is feasible and offers promise for short-term safety, local control, and rapid symptom improvement. The ability to promptly implement SRS enables its application in oncological emergencies. These findings suggest that preoperative re-irradiation can be a valuable strategy for managing symptomatic post-SRS recurrent brain metastases that require prompt surgical intervention. https://thejns.org/doi/10.3171/CASE24737.

Neurosurgical management of brain metastases in the elderly: a prospective study on adverse event prevalence and predictors

The management of brain metastases (BM) in geriatric patients poses significant challenges in the context of an aging population and advances in systemic cancer treatment. This study provides insights into the prevalence and nature of adverse events (AEs) following intracranial surgery in patients aged 65 years and older. It highlights the complexities and implications of treating this demographic patient population and identifies risk factors associated with AEs. This prospective study includes patients aged 65 years and older with BM who underwent surgery between January 2022 and December 2023. A detailed assessment of AEs, defined as any complication occurring within the first 30 days post-surgery, was conducted. Potential risk factors for the occurrence of AEs were examined. The study encompassed 104 patients, averaging 70.1 ± 2.8 years, with 102 undergoing surgery. The mean age-adjusted Charlson Comorbidity Index (CCI) score was 8.9 ± 1.2, indicating a significant comorbidity burden, predominantly cardiac conditions. The Karnofsky Performance Scale (KPS) showed substantial improvement post-surgery, increasing from 71.3% ± 7.8 to 75.1% ± 5.0 (p = 0.045). The average hospital stay was 10.6 days. Four non-surgery-related mortalities occurred within the 30-day postoperative period. Surgery-related AEs included wound complications in two patients, with one necessitating surgical revision. Advanced age and comorbidities emerged as significant predictors of AEs. Our findings suggest that neurosurgical intervention for BM in the elderly is a feasible and safe option, demonstrating favorable morbidity and mortality rates. However, careful postoperative monitoring is crucial, especially considering the baseline health status of these patients, which increases their susceptibility to AEs. Standardizing protocols for AE reporting and analysis is essential for improving clinical outcomes and maintaining the quality of healthcare for this patient population.

Postoperative stereotactic radiosurgery (SRS) vs hypofractionated stereotactic radiotherapy (SRT) for resected brain metastases - a single centre analysis

Postoperative radiotherapy improves local control (LC) after resection of brain metastases. In comparison to whole brain radiotherapy (WBRT) stereotactic radiosurgery (SRS) to resection cavity significantly reduces cognitive side effects. However, two phase-III trials have reported suboptimal LC with SRS, leading to increased interest in hypofractionated stereotactic radiotherapy (SRT) as an alternative to improve outcomes. This single-centre study, based on a prospective quality assurance protocol, included 161 patients with 185 resected brain metastases treated with either SRS or SRT between February 2018 and June 2023. Patients were assigned to treatment based on cavity size, with SRS typically used for cavities < 10 cc and SRT for larger volumes. Primary and secondary endpoints were LC and radiation necrosis (RN), respectively. Data analysis was conducted retrospectively. Median cavity size was 13.3 cc, with 20% of cavities receiving SRS and 80% SRT. 12-month LC was 92.6% (95-CI: 88.2 - 97.3%), 12-month RN incidence was 9% (95-CI: 3-14%), with RN limited to CTCAE v5 ≤ 2. In cavities < 10 cc, no significant difference in LC was found between SRS and SRT. For cavities > 10 cc, PTV volume was the only significant predictor of LC, while fractionation and dose did not significantly impact outcomes. SRS and SRT both offer excellent LC for resection cavities < 10 cc with low rates of RN, suggesting SRS as the preferred treatment in this collective, in consideration of patient comfort and resource allocation. In larger cavities, PTV volume significantly influences LC. Dose escalation might be beneficial in improving outcomes in these cases.

Transient and permanent hydrocephalus following resection of brain metastases located in the posterior fossa: incidence, risk factors and the necessity of perioperative external ventricular drainage placement

PURPOSE

Prophylactic insertion of an external ventricular drainage (EVD) prior to the resection of posterior fossa metastases (PFMs) is a common approach to address postoperative transient and permanent hydrocephalus. However, predicting surgery-related hydrocephalus in the preoperative phase continues to be a challenge. This study aims to analyze the incidence, preoperatively collectable risk factors and necessity of perioperative external ventricular drainage placement after posterior fossa metastasis surgery.

METHODS

All patients undergoing surgery for PFMs at the authors' neuro-oncological center between 2015 and 2021 were identified and assessed for postoperative hydrocephalus occurrence. Tumour volume, edema volume, and 4th ventricle volume were assessed on preoperative magnetic resonance imaging scans using the IntelliSpace Portal 5.0. A multivariable logistic regression analysis was performed to identify possible predictors for postoperative hydrocephalus occurrence.

RESULTS

Postoperative hydrocephalus occurred in 14 of the 130 identified PFM patients (11%). Multivariable analysis and receiver operating characteristic (ROC) analysis revealed a 4th -ventricle-to-tumor-volume ratio ≤ 0.02 (OR 33.1, 95% CI 3.8-284.3, p = 0.001), an edema-to- tumor-volume ratio ≤ 0.85 (OR 10.6, 95% CI 2.4-47.4, p = 0.002), an imaging-morphological contact to the 4th ventricle (OR 5, 95% CI 1.4-18, p = 0.013), and multiple intracranial metastases (OR 2.4, 95% CI 1-5.9, p = 0.045) as independent predictors for surgery-related postoperative hydrocephalus occurrence.

CONCLUSION

The present study identifies preoperatively detectable risk factors for the occurrence of postoperative hydrocephalus following surgery for PFMs. These findings may provide guidance in clinical decision-making regarding prophylactic EVD placement.

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.

Brain Metastasis in Endometrial Cancer: A Systematic Review

BACKGROUND

Brain metastases (BMs) from endometrial cancer (EC) are rare and challenging to treat, with limited standardized guidelines. This systematic review aims to evaluate the incidence, therapeutic strategies, and outcomes associated with brain metastases in EC patients, offering insights for clinical practice and future research.

METHODS

A comprehensive literature search was conducted using PRISMA guidelines, including PUBMED up to October 2024. Reports reporting individual or aggregate data on EC brain metastases were included. Descriptive and quantitative analyses were performed on incidence, treatment modalities, and survival outcomes. Three reports that used data from the Surveillance, Epidemiology, and End Results and National Cancer Database were used only to assess the incidence of brain metastases from endometrial carcinoma.

RESULTS

From 911 reports identified, we included 99 reports, identifying 594 cases; these and the case of a patient with brain metastasis from endometrial carcinoma followed at our center were used for analysis of disease characteristics; incidence; and treatment modalities, such as surgery, radiotherapy, chemotherapy, and combinations. Survival outcomes were influenced by treatment type and disease characteristics, with multimodal approaches showing improved outcomes.

DISCUSSION

This review underscores the rarity of EC brain metastases and highlights the need for tailored, multimodal treatment strategies. Future research should focus on prospective trials and molecular profiling to optimize management.

[Clinical Practice Guidelines for the Management of Brain Metastases from Non-small Cell Lung Cancer with Actionable Gene Alterations in China (2025 Edition)]

Brain metastasis has emerged as a significant challenge in the comprehensive management of patients with non-small cell lung cancer (NSCLC), particularly in those harboring driver gene mutations. Traditional treatments such as radiotherapy and surgery offer limited clinical benefits and are often accompanied by cognitive dysfunction and a decline in quality of life. In recent years, novel small molecule tyrosine kinase inhibitors targeting epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), and other pathways have been developed, effectively penetrating the blood-brain barrier while enhancing intracranial drug concentrations and improving patient outcomes. This advancement has transformed the treatment landscape for brain metastases in NSCLC. Consequently, the Lung Cancer Medical Education Committee of the Chinese Medical Education Association and the Brain Metastasis Collaboration Group of the Lung Cancer Youth Expert Committee of the Beijing Medical Reward Foundation have jointly initiated and formulated the Clinical Practice Guidelines for the Management of Brain Metastases from Non-small Cell Lung Cancer with Actionable Gene Alterations in China (2025 Edition). This guideline integrates the latest research findings with clinical experience, adhering to multidisciplinary treatment principles, and encompasses aspects such as diagnosis, timing of intervention, and systemic and local treatment options for driver gene positive NSCLC brain metastases. Additionally, it proposes individualized treatment strategies tailored to different driver gene types, aiming to provide clinicians with a reference to enhance the overall diagnostic and therapeutic standards for NSCLC brain metastases in China.
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European consensus-based interdisciplinary guideline for melanoma. Part 2: Treatment - Update 2024

A unique collaboration of multi-disciplinary experts from the European Association of Dermato-Oncology (EADO), the European Dermatology Forum (EDF), and the European Organization of Research and Treatment of Cancer (EORTC) was formed to make recommendations on cutaneous melanoma diagnosis and treatment, based on systematic literature reviews and the experts' experience. Cutaneous melanomas are excised with one to two-centimeter safety margins. For a correct stage classification and treatment decision, a sentinel lymph node biopsy shall be offered in patients with tumor thickness ≥ 1.0 mm or ≥ 0.8 mm with additional histological risk factors, although there is as yet no clear survival benefit for this approach. Therapeutic decisions should be primarily made by an interdisciplinary oncology team ("Tumor Board"). Adjuvant therapies can be proposed in completely resected stage IIB-IV. In stage II only PD-1 inhibitors are approved. In stage III anti-PD-1 therapy or dabrafenib plus trametinib for patients with BRAFV600 mutated melanoma can be discussed. In resected stage IV, nivolumab can be offered, as well as ipilimumab and nivolumab, in selected, high-risk patients. In patients with clinically detected macroscopic, resectable disease, neoadjuvant therapy with ipilimumab plus nivolumab followed complete surgical resection and adjuvant therapy according to pathological response and BRAF status can be offered. Neoadjuvant therapy with pembrolizumab followed by complete surgical resection and adjuvant pembrolizumab is also recommended. For patients with disease recurrence after (neo) adjuvant therapy, further treatment should consider the type of (neo) adjuvant therapy received as well as the time of recurrence, i.e., on or off therapy. In patients with irresectable stage III/IV disease systemic treatment is always indicated. For first line treatment PD-1 antibodies alone or in combination with CTLA-4 or LAG-3 antibodies shall be considered. In stage IV melanoma with a BRAFV600 mutation, first-line therapy with BRAF/MEK inhibitors can be offered as an alternative to immunotherapy, in selected cases. In patients with primary resistance to immunotherapy and harboring a BRAFV600 mutation, this therapy shall be offered as second line. Other second line therapies include therapy with tumor infiltrating lymphocytes and combinations of immune checkpoint inhibitors not used in first line. This guideline is valid until the end of 2026.

[The use of radiosurgery in the treatment of patients with single brain metastasis]

Brain metastases occur in approximately 20% of all cancer patients. Stereotactic radiosurgery alone and in combination with surgical resection is one of the approaches to treating patients with brain metastases.

OBJECTIVE

To evaluate the effectiveness of stereotactic radiosurgery regarding local control, overall survival and complications; to compare stereotactic radiosurgery alone and preoperative stereotactic radiotherapy.

MATERIAL AND METHODS

A retrospective study included 85 patients with single brain metastasis. The first group comprised 45 patients who underwent stereotactic radiosurgery, while the second group included 40 patients who underwent preoperative stereotactic radiotherapy and subsequent surgical treatment. Mean age was 59 and 56 years (p=0.2), radiation volume - 4.4 and 15.9 cm³, respectively (p<0.05).

RESULTS

Local growth control after preoperative stereotactic radiotherapy followed by resection was 100%, 97.5%, and 87.5% after 3, 6, and 12 months, respectively. After stereotactic radiotherapy alone, these values were 100%, 95.6% and 88.9%, respectively (p=0.4). One-year survival was 87.5% after preoperative radiotherapy and 64.4% after stereotactic radiosurgery alone (p<0.05). Among 85 patients, 16 (18.8%) ones had long-term surgical and post-radiation complications.

CONCLUSION

Stereotactic radiotherapy alone is effective. However, there are limitations in tumor size (up to 2.5 cm) and volume (9.5 cm³). Preoperative stereotactic radiotherapy followed by surgical resection is advisable for larger tumors (up to 4.5 cm and 18.9 cm³) with high rates of overall survival and local growth control.

Comprehensive Guide to Randomized Controlled Trials in Radiology: Everything You Need to Know

Evidence-based medicine integrates clinical research, personal expertise, and patient values. The most robust forms of clinical evidence, such as randomized controlled trials (RCTs) and prospective studies, provide the strongest support for medical decision-making. RCTs are vital in radiology for evaluating new imaging technologies, contrast agents, and therapeutic procedures, despite challenges in translating preclinical findings to clinical practice. This guide discusses the history, principles, methodologies, and applications of RCTs in radiology, highlighting their role in advancing the field and supporting evidence-based practice.

Targeting CNS Metastases in Non-Small Cell Lung Cancer With Evolving Approaches Using Molecular Markers: A Review

Importance

Central nervous system (CNS) metastases presenting as either brain parenchymal metastases or leptomeningeal metastases are diagnosed in up to 50% of patients with advanced non-small cell lung cancer during their disease course. While historically associated with a poor prognosis due to limited treatment options, the availability of an increasing number of targeted therapies with good CNS penetration has significantly improved clinical outcomes for these patients. This has occurred in parallel with a more nuanced understanding of prognostic factors.

Observations

Multiple clinical trials have reported that disease control can be observed with targeted therapies with adequate CNS penetration, particularly for patients with molecular alterations in EGFR, ALK, ROS1, and RET. For these tumors, systemic targeted therapy may be used first for the management of CNS metastases, prior to considering radiation therapy (RT). At the time of isolated progression in the CNS, RT may be considered for the progressing lesions with continuation of the same systemic therapy. For other molecular alterations as well as for patients treated with checkpoint inhibitors, data are not yet clear if systemic therapy is sufficient for untreated CNS metastases, and early RT may need to be integrated into the treatment planning. An increasing number of studies investigate the role that emerging techniques, such as the sequencing of tumor DNA from resected brain metastases tissue or cerebrospinal fluid or radiomics-based analysis of CNS imaging, can play in guiding treatment approaches.

Conclusions and Relevance

With multiple generations of targeted therapies now available, the treatment for CNS metastases should be tailored to the patients with consideration given to molecular testing results, CNS penetrance of systemic therapy, patient characteristics, and multidisciplinary review. More research is needed in understanding the clonal evolution of CNS metastases, and the development of novel therapeutics with CNS efficacy.

International collaboration of neoadjuvant stereotactic radiosurgery for brain metastases: The INTERNEO individual patient data pooled analysis

BACKGROUND AND PURPOSE

Neoadjuvant stereotactic radiosurgery (NaSRS) is an emerging treatment option for brain metastases (BrM) planned for resection. The aim of this study was to report on the efficacy and safety of NaSRS in an individual patient data pooled analysis.

MATERIALS AND METHODS

Patients undergoing single- and multi-fraction NaSRS for BrM at nine institutions in five countries (Australia, Canada, South Korea, Switzerland and USA) were included. Eligibility criteria included BrM from any primary malignancy and no prior local therapy. The primary endpoint was a composite of local recurrence (LR), any grade radionecrosis (RN), and/or nodular leptomeningeal disease (nLMD). Secondary endpoints included these endpoints and Grade ≥ 2 RN. Endpoints were evaluated using cumulative incidence functions.

RESULTS

NaSRS was delivered to 179 patients with 189 BrM. Median follow-up was 28.4 months. Primary malignancies included non-small cell lung carcinoma (44 %) and melanoma (17 %). The median BrM diameter was 29 mm (IQR 21-36 mm). Single- and multi-fraction NaSRS was utilised in 100 (53 %) and 89 BrM (47 %) respectively. The median single-fraction dose was 18 Gy (IQR 16-20 Gy). Multi-fraction doses included 24 Gy in three fractions (55 %) and 27 Gy in three fractions (25 %). The 12-month incidence for the composite endpoint was 8.0 %. The 12-month incidence of LR was 4.6 %, any grade RN was 3.6 %, Grade ≥ 2 RN was 1.8 % and nLMD was 1.2 %.

CONCLUSION

Neoadjuvant SRS results in favourable rates of LR, RN and nLMD. We provide a global experience of this treatment approach with long-term data and the largest cohort of patients undergoing multi-fraction SRS.

The multidisciplinary management of HER2-positive breast cancer brain metastases: from new biological insights to future therapeutic options

The advent and success of new drugs for treating HER2-positive metastatic breast cancer has led to a constant improvement in disease and progression-free survival as well as overall survival. Despite these advantages, the overall survival and quality of life of patients with HER2-positive breast cancer brain metastases are significantly worse than the ones of patients with HER2-positive breast cancer metastases outside the brain. For this reason, prevention and treatment of brain metastasis remain a major clinical challenge and the keys to further improving the clinical and survival outcomes of HER2-positive breast cancer patients. This review discusses the etiopathogenesis of brain metastasis, the currently available treatments, and the future perspective on new treatment strategies and diagnostic tools.

BMScope: A scoping review to chart the evolving clinical study landscape in brain and leptomeningeal metastasis

BACKGROUND

Recent studies have challenged the notion that patients with brain metastasis (BM) or leptomeningeal metastasis (LM) should be excluded from systemic therapy clinical trials. This scoping study summarizes the BM/LM clinical studies published between 2010 and 2023.

METHODS

MEDLINE, CINAHL, CAB Abstracts, PsycINFO, Cochrane Library, HINARI, International Pharmaceutical Abstracts, PubMed, Scopus, Web of Science, and EMBASE electronic databases were searched on June 21, 2021. An updated search was performed on February 21, 2023. Eligible studies investigated a therapeutic intervention in solid tumor patients with BM and/or LM and reported a patient outcome. Extracted study-level data, including study type, publication date, geographical location, number of BM/LM patients in the study, primary tumor type, and type of therapeutic intervention, were collected.

RESULTS

4921 unique studies were eligible for analysis. The key finding is that BM/LM clinical research is expanding globally, both in observational studies and clinical trials. Despite the shift over time toward a higher proportion of systemic therapy trials, the majority still do not include patients with symptomatic disease and lack reporting of BM/LM-specific endpoints. Globally, there has been a trend to more international collaboration in BM/LM clinical studies.

CONCLUSIONS

Our analysis of the BM/LM literature charts the evolving landscape of studies involving this previously excluded population. Given the increasing clinical research activity, particularly involving late-stage systemic therapy trials, it is imperative that due consideration is given to the intracranial activity of new investigational agents. Wider adoption of standardized reporting of intracranial-specific endpoints will facilitate the evaluation of relative intracranial efficacy.

Lung Cancer with Brain Metastasis-Treatment Strategies and Molecular Characteristics

Lung cancer is a leading cause of brain metastases (BMs), with 10-20% of patients with non-small cell lung cancer (NSCLC) presenting with BMs at diagnosis and 25-50% developing them over the course of their disease. Historically, BMs have posed significant therapeutic challenges, partly due to the blood brain barrier (BBB), which restricts drug penetration to the central nervous system. Consequently, BMs were initially managed with local treatments, including surgical resection, stereotactic radiosurgery, and whole brain radiation therapy. In recent years, however, systemic treatments for BMs have advanced significantly, particularly with the development of molecularly-targeted therapies and immunotherapies. The discovery of driver mutations and the development of novel tyrosine kinase inhibitors (TKIs) have yielded encouraging intracranial responses in NSCLC patients with actionable genetic alterations (e.g., EGFR, ALK, ROS1). Genomic profiling has also suggested genetic heterogeneity between BMs and primary sites. Immunotherapies, alone or in combination with other treatments, have demonstrated promising results in NSCLC with BMs, although most clinical trials have included only selected patients with asymptomatic or previously treated BMs. In this review, we discuss the molecular and immune characteristics of NSCLC with BMs, analyze intracranial efficacy findings from clinical trials, and explore treatment strategies for lung cancer patients with BMs.

Efficacy and safety of combining anti-angiogenic therapy, radiotherapy, and PD-1 inhibitors in patients with driver gene-negative non-small cell lung cancer brain metastases: a retrospective study

BACKGROUND

The efficacy and safety of anti-angiogenic combination therapy in patients with driver gene-negative non-small cell lung cancer (NSCLC) with brain metastases (BM) are uncertain.

METHODS

Eighty-eight records of driver gene-negative patients with NSCLC treated with craniocerebral radiotherapy (RT) and programmed death factor-1 (PD-1) inhibitors between May 2021 and May 2023 were collected. Based on whether anti-angiogenic therapy (AT) is combined or not, patients are categorized into the AT group and the non anti-angiogenic therapy (NAT) group. The NAT group patients received craniocerebral RT and PD-1 inhibitor and those in the AT group received craniocerebral RT and PD-1 inhibitor with ≥ 4 cycles of AT. Comparing the clinical efficacy and safety in these two patient cohorts was the main goal of the study.

RESULTS

By May 1, 2024, the iORR was 94.0% and 63.2% for AT and NAT group, respectively. The 1- and 2-year iLPFS for AT and NAT group were 93.6%, 80.9% and 69.7%, 36.4%, respectively. The 1- and 2-year iDPFS were 86.7%, 56.3% and 59.1%, 48.3%, respectively. The 1- and 2-year OS were 82.0%, 36.6% and 68.4%, 34.6%, respectively. Compared to the standard treatment (RT and PD-1 inhibitors), the addition of AT prolonged the median iLPFS (NR vs. 22.0 months, hazard ratio [HR] = 11.004, P < 0.001) and the median iDPFS (NR vs. 20.0 months, HR = 8.732, P = 0.003), but was not significant in the extension of the OS (21.0 vs. 19.0 months, HR = 1.601, P = 0.206). Multivariable analysis showed that combination therapy with AT is significantly associated with prolonged iLPFS (HR = 4.233, P = 0.002) and iDPFS (HR = 2.824, P = 0.007), whereas only GPA score is significantly associated with improved OS (HR = 0.589, P = 0.019). The incidence of hypertension in the AT group showed an increasing trend, and no significant increased risk of radiation-induced brain necrosis was found. No drug-related intracranial hemorrhage events occurred.

CONCLUSION

Combining AT, RT, and PD-1 inhibitors can substantially improve iLPFS and iDPFS for patients with driver gene-negative NSCLC with BM; however, it is not significantly associated with better OS.

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.

A pooled analysis of trastuzumab deruxtecan in patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer with brain metastases

BACKGROUND

This exploratory pooled analysis investigated the efficacy and safety of trastuzumab deruxtecan (T-DXd) versus comparator treatment in patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (mBC) with brain metastases (BMs) at baseline, categorized according to previous local treatment.

PATIENTS AND METHODS

T-DXd data were pooled from DESTINY-Breast01/-02/-03. Comparator data, from patients receiving physician's choice therapy and trastuzumab emtansine, were pooled from DESTINY-Breast02 and -03, respectively. Baseline BM status was assessed according to US Food and Drug Administration criteria. The endpoints included intracranial objective response rate (ORR; complete or partial response in the brain) per blinded independent central review (BICR) by RECIST version 1.1, time to intracranial response, intracranial duration of response (DoR), central nervous system progression-free survival (CNS-PFS) by BICR, overall survival (OS), and safety.

RESULTS

A total of 148 patients who received T-DXd and 83 patients who received comparator treatment had BMs at baseline. In those treated with T-DXd, the intracranial ORR of patients with treated/stable and untreated/active BMs was 45.2% and 45.5%, respectively. The median (range) time to intracranial response was 2.8 months (1.1-13.9 months) and 1.5 months (1.2-13.7 months) in patients with treated/stable and untreated/active BMs, respectively. For those with treated/stable BMs, the median intracranial DoR was 12.3 [95% confidence interval (CI) 9.1-17.9] months, and for those with untreated/active BMs, it was 17.5 months (95% CI 13.6-31.6 months). The median CNS-PFS and OS were 12.3 months (95% CI 11.1-13.8 months) and not reached (95% CI 22.1 months-not estimable) in those with treated/stable BMs, and 18.5 months (95% CI 13.6-23.3 months) and 30.2 months (95% CI 21.3 months-not estimable) in those with untreated/active BMs, respectively. Drug-related treatment-emergent adverse events grade ≥3 were experienced by 43.2% of patients with BMs and 46.4% without BMs with T-DXd.

CONCLUSIONS

T-DXd demonstrated meaningful intracranial efficacy and clinical benefit in OS, with an acceptable and manageable safety profile in patients with HER2-positive mBC with treated/stable and untreated/active BMs.

Trastuzumab deruxtecan in HER2-positive advanced breast cancer with or without brain metastases: a phase 3b/4 trial

Trastuzumab deruxtecan (T-DXd) intracranial activity has been observed in small or retrospective patient cohorts with human epidermal growth factor receptor 2-positive (HER2+) advanced/metastatic breast cancer (mBC) and stable or active (untreated/previously treated and progressing) brain metastases (BMs). The phase 3b/4 DESTINY-Breast12 study investigated T-DXd in patients with HER2+ mBC and is, to our knowledge, the largest prospective study of T-DXd in patients with BMs in this setting. Patients (stable/active BMs (n = 263) and no BMs (n = 241)) treated with one or more prior anti-HER2-based regimens received T-DXd (5.4 mg per kg). Primary endpoints were progression-free survival (PFS; BMs cohort) and objective response rate (ORR) per Response Evaluation Criteria in Solid Tumors version 1.1 (non-BMs cohort). Additional endpoints included central nervous system (CNS) PFS, ORR, time to second progression, CNS ORR (BMs cohort), incidence of new symptomatic CNS metastases (non-BMs cohort), time to progression, duration of response, overall survival and safety (both cohorts). No formal hypothesis testing was conducted for this single-arm, open-label study. In the BMs cohort, 12-month PFS was 61.6% (95% confidence interval (CI): 54.9-67.6), and 12-month CNS PFS was 58.9% (95% CI: 51.9-65.3). In the non-BMs cohort, ORR was 62.7% (95% CI: 56.5-68.8). Grade 3 or higher adverse events occurred in 51% (BMs cohort) and 49% (non-BMs cohort) of patients. Investigator-reported interstitial lung disease/pneumonitis occurred in 16% (grade ≥3: 3%) of patients with BMs and 13% (grade ≥3: 1%) of patients without BMs. These data show substantial and durable overall and intracranial activity for T-DXd, supporting its use in previously treated patients with HER2+ mBC irrespective of stable/active baseline BMs. ClinicalTrials.gov identifier: NCT04739761 .

Radiotherapy in patients with brain metastases with and without concomitant immunotherapy: comparison of patient outcome and neurotoxicity

BACKGROUND/AIM

Recently, immune checkpoint inhibitors (ICI) have been added to the treatment of brain metastases. While combining radiotherapy and ICI can enhance therapeutic effects, it might also increase the risk of severe autoimmune adverse events. This retrospective study aims to compare treatment responses and neurotoxicity in patients treated with radiotherapy alone versus those receiving a combination of radiotherapy and ICI.

PATIENTS AND METHODS

All patients with brain metastases who received radiotherapy at Hannover Medical School from 2017 to 2019 were included. The medical reports of all study participants were evaluated. Patients who received radiotherapy alone and those who received a combination of radiation and ICI were compared.

RESULTS

A total of 248 patients were analyzed, with the most common tumor types being non-small cell lung cancer (NSCLC) and malignant melanoma. Half of the patients received whole-brain radiotherapy (WBRT) and the other half stereotactic radiotherapy (SRT). Of these, 29 patients received concurrent immunotherapy and radiotherapy, 30 completed immunotherapy before radiotherapy, and 29 started ICI after completing radiotherapy. Two cases lacked information on the duration of immunotherapy. Overall survival post-initial tumor diagnosis within the total cohort was 52 months, with significantly worse survival for patients with multiple brain metastases (p = 0.020). No significant differences in survival or incidence of neurological adverse events were observed between patients with or without ICI.

CONCLUSION

Combining radiotherapy and ICI did not significantly increase neurotoxicity or improve survival in this cohort, though the heterogeneity of the subgroups limits the generalizability of these findings.

Brain Metastasis in Pediatric Patients with Osteosarcoma

BACKGROUND

Brain metastases in pediatric osteosarcoma are infrequent but associated with a dire prognosis.

METHODS

This retrospective study examined six pediatric patients at Johns Hopkins Hospital who developed brain metastases from osteosarcoma between April 2015 and November 2023.

RESULTS

Median survival post-brain metastasis was 2.5 months. The patients underwent various treatments, including chemotherapy, surgery, and radiation. Despite these interventions, outcomes were uniformly fatal. Notably, one patient survived over 13 months post-brain metastasis with a treatment regimen of cabozantinib and nivolumab along with surgical resection and radiation, highlighting the potential efficacy of multimodal treatment regimens. This case demonstrated changes in the immune microenvironment, hinting at an anti-tumoral response, although no histologic response was observed.

CONCLUSIONS

These findings emphasize the critical need for vigilant clinical monitoring, especially in patients with new neurological symptoms. The study highlights the diagnostic challenges and the rapid progression of brain metastases, underscoring the necessity for further research. Prospective studies and clinical trials focusing on novel therapeutic strategies are essential to improve outcomes. Disease biology studies examining tumor features across primary, pulmonary, and brain metastatic sites may offer insights into the mechanisms of metastasis and potential therapeutic targets, providing a foundation for better management of this devastating complication.

Advances in the Management of Lung Cancer Brain Metastases

Lung cancer, both non-small cell and small cell, harbors a high propensity for spreading to the central nervous system. Radiation therapy remains the backbone of the management of brain metastases. Recent advances in stereotactic radiosurgery have expanded its indications and ongoing studies seek to elucidate optimal fractionation and coordination with systemic therapies, especially targeted inhibitors with intracranial efficacy. Efforts in whole-brain radiotherapy aim to preserve neurocognition and to investigate the need for prophylactic cranial irradiation. As novel combinatorial strategies are tested and prognostic/predictive biomarkers are identified and tested, the management of brain metastases in lung cancer will become increasingly personalized to optimally balance intracranial efficacy with preserving neurocognitive function and patient values.

Preoperative stereotactic radiotherapy for the management of brain metastases

Traditionally, postoperative whole-brain radiation therapy (WBRT) has been used for resected brain metastases, reducing local and intracerebral relapses. However, WBRT is associated with cognitive deterioration. Postoperative stereotactic radiotherapy (SRT) has emerged due to its neurocognitive preservation benefits. Despite its advantages, postoperative SRT has several drawbacks, including difficulties in target volume delineation, increased risk of radionecrosis (RN) and leptomeningeal disease (LMD), and prolonged treatment duration. Preoperative SRT has been proposed as a potential alternative, offering promising results in retrospective studies. Retrospective studies have suggested that preoperative SRT could achieve high local control rates with fewer LMD and RN rates compared to postoperative SRT. However, preoperative SRT is primarily based on retrospective data, and no phase 2/3 trials have been published to date. Ongoing clinical trials are expected to provide further insights into the efficacy and safety of preoperative SRT, addressing key questions regarding fractionation, dose, and timing relative to surgery.

Central nervous system metastases in advanced non-small cell lung cancer: A review of the therapeutic landscape

Up to 40% of patients with non-small cell lung cancer (NSCLC) develop central nervous system (CNS) metastases. Current treatments for this subgroup of patients with advanced NSCLC include local therapies (surgery, stereotactic radiosurgery, and, less frequently, whole-brain radiotherapy), targeted therapies for oncogene-addicted NSCLC (small molecules, such as tyrosine kinase inhibitors, and antibody-drug conjugates), and immune checkpoint inhibitors (as monotherapy or combination therapy), with multiple new drugs in development. However, confirming the intracranial activity of these treatments has proven to be challenging, given that most lung cancer clinical trials exclude patients with untreated and/or progressing CNS metastases, or do not include prespecified CNS-related endpoints. Here we review progress in the treatment of patients with CNS metastases originating from NSCLC, examining local treatment options, systemic therapies, and multimodal therapeutic strategies. We also consider challenges regarding assessment of treatment response and provide thoughts around future directions for managing CNS disease in patients with advanced NSCLC.

Development of a scoring system to predict local recurrence in brain metastases following complete resection and observation

PURPOSE

Postoperative stereotactic radiosurgery to the resection cavity in patients with brain metastases is guideline-recommended therapy. However, Japanese Clinical Oncology Group 0504 study showed that postoperative observation could be a therapeutic option in patients with completed resected brain metastases. We hereby investigated the incidence and risk factors for local recurrence after complete resection without immediate radiotherapy and developed a scoring system for its prediction.

METHODS

We included 53 patients with 54 brain metastases, who underwent complete resection between January 2016 and December 2021. We identified risk factors for local recurrence and developed a scoring system to predict it using the extracted risk factors, by assigning one point to each risk factor and calculating the total scores for each patient. We evaluated the correlation between the prognostic score and time to local recurrence.

RESULTS

Local recurrence occurred in 37 of 54 tumors (68.5%), with a median follow-up duration of 21.0 months. The median time to local recurrence was 5.1 months. Univariate and multivariate analyses revealed that non-lung adenocarcinoma, infratentorial tumors, and no postoperative systemic therapy were identified as risk factors for local recurrence (non-lung adenocarcinoma, p = 0.035; infratentorial tumors, p = 0.044; and no postoperative systemic therapy, p = 0.0069). A score ≥ 2 showed a median time to local recurrence of 2.1 months, starkly contrasting with 30.8 months for a score ≤ 1 (p = 0.0002).

CONCLUSIONS

Non-lung adenocarcinoma, infratentorial tumors, and no postoperative systemic therapy were risk factors for local recurrence. Our scoring system can predict local recurrence, thus potentially aiding treatment decisions.

Effective Personalization of Stereotactic Radiosurgery for Brain Metastases in the Modern Era: Opportunities for Innovation

ABSTRACT

As survival rates improve for patients with metastatic disease, more patients are requiring complex treatment for brain metastases. Stereotactic radiosurgery (SRS) is a conformal radiotherapy technique that allows high ablative dose to be delivered to a specific target and is a standard effective local therapy for the treatment of patients with limited brain metastases. This review highlights the current landscape of SRS treatment in the context of modern therapeutic advances and identifies new research frontiers to personalize SRS and maximize the therapeutic ratio.

Treatment of brain metastases from non-small cell lung cancer: preclinical, clinical, and translational research

Lung cancer is the second most common type of cancer and is the leading cause of cancer-related deaths in the United States. Approximately 10-40% of patients with solid tumors develop brain metastases, with non-small cell lung cancer accounting for approximately 50% of all cases of patients with brain metastases. Many management options are available which can include surgery, radiation, and systemic therapy. A variety of factors go into the selection of management of brain metastases. In this review, we will focus on the treatment strategies and optimizing the management of brain metastases in patients with non-small cell lung cancer.

The role of surgery in recurrent local cerebral metastases: a multi-institutional retrospective analysis

BACKGROUND

Local recurrent brain metastases are defined as lesions that recur in the brain at the same site after a previous local therapy. In patients already submitted to surgery, a second operation may be potentially challenging due to scar formation, infiltration of cerebral vessels or eloquent brain areas and local effect of previous radiotherapy. The aim of this study is to retrospectively review the results and complications of a second surgical treatment in a series of local recurrent lesions and to review the literature on this topic.

METHODS

37 patients submitted to surgery for a local, histologically confirmed, recurrent brain metastases between 2000 and 2022 were retrospectively analyzed with respect to the following parameters: age, histology, anatomic location, time to recurrence, previous radiotherapy, size of recurrent tumors, preoperative and postoperative Karnofsky Performance Status (KPS) score, recursive partitioning analysis (RPA) class and graded prognostic assessment (GPA) score, surgery-related complications and the presence of further cerebral metastases. Overall survival (OS) was calculated using the Kaplan-Meier method. A multivariate Cox proportional hazard model was developed using stepwise regression (forwards selection) with predictive variables that were significant in the univariate analyses.

RESULTS

A significant improvement of post-operative KPS status was obtained after second surgery. At multivariate analysis better results in terms of OS were achieved in patients with a pre-operative KPS ≥ 70 and in patients who had received radiotherapy after the initial surgery. No significant postoperative complications related to previous treatments were observed.

CONCLUSIONS

Surgical resection of local recurrent brain metastases may improve patients ́ neurologic conditions allowing more time for systemic therapies to act with a low incidence of surgery-related morbidity and mortality. However, careful patient selection with a fair pre-operative clinical status seems mandatory to achieve the best post-operative results, since uniform treatment-paradigms cannot be established yet, due to the highly heterogeneous patient cohort.

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.

Pre-operative stereotactic radiosurgery and peri-operative dexamethasone for resectable brain metastases: a two-arm pilot study evaluating clinical outcomes and immunological correlates

Enhancing the efficacy of immunotherapy in brain metastases (BrM) requires an improved understanding of the immune composition of BrM and how this is affected by radiation and dexamethasone. Our two-arm pilot study (NCT04895592) allocated 26 patients with BrM to either low (Arm A) or high (Arm B) dose peri-operative dexamethasone followed by pre-operative stereotactic radiosurgery (pSRS) and resection (n= 13 per arm). The primary endpoint, a safety analysis at 4 months, was met. The secondary clinical endpoints of overall survival, distant brain failure, leptomeningeal disease and local recurrence at 12-months were 66%, 37.3%, 6%, and 0% respectively and were not significantly different between arms (p= 0.7739, p= 0.3884, p= 0.3469). Immunological data from two large retrospective BrM datasets and confirmed by correlates from both arms of this pSRS prospective trial revealed that BrM CD8 T cells were composed of predominantly PD1+ TCF1+ stem-like and PD1+ TCF1-TIM3+ effector-like cells. Clustering of TCF1+ CD8 T cells with antigen presenting cells in immune niches was prognostic for local control, even without pSRS. Following pSRS, CD8 T cell and immune niche density were transiently reduced compared to untreated BrM, followed by a rebound 6+ days post pSRS with an increased frequency of TCF1- effector-like cells. In sum, pSRS is safe and therapeutically beneficial, and these data provide a framework for how pSRS may be leveraged to maximize intracranial CD8 T cell responses.

Patterns of Care for Brain Metastases in Asia: A Real-World Survey Conducted by the Federation of Asian Organizations for Radiation Oncology

PURPOSE

To report the patterns of care for brain metastases (BMs) in the Federation of Asian Organizations for Radiation Oncology (FARO).

METHODS

Overall, 37 questions were prepared. The survey was conducted online using Google Forms, and the URL was distributed to members of the FARO research committee. Radiation oncologists associated with FARO responded to the questionnaire between May 2023 and June 2023, and their answers were analyzed.

RESULTS

Responses were received from 32 radiation oncologists in 13 countries participating in FARO. Twenty-six physicians (81.3%) were affiliated with academic centers, and 22 (68.8%) were able to perform stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (fSRT) for BMs at their institution. The most typically used prognostic index for BM was the recursive partitioning analysis classification (17 physicians, 53.1%). The maximum number of BMs indicated for SRT/SRS was ≤three (11 physicians, 34.4%), whereas eight (25.0%) physicians answered for 6-10 BMs. The maximum size of BMs considered for SRS/fSRT was ≤3 cm (14 physicians, 43.8%), whereas nine (28.1%) answered that SRS/fSRT was preferred if the maximum size was >4 cm. When whole-brain radiotherapy (RT) was indicated, hippocampal avoidance and memantine usage were limited to 50.0% and 25.0% of patients, respectively. The most typical RT modality after BM resection was SRS/fSRT alone, regardless of whether the margin was positive (19 physicians, 59.4%) or negative (13 physicians, 40.6%).

CONCLUSION

We report the survey results of the patterns of care for BMs in the FARO. This survey was conducted only among a limited number of FARO members. Since many respondents were affiliated with relatively large-scale academic centers, large-scale surveys, including community hospitals, are warranted for future initiatives.

Melanoma Brain Metastasis: Biology and Therapeutic Advances

Metastasis to the brain is a frequent complication of advanced melanoma. Historically, patients with melanoma brain metastasis (MBM) have had dismal outcomes, but outcomes have improved with the development of more effective treatments, including stereotactic radiosurgery and effective immune and targeted therapies. Despite these advances, MBM remains a leading cause of death from this disease, and many therapies show decreased efficacy against these tumors compared with extracranial metastases. This differential efficacy may be because of recently revealed unique molecular and immune features of MBMs-which may also provide rational new therapeutic strategies.