1
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Tsakonas G, Ekman S, Koulouris A, Adderley H, Ackermann CJ, Califano R. Safety and efficacy of immune checkpoint blockade in patients with advanced nonsmall cell lung cancer and brain metastasis. Int J Cancer 2023; 153:1556-1567. [PMID: 37334528 DOI: 10.1002/ijc.34628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/12/2023] [Accepted: 06/02/2023] [Indexed: 06/20/2023]
Abstract
The presence of brain metastases (BM) is a negative prognostic factor for patients with advanced nonsmall cell lung cancer (NSCLC). Their incidence seems to be higher in patients with oncogene-driven tumours, especially those with EGFR-mutated or ALK-rearranged tumours. Although targeted treatments demonstrate significant efficacy regarding BM, they only apply to a minority of NSCLC patients. On the other hand, systemic therapies for nononcogenic-driven NSCLC with BM have shown limited clinical benefit. In recent years, immunotherapy alone or combined with chemotherapy has been adopted as a new standard of care in first-line therapy. This approach seems to be beneficial to patients with BM in terms of efficacy and toxicity. Combined immune checkpoint inhibition as well as the combination of immunotherapy and radiation therapy show promising results with significant, but overall acceptable toxicity. A pragmatic approach of allowing enrolment of patients with untreated or symptomatic BM in randomised trials evaluating immune checkpoint inhibitors strategies, possibly coupled with central nervous system-related endpoints may be needed to generate data to refine treatment for this patient population.
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Affiliation(s)
- Georgios Tsakonas
- Department of Oncology-Pathology, Karolinska Institutet/Thoracic Oncology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Simon Ekman
- Department of Oncology-Pathology, Karolinska Institutet/Thoracic Oncology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Andreas Koulouris
- Department of Oncology-Pathology, Karolinska Institutet/Thoracic Oncology Center, Karolinska University Hospital, Stockholm, Sweden
- Faculty of Medicine, University of Crete, Heraklion, Greece
| | - Helen Adderley
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | | | - Raffaele Califano
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Department of Medical Oncology, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, University of Manchester, Manchester, UK
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2
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Andriani R, Rosewitasari J, Hanif MA, Mulawarman A, Kurniawati SA, Fachri A. Factors Affecting 2-Year Survival in Patients With Non-Small Cell Lung Cancer Brain Metastases: Evidence from Indonesia's National Cancer Center, Jakarta, Indonesia. Clin Med Insights Oncol 2023; 17:11795549231178172. [PMID: 37359276 PMCID: PMC10285584 DOI: 10.1177/11795549231178172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 05/09/2023] [Indexed: 06/28/2023] Open
Abstract
Background Brain metastases are a common complication in a wide range of cancers but are ubiquitous among patients with lung cancer. Limited data are available on the survival of patients with lung cancer and brain metastases in Indonesia. In this study, we aimed to identify the factors that might contribute to and predict survival in patients with non-small cell lung cancer (NSCLC) that resulted in brain metastases. Methods This retrospective study on patients with NSCLC and brain metastases was conducted using data available from the medical records of the Dharmais National Cancer Hospital, Jakarta, Indonesia. The study outcome was survival time, which was associated with sex, age, smoking status, body mass index, number of brain metastases, tumor location, systemic therapy, and other therapies. Descriptive statistics, median survival, Kaplan-Meier graphs, and Cox regression were analyzed using SPSS version 27. Results We included 111 patients with NSCLC and brain metastases in this study. The median patient age was 58 years. Long survivorship was observed among women (median: 95.4 weeks; P < .0003), patients with epidermal growth factor receptor (EGFR) mutations (median: 41.8 weeks; P < .0492), those who received chemotherapy (median: 58 weeks; P < .000), and those who received a combination of surgery and whole brain radiotherapy (WBRT; median: 64.7 weeks; P = .0174). Multivariate analysis showed consistent results for the following factors: sex, EGFR mutations, systemic therapy, and surgery plus WBRT. Conclusions Female sex and EGFR mutations in patients with NSCLC and brain metastases are associated with a high survival rate. Patients who have NSCLC with brain metastases will benefit from treatment with EGFR tyrosine kinase inhibitors, chemotherapy, and surgery plus WBRT.
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Affiliation(s)
- Rini Andriani
- Department of Neurology, Dharmais National Cancer Center Hospital, West Jakarta, Indonesia
| | - Joice Rosewitasari
- Department of Pulmonology, Dharmais National Cancer Center Hospital, West Jakarta, Indonesia
| | - Muhammad Alfin Hanif
- Department of Pulmonology, Dharmais National Cancer Center Hospital, West Jakarta, Indonesia
| | - Achmad Mulawarman
- Department of Pulmonology, Dharmais National Cancer Center Hospital, West Jakarta, Indonesia
| | - Sri Agustini Kurniawati
- Department of Hematology and Medical Oncology, Dharmais National Cancer Center Hospital, West Jakarta, Indonesia
| | - Achmad Fachri
- Department of Radiology, Dharmais National Cancer Center Hospital, West Jakarta, Indonesia
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3
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Matsui JK, Perlow HK, Raj RK, Nalin AP, Lehrer EJ, Kotecha R, Trifiletti DM, McClelland S, Kendra K, Williams N, Owen DH, Presley CJ, Thomas EM, Beyer SJ, Blakaj DM, Ahluwalia MS, Raval RR, Palmer JD. Treatment of Brain Metastases: The Synergy of Radiotherapy and Immune Checkpoint Inhibitors. Biomedicines 2022; 10:2211. [PMID: 36140312 PMCID: PMC9496359 DOI: 10.3390/biomedicines10092211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/31/2022] [Accepted: 09/02/2022] [Indexed: 11/27/2022] Open
Abstract
Brain metastases are a devastating sequela of common primary cancers (e.g., lung, breast, and skin) and have limited effective therapeutic options. Previously, systemic chemotherapy failed to demonstrate significant benefit in patients with brain metastases, but in recent decades, targeted therapies and more recently immune checkpoint inhibitors (ICIs) have yielded promising results in preclinical and clinical studies. Furthermore, there is significant interest in harnessing the immunomodulatory effects of radiotherapy (RT) to synergize with ICIs. Herein, we discuss studies evaluating the impact of RT dose and fractionation on the immune response, early studies supporting the synergistic interaction between RT and ICIs, and ongoing clinical trials assessing the benefit of combination therapy in patients with brain metastases.
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Affiliation(s)
| | - Haley K. Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Rohit K. Raj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Ansel P. Nalin
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | | | - Shearwood McClelland
- Departments of Radiation Oncology and Neurological Surgery, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Kari Kendra
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Nicole Williams
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Dwight H. Owen
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Carolyn J. Presley
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Evan M. Thomas
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Sasha J. Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Manmeet S. Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Raju R. Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Joshua D. Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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4
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Chu X, Niu L, Xiao G, Peng H, Deng F, Liu Z, Wu H, Yang L, Tan Z, Li Z, Zhou R. The Long-Term and Short-Term Efficacy of Immunotherapy in Non-Small Cell Lung Cancer Patients With Brain Metastases: A Systematic Review and Meta-Analysis. Front Immunol 2022; 13:875488. [PMID: 35693805 PMCID: PMC9175180 DOI: 10.3389/fimmu.2022.875488] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/20/2022] [Indexed: 12/12/2022] Open
Abstract
Background Although immunotherapy has been widely used, there is currently no research comparing immunotherapy for non-small cell lung cancer (NSCLC) patients with brain metastases (BMs). This meta-analysis addresses a gap in the comparison of immunotherapy efficacy, including immune checkpoint inhibitors (ICIs), chemotherapy (CT), radiotherapy (RT), and ICI combined CT or RT. Methods A search of Pubmed, Cochrane, EMBASE, and ClinicalTrial.gov was conducted to identify studies which enrolled NSCLC patients with BM treated with ICIs. The outcomes consisted of intracerebral overall response rate (iORR), intracerebral disease control rate (iDCR), extracranial overall response rate (EORR), distant brain failure (DBF), local control (LC), progression-free survival (PFS), and overall survival (OS). Results A total of 3160 participants from 46 trials were included in the final analysis. Patients treated with immunotherapy were associated with a longer PFS (0.48, 95%CI: 0.41-0.56), and a longer OS (0.64, 95%CI: 0.60-0.69) compared with immunotherapy-naive patients. In prospective studies, dual ICI combined CT and ICI combined CT achieved a better OS. The hazard ratio (HR) of dual ICI combined CT versus dual ICI was 0.61, and the HR of ICI combined CT versus ICI monotherapy was 0.58. Moreover, no statistical difference in PFS, OS, EORR, iORR, iDCR, and EDCR was found between patients with ICI monotherapy and ICI combined cranial radiotherapy. Concurrent ICI combined RT was shown to decrease the rate of DBF (OR = 0.15, 95% CI: 0.03-0.73) compared with RT after ICI. Patients treated with WBRT might have an inferior efficacy than those with SRS because the iORR of SRS was 0.75 (0.70, 0.80) and WBRT was 0. Furthermore, no obvious difference in PFS and OS was observed among the three different types of ICI, which targets PD-1, PD-L1, and CTLA-4, respectively. Conclusions Patients treated with ICI got superior efficacy to those without ICI. Furthermore, dual ICI combined CT and ICI combined CT seemed to be optimal for NSCLC patients with BM. In terms of response and survival, concurrent administration of SRS and ICI led to better outcomes for patients with BMs than non-concurrent or non-SRS. Importance of the Study In the new era of immunotherapy, our meta-analysis validated the importance of immunotherapy for non-small cell lung cancer (NSCLC) patients with brain metastases (BMs). By comparing the long-term and short-term impacts of various regimens, all immunotherapy treatments had superior efficacy to immunotherapy-naive. At the same time, through pairwise comparison in immunotherapy, our findings can help clinicians to make treatment decisions for NSCLC patients with BMs. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=269621, identifier CRD42021269621.
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Affiliation(s)
- Xianjing Chu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Lishui Niu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Gang Xiao
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Haiqin Peng
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Fuxing Deng
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhiyuan Liu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Honghua Wu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Lei Yang
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhuguilong Tan
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhanzhan Li
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Rongrong Zhou, ; Zhanzhan Li,
| | - Rongrong Zhou
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
- Xiangya Lung Cancer Center, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Rongrong Zhou, ; Zhanzhan Li,
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5
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Rodríguez De Dios N, Navarro-Martin A, Cigarral C, Chicas-Sett R, García R, Garcia V, Gonzalez JA, Gonzalo S, Murcia-Mejía M, Robaina R, Sotoca A, Vallejo C, Valtueña G, Couñago F. GOECP/SEOR radiotheraphy guidelines for non-small-cell lung cancer. World J Clin Oncol 2022; 13:237-266. [PMID: 35582651 PMCID: PMC9052073 DOI: 10.5306/wjco.v13.i4.237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 08/27/2021] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
Non-small cell lung cancer (NSCLC) is a heterogeneous disease accounting for approximately 85% of all lung cancers. Only 17% of patients are diagnosed at an early stage. Treatment is multidisciplinary and radiotherapy plays a key role in all stages of the disease. More than 50% of patients with NSCLC are treated with radiotherapy (curative-intent or palliative). Technological advances-including highly conformal radiotherapy techniques, new immobilization and respiratory control systems, and precision image verification systems-allow clinicians to individualize treatment to maximize tumor control while minimizing treatment-related toxicity. Novel therapeutic regimens such as moderate hypofractionation and advanced techniques such as stereotactic body radiotherapy (SBRT) have reduced the number of radiotherapy sessions. The integration of SBRT into routine clinical practice has radically altered treatment of early-stage disease. SBRT also plays an increasingly important role in oligometastatic disease. The aim of the present guidelines is to review the role of radiotherapy in the treatment of localized, locally-advanced, and metastatic NSCLC. We review the main radiotherapy techniques and clarify the role of radiotherapy in routine clinical practice. These guidelines are based on the best available evidence. The level and grade of evidence supporting each recommendation is provided.
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Affiliation(s)
- Núria Rodríguez De Dios
- Department of Radiation Oncology, Hospital del Mar, Barcelona 08003, Spain
- Radiation Oncology Research Group, Hospital Del Mar Medical Research Institution, Barcelona 08003, Spain
- Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona 08003, Spain
| | - Arturo Navarro-Martin
- Department of Radiation Oncology, Thoracic Malignancies Unit, Hospital Duran i Reynals. ICO, L´Hospitalet de L, Lobregat 08908, Spain
| | - Cristina Cigarral
- Department of Radiation Oncology, Hospital Clínico de Salamanca, Salamanca 37007, Spain
| | - Rodolfo Chicas-Sett
- Department of Radiation Oncology, ASCIRES Grupo Biomédico, Valencia 46004, Spain
| | - Rafael García
- Department of Radiation Oncology, Hospital Ruber Internacional, Madrid 28034, Spain
| | - Virginia Garcia
- Department of Radiation Oncology, Hospital Universitario Arnau de Vilanova, Lleida 25198, Spain
| | | | - Susana Gonzalo
- Department of Radiation Oncology, Hospital Universitario La Princesa, Madrid 28006, Spain
| | - Mauricio Murcia-Mejía
- Department of Radiation Oncology, Hospital Universitario Sant Joan de Reus, Reus 43204, Tarragona, Spain
| | - Rogelio Robaina
- Department of Radiation Oncology, Hospital Universitario Arnau de Vilanova, Lleida 25198, Spain
| | - Amalia Sotoca
- Department of Radiation Oncology, Hospital Ruber Internacional, Madrid 28034, Spain
| | - Carmen Vallejo
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - German Valtueña
- Department of Radiation Oncology, Hospital Clínico Universitario Lozano Blesa, Zaragoza 50009, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud, Madrid 28223, Spain
- Department of Radiation Oncology, Hospital La Luz, Madrid 28003, Spain
- Department of Clinical, Universidad Europea, Madrid 28670, Spain
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6
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Myall NJ, Yu H, Soltys SG, Wakelee HA, Pollom E. Management of brain metastases in lung cancer: evolving roles for radiation and systemic treatment in the era of targeted and immune therapies. Neurooncol Adv 2021; 3:v52-v62. [PMID: 34859233 PMCID: PMC8633733 DOI: 10.1093/noajnl/vdab106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Brain metastases are a common occurrence in both non-small cell and small cell lung cancer with the potential to affect quality of life and prognosis. Due to concerns about the accessibility of the central nervous system by systemic chemotherapy agents, the management of brain metastases has historically relied on local therapies including surgery and radiation. However, novel targeted and immune therapies that improve overall outcomes in lung cancer have demonstrated effective intracranial activity. As a result, the management of brain metastases in lung cancer has evolved, with both local and systemic therapies now playing an important role. Factors such as tumor histology (non-small versus small cell), oncogenic driver mutations, and symptom burden from intracranial disease impact treatment decisions. Here, we review the current management of brain metastases in lung cancer, highlighting the roles of stereotactic radiosurgery and novel systemic therapies as well as the ongoing questions that remain under investigation.
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Affiliation(s)
- Nathaniel J Myall
- Division of Oncology, Department of Medicine, Stanford Cancer Institute, Palo Alto, California, USA
| | - Helena Yu
- Department of Medicine-Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford Cancer Institute, Palo Alto, California, USA
| | - Heather A Wakelee
- Division of Oncology, Department of Medicine, Stanford Cancer Institute, Palo Alto, California, USA
| | - Erqi Pollom
- Department of Radiation Oncology, Stanford Cancer Institute, Palo Alto, California, USA
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Blethen KE, Arsiwala TA, Fladeland RA, Sprowls SA, Panchal DM, Adkins CE, Kielkowski BN, Earp LE, Glass MJ, Pritt TA, Cabuyao YM, Aulakh S, Lockman PR. Modulation of the blood-tumor barrier to enhance drug delivery and efficacy for brain metastases. Neurooncol Adv 2021; 3:v133-v143. [PMID: 34859240 PMCID: PMC8633736 DOI: 10.1093/noajnl/vdab123] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The blood-brain barrier is the selectively permeable vasculature of the brain vital for maintaining homeostasis and neurological function. Low permeability is beneficial in the presence of toxins and pathogens in the blood. However, in the presence of metastatic brain tumors, it is a challenge for drug delivery. Although the blood-tumor barrier is slightly leaky, it still is not permissive enough to allow the accumulation of therapeutic drug concentrations in brain metastases. Herein, we discuss the differences between primary brain tumors and metastatic brain tumors vasculature, effects of therapeutics on the blood-tumor barrier, and characteristics to be manipulated for more effective drug delivery.
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Affiliation(s)
- Kathryn E Blethen
- Department of Basic Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, West Virginia, USA
| | - Tasneem A Arsiwala
- Department of Basic Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, West Virginia, USA
| | - Ross A Fladeland
- Department of Basic Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, West Virginia, USA
| | - Samuel A Sprowls
- Department of Basic Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, West Virginia, USA
| | - Dhruvi M Panchal
- Department of Basic Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, West Virginia, USA.,Department of Chemical and Biomedical Engineering, Benjamin M. Statler College of Engineering and Mineral Resources, West Virginia University, Morgantown, West Virginia, USA
| | - Chris E Adkins
- Department of Pharmaceutical Sciences, School of Pharmacy, South University, Savannah, Georgia, USA
| | - Brooke N Kielkowski
- Department of Basic Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, West Virginia, USA
| | - Leland E Earp
- Department of Cancer Cell Biology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Morgan J Glass
- Department of Basic Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, West Virginia, USA
| | - Trenton A Pritt
- Department of Basic Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, West Virginia, USA
| | - Yssabela M Cabuyao
- Department of Basic Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, West Virginia, USA
| | - Sonikpreet Aulakh
- Department of Cancer Cell Biology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Paul R Lockman
- Department of Basic Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, West Virginia, USA
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8
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Liu HM, Meng CL, Zhao LJ. Survival Outcomes of Local Compared With Systemic First Treatment of Non-Small Cell Lung Cancer Brain Metastases. Front Oncol 2021; 11:706409. [PMID: 34858806 PMCID: PMC8631277 DOI: 10.3389/fonc.2021.706409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 10/18/2021] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE This retrospective study evaluated the survival advantage of local treatment targeted to brain metastases, relative to systemic therapy, as the first option for brain metastases of non-small cell lung cancer (NSCLC). METHODS First reviewed were 291 cases of NSCLC brain metastases from two centers. All patients were at least 18 years old, with histologically confirmed NSCLC, and required and underwent both local (radiotherapy or brain surgery) and systemic treatment (chemotherapy and tyrosine kinase inhibitor [TKI] medication). Demographics, clinical characteristics, and treatment-related variables were collected. RESULTS The final population comprised 160 patients. Overall, the multivariate analysis suggested that the following were associated with better survival: >3 cycles of chemotherapy; stereotactic radiosurgery; and TKI medication (all, P = 0.000). Local treatment that began within 1 week of the diagnosis of brain metastases was associated with poorer survival (P = 0.006). Among the 111 patients with symptomatic brain metastases, the multivariate analysis indicated that better survival was associated with >3 cycles of chemotherapy (P = 0.000), radiation dose >40 Gy (P = 0.001), stereotactic radiosurgery (P = 0.000), and TKI medication (P = 0.000), while local treatment that began within 1 week after the diagnosis of brain metastases was associated with poorer survival (P = 0.015). CONCLUSIONS For patients with NSCLC brain metastases, regardless of the presence of clinical symptoms associated with brain metastases, systemic treatment before local may be better for survival. Even when used to relieve clinical symptoms, local treatment should be within a setting of sufficient systemic treatment.
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Affiliation(s)
- Hong-Mei Liu
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin’s Clinical Research Center for Cancer, Tianjin, China
- Department of Radiation Oncology, Tangshan Gongren Hospital, Tangshan, China
| | - Chun-Liu Meng
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Lu-Jun Zhao
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin’s Clinical Research Center for Cancer, Tianjin, China
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9
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Nieblas-Bedolla E, Zuccato J, Kluger H, Zadeh G, Brastianos PK. Central Nervous System Metastases. Hematol Oncol Clin North Am 2021; 36:161-188. [PMID: 34711458 DOI: 10.1016/j.hoc.2021.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The proportion of patients developing central nervous system (CNS) metastasis is increasing. Most are identified once symptomatic. Surgical resection is indicated for solitary or symptomatic brain metastases, separation surgery for compressive radioresistant spinal metastases, and instrumentation for unstable spinal lesions. Surgical biopsies are performed when histological diagnoses are required. Stereotactic radiosurgery is an option for limited small brain metastases and radioresistant spinal metastases. Whole-brain radiotherapy is reserved for extensive brain metastases and leptomeningeal disease with approaches to reduce cognitive side effects. Radiosensitive and inoperable spinal metastases typically receive external beam radiotherapy. Systemic therapy is increasingly being utilized for CNS metastases.
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Affiliation(s)
- Edwin Nieblas-Bedolla
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Jeffrey Zuccato
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, 14-701, Toronto Medical Discovery Tower (TMDT), 101 College Street, Toronto, Ontario M5G 1L7, Canada
| | - Harriet Kluger
- Section of Medical Oncology-WWW211, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA
| | - Gelareh Zadeh
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, 14-701, Toronto Medical Discovery Tower (TMDT), 101 College Street, Toronto, Ontario M5G 1L7, Canada.
| | - Priscilla K Brastianos
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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10
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Hiranuma H, Ishibashi N, Maebayashi T, Aizawa T, Sakaguchi M, Hata M, Okada M, Gon Y. Whole-brain Radiation Therapy for Intracranial Metastases as Initial or Late Treatment. In Vivo 2021; 35:2445-2450. [PMID: 34182529 DOI: 10.21873/invivo.12523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/03/2021] [Accepted: 04/08/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM We examined the difference between whole-brain radiation therapy (WBRT) for intracranial metastases (IM) from lung cancer as an initial and as a late treatment affecting overall survival (OS). PATIENTS AND METHODS Thirty-three patients who presented with IM at initial examination who received WBRT as the initial treatment (initial WBRT group) and 47 patients without IM or with asymptomatic IM at initial examination who received WBRT after systemic therapy, between January 2014 and December 2020, were retrospectively analyzed. Patients' OS after WBRT were compared. RESULTS Median OS was significantly longer in patients treated with systemic anticancer therapy after WBRT than in patients who were not (176 vs. 47 days, respectively; p<0.001), and systemic anticancer therapy after WBRT was a significant prognostic factor (p<0.001). CONCLUSION Treatment with systemic anticancer therapy after WBRT may prolong the survival of patients who present with IM at initial examination.
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Affiliation(s)
- Hisato Hiranuma
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Naoya Ishibashi
- Department of Radiology, Nihon University School of Medicine, Tokyo, Japan;
| | - Toshiya Maebayashi
- Department of Radiology, Nihon University School of Medicine, Tokyo, Japan
| | - Takuya Aizawa
- Department of Radiology, Nihon University School of Medicine, Tokyo, Japan
| | - Masakuni Sakaguchi
- Department of Radiology, Nihon University School of Medicine, Tokyo, Japan
| | - Masaharu Hata
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Masahiro Okada
- Department of Radiology, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuhiro Gon
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
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Radiation Therapy for Brain Metastases: A Systematic Review. Pract Radiat Oncol 2021; 11:354-365. [PMID: 34119447 DOI: 10.1016/j.prro.2021.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/13/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE This evidence report synthesizes the available evidence on radiation therapy for brain metastases. METHODS AND MATERIALS The literature search included PubMed, EMBASE, Web of Science, Scopus, CINAHL, clinicaltrials.gov, and published guidelines in July 2020; independently submitted data, expert consultation, and contacting authors. Included studies were randomized controlled trials (RCTs) and large observational studies (for safety assessments), evaluating whole brain radiation therapy (WBRT) and stereotactic radiosurgery (SRS) alone or in combination, as initial or postoperative treatment, with or without systemic therapy for adults with brain metastases due to lung cancer, breast cancer, or melanoma. RESULTS Ninety-seven studies reported in 189 publications were identified, but the number of analyses was limited owing to different intervention and comparator combinations as well as insufficient reporting of outcome data. Risk of bias varied, and 25 trials were terminated early, predominantly owing to poor accrual. The combination of SRS plus WBRT compared with SRS alone or WBRT alone showed no statistically significant difference in overall survival (hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.69%-1.73%; 4 RCTs) or death owing to brain metastases (relative risk [RR], 0.93; 95% CI, 0.48%-1.81%; 3 RCTs). Radiation therapy after surgery did not improve overall survival compared with surgery alone (HR, 0.98; 95% CI, 0.76%-1.26%; 5 RCTs). Data for quality of life, functional status, and cognitive effects were insufficient to determine effects of WBRT, SRS, or postsurgery interventions. We did not find systematic differences across interventions in serious adverse events, number of adverse events, radiation necrosis, fatigue, or seizures. WBRT plus systemic therapy (RR 1.44; 95% CI, 1.03%-2.00%; 14 studies) was associated with increased risks for vomiting compared with WBRT alone. CONCLUSIONS Despite the substantial research literature on radiation therapy, comparative effectiveness information is limited. There is a need for more data on patient-relevant outcomes such as quality of life, functional status, and cognitive effects.
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Monnet I, Vergnenègre A, Robinet G, Berard H, Lamy R, Falchero L, Vieillot S, Schott R, Ricordel C, Chouabe S, Thomas P, Gervais R, Madroszyk A, Abdiche S, Chiappa AM, Greillier L, Decroisette C, Auliac JB, Chouaïd C. Phase III randomized study of carboplatin pemetrexed with or without bevacizumab with initial versus "at progression" cerebral radiotherapy in advanced non squamous non-small cell lung cancer with asymptomatic brain metastasis. Ther Adv Med Oncol 2021; 13:17588359211006983. [PMID: 33948123 PMCID: PMC8053829 DOI: 10.1177/17588359211006983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/11/2021] [Indexed: 12/25/2022] Open
Abstract
Background: The role and timing of whole or stereotaxic brain radiotherapy (BR) in patients with advanced non-small cell lung cancer (aNSCLC) and asymptomatic brain metastases (aBMs) are not well established. This study investigates whether deferring BR until cerebral progression was superior to upfront BR for patients with aNSCLC and aBM. Methods: This open-label, multicenter, phase III trial, randomized (1:1) aNSCLC patients with aBMs to receive upfront BR and chemotherapy: platin–pemetrexed and bevacizumab in eligible patients, followed by maintenance pemetrexed with or without bevacizumab, BR arm, or the same chemotherapy with BR only at cerebral progression, chemotherapy (ChT) arm. Primary endpoint was progression-free survival (PFS), secondary endpoints were overall survival (OS), global, extra-cerebral and cerebral objective response rate (ORR), toxicity, and quality of life [ClinicalTrials.gov identifier: NCT02162537]. Results: The trial was stopped early because of slow recruitment. Among 95 included patients, 91 were randomized in 24 centers: 45 to BR and 46 to ChT arms (age: 60 ± 8.1, men: 79%, PS 0/1: 51.7%/48.3%; adenocarcinomas: 92.2%, extra-cerebral metastases: 57.8%, without differences between arms.) Significantly more patients in the BR-arm received BR compare with those in the ChT arm (87% versus 20%; p < 0.001); there were no significant differences between BR and ChT arms for median PFS: 4.7, 95% confidence interval (CI):3.4–7.5 versus 4.8, 95% CI: 2.4–6.5 months, for median OS: 8.5, 95% CI:.6–11.1 versus 8.3, 95% CI:4.5–11.5 months, cerebral and extra-cerebral ORR (27% versus 13%, p = 0.064, and 30% versus 41%, p = 0.245, respectively). The ChT arm had more grade 3/4 neutropenia than the BR arm (13% versus 6%, p = 0.045); others toxicities were comparable. Conclusion: The significant BR rate difference between the two arms suggests that upfront BR is not mandatory in aNSCLC with aBM but this trial failed to show that deferring BR for aBM is superior in terms of PFS from upfront BR.
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Affiliation(s)
| | | | | | - Henri Berard
- Service de Pneumologie, Hôpital d'instruction des armées Sainte-Anne, Toulon, France
| | - Regine Lamy
- Service de Pneumologie, CH Bretagne Sud, Lorient, France
| | - Lionel Falchero
- Service de Pneumologie, Centre Hospitalier de Villefranche de Rouergue, Villefranche, France
| | | | - Roland Schott
- Service d'Oncologie, Centre Paul Strauss, Strasbourg, France
| | | | - Stephane Chouabe
- Service de Pneumologie, CH Charleville Mézière, Charleville Mézière, France
| | | | - Radj Gervais
- Service d'Oncologie, Centre François Baclesse, Caen, France
| | - Anne Madroszyk
- Service d'Oncologie, Institut Paoli-Calmettes, Marseille, France
| | | | | | - Laurent Greillier
- Department of Multidisciplinary Oncology and Therapeutic Innovations, APHM, Hôpital Nord, Marseille, France
| | | | | | - Christos Chouaïd
- Service de Pneumologie, CHI Créteil, 40 avenue de Verdun, Créteil, 94010, France
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Alemany M, Domènech M, Argyriou AA, Vilariño N, Majós C, Naval-Baudin P, Lucas A, Palmero R, Simó M, Nadal E, Bruna J. Perilesional edema in brain metastases as predictive factor of response to systemic therapy in non-small cell lung cancer patients: a preliminary study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:648. [PMID: 33987346 PMCID: PMC8106019 DOI: 10.21037/atm-20-6497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The significance of upfront systemic therapies as an alternative to whole brain radiotherapy (WBRT) for multiple brain metastases (BM) is debatable. Our purpose is to investigate if peritumoral edema could predict the intracranial response to systemic chemotherapy (chemo) in patients with advanced non-squamous non-small cell lung cancer (non-SQ-NSCLC) and synchronous multiple BM. METHODS In this observational cohort study, we evaluated the outcome of 28 patients with multiple BM (≥3) treated with chemo based on cisplatin/carboplatin plus pemetrexed (chemo, group A, n=17) or WBRT plus subsequent chemo (group B, n=11). The intracranial response, assessed by the response assessment neuro-oncology (RANO) BM criteria, was correlated with the degree of BM-associated edema estimated by the maximum diameter ratio among fluid attenuated inversion recovery (FLAIR) and gadolinium-enhanced T1WI (T1Gd) per each BM at the baseline brain magnetic resonance imaging (MRI). RESULTS No differences were observed in baseline characteristics between both groups, except for the number of patients under steroid treatment that was clearly superior in group B (P=0.007). Median OS was similar between groups. Regarding FLAIR/T1Gd ratio (F/Gd), patients treated with chemo alone exhibited significantly higher values (P=0.001) in those who developed intracranial progression disease (PD) (2.80±0.32 mm), compared with those who achieved partial response (PR) (1.30±0.11 mm) or stable disease (SD) (1.35±0.09 mm). In patients treated with WBRT, F/Gd ratio was not predictive of response. CONCLUSIONS Peritumoral edema estimated by F/Gd ratio appears a promising predictive tool to identify oligosymptomatic patients with multiple BM in whom WBRT can be postponed.
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Affiliation(s)
- Montse Alemany
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L’Hospitalet (IDIBELL), Barcelona, Spain
| | - Marta Domènech
- Thoracic Oncology Unit, Catalan Institute of Oncology, L’Hospitalet, Barcelona, Spain
| | - Andreas A. Argyriou
- Department of Neurology, Saint Andrew’s State General Hospital of Patras, Patras, Greece
| | - Noelia Vilariño
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L’Hospitalet (IDIBELL), Barcelona, Spain;,Thoracic Oncology Unit, Catalan Institute of Oncology, L’Hospitalet, Barcelona, Spain
| | - Carles Majós
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L’Hospitalet (IDIBELL), Barcelona, Spain;,Radiology Department ICS-IDI, Hospital Universitari Bellvitge, L’Hospitalet, Barcelona, Spain
| | - Pablo Naval-Baudin
- Radiology Department ICS-IDI, Hospital Universitari Bellvitge, L’Hospitalet, Barcelona, Spain
| | - Anna Lucas
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L’Hospitalet (IDIBELL), Barcelona, Spain
| | - Ramón Palmero
- Thoracic Oncology Unit, Catalan Institute of Oncology, L’Hospitalet, Barcelona, Spain
| | - Marta Simó
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L’Hospitalet (IDIBELL), Barcelona, Spain
| | - Ernest Nadal
- Thoracic Oncology Unit, Catalan Institute of Oncology, L’Hospitalet, Barcelona, Spain
| | - Jordi Bruna
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L’Hospitalet (IDIBELL), Barcelona, Spain
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Rybarczyk-Kasiuchnicz A, Ramlau R, Stencel K. Treatment of Brain Metastases of Non-Small Cell Lung Carcinoma. Int J Mol Sci 2021; 22:ijms22020593. [PMID: 33435596 PMCID: PMC7826874 DOI: 10.3390/ijms22020593] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 12/28/2020] [Accepted: 12/30/2020] [Indexed: 02/07/2023] Open
Abstract
Lung cancer is one of the most common malignant neoplasms. As a result of the disease's progression, patients may develop metastases to the central nervous system. The prognosis in this location is unfavorable; untreated metastatic lesions may lead to death within one to two months. Existing therapies-neurosurgery and radiation therapy-do not improve the prognosis for every patient. The discovery of Epidermal Growth Factor Receptor (EGFR)-activating mutations and Anaplastic Lymphoma Kinase (ALK) rearrangements in patients with non-small cell lung adenocarcinoma has allowed for the introduction of small-molecule tyrosine kinase inhibitors to the treatment of advanced-stage patients. The Epidermal Growth Factor Receptor (EGFR) is a transmembrane protein with tyrosine kinase-dependent activity. EGFR is present in membranes of all epithelial cells. In physiological conditions, it plays an important role in the process of cell growth and proliferation. Binding the ligand to the EGFR causes its dimerization and the activation of the intracellular signaling cascade. Signal transduction involves the activation of MAPK, AKT, and JNK, resulting in DNA synthesis and cell proliferation. In cancer cells, binding the ligand to the EGFR also leads to its dimerization and transduction of the signal to the cell interior. It has been demonstrated that activating mutations in the gene for EGFR-exon19 (deletion), L858R point mutation in exon 21, and mutation in exon 20 results in cancer cell proliferation. Continuous stimulation of the receptor inhibits apoptosis, stimulates invasion, intensifies angiogenesis, and facilitates the formation of distant metastases. As a consequence, the cancer progresses. These activating gene mutations for the EGFR are present in 10-20% of lung adenocarcinomas. Approximately 3-7% of patients with lung adenocarcinoma have the echinoderm microtubule-associated protein-like 4 (EML4)/ALK fusion gene. The fusion of the two genes EML4 and ALK results in a fusion gene that activates the intracellular signaling pathway, stimulates the proliferation of tumor cells, and inhibits apoptosis. A new group of drugs-small-molecule tyrosine kinase inhibitors-has been developed; the first generation includes gefitinib and erlotinib and the ALK inhibitor crizotinib. These drugs reversibly block the EGFR by stopping the signal transmission to the cell. The second-generation tyrosine kinase inhibitor (TKI) afatinib or ALK inhibitor alectinib block the receptor irreversibly. Clinical trials with TKI in patients with non-small cell lung adenocarcinoma with central nervous system (CNS) metastases have shown prolonged, progression-free survival, a high percentage of objective responses, and improved quality of life. Resistance to treatment with this group of drugs emerging during TKI therapy is the basis for the detection of resistance mutations. The T790M mutation, present in exon 20 of the EGFR gene, is detected in patients treated with first- and second-generation TKI and is overcome by Osimertinib, a third-generation TKI. The I117N resistance mutation in patients with the ALK mutation treated with alectinib is overcome by ceritinib. In this way, sequential therapy ensures the continuity of treatment. In patients with CNS metastases, attempts are made to simultaneously administer radiation therapy and tyrosine kinase inhibitors. Patients with lung adenocarcinoma with CNS metastases, without activating EGFR mutation and without ALK rearrangement, benefit from immunotherapy. This therapeutic option blocks the PD-1 receptor on the surface of T or B lymphocytes or PD-L1 located on cancer cells with an applicable antibody. Based on clinical trials, pembrolizumab and all antibodies are included in the treatment of non-small cell lung carcinoma with CNS metastases.
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15
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Chen XR, Hou X, Dinglin XX, Liu YD, Li Y, Zheng W, Li DL, Chen J, Wu XL, Wang KC, Ma SX, Zeng YD, Chen LK. Treatment Patterns and Survival Outcomes of Non-Small Cell Lung Cancer Patients Initially Diagnosed With Brain Metastases in Real-World Clinical Practice. Front Oncol 2020; 10:581729. [PMID: 33163410 PMCID: PMC7581726 DOI: 10.3389/fonc.2020.581729] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/21/2020] [Indexed: 12/20/2022] Open
Abstract
Background This study aimed to comprehensively analyze the characteristics, treatment patterns, and survival outcomes of non-small-cell lung cancer (NSCLC) patients initially diagnosed with brain metastases (BMs) in real-world practice. Methods We enrolled NSCLC patients initially diagnosed with BMs between Jan 2004 and Jan 2018 in our institution. Patient demographics, treatment modalities, and survival outcomes were then analyzed. Brain localized treatment (BLT) included early brain radiotherapy (EBR), deferred brain radiotherapy (DBR), and surgery. Results A total of 954 patients were identified. Concerning initial treatment, 525 patients (55.0%) received systemic medication (SM)+BLT, 400 patients (41.9%) received SM only, and 29 patients received BLT only (3.0%). SM+BLT cohort was associated with longer median overall survival (mOS) than the SM only and the BLT only cohorts both in epidermal growth factor receptor (EGFR)/anaplastic lymphoma kinase (ALK)-negative/unknown patients (15.3 months, 95% confidence interval [CI], 14.2–16.4; 11.1 months, 9.0–13.2; 7.0 months, 5.4–8.6; p<0.001) and in EGFR/ALK-positive patients (33.7 months, 28.5–38.9; 22.1 months, 17.8–26.4; 4.0 months, 3.6–4.4; p < 0.001). As for timing of radiotherapy, SM+EBR (14.1 months, 12.7–15.5) was associated with inferior mOS than SM+DBR (19.4 months, 14.2–24.6) in EGFR/ALK-negative/unknown patients. No significant difference was found in EGFR/ALK-positive patients (28.3 months, 19.1–37.5; 33.3 months, 28.1–38.5). Patients in the EGFR/ALK-negative/unknown cohort treated with first-line pemetrexed with platinum (PP) (15.8 months, 14.0–17.6, p<0.001) had longer mOS than those received non-PP regimens (13.1 months, 11.6–14.6). However, no difference was observed among EGFR/ALK-positive patients who were treated with tyrosine kinase inhibitors (TKIs) (29.5 months, 21.1–37.9; p = 0.140), PP (27.2 months, 21.6–32.8) and non-PP regimens (25.0 months, 16.0–34.0). Conclusions Our study confirmed that the use of SM+BLT is associated with superior mOS than those treated with SM only and BLT only. SM+DBR might be a better radiotherapeutic strategy for this patient population. EGFR/ALK-negative/unknown patients showed a survival benefit with PP treatment.
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Affiliation(s)
- Xin-Ru Chen
- State Key Laboratory of Oncology in South, China Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Xue Hou
- State Key Laboratory of Oncology in South, China Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Xiao-Xiao Dinglin
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yong-Dong Liu
- Department of Pathology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yin Li
- Department of Endoscopy, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Wei Zheng
- Department of Endoscopy, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - De-Lan Li
- Department of Chemotherapy, Zhongshan City People's Hospital, Zhongshan, China
| | - Jing Chen
- State Key Laboratory of Oncology in South, China Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Xiao-Liang Wu
- Department of Oncology, Guizhou Provincial People's Hospital, Guiyang, China
| | - Kai-Cheng Wang
- State Key Laboratory of Oncology in South, China Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Shu-Xiang Ma
- Department of Oncology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Yin-Duo Zeng
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Li-Kun Chen
- State Key Laboratory of Oncology in South, China Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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Gal O, Dudnik E, Rotem O, Finkel I, Peretz I, Zer A, Mandel J, Amiel A, Siegal T, Bar J, Lobachov A, Yust S. Tyrosine Kinase Inhibitors as a Treatment of Symptomatic CNS Metastases in Oncogene-Driven NSCLC. JOURNAL OF ONCOLOGY 2020; 2020:1980891. [PMID: 32963526 PMCID: PMC7486631 DOI: 10.1155/2020/1980891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/12/2020] [Accepted: 08/25/2020] [Indexed: 12/25/2022]
Abstract
Central nervous system (CNS) metastases occur frequently in oncogene-driven non-small cell lung cancer (NSCLC). Standard treatment approaches can potentially delay systemic treatment (surgical intervention) or result in neurocognitive impairment (radiotherapy). Recently, next-generation tyrosine kinase inhibitors (TKIs) have demonstrated remarkable intracranial activity. However, most clinical trials did not enroll patients suffering neurological symptoms. Our study aimed to assess the CNS activity of targeted therapies in this patient population. We present a case series of nine NSCLC patients with either EGFR mutation or ALK rearrangement and symptomatic CNS metastases that were treated with TKIs. Clinicopathological characteristics, treatment, and outcomes were analyzed. Most patients presented with symptomatic CNS metastases at time of metastatic disease presentation (6/9). Additionally, the majority of patients had leptomeningeal disease (6/9) and multiple parenchymal metastases. Patients presented with a variety of CNS symptoms with the most common being nausea, vomiting, headache, and confusion. Most patients (6/9) responded rapidly both clinically and radiographically to the targeted treatment, with a marked correlation between systemic and intracranial radiographic response. In conclusion, upfront use of next-generation TKIs in patients with oncogene-driven NSCLC with symptomatic CNS metastases is associated with reasonable intracranial activity and represents a valuable treatment option.
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Affiliation(s)
- Omer Gal
- Neuro-Oncology Unit, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
| | - Elizabeth Dudnik
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Thoracic Cancer Service, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
| | - Ofer Rotem
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Thoracic Cancer Service, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
| | - Inbar Finkel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Thoracic Cancer Service, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
| | - Idit Peretz
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Thoracic Cancer Service, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
| | - Alona Zer
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Thoracic Cancer Service, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
| | - Jacob Mandel
- Baylor College of Medicine, 7200 Cambridge Suite 9a, Houston, Texas 77030, USA
| | - Alexandra Amiel
- Neuro-Oncology Unit, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
| | - Tali Siegal
- Neuro-Oncology Unit, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
| | - Jair Bar
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Thoracic Oncology, Institute of Oncology, Sheba Medical Center, Tel HaShomer, Ramat Gan 5262000, Israel
| | - Anastasiya Lobachov
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Thoracic Oncology, Institute of Oncology, Sheba Medical Center, Tel HaShomer, Ramat Gan 5262000, Israel
| | - Shlomit Yust
- Neuro-Oncology Unit, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
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17
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Page S, Milner-Watts C, Perna M, Janzic U, Vidal N, Kaudeer N, Ahmed M, McDonald F, Locke I, Minchom A, Bhosle J, Welsh L, O'Brien M. Systemic treatment of brain metastases in non-small cell lung cancer. Eur J Cancer 2020; 132:187-198. [PMID: 32380429 DOI: 10.1016/j.ejca.2020.03.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/04/2020] [Indexed: 12/20/2022]
Abstract
Brain metastases (BrMs) are associated with significant morbidity and are found in up to 50% of patients with advanced non-small cell lung cancer (NSCLC). Most of the literature focuses on symptomatic BrMs, with a lack of baseline brain imaging in asymptomatic patients. Unfortunately, much of the data on local treatments with or without systemic treatment is retrospective. Clinical trials of systemic treatments largely exclude patients with BrMs. Chemotherapy is an active treatment for BrM with response rates in the brain similar to other sites of disease. Targeted systemic treatments in patients with driver mutations (EGFR and ALK-MET to date) have impressive central nervous system (CNS) penetrance and response rates. Unfortunately, no prospective data can currently guide the timings or modality of local therapies with systemic treatments in these patients who have a high incidence of CNS disease, but retrospective data suggest that early local therapies may give better intracranial progression-free survival (ICPFS). Recent immunotherapy trials have included patients with BrMs. These patients have largely been pre-treated with local therapies and are asymptomatic. Thus, the current standard is becoming, early local therapies before or in conjunction with immunotherapy agents. The approach seems to be safe. Prospective studies are needed in NSCLC BrMs patients to make sure any benefit from local therapies on the ICPFS and quality of life is not overlooked. Here we report what we think are reasonable conclusions from the available data and make suggestions for future clinical trials in the management of NSCLC BrMs.
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Affiliation(s)
| | | | - Marco Perna
- Azienda Ospedaliero Universitaria Careggi, Italy
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Abstract
Brain metastases are a very common manifestation of cancer that have historically been approached as a single disease entity given the uniform association with poor clinical outcomes. Fortunately, our understanding of the biology and molecular underpinnings of brain metastases has greatly improved, resulting in more sophisticated prognostic models and multiple patient-related and disease-specific treatment paradigms. In addition, the therapeutic armamentarium has expanded from whole-brain radiotherapy and surgery to include stereotactic radiosurgery, targeted therapies and immunotherapies, which are often used sequentially or in combination. Advances in neuroimaging have provided additional opportunities to accurately screen for intracranial disease at initial cancer diagnosis, target intracranial lesions with precision during treatment and help differentiate the effects of treatment from disease progression by incorporating functional imaging. Given the numerous available treatment options for patients with brain metastases, a multidisciplinary approach is strongly recommended to personalize the treatment of each patient in an effort to improve the therapeutic ratio. Given the ongoing controversies regarding the optimal sequencing of the available and expanding treatment options for patients with brain metastases, enrolment in clinical trials is essential to advance our understanding of this complex and common disease. In this Review, we describe the key features of diagnosis, risk stratification and modern paradigms in the treatment and management of patients with brain metastases and provide speculation on future research directions.
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Sheppard JP, Prashant GN, Chen CHJ, Peeters S, Lagman C, Ong V, Udawatta M, Duong C, Nguyen T, Romiyo P, Gaonkar B, Yong WH, Kaprealian TB, Tenn S, Lee P, Yang I. Timing of adjuvant radiation therapy and survival outcomes after surgical resection of intracranial non-small cell lung cancer metastases. Clin Neurol Neurosurg 2019; 183:105389. [PMID: 31280101 DOI: 10.1016/j.clineuro.2019.105389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 05/14/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate if delay of adjuvant radiotherapy (ART) beyond 6 post-operative weeks affects survival outcomes in patients undergoing craniotomy or craniectomy for resection of non-small cell lung cancer (NSCLC) intracranial metastases. PATIENTS AND METHODS We performed a retrospective analysis of 28 patients undergoing resection of intracranial metastases and ART at our institution from 2001 to 2016. We assessed survival outcomes for patients who received delayed versus non-delayed ART, as well as associated risk factors. RESULTS Among 28 patients, 8 (29%) had delayed ART beyond 6 post-operative weeks. Fifteen received stereotactic radiotherapy (SRT), 8 (29%) received whole brain radiotherapy (WBRT), and 5 (18%) received combination WBRT + SRT. There were no significant differences in ART modality or dosing, age, sex, number of intracranial metastases, primary metastasis volume, rates of chemotherapy, extracranial metastases, or post-operative functional scores between groups. Expected post-operative survival was shorter with delayed ART (7 months versus 28 months, P = 0.01). The most common reason for delayed ART was complicated post-operative course (n = 3.38%). Significant risk factors for delayed ART included non-routine discharge (P = 0.01) and additional invasive procedures between surgery and ART start date (P = 0.02). CONCLUSIONS Our results suggest delayed ART in patients undergoing surgical resection of intracranial NSCLC metastases is associated with shorter overall survival. However, risk factors for delayed ART, including non-routine discharge and the need for additional invasive procedures, may have in themselves reflected poorer clinical courses that may have also contributed to the observed survival differences.
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Affiliation(s)
- John P Sheppard
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Giyarpuram N Prashant
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Cheng Hao Jacky Chen
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Sophie Peeters
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Carlito Lagman
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Vera Ong
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Methma Udawatta
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Courtney Duong
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Thien Nguyen
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Prasanth Romiyo
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Bilwaj Gaonkar
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - William H Yong
- Department of Pathology, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Tania B Kaprealian
- Department of Radiation Oncology, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Stephen Tenn
- Department of Radiation Oncology, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Percy Lee
- Department of Radiation Oncology, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States
| | - Isaac Yang
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States; Department of Radiation Oncology, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States; Department of Head and Neck Surgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States; Department of UCLA Jonsson Comprehensive Cancer Center, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, United States; Department of Neurosurgery Harbor-UCLA Medical Center, Torrance, CA, United States; Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA, United States.
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20
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Andratschke N, Kraft J, Nieder C, Tay R, Califano R, Soffietti R, Guckenberger M. Optimal management of brain metastases in oncogenic-driven non-small cell lung cancer (NSCLC). Lung Cancer 2019; 129:63-71. [DOI: 10.1016/j.lungcan.2018.12.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/29/2018] [Accepted: 12/08/2018] [Indexed: 02/07/2023]
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Nassif EF, Arsène-Henry A, Kirova YM. Brain metastases and treatment: multiplying cognitive toxicities. Expert Rev Anticancer Ther 2019; 19:327-341. [PMID: 30755047 DOI: 10.1080/14737140.2019.1582336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Thirty per cent of cancer patients develop brain metastases, with multiple combination or sequential treatment modalities available, to treat systemic or central nervous system (CNS) disease. Most patients experience toxicities as a result of these treatments, of which cognitive impairment is one of the adverse events most commonly reported, causing major impairment of the patient's quality of life. Areas covered: This article reviews the role of cancer treatments in cognitive decline of patients with brain metastases: surgery, radiotherapy, chemotherapy, targeted therapies, immunotherapies and hormone therapy. Pathological and molecular mechanisms, as well as future directions for limiting cognitive toxicities are also presented. Other causes of cognitive impairment in this population are discussed in order to refine the benefit-risk balance of each treatment modality. Expert opinion: Cumulative cognitive toxicity should be taken into account, and tailored to the patient's cognitive risk in the light of the expected survival benefit. Standardization of cognitive assessment in this context is needed in order to better appreciate each treatment's responsibility in cognitive impairment, keeping in mind disease itself impacts cognition in this context.
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Affiliation(s)
- Elise F Nassif
- a Department of Radiotherapy , Institut Curie , Paris , France
| | | | - Youlia M Kirova
- a Department of Radiotherapy , Institut Curie , Paris , France
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22
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Wu YL, Planchard D, Lu S, Sun H, Yamamoto N, Kim DW, Tan DSW, Yang JCH, Azrif M, Mitsudomi T, Park K, Soo RA, Chang JWC, Alip A, Peters S, Douillard JY. Pan-Asian adapted Clinical Practice Guidelines for the management of patients with metastatic non-small-cell lung cancer: a CSCO-ESMO initiative endorsed by JSMO, KSMO, MOS, SSO and TOS. Ann Oncol 2019; 30:171-210. [PMID: 30596843 DOI: 10.1093/annonc/mdy554] [Citation(s) in RCA: 193] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of metastatic non-small-cell lung cancer (NSCLC) was published in 2016. At the ESMO Asia Meeting in November 2017 it was decided by both ESMO and the Chinese Society of Clinical Oncology (CSCO) to convene a special guidelines meeting immediately after the Chinese Thoracic Oncology Group Annual Meeting 2018, in Guangzhou, China. The aim was to adapt the ESMO 2016 guidelines to take into account the ethnic differences associated with the treatment of metastatic NSCLC cancer in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with metastatic NSCLC representing the oncological societies of China (CSCO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence, and was independent of both the current treatment practices and the drug availability and reimbursement situations in the six participating Asian countries. During the review process, the updated ESMO 2018 Clinical Practice Guidelines for metastatic NSCLC were released and were also considered, during the final stages of the development of the Pan-Asian adapted Clinical Practice Guidelines.
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Affiliation(s)
- Y-L Wu
- Guangdong Lung Cancer Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, P.R. China.
| | - D Planchard
- Department of Medical Oncology, Thoracic Group, Gustave Roussy, Villejuif, France
| | - S Lu
- Shanghai Chest Hospital, Shanghai, P.R. China
| | - H Sun
- Guangdong Lung Cancer Institute, Guangdong Lung Cancer Institute, Guangdong General Hospital, School of Medicine, South China University of Technology, Guangzhou, P.R. China
| | - N Yamamoto
- Department of Internal Medicine 3, Wakayama Medical University, Wakayama, Japan
| | - D-W Kim
- Seoul National University Hospital, Seoul, Korea
| | - D S W Tan
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - J C-H Yang
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - M Azrif
- Department of Radiotherapy & Oncology, Prince Court Medical Centre, Kuala Lumpur, Malaysia
| | - T Mitsudomi
- Faculty of Medicine, Department of Thoracic Surgery, Kindai University, Osaka-Sayama, Japan
| | - K Park
- Division of Hematology/Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - R A Soo
- Department of Haematology-Oncology, National University Hospital, Singapore, Singapore
| | - J W C Chang
- Division of Haematology/Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung, Taiwan
| | - A Alip
- Faculty of Medicine, Department of Clinical Oncology, University of Malaya, Kuala Lumpur, Malaysia
| | - S Peters
- Oncology Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
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Achrol AS, Rennert RC, Anders C, Soffietti R, Ahluwalia MS, Nayak L, Peters S, Arvold ND, Harsh GR, Steeg PS, Chang SD. Brain metastases. Nat Rev Dis Primers 2019; 5:5. [PMID: 30655533 DOI: 10.1038/s41572-018-0055-y] [Citation(s) in RCA: 520] [Impact Index Per Article: 104.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
An estimated 20% of all patients with cancer will develop brain metastases, with the majority of brain metastases occurring in those with lung, breast and colorectal cancers, melanoma or renal cell carcinoma. Brain metastases are thought to occur via seeding of circulating tumour cells into the brain microvasculature; within this unique microenvironment, tumour growth is promoted and the penetration of systemic medical therapies is limited. Development of brain metastases remains a substantial contributor to overall cancer mortality in patients with advanced-stage cancer because prognosis remains poor despite multimodal treatments and advances in systemic therapies, which include a combination of surgery, radiotherapy, chemotherapy, immunotherapy and targeted therapies. Thus, interest abounds in understanding the mechanisms that drive brain metastases so that they can be targeted with preventive therapeutic strategies and in understanding the molecular characteristics of brain metastases relative to the primary tumour so that they can inform targeted therapy selection. Increased molecular understanding of the disease will also drive continued development of novel immunotherapies and targeted therapies that have higher bioavailability beyond the blood-tumour barrier and drive advances in radiotherapies and minimally invasive surgical techniques. As these discoveries and innovations move from the realm of basic science to preclinical and clinical applications, future outcomes for patients with brain metastases are almost certain to improve.
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Affiliation(s)
- Achal Singh Achrol
- Department of Neurosurgery and Neurosciences, John Wayne Cancer Institute and Pacific Neuroscience Institute, Santa Monica, CA, USA.
| | - Robert C Rennert
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA.
| | - Carey Anders
- Division of Hematology/Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | | | - Manmeet S Ahluwalia
- Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Lakshmi Nayak
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Solange Peters
- Medical Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Nils D Arvold
- Department of Radiation Oncology, St. Luke's Cancer Center, Duluth, MN, USA
| | - Griffith R Harsh
- Department of Neurosurgery, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Patricia S Steeg
- Women's Malignancies Branch, Center for Cancer Research, National Cancer Center, Bethesda, MD, USA
| | - Steven D Chang
- Department of Neurosurgery, University of California-Davis, School of Medicine, Sacramento, CA, USA.
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Planchard D, Popat S, Kerr K, Novello S, Smit EF, Faivre-Finn C, Mok TS, Reck M, Van Schil PE, Hellmann MD, Peters S. Metastatic non-small cell lung cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2018; 29:iv192-iv237. [PMID: 30285222 DOI: 10.1093/annonc/mdy275] [Citation(s) in RCA: 1390] [Impact Index Per Article: 231.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- D Planchard
- Department of Medical Oncology, Thoracic Group, Gustave-Roussy Villejuif, France
| | - S Popat
- Royal Marsden Hospital, London
| | - K Kerr
- Aberdeen Royal Infirmary, Aberdeen University Medical School, Aberdeen, UK
| | - S Novello
- Department of Oncology, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - E F Smit
- Thoracic Oncology Service, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - C Faivre-Finn
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - T S Mok
- Department of Clinical Oncology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - M Reck
- LungenClinic Airway Research Center North (ARCN), German Center for Lung Research, Grosshansdorf, Germany
| | - P E Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital and Antwerp University, Antwerp, Belgium
| | | | - S Peters
- Medical Oncology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Li J, Chai X, Cao Y, Hu X, Zhu H, Wang J, Wu Y. Intensity-modulated radiation therapy combined with concomitant temozolomide for brain metastases from lung adenocarcinoma. Oncol Lett 2018; 16:4285-4290. [PMID: 30214562 PMCID: PMC6126327 DOI: 10.3892/ol.2018.9171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 06/19/2018] [Indexed: 12/25/2022] Open
Abstract
Short-term efficacy, adverse effects and the impact on quality of life (QoL) of a concomitant treatment with intensity-modulated radiation therapy (IMRT) and temozolomide (TMZ) in patients with brain metastases (BMs) from lung adenocarcinoma were evaluated. This study sought to confirm the benefit of adding TMZ to IMRT in patients with BMs from lung adenocarcinoma. Nine patients were enrolled and received a dose of 30 Gy in 10 daily fractions to clinical tumor volume (CTV) according to IMRT, then additional dose of 9 Gy in 3 fractions of IMRT was delivered to gross tumor volume (GTV) only with concomitant TMZ (75 mg/m2/day) orally during RT for 3 weeks. One patient achieved complete response (CR) (11.1%), 6 patients obtained partial response (PR) (66.7%), and there were no patients in progression. Therefore, objective response (OR) reached 77.8%. The main adverse effects included neutropenia, anemia, vomiting, fatigue and dizziness. Grade ≥3 of hematologic toxicities did not occur. However, the other 9 patients who received only intensity-modulated radiation had much worse results. The CR was 0, PR rate was 44.4%, OR rate was 44.4%. The results indicated that the benefit of adding TMZ to IMRT was confirmed in patients with BMs from lung adenocarcinoma. The treatment was active, a significant OR was observed, and achieved an improvement in QoL demonstrated by QoL grade (p<0.05).
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Affiliation(s)
- Jinli Li
- Department of Radiation Oncology, The Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Xiaoyan Chai
- Department of Oncology, Suzhou Science and Technology Town Hospital, Suzhou, Jiangsu 215153, P.R. China
| | - Ying Cao
- Department of Radiation Oncology, The Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Xiaochu Hu
- Department of Radiation Oncology, The Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Hongyu Zhu
- Department of Radiation Oncology, The Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Jianping Wang
- Department of Radiation Oncology, The Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Yiwei Wu
- Department of Nuclear Medicine, The Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
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26
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Turkaj A, Morelli AM, Vavalà T, Novello S. Management of Leptomeningeal Metastases in Non-oncogene Addicted Non-small Cell Lung Cancer. Front Oncol 2018; 8:278. [PMID: 30140655 PMCID: PMC6094962 DOI: 10.3389/fonc.2018.00278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/04/2018] [Indexed: 12/13/2022] Open
Abstract
Brain metastases in non-small cell lung cancer (NSCLC) patients are more often detected due to imaging modalities improvements but also emerge because of improved treatments of the primary tumor which lead to a longer survival. In this context, development of leptomeningeal metastases (LM) is a devastating complication and its prognosis remains poor despite advances in systemic and local approaches. Histology characterization of NSCLC and molecular expression influence LM management. For those with “oncogene addiction,” new generation epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) were developed to strongly penetrate the blood-brain barrier (BBB) with the aim to prevent central nervous system cancer dissemination, eventually impacting on LM appearance and its subsequent management. Systemic chemotherapy, often combined with intrathecal chemotherapy (when possible), was one of common indications for lung cancer patients affected by LM, without driver mutations and a good performance status but currently, with the advent of innovative systemic approaches treatment solutions in this subgroup of patients are rapidly evolving. Whole brain radiation therapy (WBRT) is the conventional treatment for patients with brain metastases. Furthermore, modern radiation techniques, as stereotactic radiotherapy (SRT), improve outcomes in those cases with a limited number of lesions. However, LM represent a minority of CNS metastases and few literature data are available to drive the radiotherapy approach. Considering all relevant progress made in this setting, after a literature review, the aim of this paper is to discuss about recent developments and therapeutic options in LM management of non-oncogene addicted NSCLC.
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Affiliation(s)
- Ana Turkaj
- Department of Oncology, University of Torino, Ospedale San Luigi Gonzaga, Orbassano, Italy
| | - Anna M Morelli
- Department of Oncology, University of Torino, Ospedale San Luigi Gonzaga, Orbassano, Italy
| | - Tiziana Vavalà
- SC of Oncology, ASL CN1, Ospedale Civile di Saluzzo, Saluzzo, Italy
| | - Silvia Novello
- Department of Oncology, University of Torino, Ospedale San Luigi Gonzaga, Orbassano, Italy
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27
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Vinod SK. Should we screen for brain metastases in non-small cell lung cancer? J Med Imaging Radiat Oncol 2018; 62:380-382. [PMID: 29873943 DOI: 10.1111/1754-9485.12743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 04/18/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Shalini K Vinod
- Cancer Therapy Centre, Liverpool Hospital, Sydney, New South Wales, Australia
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28
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O'Kane GM, Leighl NB. Systemic Therapy of Lung Cancer CNS Metastases Using Molecularly Targeted Agents and Immune Checkpoint Inhibitors. CNS Drugs 2018; 32:527-542. [PMID: 29799091 DOI: 10.1007/s40263-018-0526-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Central nervous system (CNS) metastases most commonly arise from lung cancer, with the majority of patients affected during their disease course. The prognosis for patients with untreated brain metastases is poor, with surgical resection and/or radiotherapy as classic therapeutic options. However, the value of systemic therapy in the management of CNS metastases from lung cancer is growing. Novel targeted agents for the treatment of non-small cell lung cancer (NSCLC) have demonstrated activity in treating patients with CNS involvement, and are potential alternatives to radiation and surgery. These agents include anaplastic lymphoma kinase (ALK) inhibitors such as alectinib, crizotinib, ceritinib, lorlatinib, and others; epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors, including the recently developed third-generation inhibitor osimertinib, and even immune checkpoint inhibitors such as nivolumab, pembrolizumab, and atezolizumab. This review summarizes current activity of systemic agents in the management of CNS metastases from NSCLC, as well as potential mechanisms of action of these small and large molecules.
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Affiliation(s)
- Grainne M O'Kane
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, 7W-389, 700 University Avenue, Toronto, ON, M5G 1Z5, Canada. Grainne.O'
| | - Natasha B Leighl
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, 7W-389, 700 University Avenue, Toronto, ON, M5G 1Z5, Canada
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29
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Levy A, Faivre-Finn C, Hasan B, De Maio E, Berghoff AS, Girard N, Greillier L, Lantuéjoul S, O'Brien M, Reck M, Dingemans AMC, Novello S, Berghmans T, Besse B, Hendriks L. Diversity of brain metastases screening and management in non-small cell lung cancer in Europe: Results of the European Organisation for Research and Treatment of Cancer Lung Cancer Group survey. Eur J Cancer 2018; 93:37-46. [PMID: 29477100 DOI: 10.1016/j.ejca.2018.01.067] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/03/2018] [Accepted: 01/04/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Brain metastases (BM) are frequent in non-small cell lung cancer (NSCLC) patients, but there is a lack of evidence-based management of this patient group. We aimed to capture a snapshot of routine BM management in Europe to identify relevant research questions for future clinical trials. METHODS An EORTC Lung Cancer Group (LCG) online survey containing questions on NSCLC BM screening and treatment was distributed between 16/02/17 and 15/06/17 to worldwide EORTC LCG members, and through several European scientific societies in the thoracic oncology field. RESULTS A total of 462 European physician responses (394 institutions) were analysed (radiation oncologist: 53% [n = 247], pulmonologist: 26% [n = 119], medical oncologist: 18% [n = 84]; 84% with >5 years' experience in NSCLC). Italy (18%, n = 85), Netherlands (15%, n = 68), UK (14%, n = 66), and France (12%, n = 55) contributed most. 393 physicians (85%) screened neurologically asymptomatic patients for BM at diagnosis (52% using magnetic resonance imaging). Most often screened patients were those with a driver mutation (MUT+; 51%, n = 234), stage III (63%, n = 289), and IV (43%, n = 199). 158 physicians (34%) used a prognostic classification to guide initial treatment decisions, and in 50%, lowest prognostic-score threshold to receive treatment differed between MUT+ and non-driver mutation (MUT-) patients. MUT+ patients with >4 BM were more likely to receive stereotactic radiosurgery (SRS) compared with MUT- (27% versus. 21%; p < 0.01). Most physicians (90%) had access to SRS. After single BM surgery, 50% systematically prescribed SRS or WBRT, and 45% only in case of incomplete resection. The preferred treatment in neurologically asymptomatic treatment-naive patients diagnosed with >5 BM was systemic treatment (79%). Of all, 45%/49% physicians stated that all tyrosine kinase inhibitors and immune checkpoint blockers were discontinued (timing varied) during SRS/WBRT, respectively. Drugs most often continued during SRS/WBRT were erlotinib (44%/40%), gefitinib (39%/34%), afatinib (29%/25%), crizotinib (33%/26%) and anti-PD-(L)-1 (28%/22%). CONCLUSION BM management is highly variable in Europe: screening is not uniform, prognostic classifications are not often used and MUT+ NSCLC patients generally receive more intensive local treatment. Prospective assessment of BM management in MUT+ NSCLC patients is required.
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Affiliation(s)
- Antonin Levy
- Department of Radiation Oncology, Gustave Roussy, Institut d'Oncologie Thoracique (IOT), INSERM U1030 Molecular Radiotherapy, Université Paris-Saclay, F-94805, Villejuif, France; Univ Paris Sud, Université Paris-Saclay, F-94270, Le Kremlin-Bicêtre, France.
| | - Corinne Faivre-Finn
- Manchester Academic Health Science Centre, Institute of Cancer Sciences, Manchester Cancer Research Centre (MCRC), University of Manchester, Manchester, UK
| | - Baktiar Hasan
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Eleonora De Maio
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Anna S Berghoff
- Department of Medicine I and Comprehensive Cancer Center CNS Unit (CCC-CNS), Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Nicolas Girard
- Department of Medical Oncology, Institut Curie, Paris, France
| | - Laurent Greillier
- Multidisciplinary Oncology and Therapeutic Innovations, Assistance Publique Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - Sylvie Lantuéjoul
- Department of Biopathology, Centre Léon Bérard UNICANCER, Lyon, Université Grenoble Alpes, INSERM U1209/CNRS 5309 Institute for Advanced Biosciences, Grenoble France
| | - Mary O'Brien
- Department of Medicine, Royal Marsden NHS Foundation Trust, London, UK
| | - Martin Reck
- LungenClinic Grosshansdorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany
| | - Anne-Marie C Dingemans
- Department of Pulmonary Diseases, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Silvia Novello
- Oncology Department, University of Turin, AOU San Luigi, Orbassano (TO), Italy
| | - Thierry Berghmans
- Department of Intensive Care and Oncological Emergencies & Thoracic Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Benjamin Besse
- Univ Paris Sud, Université Paris-Saclay, F-94270, Le Kremlin-Bicêtre, France; Department of Medical Oncology, Gustave Roussy, Institut d'Oncologie Thoracique (IOT), Gustave Roussy, Université Paris-Saclay, F-94805, Villejuif, France
| | - Lizza Hendriks
- Department of Pulmonary Diseases, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.
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Gauvain C, Vauléon E, Chouaid C, Le Rhun E, Jabot L, Scherpereel A, Vinas F, Cortot AB, Monnet I. Intracerebral efficacy and tolerance of nivolumab in non–small-cell lung cancer patients with brain metastases. Lung Cancer 2018; 116:62-66. [DOI: 10.1016/j.lungcan.2017.12.008] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 12/04/2017] [Accepted: 12/13/2017] [Indexed: 12/01/2022]
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31
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Tsao MN, Xu W, Wong RKS, Lloyd N, Laperriere N, Sahgal A, Rakovitch E, Chow E. Whole brain radiotherapy for the treatment of newly diagnosed multiple brain metastases. Cochrane Database Syst Rev 2018; 1:CD003869. [PMID: 29365347 PMCID: PMC6491334 DOI: 10.1002/14651858.cd003869.pub4] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND This is an update to the review published in the Cochrane Library (2012, Issue 4).It is estimated that 20% to 40% of people with cancer will develop brain metastases during the course of their illness. The burden of brain metastases impacts quality and length of survival. OBJECTIVES To assess the effectiveness and adverse effects of whole brain radiotherapy (WBRT) given alone or in combination with other therapies to adults with newly diagnosed multiple brain metastases. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase to May 2017 and the National Cancer Institute Physicians Data Query for ongoing trials. SELECTION CRITERIA We included phase III randomised controlled trials (RCTs) comparing WBRT versus other treatments for adults with newly diagnosed multiple brain metastases. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and abstracted information in accordance with Cochrane methods. MAIN RESULTS We added 10 RCTs to this updated review. The review now includes 54 published trials (45 fully published reports, four abstracts, and five subsets of data from previously published RCTs) involving 11,898 participants.Lower biological WBRT doses versus controlThe hazard ratio (HR) for overall survival (OS) with lower biological WBRT doses as compared with control (3000 cGy in 10 daily fractions) was 1.21 (95% confidence interval (CI) 1.04 to 1.40; P = 0.01; moderate-certainty evidence) in favour of control. The HR for neurological function improvement (NFI) was 1.74 (95% CI 1.06 to 2.84; P = 0.03; moderate-certainty evidence) in favour of control fractionation.Higher biological WBRT doses versus controlThe HR for OS with higher biological WBRT doses as compared with control (3000 cGy in 10 daily fractions) was 0.97 (95% CI 0.83 to 1.12; P = 0.65; moderate-certainty evidence). The HR for NFI was 1.14 (95% CI 0.92 to 1.42; P = 0.23; moderate-certainty evidence).WBRT and radiosensitisersThe addition of radiosensitisers to WBRT did not confer additional benefit for OS (HR 1.05, 95% CI 0.99 to 1.12; P = 0.12; moderate-certainty evidence) or for brain tumour response rates (odds ratio (OR) 0.84, 95% CI 0.63 to 1.11; P = 0.22; high-certainty evidence).Radiosurgery and WBRT versus WBRT aloneThe HR for OS with use of WBRT and radiosurgery boost as compared with WBRT alone for selected participants was 0.61 (95% CI 0.27 to 1.39; P = 0.24; moderate-certainty evidence). For overall brain control at one year, the HR was 0.39 (95% CI 0.25 to 0.60; P < 0.0001; high-certainty evidence) favouring the WBRT and radiosurgery boost group.Radiosurgery alone versus radiosurgery and WBRTThe HR for local brain control was 2.73 (95% CI 1.87 to 3.99; P < 0.00001; high-certainty evidence)favouring the addition of WBRT to radiosurgery. The HR for distant brain control was 2.34 (95% CI 1.73 to 3.18; P < 0.00001; high-certainty evidence) favouring WBRT and radiosurgery. The HR for OS was 1.00 (95% CI 0.80 to 1.25; P = 0.99; moderate-certainty evidence). Two trials reported worse neurocognitive outcomes and one trial reported worse quality of life outcomes when WBRT was added to radiosurgery.We could not pool data from trials related to chemotherapy, optimal supportive care (OSC), molecular targeted agents, neurocognitive protective agents, and hippocampal sparing WBRT. However, one trial reported no differences in quality-adjusted life-years for selected participants with brain metastases from non-small-cell lung cancer randomised to OSC and WBRT versus OSC alone. AUTHORS' CONCLUSIONS None of the trials with altered higher biological WBRT dose-fractionation schemes reported benefit for OS, NFI, or symptom control compared with standard care. However, OS and NFI were worse for lower biological WBRT dose-fractionation schemes than for standard dose schedules.The addition of WBRT to radiosurgery improved local and distant brain control in selected people with brain metastases, but data show worse neurocognitive outcomes and no differences in OS.Selected people with multiple brain metastases from non-small-cell lung cancer may show no difference in OS when OSC is given and WBRT is omitted.Use of radiosensitisers, chemotherapy, or molecular targeted agents in conjunction with WBRT remains experimental.Further trials are needed to evaluate the use of neurocognitive protective agents and hippocampal sparing with WBRT. As well, future trials should examine homogeneous participants with brain metastases with focus on prognostic features and molecular markers.
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Affiliation(s)
- May N Tsao
- University of TorontoDepartment of Radiation Oncology2075 Bayview AvenueTorontoOntarioCanadaM4N 3M5
| | - Wei Xu
- University of TorontoDepartment of BiostatisticsUniversity Health NetworkTorontoOntarioCanada
| | - Rebecca KS Wong
- Princess Margaret Cancer CentreDepartment of Radiation Oncology5th Floor, 610 University AvenueTorontoONCanadaM5G 2M9
| | - Nancy Lloyd
- McMaster UniversityDepartment of Clinical Epidemiology and Biostatistics1280 Main Street WestCourthouse T‐27, 3rd FloorHamiltonOntarioCanadaL8S 4L8
| | - Normand Laperriere
- Princess Margaret Cancer CentreDepartment of Radiation Oncology5th Floor, 610 University AvenueTorontoONCanadaM5G 2M9
| | - Arjun Sahgal
- Odette Cancer CentreDepartment of Radiation OncologySunnybrook Health Sciences Centre2075 Bayview Avenue, T‐WingTorontoCanadaM4N 3M5
| | - Eileen Rakovitch
- Odette Cancer CentreDepartment of Radiation OncologySunnybrook Health Sciences Centre2075 Bayview Avenue, T‐WingTorontoCanadaM4N 3M5
| | - Edward Chow
- Odette Cancer CentreDepartment of Radiation OncologySunnybrook Health Sciences Centre2075 Bayview Avenue, T‐WingTorontoCanadaM4N 3M5
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Abstract
Central nervous system metastases cause grave morbidity in patients with advanced malignancies. Lung cancer, breast cancer, and melanoma are the three most common causes of brain metastases. Although the exact incidence of brain metastases is unclear, there appears to be an increasing incidence which has been attributed to longer survival, better control of systemic disease, and better imaging modalities. Until recently surgical resection of solitary or symptomatic brain metastases, and radiation therapy (either whole-brain radiation therapy or stereotactic radiation) were the mainstay of treatment for patients with brain metastases. The majority of traditional chemotherapies have shown limited activity in the central nervous system, which has been attributed to the blood-brain barrier and the molecular structure of the used agents. The discovery of driver mutations and drugs targeting these mutations has changed the treatment landscape. Several of these targeted small-molecule tyrosine kinase inhibitors do cross the blood-brain barrier and/or have shown activity in the central nervous system. Another major advance in the care of brain metastases has been the advent of new immunotherapeutic agents, for which initial studies have shown intracranial activity. In this chapter, we will review the unique challenges in the treatment of brain metastases. The pertinent clinical studies of chemotherapy in brain metastases will be discussed. The currently reported clinical trials and evidence for use of targeted therapies and immunotherapeutic agents will be emphasized.
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Effectiveness and safety of nivolumab in advanced non-small cell lung cancer: The real-life data. Lung Cancer 2017; 126:217-223. [PMID: 29254746 DOI: 10.1016/j.lungcan.2017.11.015] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 04/12/2017] [Accepted: 11/17/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Nivolumab has recently received regulatory approval as a 2nd-line treatment of non-small cell lung cancer (NSCLC). The data regarding its effectiveness and safety in real life setting is lacking. MATERIALS AND METHODS 260 consecutive patients with advanced NSCLC treated with nivolumab at five Israeli cancer centers between January 2015 and March 2016 were evaluated for overall survival (OS) and toxicity. OS was analyzed by the Cox proportional-hazards regression model. Overall response rate (ORR) and progression-free survival (PFS) were assessed in 49 patients using RECIST, v.1.1. RESULTS Median age was 67y (41-99); males 68%; smokers 76%; ECOG PS ≥2 46%; non-squamous/squamous/other/NR 70%/23%/6%/1%; brain metastases 21%; liver metastases 21%; treatment line: 1st/2nd/3rd+-line/NR 6%/64%/26%/4%. With median survival follow-up of 18.5 months (range, 12.0-26.9), 155 (60%) patients died; median OS comprised 5.9 months (95% CI 4.7-7.4). In univariate and multivariate analysis, the only variable which significantly correlated with OS was ECOG PS. Median OS of patients with ECOG PS 0/1 and ECOG PS ≥2 comprised 9.5 months (95% CI, 6.7-NR) and 3.5 months (95% CI, 2.6-4.5), respectively. For 49 patients evaluable for response (median follow-up of 8.4 months (range, 2-16.8), ORR was 35%, median PFS was 2.8 months (95% CI, 1.8-7.7), incidence of pseudo-progression was 9%. The nivolumab safety profile was in accordance with the literature data, except for febrile neutropenia and pericarditis (observed in 1 case each). CONCLUSION In real life setting, the effectiveness of nivolumab is reasonable yet less prominent than it has been demonstrated in clinical trials. ECOG PS ≥2 is associated with poor prognosis.
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Systematic Review of Brain Metastases in Patients With Non–Small-Cell Lung Cancer in the United States, European Union, and Japan. Clin Lung Cancer 2017; 18:607-614. [DOI: 10.1016/j.cllc.2017.04.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 04/03/2017] [Accepted: 04/18/2017] [Indexed: 11/17/2022]
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McGranahan T, Nagpal S. A Neuro-oncologist's Perspective on Management of Brain Metastases in Patients with EGFR Mutant Non-small Cell Lung Cancer. Curr Treat Options Oncol 2017; 18:22. [PMID: 28391420 PMCID: PMC5385200 DOI: 10.1007/s11864-017-0466-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Management of non-small cell lung cancer (NSCLC) with brain metastasis (BrM) has been revolutionized by identification of molecular subsets that have targetable oncogenes. Historically, survival for NSCLC with symptomatic BrM was weeks to months. Now, many patients are surviving years with limited data to guide treatment decisions. Tumors with activating mutations in epidermal growth factor receptor (EGFRact+) have a higher incidence of BrM, but a longer overall survival. The high response rate of both systemic and BrM EGFRact+ NSCLC to tyrosine kinase inhibitors (TKIs) has led to the rapid incorporation of new therapies but is outpacing evidence-based decisions for BrM in NSCLC. While whole brain radiation therapy (WBRT) was the foundation of management of BrM, extended survival raises concerns for the subacute and late effects radiotherapy. We favor the use of TKIs and delaying the use of WBRT when able. At inevitable disease progression, we consider alternative dosing schedules to increase CNS penetration (such as pulse dosing of erlotinib) or advance to next generation TKI if available. We utilize local control options of surgery or stereotactic radiosurgery (SRS) for symptomatic accessible lesions based on size and edema. At progression despite available TKIs, we use pemetrexed-based platinum doublet chemotherapy or immunotherapy if the tumor has high expression of PDL-1. We reserve the use of WBRT for patients with more than 10 BrM and progression despite TKI and conventional chemotherapy, if performance status is appropriate.
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Affiliation(s)
- Tresa McGranahan
- Department of Neurology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.
| | - Seema Nagpal
- Department of Neurology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
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Loganadane G, Hendriks L, Le Péchoux C, Levy A. The Current Role of Whole Brain Radiation Therapy in Non-Small Cell Lung Cancer Patients. J Thorac Oncol 2017; 12:1467-1477. [PMID: 28733269 DOI: 10.1016/j.jtho.2017.07.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 06/19/2017] [Accepted: 07/07/2017] [Indexed: 10/19/2022]
Abstract
The incidence of brain metastases has increased in patients with NSCLC as a result of better systemic disease control and advances in imaging modalities. Whole brain radiotherapy (WBRT) has been the mainstay treatment of multiple symptomatic brain metastases for years. A number of recent publications have questioned its place in the absence of a survival and quality of life benefit and the possible risk for long-term neurotoxicity. Omission or deferral of WBRT and strategies consisting of stereotactic radiosurgery or delivery of systemic therapies alone are being proposed more and more. However, critical analysis of the literature shows that WBRT still has relevant indications in well-selected patients. Within this review, we discuss the place of WBRT in the modern management of patients with NSCLC.
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Affiliation(s)
- Gokoulakrichenane Loganadane
- Assistance Publique-Hôpitaux de Paris, Department of Radiation Oncology, CHU Henri Mondor, University of Paris-Est, Créteil, France
| | - Lizza Hendriks
- Department of Pulmonary Diseases, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Cécile Le Péchoux
- Department of Radiation Oncology, Gustave Roussy, Institut d'Oncologie Thoracique, Université Paris-Saclay, Villejuif, France
| | - Antonin Levy
- Department of Radiation Oncology, Gustave Roussy, Institut d'Oncologie Thoracique, Université Paris-Saclay, Villejuif, France; INSERM U1030, Molecular Radiotherapy, Gustave Roussy, Université Paris-Saclay, Villejuif, France; Univ Paris Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France.
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Waqar SN, Morgensztern D, Govindan R. Systemic Treatment of Brain Metastases. Hematol Oncol Clin North Am 2017; 31:157-176. [PMID: 27912831 DOI: 10.1016/j.hoc.2016.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Lung cancer continues to be the leading cause of cancer-related mortality in the United States. Brain metastases are a significant problem in patients with lung cancer and have conventionally been treated with whole-brain radiation. This article reviews the data for systemic chemotherapy to treat brain metastasis from lung cancer and examines the activity of small molecule tyrosine kinase inhibitors for the targeted therapy for brain metastases from EGFR-mutant and ALK-rearranged non-small cell lung cancer. Future directions for evaluating the role of immunotherapy in treating brain metastasis are also discussed.
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Affiliation(s)
- Saiama N Waqar
- Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8056, St Louis, MO 63110, USA.
| | - Daniel Morgensztern
- Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8056, St Louis, MO 63110, USA
| | - Ramaswamy Govindan
- Section of Medical Oncology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8056, St Louis, MO 63110, USA
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Rancoule C, Vallard A, Guy JB, Espenel S, Diao P, Chargari C, Magné N. Brain metastases from non-small cell lung carcinoma: Changing concepts for improving patients' outcome. Crit Rev Oncol Hematol 2017; 116:32-37. [PMID: 28693798 DOI: 10.1016/j.critrevonc.2017.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/16/2017] [Indexed: 11/29/2022] Open
Abstract
The management of Non Small Cell Lung Cancer (NSCLC) brain metastases is challenging, as this frequent complication negatively impacts patients' quality of life, and can be a life-threatening event. Through a review of the literature, we discuss the main therapeutic options and the recent developments that improved (and complicated) the management of NSCLC brain metastases patients. Most current validated approaches are local with exclusive or combined surgery, whole brain radiotherapy (WBRT) and stereotactic radiotherapy (SRT). At the same time, there is a growing role for systemic treatments that might significantly postpone WBRT. Targeted therapies efficacy/toxicity profile remains to be defined but predictive and prognostic molecular factors integration could help to select treatments fully adapted to life expectancy and progression risk.
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Affiliation(s)
- Chloé Rancoule
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, 108 bis, Avenue Albert Raimond, BP 60008, 42271 Saint-Priest en Jarez, France
| | - Alexis Vallard
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, 108 bis, Avenue Albert Raimond, BP 60008, 42271 Saint-Priest en Jarez, France
| | - Jean-Baptiste Guy
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, 108 bis, Avenue Albert Raimond, BP 60008, 42271 Saint-Priest en Jarez, France; Laboratoire de Radiobiologie Cellulaire et Moléculaire, CNRS UMR 5822, Institut de Physique Nucléaire de Lyon, IPNL, 69622 Villeurbanne, France
| | - Sophie Espenel
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, 108 bis, Avenue Albert Raimond, BP 60008, 42271 Saint-Priest en Jarez, France
| | - Peng Diao
- Department of Radiotherapy, Sichuan Cancer Hospital, 55 Renmin Nan Lu, Sect 4. Wuhou District, Chengdu, 610041, China
| | - Cyrus Chargari
- Department of Radiotherapy, Institut Gustave Roussy, 114, Rue Edouard Vaillant, 94805 Villejuif, France; Institut de Recherche Biomédicale des Armées, D19, 91220 Brétigny sur Orge, France; French Military Health Services Academy, Ecole du Val-de-Grâce, Paris, France
| | - Nicolas Magné
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, 108 bis, Avenue Albert Raimond, BP 60008, 42271 Saint-Priest en Jarez, France; Laboratoire de Radiobiologie Cellulaire et Moléculaire, CNRS UMR 5822, Institut de Physique Nucléaire de Lyon, IPNL, 69622 Villeurbanne, France.
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Frontline Systemic Therapy With Pemetrexed-Platinum in Nonsquamous Non-Small-Cell Lung Cancer With Asymptomatic Brain Metastases. Am J Ther 2017; 24:e111-e120. [PMID: 25153672 DOI: 10.1097/mjt.0000000000000106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The incidence of brain metastases from nonsquamous non-small-lung cancer is increasing as a result of superior imaging techniques for early detection of distant metastases. Although whole-brain radiation therapy and stereotactic radiosurgery along with systemic chemotherapy have shown to be effective in alleviating symptoms and improving outcomes, the approach to patients with asymptomatic brain metastases remains elusive. We explored the literature for a possible role of frontline systemic chemotherapy in asymptomatic brain metastases from nonsquamous non-small-lung cancer and found promising evidence that upfront systemic therapy with pemetrexed-platinum regimens might be a reasonable option for these patients and would forestall the need for upfront brain radiation therapy. More large-scale phase II and phase III clinical trials are needed to further investigate the frontline use of pemetrexed-platinum regimens in this setting.
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Tsakonas G, De Petris L, Ekman S. Management of brain metastasized non-small cell lung cancer (NSCLC) – From local treatment to new systemic therapies. Cancer Treat Rev 2017; 54:122-131. [DOI: 10.1016/j.ctrv.2017.02.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 01/31/2017] [Accepted: 02/07/2017] [Indexed: 01/24/2023]
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Verduin M, Zindler JD, Martinussen HMA, Jansen RLH, Croes S, Hendriks LEL, Eekers DBP, Hoeben A. Use of Systemic Therapy Concurrent With Cranial Radiotherapy for Cerebral Metastases of Solid Tumors. Oncologist 2017; 22:222-235. [PMID: 28167569 PMCID: PMC5330699 DOI: 10.1634/theoncologist.2016-0117] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 09/02/2016] [Indexed: 12/25/2022] Open
Abstract
The incidence of brain metastases of solid tumors is increasing. Local treatment of brain metastases is generally straightforward: cranial radiotherapy (e.g., whole-brain radiotherapy or stereotactic radiosurgery) or resection when feasible. However, treatment becomes more complex when brain metastases occur while other metastases, outside of the central nervous system, are being controlled with systemic therapy (chemotherapeutics, molecular targeted agents, or monoclonal antibodies). It is known that some anticancer agents can increase the risk for neurotoxicity when used concurrently with radiotherapy. Increased neurotoxicity decreases quality of life, which is undesirable in this predominantly palliative patient group. Therefore, it is of utmost importance to identify the compounds that should be temporarily discontinued when cranial radiotherapy is needed.This review summarizes the (neuro)toxicity data for combining systemic therapy (chemotherapeutics, molecular targeted agents, or monoclonal antibodies) with concurrent radiotherapy of brain metastases. Because only a limited amount of high-level data has been published, a risk assessment of each agent was done, taking into account the characteristics of each compound (e.g., lipophilicity) and the microenvironment of brain metastasis. The available trials suggest that only gemcitabine, erlotinib, and vemurafenib induce significant neurotoxicity when used concurrently with cranial radiotherapy. We conclude that for most systemic therapies, the currently available literature does not show an increase in neurotoxicity when these therapies are used concurrently with cranial radiotherapy. However, further studies are needed to confirm safety because there is no high-level evidence to permit definitive conclusions. The Oncologist 2017;22:222-235Implications for Practice: The treatment of symptomatic brain metastases diagnosed while patients are receiving systemic therapy continues to pose a dilemma to clinicians. Will concurrent treatment with cranial radiotherapy and systemic therapy (chemotherapeutics, molecular targeted agents, and monoclonal antibodies), used to control intra- and extracranial tumor load, increase the risk for neurotoxicity? This review addresses this clinically relevant question and evaluates the toxicity of combining systemic therapies with cranial radiotherapy, based on currently available literature, in order to determine the need to and interval to interrupt systemic treatment.
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Affiliation(s)
- Maikel Verduin
- Department of Medical Oncology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jaap D Zindler
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Hanneke M A Martinussen
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rob L H Jansen
- Department of Medical Oncology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sander Croes
- Department of Clinical Pharmacy & Toxicology, CAPHRI-School for Public Health and Primary Care, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Lizza E L Hendriks
- Department of Pulmonary Diseases, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Danielle B P Eekers
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ann Hoeben
- Department of Medical Oncology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
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Chamberlain MC, Baik CS, Gadi VK, Bhatia S, Chow LQM. Systemic therapy of brain metastases: non-small cell lung cancer, breast cancer, and melanoma. Neuro Oncol 2017; 19:i1-i24. [PMID: 28031389 PMCID: PMC5193029 DOI: 10.1093/neuonc/now197] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Brain metastases (BM) occur frequently in many cancers, particularly non-small cell lung cancer (NSCLC), breast cancer, and melanoma. The development of BM is associated with poor prognosis and has an adverse impact on survival and quality of life. Commonly used therapies for BM such as surgery or radiotherapy are associated with only modest benefits. However, recent advances in systemic therapy of many cancers have generated considerable interest in exploration of those therapies for treatment of intracranial metastases.This review discusses the epidemiology of BM from the aforementioned primary tumors and the challenges of using systemic therapies for metastatic disease located within the central nervous system. Cumulative data from several retrospective and small prospective studies suggest that molecularly targeted systemic therapies may be an effective option for the treatment of BM from NSCLC, breast cancer, and melanoma, either as monotherapy or in conjunction with other therapies. Larger prospective studies are warranted to further characterize the efficacy and safety profiles of these targeted agents for the treatment of BM.
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Affiliation(s)
- Marc C Chamberlain
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| | - Christina S Baik
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| | - Vijayakrishna K Gadi
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| | - Shailender Bhatia
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| | - Laura Q M Chow
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
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Economopoulou P, Mountzios G. Non-small cell lung cancer (NSCLC) and central nervous system (CNS) metastases: role of tyrosine kinase inhibitors (TKIs) and evidence in favor or against their use with concurrent cranial radiotherapy. Transl Lung Cancer Res 2016; 5:588-598. [PMID: 28149754 DOI: 10.21037/tlcr.2016.12.06] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Central nervous system (CNS) metastases, including brain metastases (BM) and leptomeningeal metastases (LM) represent a frequent complication of non-small cell lung cancer (NSCLC). Patients with BM comprise a heterogeneous group, with a median survival that ranges from 3 to 14 months. However, in the majority of patients, the occurrence of CNS metastases is usually accompanied by severe morbidity and substantial deterioration in quality of life. Local therapies, such as whole brain radiotherapy (WBRT), stereotactic radiosurgery (SRS) or surgical resection, either alone or as part of a multimodality treatment are available treatment strategies for BM and the choice of therapy varies depending on patient group and prognosis. Meanwhile, introduction of tyrosine kinase inhibitors (TKIs) in clinical practice has led to individualization of therapy based upon the presence of the exact abnormality, resulting in a major therapeutic improvement in patients with NSCLC who harbor epidermal growth factor receptor (EGFR) activating mutations or anaplastic lymphoma kinase (ALK) gene rearrangements, respectively. Based on their clinical activity in systemic disease, such molecular agents could offer the promise of improved BM control without substantial toxicity; however, their role in combination with radiotherapy is controversial. In this review, we discuss the controversy regarding the use of TKIs in combination with radiotherapy and illustrate future perspectives in the treatment of BM in NSCLC.
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Affiliation(s)
| | - Giannis Mountzios
- Department of Medical Oncology, 251 Airforce General Hospital, Athens, Greece
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Inno A, Di Noia V, D'Argento E, Modena A, Gori S. State of the art of chemotherapy for the treatment of central nervous system metastases from non-small cell lung cancer. Transl Lung Cancer Res 2016; 5:599-609. [PMID: 28149755 DOI: 10.21037/tlcr.2016.11.01] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chemotherapy is the mainstay of treatment of advanced non-small cell lung cancer (NSCLC) without molecular drivers. Despite a low penetration of central nervous system (CNS), chemotherapy drugs demonstrated encouraging activity against CNS metastases from NSCLC. Based on the available data, chemotherapy should be considered as an important part of the multidisciplinary treatment of CNS metastases. Particularly, platinum-based regimens represent the most active combinations and pemetrexed is associated with a meaningful clinical benefit for patients with non-squamous histology. How to integrate chemotherapy and radiotherapy for newly diagnosed brain metastases (BMs) is still debated. Although flawed by some limitations, the available evidence suggests a role for upfront chemotherapy for the treatment of NSCLC patients with synchronous, asymptomatic BMs, thus allowing a delay of radiotherapy. Despite the introduction of modern and more effective chemotherapy, however, the prognosis of NSCLC patients with CNS metastases remains poor, especially for those with progressive BMs or leptomeningeal carcinomatosis (LC).
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Affiliation(s)
- Alessandro Inno
- Medical Oncology Unit, Sacro Cuore don Calabria Hospital, Cancer Care Center, Verona, Italy
| | - Vincenzo Di Noia
- Medical Oncology Unit, Policlinico Gemelli Foundation, Catholic University of the Sacred Heart, Rome, Italy
| | - Ettore D'Argento
- Medical Oncology Unit, Policlinico Gemelli Foundation, Catholic University of the Sacred Heart, Rome, Italy
| | - Alessandra Modena
- Medical Oncology Unit, Sacro Cuore don Calabria Hospital, Cancer Care Center, Verona, Italy
| | - Stefania Gori
- Medical Oncology Unit, Sacro Cuore don Calabria Hospital, Cancer Care Center, Verona, Italy
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Proto C, Imbimbo M, Gallucci R, Brissa A, Signorelli D, Vitali M, Macerelli M, Corrao G, Ganzinelli M, Greco FG, Garassino MC, Lo Russo G. Epidermal growth factor receptor tyrosine kinase inhibitors for the treatment of central nervous system metastases from non-small cell lung cancer: the present and the future. Transl Lung Cancer Res 2016; 5:563-578. [PMID: 28149752 DOI: 10.21037/tlcr.2016.10.16] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Lung cancer is one of the major causes of cancer related mortality worldwide. Brain metastases (BM) complicate clinical evolution of non-small cell lung cancer (NSCLC) in approximately 25-40% of cases, adversely influencing quality of life (QoL) and overall survival (OS). Systemic therapy remains the standard strategy for metastatic disease. Nevertheless, the blood-brain barrier (BBB) makes central nervous system (CNS) a sanctuary site. To date, the combination of chemotherapy with whole brain radiation therapy (WBRT), surgery and/or stereotactic radiosurgery (SRS) represents the most used treatment for patients (pts) with intracranial involvement. However, due to their clinical conditions, many pts are not able to undergo local treatments. Targeted therapies directed against epidermal growth factor receptor (EGFR), such as gefitinib, erlotinib and afatinib, achieved important improvements in EGFR mutated NSCLC with favorable toxicity profile. Although their role is not well defined, the reported objective response rate (ORR) and the good tolerance make EGFR-tyrosine kinase inhibitors (TKIs) an interesting valid alternative for NSCLC pts with BM, especially for those harboring EGFR mutations. Furthermore, new-generation TKIs, such as osimertinib and rociletinib, have already shown important activity on intracranial disease and several trials are still ongoing to evaluate their efficacy. In this review we want to highlight literature data about the use and the effectiveness of EGFR-TKIs in pts with BM from NSCLC.
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Affiliation(s)
- Claudia Proto
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Martina Imbimbo
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Rosaria Gallucci
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Angela Brissa
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Diego Signorelli
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Milena Vitali
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Marianna Macerelli
- Department of Medical Oncology, University-Hospital of Santa Maria delle Grazie, Udine, Italy
| | - Giulia Corrao
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Monica Ganzinelli
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | | | - Marina Chiara Garassino
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Giuseppe Lo Russo
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
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Khalifa J, Amini A, Popat S, Gaspar LE, Faivre-Finn C. Brain Metastases from NSCLC: Radiation Therapy in the Era of Targeted Therapies. J Thorac Oncol 2016; 11:1627-43. [PMID: 27343440 DOI: 10.1016/j.jtho.2016.06.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/02/2016] [Accepted: 06/09/2016] [Indexed: 02/07/2023]
Abstract
Brain metastases (BMs) will develop in a large proportion of patients with NSCLC throughout the course of their disease. Among patients with NSCLC with oncogenic drivers, mainly EGFR activating mutations and anaplastic lymphoma receptor tyrosine kinase gene (ALK) rearrangements, the presence of BM is a common secondary localization of disease both at the time of diagnosis and at relapse. Because of the limited penetration of a wide range of drugs across the blood-brain barrier, radiotherapy is considered the cornerstone of treatment of BMs. However, evidence of dramatic intracranial response rates has been reported in recent years with targeted therapies such as tyrosine kinase inhibitors and has been supported by new insights into pharmacokinetics to increase rates of tyrosine kinase inhibitors' penetration of the cerebrospinal fluid (CSF). In this context, the combination of brain radiotherapy and targeted therapies seems relevant, and there is a strong radiobiological rationale to harness the radiosentizing effect of the drugs. Nevertheless, to date, there is a paucity of high-level clinical evidence supporting the combination of brain radiotherapy and targeted therapies in patients with NSCLC and BMs, and there are often methodological biases in reported studies, such as the lack of stratification by mutation status. Moreover, among asymptomatic patients not suitable for ablative treatment, this strategy is challenged by the promising results associated with the administration of targeted therapies alone. Herein, we review the biological rationale to combine targeted therapies and brain radiotherapy for patients with NSCLC and BMs, report the clinical data available to date, and discuss future directions to improve outcome in this group of patients.
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Affiliation(s)
- Jonathan Khalifa
- Radiotherapy Related Research, The Christie National Health Service Foundation Trust, Manchester, United Kingdom.
| | - Arya Amini
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Sanjay Popat
- Lung Cancer Unit, Royal Marsden Hospital, London, United Kingdom
| | - Laurie E Gaspar
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Corinne Faivre-Finn
- Radiotherapy Related Research, The Christie National Health Service Foundation Trust, Manchester, United Kingdom; Manchester Academic Health Science Centre, Institute of Cancer Sciences, Manchester Cancer Research Centre, The University of Manchester, Manchester, United Kingdom
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Larkin JR, Dickens AM, Claridge TDW, Bristow C, Andreou K, Anthony DC, Sibson NR. Early Diagnosis of Brain Metastases Using a Biofluids-Metabolomics Approach in Mice. Theranostics 2016; 6:2161-2169. [PMID: 27924154 PMCID: PMC5135440 DOI: 10.7150/thno.16538] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 06/27/2016] [Indexed: 12/25/2022] Open
Abstract
Over 20% of cancer patients will develop brain metastases. Prognosis is currently extremely poor, largely owing to late-stage diagnosis. We hypothesized that biofluid metabolomics could detect tumours at the micrometastatic stage, prior to the current clinical gold-standard of blood-brain barrier breakdown. Metastatic mammary carcinoma cells (4T1-GFP) were injected into BALB/c mice via intracerebral, intracardiac or intravenous routes to induce differing cerebral and systemic tumour burdens. B16F10 melanoma and MDA231BR-GFP human breast carcinoma cells were used for additional modelling. Urine metabolite composition was analysed by 1H NMR spectroscopy. Statistical pattern recognition and modelling was applied to identify differences or commonalities indicative of brain metastasis burden. Significant metabolic profile separations were found between control cohorts and animals with tumour burdens at all time-points for the intracerebral 4T1-GFP time-course. Models became stronger, with higher sensitivity and specificity, as the time-course progressed indicating a more severe tumour burden. Sensitivity and specificity for predicting a blinded testing set were 0.89 and 0.82, respectively, at day 5, both rising to 1.00 at day 35. Significant separations were also found between control and all 4T1-GFP injected mice irrespective of route. Likewise, significant separations were observed in B16F10 and MDA231BR-GFP cell line models. Metabolites underpinning each separation were identified. These findings demonstrate that brain metastases can be diagnosed in an animal model based on urinary metabolomics from micrometastatic stages. Furthermore, it is possible to separate differing systemic and CNS tumour burdens, suggesting a metabolite fingerprint specific to brain metastasis. This method has strong potential for clinical translation.
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Affiliation(s)
- James R. Larkin
- Cancer Research UK and Medical Research Council Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
| | - Alex M. Dickens
- Cancer Research UK and Medical Research Council Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
- Department of Pharmacology, University of Oxford, Oxford, UK
| | | | - Claire Bristow
- Cancer Research UK and Medical Research Council Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
| | - Kleopatra Andreou
- Cancer Research UK and Medical Research Council Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
| | | | - Nicola R. Sibson
- Cancer Research UK and Medical Research Council Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
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Novello S, Barlesi F, Califano R, Cufer T, Ekman S, Levra MG, Kerr K, Popat S, Reck M, Senan S, Simo G, Vansteenkiste J, Peters S. Metastatic non-small-cell lung cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2016; 27:v1-v27. [DOI: 10.1093/annonc/mdw326] [Citation(s) in RCA: 654] [Impact Index Per Article: 81.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Dudnik E, Yust-Katz S, Nechushtan H, Goldstein DA, Zer A, Flex D, Siegal T, Peled N. Intracranial response to nivolumab in NSCLC patients with untreated or progressing CNS metastases. Lung Cancer 2016; 98:114-117. [DOI: 10.1016/j.lungcan.2016.05.031] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/23/2016] [Accepted: 05/30/2016] [Indexed: 11/30/2022]
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50
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Prise en charge des métastases cérébrales des cancers du poumon. ONCOLOGIE 2016. [DOI: 10.1007/s10269-016-2636-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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