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Puri S, Chaudhry A, Bayable A, Ganesh A, Daher A, Gadi VK, Maraka S. Systemic Treatment for Brain Metastasis and Leptomeningeal Disease in Breast Cancer Patients. Curr Oncol Rep 2023; 25:1419-1430. [PMID: 37924439 DOI: 10.1007/s11912-023-01468-4] [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] [Accepted: 10/06/2023] [Indexed: 11/06/2023]
Abstract
PURPOSE OF REVIEW Breast cancer with brain metastasis (BCBM) and leptomeningeal disease (LMD) are important clinical problems. Traditionally, patients with metastases to the brain and meninges were excluded from clinical trials; hence, robust, evidence-based treatment recommendations are lacking. In this review, we outline the systemic treatment options and ongoing clinical trials. RECENT FINDINGS Several recent studies have added to the systemic treatment options available. Antibody-drug conjugates have changed the therapeutic landscape. Combination treatment modalities that target multiple mechanisms including disruption of the blood brain barrier are increasingly being studied. Breast cancer with brain metastases and LMD is a heterogenous disease. While the prognosis remains grim, with more systemic treatment options, patients with BCBM are now living longer. Many ongoing clinical trials hold promise to further improve outcomes.
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Affiliation(s)
- Sushant Puri
- Neurooncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
- Department of Oncology, Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Amina Chaudhry
- Division of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Asnakech Bayable
- Department of Oncology, Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ashwin Ganesh
- Department of Neurology& Rehabilitation, University of Illinois at Chicago, 912 South Wood Street 174N m/c, Chicago, IL, 60612, USA
| | - Ahmad Daher
- Department of Neurology& Rehabilitation, University of Illinois at Chicago, 912 South Wood Street 174N m/c, Chicago, IL, 60612, USA
- Translational Oncology Program, University of Illinois Cancer Center, Chicago, IL, USA
| | - Vijayakrishna K Gadi
- Division of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
- Translational Oncology Program, University of Illinois Cancer Center, Chicago, IL, USA
| | - Stefania Maraka
- Department of Neurology& Rehabilitation, University of Illinois at Chicago, 912 South Wood Street 174N m/c, Chicago, IL, 60612, USA.
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Temozolomide-Associated Organizing Pneumonia. Am J Ther 2022; 29:e781-e783. [PMID: 32195668 DOI: 10.1097/mjt.0000000000001162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Yang G, Yang J, Yang X, Wang W. On optimal subset designs for phase II clinical trials with both total response and disease control. J Stat Plan Inference 2021. [DOI: 10.1016/j.jspi.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Jablonska PA, Bosch-Barrera J, Serrano D, Valiente M, Calvo A, Aristu J. Challenges and Novel Opportunities of Radiation Therapy for Brain Metastases in Non-Small Cell Lung Cancer. Cancers (Basel) 2021; 13:cancers13092141. [PMID: 33946751 PMCID: PMC8124815 DOI: 10.3390/cancers13092141] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/18/2021] [Accepted: 04/26/2021] [Indexed: 12/25/2022] Open
Abstract
Simple Summary Lung cancer is the most common primary malignancy that tends to metastasize to the brain. Owing to improved survival of lung cancer patients, the prevalence of brain metastases is a matter of growing concern. Brain radiotherapy remains the mainstay in the management of metastatic CNS disease. However, new targeted therapies such as the tyrosine kinase or immune checkpoint inhibitors have demonstrated intracranial activity and promising tumor response rates. Here, we review the current and emerging therapeutical strategies for brain metastases from non-small cell lung cancer, both brain-directed and systemic, as well as the uncertainties that may arise from their combination. Abstract Approximately 20% patients with non-small cell lung cancer (NSCLC) present with CNS spread at the time of diagnosis and 25–50% are found to have brain metastases (BMs) during the course of the disease. The improvement in the diagnostic tools and screening, as well as the use of new systemic therapies have contributed to a more precise diagnosis and prolonged survival of lung cancer patients with more time for BMs development. In the past, most of the systemic therapies failed intracranially because of the inability to effectively cross the blood brain barrier. Some of the new targeted therapies, especially the group of tyrosine kinase inhibitors (TKIs) have shown durable CNS response. However, the use of ionizing radiation remains vital in the management of metastatic brain disease. Although a decrease in CNS-related deaths has been achieved over the past decade, many challenges arise from the need of multiple and repeated brain radiation treatments, which carry along not insignificant risks and toxicity. The combination of stereotactic radiotherapy and systemic treatments in terms of effectiveness and adverse effects, such as radionecrosis, remains a subject of ongoing investigation. This review discusses the challenges of the use of radiation therapy in NSCLC BMs in view of different systemic treatments such as chemotherapy, TKIs and immunotherapy. It also outlines the future perspectives and strategies for personalized BMs management.
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Affiliation(s)
- Paola Anna Jablonska
- Brain Metastases and CNS Oncology Radiation Medicine Program, Princess Margaret Cancer Center, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, Clinica Universidad de Navarra, 31008 Pamplona, Spain
- Correspondence: ; Tel.: +1-416-946-2000
| | - Joaquim Bosch-Barrera
- Department of Medical Oncology, Catalan Institute of Oncology, Doctor Josep Trueta University Hospital, 17007 Girona, Spain;
- Girona Biomedical Research Institute (IDIBGI), Salt, 17190 Girona, Spain
- Department of Medical Sciences, Medical School, University of Girona, 17071 Girona, Spain
| | - Diego Serrano
- IDISNA and Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain; (D.S.); (A.C.)
- Department of Pathology, Anatomy and Physiology, School of Medicine, University of Navarra, 31008 Pamplona, Spain
| | | | - Alfonso Calvo
- IDISNA and Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain; (D.S.); (A.C.)
- Department of Pathology, Anatomy and Physiology, School of Medicine, University of Navarra, 31008 Pamplona, Spain
- CIBERONC, ISCIII, 28029 Madrid, Spain
| | - Javier Aristu
- Department of Radiation Oncology and Protontherapy Unit, Clinica Universidad de Navarra, 28027 Madrid, Spain;
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Yalamanchi M, Sharma A, Nguyen M, Truong J, Carrillo JA, Wagle N, Gill JM, Kesari S. Successful and durable response of primary CNS T-cell lymphoma to upfront temozolomide monotherapy. Leuk Lymphoma 2021; 62:2044-2046. [PMID: 33615978 DOI: 10.1080/10428194.2021.1889538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Meghna Yalamanchi
- Chicago Medical School, Rosalind Franklin University, Chicago, IL, USA
| | - Akanksha Sharma
- Department of Translational Neurosciences, Saint John Cancer Institute & Pacific Neuroscience Institute, Santa Monica, CA, USA
| | - Minh Nguyen
- Department of Translational Neurosciences, Saint John Cancer Institute & Pacific Neuroscience Institute, Santa Monica, CA, USA
| | - Judy Truong
- Department of Translational Neurosciences, Saint John Cancer Institute & Pacific Neuroscience Institute, Santa Monica, CA, USA
| | - Jose A Carrillo
- Department of Translational Neurosciences, Saint John Cancer Institute & Pacific Neuroscience Institute, Santa Monica, CA, USA
| | - Naveed Wagle
- Department of Translational Neurosciences, Saint John Cancer Institute & Pacific Neuroscience Institute, Santa Monica, CA, USA
| | - Jaya M Gill
- Department of Translational Neurosciences, Saint John Cancer Institute & Pacific Neuroscience Institute, Santa Monica, CA, USA
| | - Santosh Kesari
- Department of Translational Neurosciences, Saint John Cancer Institute & Pacific Neuroscience Institute, Santa Monica, CA, USA
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Ventriculoperitoneal Shunt for CNS Metastasis in Breast Cancer: Clinical Outcomes Based on Intrinsic Subtype. Clin Breast Cancer 2021; 21:e402-e414. [PMID: 33526378 DOI: 10.1016/j.clbc.2020.12.013] [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: 03/18/2020] [Revised: 12/16/2020] [Accepted: 12/31/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Leptomeningeal metastasis (LM) is associated with a grave prognosis in breast cancer (BC) and can be controlled with a ventriculoperitoneal shunt (VPS). Information regarding LM and VPS based on intrinsic subtype is limited; thus, we investigated the clinical outcomes of BC treated with VPS. PATIENTS AND METHODS The present retrospective study comprised 70 patients diagnosed with LM who received a VPS. The patients were divided into 4 groups based on BC subtype: hormone receptor (HR)+/human epidermal growth factor receptor 2 (HER2)-, HR+/HER2+, HR-/HER2+, and triple negative BC (TNBC). RESULTS The most common indications for VPS were uncontrolled intracranial pressure (57.1%) and uncontrolled headache (55.7%), which improved in 54 (77.1%) of 70 patients after VPS. The median overall survival (OS) after brain or LM and overall survival after VPS were 7.6 and 2.3 months, respectively. Anti-HER2 treatment was a significant prognostic factor for better OS after brain or LM based on multivariate analysis (hazard ratio, 0.15; 95% confidence interval, 0.04-0.57; P = .005), whereas TNBC was correlated with shorter OS after central nervous system metastasis (hazard ratio, 2.82; 95% confidence interval, 1.46-5.48; P = .002). CONCLUSIONS There were significant differences in clinical outcome based on the intrinsic subtype of patients with BC with LM who received a VPS. Anti-HER2 treatment in patients with HER2+ BC was associated with better survival in patients with metastatic BC with VPS insertion compared with those without. Survival of metastatic BC with VPS remained poor, especially in the TNBC subgroup.
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Phase II study of irinotecan and temozolomide in breast cancer patients with progressing central nervous system disease. Breast Cancer Res Treat 2019; 177:401-408. [PMID: 31172405 DOI: 10.1007/s10549-019-05309-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 05/29/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Breast cancer patients with progressing central nervous system (CNS) disease have limited treatment options. Few chemotherapy drugs with activity in breast cancer have well-documented CNS penetration. This phase 2 trial evaluated efficacy and safety of irinotecan 125 mg/m2 on days 1 and 15 with temozolomide 100 mg/m2 days 1-7 and days 15-21 of a 28 day cycle. METHODS Breast cancer patients of any biological subtype and progressing brain metastases and/or leptomeningeal disease (LMD) were eligible. The primary endpoint was CNS response rate. Secondary endpoints were clinical benefit rate (CBR), time to progression (TTP), and overall survival (OS). Imaging studies evaluating intracranial and extracranial response were performed every 8 weeks. RESULTS Thirty patients were evaluable for safety and efficacy. The most common hematologic and non-hematologic adverse events were neutropenia, and nausea and fatigue, respectively. There were two confirmed CNS partial responses (PR) and five patients with stable disease in the CNS ≥ 16 weeks, resulting in a 7% PR and 23% CBR. Median TTP was 2.3 months (range 13-444 days), and median OS from treatment initiation until death was 4.9 months (range 20-1023 days). Excluding patients with LMD, median TTP and OS were 3.1 and 5.6 months, respectively. Only one patient progressed systemically before CNS progression. CONCLUSIONS The combination of irinotecan and temozolomide was well tolerated, demonstrated some clinical activity across multiple breast cancer subtypes with progressing CNS disease, and offers a reasonable option for patients who are not candidates for further radiation or clinical trials.
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Mrugala MM, Kim B, Sharma A, Johnson N, Graham C, Kurland BF, Gralow J. Phase II Study of Systemic High-dose Methotrexate and Intrathecal Liposomal Cytarabine for Treatment of Leptomeningeal Carcinomatosis From Breast Cancer. Clin Breast Cancer 2019; 19:311-316. [PMID: 31175053 DOI: 10.1016/j.clbc.2019.04.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/23/2019] [Accepted: 04/08/2019] [Indexed: 12/30/2022]
Abstract
Metastatic breast cancer frequently leads to brain metastases and, less commonly, leptomeningeal carcinomatosis (LC). Once cerebrospinal fluid involvement occurs, the prognosis is poor. There are limited treatment options available, but none offer significant survival benefit. Methotrexate, given systemically at high doses (3.5-8 gm/m2), achieves cytotoxic concentrations in the CSF and has been shown to prolong survival in patients with LC. Intrathecal liposomal cytarabine has been shown to increase time to neurologic progression in patients with breast cancer and LC. The combination of these 2 agents in LC has not been studied extensively. Here, we present the results of the phase II study with this combination showing promising efficacy and very good tolerability.
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Affiliation(s)
- Maciej M Mrugala
- Comprehensive Neuro-Oncology Program, Department of Neurology, Mayo Clinic Cancer Center, Phoenix, AZ.
| | - Bryan Kim
- Department of Neurology, University of Washington Medical School, Seattle, WA
| | | | | | | | - Brenda F Kurland
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA
| | - Julie Gralow
- Department of Medical Oncology, University of Washington and Fred Hutchinson Cancer Research Center, Seattle, WA
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Frega S, Bonanno L, Guarneri V, Conte P, Pasello G. Therapeutic perspectives for brain metastases in non-oncogene addicted non-small cell lung cancer (NSCLC): Towards a less dismal future? Crit Rev Oncol Hematol 2018; 128:19-29. [DOI: 10.1016/j.critrevonc.2018.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 05/14/2018] [Indexed: 12/16/2022] Open
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Gril B, Paranjape AN, Woditschka S, Hua E, Dolan EL, Hanson J, Wu X, Kloc W, Izycka-Swieszewska E, Duchnowska R, Pęksa R, Biernat W, Jassem J, Nayyar N, Brastianos PK, Hall OM, Peer CJ, Figg WD, Pauly GT, Robinson C, Difilippantonio S, Bialecki E, Metellus P, Schneider JP, Steeg PS. Reactive astrocytic S1P3 signaling modulates the blood-tumor barrier in brain metastases. Nat Commun 2018; 9:2705. [PMID: 30006619 PMCID: PMC6045677 DOI: 10.1038/s41467-018-05030-w] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/07/2018] [Indexed: 02/08/2023] Open
Abstract
Brain metastases are devastating complications of cancer. The blood-brain barrier (BBB), which protects the normal brain, morphs into an inadequately characterized blood-tumor barrier (BTB) when brain metastases form, and is surrounded by a neuroinflammatory response. These structures contribute to poor therapeutic efficacy by limiting drug uptake. Here, we report that experimental breast cancer brain metastases of low- and high permeability to a dextran dye exhibit distinct microenvironmental gene expression patterns. Astrocytic sphingosine-1 phosphate receptor 3 (S1P3) is upregulated in the neuroinflammatory response of the highly permeable lesions, and is expressed in patients' brain metastases. S1P3 inhibition functionally tightens the BTB in vitro and in vivo. S1P3 mediates its effects on BTB permeability through astrocytic secretion of IL-6 and CCL2, which relaxes endothelial cell adhesion. Tumor cell overexpression of S1P3 mimics this pathway, enhancing IL-6 and CCL-2 production and elevating BTB permeability. In conclusion, neuroinflammatory astrocytic S1P3 modulates BTB permeability.
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Affiliation(s)
- Brunilde Gril
- Women's Malignancies Branch, CCR, NCI, Bethesda, 20892, MD, USA.
| | | | - Stephan Woditschka
- Women's Malignancies Branch, CCR, NCI, Bethesda, 20892, MD, USA
- Department of Biology and Marine Biology, University of North Carolina at Wilmington, 601 South College Road, Wilmington, NC, 28403, USA
| | - Emily Hua
- Women's Malignancies Branch, CCR, NCI, Bethesda, 20892, MD, USA
| | - Emma L Dolan
- Women's Malignancies Branch, CCR, NCI, Bethesda, 20892, MD, USA
| | - Jeffrey Hanson
- Laboratory of Pathology, CCR, NCI, Bethesda, 20892, MD, USA
| | - Xiaolin Wu
- Genomics Laboratory, Frederick National Laboratory for Cancer Research, Frederick, 21702, MD, USA
| | - Wojciech Kloc
- Department of Neurology & Neurosurgery, Varmia & Masuria University, Olsztyn, 10-719, Poland
- Department of Neurosurgery, Copernicus Hospital Gdańsk, Gdańsk, 80-803, Poland
| | - Ewa Izycka-Swieszewska
- Department of Pathology & Neuropathology, Medical University of Gdańsk, Gdańsk, 80-210, Poland
- Department of Pathomorphology, Copernicus Hospital Gdańsk, Gdańsk, 80-803, Poland
| | - Renata Duchnowska
- Department of Oncology, Military Institute of Medicine, Warsaw, 04-141, Poland
| | - Rafał Pęksa
- Department of Pathology, Medical University of Gdańsk, 7 Dębinki St, 80-211, Gdańsk, Poland
| | - Wojciech Biernat
- Department of Pathology, Medical University of Gdańsk, 7 Dębinki St, 80-211, Gdańsk, Poland
| | - Jacek Jassem
- Department of Oncology and Radiotherapy, Medical University of Gdańsk, Gdańsk, 80-211, Poland
| | - Naema Nayyar
- Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, 02114, MA, USA
| | - Priscilla K Brastianos
- Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, 02114, MA, USA
| | - O Morgan Hall
- Genitourinary Malignancies Branch, CCR, NCI, Bethesda, 20892, MD, USA
| | - Cody J Peer
- Genitourinary Malignancies Branch, CCR, NCI, Bethesda, 20892, MD, USA
| | - William D Figg
- Genitourinary Malignancies Branch, CCR, NCI, Bethesda, 20892, MD, USA
| | - Gary T Pauly
- Chemical Biology Laboratory, CCR, NCI, Frederick, 21702, MD, USA
| | - Christina Robinson
- Laboratory Animal Sciences Program, Frederick National Laboratory for Cancer Research, Frederick, 21702, MD, USA
| | - Simone Difilippantonio
- Laboratory Animal Sciences Program, Frederick National Laboratory for Cancer Research, Frederick, 21702, MD, USA
| | - Emilie Bialecki
- Département de Neurochirurgie, Hôpital Privé Clairval, Ramsay Général de Santé, Marseille, 13009, France
| | - Philippe Metellus
- Département de Neurochirurgie, Hôpital Privé Clairval, Ramsay Général de Santé, Marseille, 13009, France
- Institut de Neurophysiopathologie-UMR 7051, Aix-Marseille Université, Marseille, 13344, France
| | - Joel P Schneider
- Chemical Biology Laboratory, CCR, NCI, Frederick, 21702, MD, USA
| | - Patricia S Steeg
- Women's Malignancies Branch, CCR, NCI, Bethesda, 20892, MD, USA.
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Wilson GD, Johnson MD, Ahmed S, Cardenas PY, Grills IS, Thibodeau BJ. Targeted DNA sequencing of non-small cell lung cancer identifies mutations associated with brain metastases. Oncotarget 2018; 9:25957-25970. [PMID: 29899834 PMCID: PMC5995256 DOI: 10.18632/oncotarget.25409] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/24/2018] [Indexed: 12/27/2022] Open
Abstract
Introduction This study explores the hypothesis that dominant molecular oncogenes in non-small cell lung cancer (NSCLC) are associated with metastatic spread to the brain. Methods NSCLC patient groups with no evidence of metastasis, with metastatic disease to a non-CNS site, who developed brain metastasis after diagnosis, and patients with simultaneous diagnosis of NSCLC and metastatic brain lesions were studied using targeted sequencing. Results In patients with brain metastasis versus those without, only 2 variants (one each in BCL6 and NOTHC2) were identified that occurred in ≥ 4 NSCLC of patients with brain metastases but ≤ 1 of the NSCLC samples without brain metastases. At the gene level, 20 genes were found to have unique variants in more than 33% of the patients with brain metastases. When analyzed at the patient level, these 20 genes formed the basis of a predictive test to discriminate those with brain metastasis. Further analysis showed that PI3K/AKT signaling is altered in both the primary and metastases of NSCLC patients with brain lesions. Conclusion While no single variant was associated with brain metastasis, this study describes a potential gene panel for the identification of patients at risk and implicates PI3K/AKT signaling as a therapeutic target.
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Affiliation(s)
- George D Wilson
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI, USA.,Beaumont BioBank, William Beaumont Hospital, Royal Oak, MI, USA
| | - Matthew D Johnson
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI, USA.,Department of Radiation Oncology, McLaren Health Care, Macomb, MI, USA
| | - Samreen Ahmed
- Beaumont BioBank, William Beaumont Hospital, Royal Oak, MI, USA
| | | | - Inga S Grills
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI, USA
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Bowman KM, Kumthekar P. Medical management of brain metastases and leptomeningeal disease in patients with breast carcinoma. Future Oncol 2018; 14:391-407. [DOI: 10.2217/fon-2017-0255] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Breast cancer is the most common malignancy among women and accounts for the second highest number of cancer-related deaths. With patients surviving longer due to advances in systemic control, the incidence of CNS involvement is increasing; however, the management of CNS metastases has not undergone parallel advancements. The blood–brain barrier limits the efficacy of most systemic chemotherapies, and the utilization of surgery and radiation beyond first-line therapy is limited. We will explore the recent developments in the medical management of breast cancer brain metastasis. Beyond traditional chemotherapy, we will also discuss targeted therapies and immunotherapies which may provide a survival benefit to this population and thus, offer further treatment options and a path for future research and treatment advances.
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Affiliation(s)
- Kelsey M Bowman
- Department of Neurology, Northwestern University Feinberg School of Medicine, Abbott Hall, Chicago, IL 60607, USA
| | - Priya Kumthekar
- Department of Neurology, Robert H Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL 60607, USA
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13
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Lin NU, Gaspar LE, Soffietti R. Breast Cancer in the Central Nervous System: Multidisciplinary Considerations and Management. Am Soc Clin Oncol Educ Book 2017; 37:45-56. [PMID: 28561683 DOI: 10.1200/edbk_175338] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Breast cancer is the second most common primary tumor associated with central nervous system (CNS) metastases. Patients with metastatic HER2-positive or triple-negative (estrogen receptor (ER)-negative, progesterone receptor (PR)-negative, HER2-negative) breast cancer are at the highest risk of developing parenchymal brain metastases. Leptomeningeal disease is less frequent but is distributed across breast cancer subtypes, including lobular breast cancer. Initial treatment strategies can include surgery, radiation, intravenous or intrathecal chemotherapy, and/or targeted approaches. In this article, we review the epidemiology of breast cancer brain metastases, differences in clinical behavior and natural history by tumor subtype, and important considerations in the multidisciplinary treatment of these patients. We will highlight new findings that impact current standards of care, clinical controversies, and notable investigational approaches in clinical testing.
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Affiliation(s)
- Nancy U Lin
- From the Breast Oncology Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO; Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, Turin, Italy
| | - Laurie E Gaspar
- From the Breast Oncology Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO; Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, Turin, Italy
| | - Riccardo Soffietti
- From the Breast Oncology Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO; Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, Turin, Italy
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Lung cancer-associated brain metastasis: Molecular mechanisms and therapeutic options. Cell Oncol (Dordr) 2017; 40:419-441. [PMID: 28921309 DOI: 10.1007/s13402-017-0345-5] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Lung cancer is the most common cause of cancer-related mortality in humans. There are several reasons for this high rate of mortality, including metastasis to several organs, especially the brain. In fact, lung cancer is responsible for approximately 50% of all brain metastases, which are very difficult to manage. Understanding the cellular and molecular mechanisms underlying lung cancer-associated brain metastasis brings up novel therapeutic promises with the hope to ameliorate the severity of the disease. Here, we provide an overview of the molecular mechanisms underlying the pathogenesis of lung cancer dissemination and metastasis to the brain, as well as promising horizons for impeding lung cancer brain metastasis, including the role of cancer stem cells, the blood-brain barrier, interactions of lung cancer cells with the brain microenvironment and lung cancer-driven systemic processes, as well as the role of growth factor/receptor tyrosine kinases, cell adhesion molecules and non-coding RNAs. In addition, we provide an overview of current and novel therapeutic approaches, including radiotherapy, surgery and stereotactic radiosurgery, chemotherapy, as also targeted cancer stem cell and epithelial-mesenchymal transition (EMT)-based therapies, micro-RNA-based therapies and other small molecule or antibody-based therapies. We will also discuss the daunting potential of some combined therapies. CONCLUSIONS The identification of molecular mechanisms underlying lung cancer metastasis has opened up new avenues towards their eradication and provides interesting opportunities for future research aimed at the development of novel targeted therapies.
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15
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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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16
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O 6 -Methylguanine-DNA methyltransferase (MGMT): A drugable target in lung cancer? Lung Cancer 2017; 107:91-99. [DOI: 10.1016/j.lungcan.2016.07.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 07/07/2016] [Accepted: 07/17/2016] [Indexed: 01/01/2023]
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17
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Liu MC, Cortés J, O'Shaughnessy J. Challenges in the treatment of hormone receptor-positive, HER2-negative metastatic breast cancer with brain metastases. Cancer Metastasis Rev 2017; 35:323-32. [PMID: 27023712 DOI: 10.1007/s10555-016-9619-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Brain metastases are a major cause of morbidity and mortality for women with hormone receptor (HR)-positive breast cancer, yet little is known about the optimal treatment of brain disease in this group of patients. Although these patients are at lower risk for brain metastases relative to those with HER2-positive and triple-negative disease, they comprise the majority of women diagnosed with breast cancer. Surgery and radiation continue to have a role in the treatment of brain metastases, but there is a dearth of effective systemic therapies due to the poor penetrability of many systemic drugs across the blood-brain barrier (BBB). Additionally, patients with brain metastases have long been excluded from clinical trials, and few studies have been conducted to evaluate the safety and effectiveness of systemic therapies specifically for the treatment of HER2-negative breast cancer brain metastases. New approaches are on the horizon, such as nanoparticle-based cytotoxic drugs that have the potential to cross the BBB and provide clinically meaningful benefits to patients with this life-threatening consequence of HR-positive breast cancer.
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Affiliation(s)
- Minetta C Liu
- Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Javier Cortés
- Ramon y Cajal University Hospital, Madrid, Spain
- Vall D'Hebron Institute of Oncology, Barcelona, Spain
| | - Joyce O'Shaughnessy
- Baylor-Sammons Cancer Center, Texas Oncology, U.S. Oncology, Dallas, TX, USA
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18
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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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19
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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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20
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Sinha R, Sage W, Watts C. The evolving clinical management of cerebral metastases. Eur J Surg Oncol 2016; 43:1173-1185. [PMID: 27986364 DOI: 10.1016/j.ejso.2016.10.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 10/05/2016] [Indexed: 11/26/2022] Open
Abstract
Concepts in the management of brain metastases are evolving. Until recently, brain metastases have been considered as a homogenous condition, managed with whole brain radiotherapy, surgical resection for large lesions and stereotactic radiosurgery for smaller lesions. Increasingly, specific systemic medical therapies are being used to treat brain metastases based on the primary site of disease. This disease specific management is causing a change in perspective about brain metastases and has led to improved survival for patients with primary disease subtypes amenable to tailored medical therapies. We review the recent literature to present evidence for the use of subtype specific medical therapies, advances in surgical resection techniques and stereotactic radiosurgery as the primary treatment modalities. The decline in use of whole brain radiotherapy as first line treatment is also discussed. Based on the recent literature, we propose a new management algorithm to reflect the progress in available options for tailoring disease specific treatments and support the change in paradigm to consider brain metastases as separate disease states based on the primary site of cancer rather than as a homogenous entity.
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Affiliation(s)
- R Sinha
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - W Sage
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - C Watts
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK.
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21
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Perillyl Alcohol and Its Drug-Conjugated Derivatives as Potential Novel Methods of Treating Brain Metastases. Int J Mol Sci 2016; 17:ijms17091463. [PMID: 27598140 PMCID: PMC5037741 DOI: 10.3390/ijms17091463] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/22/2016] [Accepted: 08/26/2016] [Indexed: 12/02/2022] Open
Abstract
Metastasis to the central nervous system remains difficult to treat, and such patients are faced with a dismal prognosis. The blood-brain barrier (BBB), despite being partially compromised within malignant lesions in the brain, still retains much of its barrier function and prevents most chemotherapeutic agents from effectively reaching the tumor cells. Here, we review some of the recent developments aimed at overcoming this obstacle in order to more effectively deliver chemotherapeutic agents to the intracranial tumor site. These advances include intranasal delivery to achieve direct nose-to-brain transport of anticancer agents and covalent modification of existing drugs to support enhanced penetration of the BBB. In both of these areas, use of the natural product perillyl alcohol, a monoterpene with anticancer properties, contributed to promising new results, which will be discussed here.
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22
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Lyle LT, Lockman PR, Adkins CE, Mohammad AS, Sechrest E, Hua E, Palmieri D, Liewehr DJ, Steinberg SM, Kloc W, Izycka-Swieszewska E, Duchnowska R, Nayyar N, Brastianos PK, Steeg PS, Gril B. Alterations in Pericyte Subpopulations Are Associated with Elevated Blood-Tumor Barrier Permeability in Experimental Brain Metastasis of Breast Cancer. Clin Cancer Res 2016; 22:5287-5299. [PMID: 27245829 DOI: 10.1158/1078-0432.ccr-15-1836] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 05/19/2016] [Indexed: 01/23/2023]
Abstract
PURPOSE The blood-brain barrier (BBB) is modified to a blood-tumor barrier (BTB) as a brain metastasis develops from breast or other cancers. We (i) quantified the permeability of experimental brain metastases, (ii) determined the composition of the BTB, and (iii) identified which elements of the BTB distinguished metastases of lower permeability from those with higher permeability. EXPERIMENTAL DESIGN A SUM190-BR3 experimental inflammatory breast cancer brain metastasis subline was established. Experimental brain metastases from this model system and two previously reported models (triple-negative MDA-231-BR6, HER2+ JIMT-1-BR3) were serially sectioned; low- and high-permeability lesions were identified with systemic 3-kDa Texas Red dextran dye. Adjoining sections were used for quantitative immunofluorescence to known BBB and neuroinflammatory components. One-sample comparisons against a hypothesized value of one were performed with the Wilcoxon signed-rank test. RESULTS When uninvolved brain was compared with any brain metastasis, alterations in endothelial, pericytic, astrocytic, and microglial components were observed. When metastases with relatively low and high permeability were compared, increased expression of a desmin+ subpopulation of pericytes was associated with higher permeability (231-BR6 P = 0.0002; JIMT-1-BR3 P = 0.004; SUM190-BR3 P = 0.008); desmin+ pericytes were also identified in human craniotomy specimens. Trends of reduced CD13+ pericytes (231-BR6 P = 0.014; JIMT-1-BR3 P = 0.002, SUM190-BR3, NS) and laminin α2 (231-BR6 P = 0.001; JIMT-1-BR3 P = 0.049; SUM190-BR3 P = 0.023) were also observed with increased permeability. CONCLUSIONS We provide the first account of the composition of the BTB in experimental brain metastasis. Desmin+ pericytes and laminin α2 are potential targets for the development of novel approaches to increase chemotherapeutic efficacy. Clin Cancer Res; 22(21); 5287-99. ©2016 AACR.
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Affiliation(s)
- L Tiffany Lyle
- Women's Malignancies Branch, Center for Cancer Research, NCI, Bethesda, Maryland
| | - Paul R Lockman
- Department of Basic Pharmaceutical Sciences, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Chris E Adkins
- Department of Basic Pharmaceutical Sciences, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Afroz Shareef Mohammad
- Department of Basic Pharmaceutical Sciences, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Emily Sechrest
- Department of Basic Pharmaceutical Sciences, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Emily Hua
- Women's Malignancies Branch, Center for Cancer Research, NCI, Bethesda, Maryland
| | - Diane Palmieri
- Women's Malignancies Branch, Center for Cancer Research, NCI, Bethesda, Maryland
| | - David J Liewehr
- Biostatistics and Data Management Section, Center for Cancer Research, NCI, Bethesda, Maryland
| | - Seth M Steinberg
- Biostatistics and Data Management Section, Center for Cancer Research, NCI, Bethesda, Maryland
| | - Wojciech Kloc
- Departments of Neurology & Neurosurgery, University of Varmia & Masuria University, Olsztyn, Poland.,Department of Neurosurgery, Copernicus Hospital Gdańsk, Poland
| | - Ewa Izycka-Swieszewska
- Departments of Pathology & Neuropathology, Medical University of Gdańsk, Poland.,Department of Pathomorphology, Copernicus Hospital, Gdańsk, Poland
| | - Renata Duchnowska
- Department of Oncology, Military Institute of Medicine, Warsaw, Poland
| | - Naema Nayyar
- Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Priscilla K Brastianos
- Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Patricia S Steeg
- Women's Malignancies Branch, Center for Cancer Research, NCI, Bethesda, Maryland
| | - Brunilde Gril
- Women's Malignancies Branch, Center for Cancer Research, NCI, Bethesda, Maryland.
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23
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Fiveash JB, Arafat WO, Naoum GE, Guthrie BL, Sawrie SM, Spencer SA, Meredith RF, Markert JM, Conry RM, Nabors BL. A phase 2 study of radiosurgery and temozolomide for patients with 1 to 4 brain metastases. Adv Radiat Oncol 2016; 1:83-88. [PMID: 28740873 PMCID: PMC5506740 DOI: 10.1016/j.adro.2016.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 03/10/2016] [Accepted: 03/18/2016] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To determine if temozolomide reduces the risk of distant brain failure (DBF, metachronous brain metastases) in patients with 1 to 4 brain metastases treated with radiosurgery without whole-brain radiation therapy (WBRT). METHODS AND MATERIALS Twenty-five patients with newly diagnosed brain metastases were enrolled in a single institution phase 2 trial of radiosurgery (15-24 Gy) and adjuvant temozolomide. Temozolomide was continued for a total of 12 cycles unless the patient developed DBF, unacceptable toxicity, or systemic progression requiring other therapy. RESULTS Twenty-five patients were enrolled between 2002 and 2005; 3 were not evaluable for determining DBF. Of the remaining 22 patients, tumor types included non-small cell lung cancer (n = 8), melanoma (n = 7), and other (n = 7). Extracranial disease was present in 10 (45%) patients. The median number of tumors at the time of radiosurgery was 3 (range, 1-6). The median overall survival was 31 weeks. The median radiographic follow-up for patients who did not develop DBF was 33 weeks. Six patients developed DBF. The 1-year actuarial risk of DBF was 37%. CONCLUSIONS In this study, there was a relatively low risk of distant brain failure observed in the nonmelanoma subgroup receiving temozolamide. However, patient selection factors rather than chemotherapy treatment efficacy are more likely the reason for the relatively low risk of distant brain failure observed in this study. Future trial design should account for these risk factors.
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Affiliation(s)
- John B Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Waleed O Arafat
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama.,Clinical Oncology Department, University of Alexandria, Alexandria, Egypt
| | - George E Naoum
- Alexandria Comprehensive Cancer Center, Alexandria, Egypt
| | - Barton L Guthrie
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Stephen M Sawrie
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sharon A Spencer
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ruby F Meredith
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - James M Markert
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert M Conry
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Burt L Nabors
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
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24
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Sampson VB, Vetter NS, Kamara DF, Collier AB, Gresh RC, Kolb EA. Vorinostat Enhances Cytotoxicity of SN-38 and Temozolomide in Ewing Sarcoma Cells and Activates STAT3/AKT/MAPK Pathways. PLoS One 2015; 10:e0142704. [PMID: 26571493 PMCID: PMC4646493 DOI: 10.1371/journal.pone.0142704] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 10/26/2015] [Indexed: 11/03/2022] Open
Abstract
Histone deacetylase inhibitors (HDACi) have been evaluated in patients with Ewing sarcoma (EWS) but demonstrated limited activity. To better understand the potential for HDACi in EWS, we evaluated the combination of the HDACi vorinostat, with DNA damaging agents SN-38 (the active metabolite of irinotecan and topoisomerase 1 inhibitor) plus the alkylating agent temozolomide (ST). Drugs were evaluated in sequential and simultaneous combinations in two EWS cell lines. Results demonstrate that cell viability, DNA damage and reactive oxygen species (ROS) production are dependent on the sequence of drug administration. Enhanced cytotoxicity is exhibited in vitro in EWS cell lines treated with ST administered before vorinostat, which was modestly higher than concomitant treatment and superior to vorinostat administered before ST. Drug combinations downregulate cyclin D1 to induce G0/G1 arrest and promote apoptosis by cleavage of caspase-3 and PARP. When ST is administered before or concomitantly with vorinostat there is activation of STAT3, MAPK and the p53 pathway. In contrast, when vorinostat is administered before ST, there is DNA repair, increased AKT phosphorylation and reduced H2B acetylation. Inhibition of AKT using the small molecule inhibitor MK-2206 did not restore H2B acetylation. Combining ST with the dual ALK and IGF-1R inhibitor, AZD3463 simultaneously inhibited STAT3 and AKT to enhance the cytotoxic effects of ST and further reduce cell growth suggesting that STAT3 and AKT activation were in part mediated by ALK and IGF-1R signaling. In summary, potent antiproliferative and proapoptotic activity were demonstrated for ST induced DNA damage before or simultaneous with HDAC inhibition and cell death was mediated through the p53 pathway. These observations may aid in designing new protocols for treating pediatric patients with high-risk EWS.
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Affiliation(s)
- Valerie B. Sampson
- Nemours Center for Cancer and Blood Disorders, Nemours/A.I. duPont Hospital for Children, Wilmington, Delaware, United States of America
| | - Nancy S. Vetter
- Nemours Center for Cancer and Blood Disorders, Nemours/A.I. duPont Hospital for Children, Wilmington, Delaware, United States of America
| | - Davida F. Kamara
- Nemours Center for Cancer and Blood Disorders, Nemours/A.I. duPont Hospital for Children, Wilmington, Delaware, United States of America
| | - Anderson B. Collier
- Department of Pediatrics, Division of Hematology and Oncology, Children's Healthcare of Mississippi, University of Mississippi Medical Center, Jackson, MS, United States of America
| | - Renee C. Gresh
- Nemours Center for Cancer and Blood Disorders, Nemours/A.I. duPont Hospital for Children, Wilmington, Delaware, United States of America
| | - E. Anders Kolb
- Nemours Center for Cancer and Blood Disorders, Nemours/A.I. duPont Hospital for Children, Wilmington, Delaware, United States of America
- * E-mail:
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25
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Marcos PJ, Consuegra Vanegas A, Matachana Martínez M, Cordero Lorenzana L, Vidal García I, Montero Martínez C. Organized Pneumonia Secondary to Increasing Doses of Temozolomide. Cureus 2015; 7:e318. [PMID: 26487994 PMCID: PMC4601909 DOI: 10.7759/cureus.318] [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] [Indexed: 11/06/2022] Open
Abstract
Surgery, radiotherapy (RT), and chemotherapy have a role in the control of tumor growth, progression, and recurrence in high-grade gliomas. Temozolomide has been incorporated as the main chemotherapy agent for managing these tumors. Here, we present a case of a patient who developed a severe organizing pneumonia after increasing doses of temozolomide for a high-grade glioma.
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Affiliation(s)
- Pedro J Marcos
- Servicio de Neumología. Instituto de Investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña (CHUAC), Sergas. Universidade da Coruña (UDC)
| | - Angélica Consuegra Vanegas
- Servicio de Neumología. Instituto de investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña (CHUAC), Sergas. Universidade da Coruña (UDC)
| | - María Matachana Martínez
- Unidad de Cuidados Intensivos. Instituto de investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña (CHUAC), Sergas. Universidade da Coruña (UDC)
| | - Lourdes Cordero Lorenzana
- Unidad de Cuidados Intensivos. Instituto de investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña (CHUAC), Sergas. Universidade da Coruña (UDC)
| | - Iria Vidal García
- Servicio de Neumología. Instituto de investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña (CHUAC), Sergas. Universidade da Coruña (UDC)
| | - Carmen Montero Martínez
- Servicio de Neumología. Instituto de investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña (CHUAC), Sergas. Universidade da Coruña (UDC)
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26
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Nayak L, DeAngelis LM, Robins HI, Govindan R, Gadgeel S, Kelly K, Rigas JR, Peereboom DM, Rosenfeld SS, Muzikansky A, Zheng M, Urban P, Abrey LE, Omuro A, Wen PY. Multicenter phase 2 study of patupilone for recurrent or progressive brain metastases from non-small cell lung cancer. Cancer 2015; 121:4165-72. [PMID: 26308485 DOI: 10.1002/cncr.29636] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 07/09/2015] [Accepted: 07/13/2015] [Indexed: 01/07/2023]
Abstract
BACKGROUND Treatment options for patients with non-small cell lung cancer (NSCLC) with brain metastases are limited. Patupilone (EPO906), a blood-brain barrier-penetrating, microtubule-targeting, cytotoxic agent, has shown clinical activity in phase 1/2 studies in patients with NSCLC. This study evaluates the efficacy, pharmacokinetics, and safety of patupilone in NSCLC brain metastases. METHODS Adult patients with NSCLC and confirmed progressive brain metastases received patupilone intravenously at 10 mg/m(2) every 3 weeks. The primary endpoint of this multinomial 2-stage study combined early progression (EP; death or progression within 3 weeks) and progression-free survival at 9 weeks (PFS9w) to determine drug activity. RESULTS Fifty patients with a median age of 60 years (range, 33-74 years) were enrolled; the majority were men (58%), and most had received prior therapy for brain metastases (98%). The PFS9w rate was 36%, and the EP rate was 26%. Patupilone blood pharmacokinetic analyses showed mean areas under the concentration-time curve from time zero to 504 hours for cycles 1 and 3 of 1544 and 1978 ng h/mL, respectively, and a mean steady state distribution volume of 755 L/m(2) . Grade 3/4 adverse events (AEs), regardless of their relation with the study drug, included diarrhea (24%), pulmonary embolisms (8%), convulsions (4%), and peripheral neuropathy (4%). All patients discontinued the study drug: 31 (62%) for disease progression and 13 (26%) for AEs. Twenty-five of 32 deaths were due to brain metastases. The median time to progression and the overall survival were 3.2 and 8.8 months, respectively. CONCLUSIONS This is the first prospective study of chemotherapy for recurrent brain metastases from NSCLC. In this population, patupilone demonstrated activity in heavily treated patients.
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Affiliation(s)
- Lakshmi Nayak
- Center For Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - H Ian Robins
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Ramaswamy Govindan
- Division of Oncology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Shirish Gadgeel
- Karmanos Cancer Institute/Wayne State University, Detroit, Michigan
| | - Karen Kelly
- Division of Hematology and Oncology, Davis Comprehensive Cancer Center, University of California, Sacramento, California
| | - James R Rigas
- Norris Cotton Cancer Center/Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - David M Peereboom
- Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Steven S Rosenfeld
- Department of Neurology, Columbia University Medical Center/New York Presbyterian, New York, New York
| | - Alona Muzikansky
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Ming Zheng
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Patrick Urban
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Lauren E Abrey
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Antonio Omuro
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Patrick Y Wen
- Center For Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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27
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Abstract
Brain metastases are a common complication of cancer and continue to be associated with a poor prognosis. Management of brain metastases typically requires a multidisciplinary approach which may include whole-brain radiation therapy, stereotactic radiosurgery, surgery, and systemic therapy. Historically, the use of systemic therapy in brain metastases has been challenging because of the resistance to conventional chemotherapies secondary to the blood-brain barrier and an often heavily pre-treated patient population, and the paucity of well-conducted randomized trials in these heterogeneous patient populations. Newer agents, including immunotherapy and targeted therapies, are playing increasingly important roles in the up-front management of brain metastases. In this overview, we review recent advances in systemic therapies for brain metastases and the evidence supporting their use in this patient population.
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Affiliation(s)
- Harry C Brastianos
- Department of Radiation Oncology, Queen's University, Kingston, ON, Canada
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Arslan C, Dizdar O, Altundag K. Chemotherapy and biological treatment options in breast cancer patients with brain metastasis: an update. Expert Opin Pharmacother 2014; 15:1643-58. [PMID: 25032884 DOI: 10.1517/14656566.2014.929664] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Breast cancer (BC) is the second most common cause of CNS metastasis. Ten to 20% of all, and 38% of human epidermal growth factor-2(+), metastatic BC patients experience brain metastasis (BM). Prolonged survival with better control of systemic disease and limited penetration of drugs to CNS increased the probability of CNS metastasis as a sanctuary site of relapse. Treatment of CNS disease has become an important component of overall disease control and quality of life. AREAS COVERED Current standard therapy for BM is whole-brain radiotherapy, surgery, stereotactic body radiation therapy for selected cases, corticosteroids and systemic chemotherapy. Little progress has been made in chemotherapy for the treatment of BM in patients with BC. Nevertheless, new treatment choices have emerged. In this review, we aimed to update current and future treatment options in systemic treatment for BM of BC. EXPERT OPINION Cornerstone local treatment options for BM of BC are radiotherapy and surgery in selected cases. Efficacy of cytotoxic chemotherapeutics is limited. Among targeted therapies, lapatinib has activity in systemic treatment of BM particularly when used in combination with capecitabine. Novel agents are currently investigated.
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Affiliation(s)
- Cagatay Arslan
- Izmir University Medical Park Hospital, Department of Medical Oncology , Izmir , Turkey
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Strategies to Prevent Brain Metastasis in High-Risk Non–Small-Cell Lung Cancer: Lessons Learned From a Randomized Study of Maintenance Temozolomide Versus Observation. Clin Lung Cancer 2014; 15:433-40. [DOI: 10.1016/j.cllc.2014.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 05/12/2014] [Accepted: 06/17/2014] [Indexed: 12/18/2022]
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Adkins CE, Nounou MI, Mittapalli RK, Terrell-Hall TB, Mohammad AS, Jagannathan R, Lockman PR. A novel preclinical method to quantitatively evaluate early-stage metastatic events at the murine blood-brain barrier. Cancer Prev Res (Phila) 2014; 8:68-76. [PMID: 25348853 DOI: 10.1158/1940-6207.capr-14-0225] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The observation that approximately 15% of women with disseminated breast cancer will develop symptomatic brain metastases combined with treatment guidelines discouraging single-agent chemotherapeutic strategies facilitates the desire for novel strategies aimed at outright brain metastasis prevention. Effective and robust preclinical methods to evaluate early-stage metastatic processes, brain metastases burden, and overall mean survival are lacking. Here, we develop a novel method to quantitate early metastatic events (arresting and extravasation) in addition to traditional end time-point parameters such as tumor burden and survival in an experimental mouse model of brain metastases of breast cancer. Using this method, a reduced number of viable brain-seeking metastatic cells (from 3,331 ± 263 cells/brain to 1,079 ± 495 cells/brain) were arrested in brain one week postinjection after TGFβ knockdown. Treatment with a TGFβ receptor inhibitor, galunisertib, reduced the number of arrested cells in brain to 808 ± 82 cells/brain. Furthermore, we observed a reduction in the percentage of extravasated cells (from 63% to 30%) compared with cells remaining intralumenal when TGFβ is knocked down or inhibited with galunisertib (40%). The observed reduction of extravasated metastatic cells in brain translated to smaller and fewer brain metastases and resulted in prolonged mean survival (from 36 days to 62 days). This method opens up potentially new avenues of metastases prevention research by providing critical data important to early brain metastasis of breast cancer events.
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Affiliation(s)
- Chris E Adkins
- Department of Basic Pharmaceutical Sciences, Health Sciences Center, School of Pharmacy, West Virginia University, Morgantown, West Virginia. Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center, School of Pharmacy, Amarillo, Texas
| | - Mohamed I Nounou
- Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center, School of Pharmacy, Amarillo, Texas. Department of Pharmaceutics, School of Pharmacy, Alexandria University, Alexandria, Egypt
| | - Rajendar K Mittapalli
- Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center, School of Pharmacy, Amarillo, Texas
| | - Tori B Terrell-Hall
- Department of Basic Pharmaceutical Sciences, Health Sciences Center, School of Pharmacy, West Virginia University, Morgantown, West Virginia. Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center, School of Pharmacy, Amarillo, Texas
| | - Afroz S Mohammad
- Department of Basic Pharmaceutical Sciences, Health Sciences Center, School of Pharmacy, West Virginia University, Morgantown, West Virginia. Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center, School of Pharmacy, Amarillo, Texas
| | - Rajaganapathi Jagannathan
- Department of Basic Pharmaceutical Sciences, Health Sciences Center, School of Pharmacy, West Virginia University, Morgantown, West Virginia
| | - Paul R Lockman
- Department of Basic Pharmaceutical Sciences, Health Sciences Center, School of Pharmacy, West Virginia University, Morgantown, West Virginia. Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center, School of Pharmacy, Amarillo, Texas.
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Intracranial microcapsule chemotherapy delivery for the localized treatment of rodent metastatic breast adenocarcinoma in the brain. Proc Natl Acad Sci U S A 2014; 111:16071-6. [PMID: 25349381 DOI: 10.1073/pnas.1313420110] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Metastases represent the most common brain tumors in adults. Surgical resection alone results in 45% recurrence and is usually accompanied by radiation and chemotherapy. Adequate chemotherapy delivery to the CNS is hindered by the blood-brain barrier. Efforts at delivering chemotherapy locally to gliomas have shown modest increases in survival, likely limited by the infiltrative nature of the tumor. Temozolomide (TMZ) is first-line treatment for gliomas and recurrent brain metastases. Doxorubicin (DOX) is used in treating many types of breast cancer, although its use is limited by severe cardiac toxicity. Intracranially implanted DOX and TMZ microcapsules are compared with systemic administration of the same treatments in a rodent model of breast adenocarcinoma brain metastases. Outcomes were animal survival, quantified drug exposure, and distribution of cleaved caspase 3. Intracranial delivery of TMZ and systemic DOX administration prolong survival more than intracranial DOX or systemic TMZ. Intracranial TMZ generates the more robust induction of apoptotic pathways. We postulate that these differences may be explained by distribution profiles of each drug when administered intracranially: TMZ displays a broader distribution profile than DOX. These microcapsule devices provide a safe, reliable vehicle for intracranial chemotherapy delivery and have the capacity to be efficacious and superior to systemic delivery of chemotherapy. Future work should include strategies to improve the distribution profile. These findings also have broader implications in localized drug delivery to all tissue, because the efficacy of a drug will always be limited by its ability to diffuse into surrounding tissue past its delivery source.
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Lukas RV, Gabikian P, Garza M, Chmura SJ. Treatment of brain metastases. Oncology 2014; 87:321-9. [PMID: 25227433 DOI: 10.1159/000362389] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 03/18/2014] [Indexed: 11/19/2022]
Abstract
Brain metastases are associated with substantial morbidity and mortality. Key prognostic classification systems for brain metastases are reviewed. The role of surgery, particularly for single brain metastases, is discussed. This is followed by an overview of radiation, both whole brain and focal, in the treatment of brain metastases. Finally, we review examples of important concepts regarding the role of systemic therapy in the treatment of brain metastases.
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Affiliation(s)
- Rimas V Lukas
- Department of Neurology,University of Chicago, Chicago, Ill., USA
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Zimmermann S, Dziadziuszko R, Peters S. Indications and limitations of chemotherapy and targeted agents in non-small cell lung cancer brain metastases. Cancer Treat Rev 2014; 40:716-22. [DOI: 10.1016/j.ctrv.2014.03.005] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/20/2014] [Accepted: 03/30/2014] [Indexed: 12/22/2022]
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D'Antonio C, Passaro A, Gori B, Del Signore E, Migliorino MR, Ricciardi S, Fulvi A, de Marinis F. Bone and brain metastasis in lung cancer: recent advances in therapeutic strategies. Ther Adv Med Oncol 2014; 6:101-14. [PMID: 24790650 DOI: 10.1177/1758834014521110] [Citation(s) in RCA: 149] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Bone and brain metastases are a very common secondary localization of disease in patients with lung cancer. The prognosis of these patients is still poor with a median survival of less than 1 year. Current therapeutic approaches include palliative radiotherapy and systemic therapy with chemotherapy and targeted agents. For bone metastasis, zoledronic acid is the most commonly used bisphosphonate to prevent, reduce the incidence and delay the onset of skeletal-related events (SREs). Recently, denosumab, a fully human monoclonal antibody directed against the receptor activator of nuclear factor κB (RANK) ligand inhibiting the maturation of pre-osteoclasts into osteoclasts, showed increased time to SREs and overall survival compared with zoledronic acid. The treatment of brain metastasis is still controversial. Available standard therapeutic options, such as whole brain radiation therapy and systemic chemotherapy, provide a slight improvement in local control, overall survival and symptom relief. More recently, novel target agents such as the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) erlotinib, gefitinib and afatinib have shown activity in patients with brain metastasis. Inter alia, in patients harboring EGFR mutations, the administration of EGFR TKIs is followed by a response rate of 70-80%, and a longer progression-free and overall survival than those obtained with standard chemotherapeutic regimens. This review is focused on the evidence for therapeutic strategies in bone and brain metastases due to lung cancer.
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Affiliation(s)
- Chiara D'Antonio
- 1st Oncological Pulmonary Unit/Department of Medical and Surgical Sciences and Translational Medicine, 'Sapienza' University of Rome, Sant'Andrea Hospital San Camillo, High Specialization Hospital/University of Rome, Sant'Andrea Hospital, Cir. ne Gianicolense 87, 00151, Rome, Italy
| | - Antonio Passaro
- Division of Thoracic Oncology, European Institute of Oncology, Milan, Italy
| | - Bruno Gori
- 1st Oncological Pulmonary Unit, San Camillo, High Specialization Hospital, Rome, Italy
| | - Ester Del Signore
- Division of Thoracic Oncology, European Institute of Oncology, Milan, Italy
| | - Maria Rita Migliorino
- 1st Oncological Pulmonary Unit, San Camillo, High Specialization Hospital, Rome, Italy
| | - Serena Ricciardi
- 1st Oncological Pulmonary Unit, San Camillo, High Specialization Hospital, Rome, Italy
| | - Alberto Fulvi
- 1st Oncological Pulmonary Unit, San Camillo, High Specialization Hospital, Rome, Italy
| | - Filippo de Marinis
- Division of Thoracic Oncology, European Institute of Oncology, Milan, Italy
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Ji Z, Bi N, Wang J, Hui Z, Xiao Z, Feng Q, Zhou Z, Chen D, Lv J, Liang J, Fan C, Liu L, Wang L. Risk factors for brain metastases in locally advanced non-small cell lung cancer with definitive chest radiation. Int J Radiat Oncol Biol Phys 2014; 89:330-7. [PMID: 24725335 DOI: 10.1016/j.ijrobp.2014.02.025] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 02/13/2014] [Accepted: 02/14/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE We intended to identify risk factors that affect brain metastases (BM) in patients with locally advanced non-small cell lung cancer (LA-NSCLC) receiving definitive radiation therapy, which may guide the choice of selective prevention strategies. METHODS AND MATERIALS The characteristics of 346 patients with stage III NSCLC treated with thoracic radiation therapy from January 2008 to December 2010 in our institution were retrospectively reviewed. BM rates were analyzed by the Kaplan-Meier method. Multivariate Cox regression analysis was performed to determine independent risk factors for BM. RESULTS The median follow-up time was 48.3 months in surviving patients. A total of 74 patients (21.4%) experienced BM at the time of analysis, and for 40 (11.7%) of them, the brain was the first site of failure. The 1-year and 3-year brain metastasis rates were 15% and 28.1%, respectively. In univariate analysis, female sex, age ≤60 years, non-squamous cell carcinoma, T3-4, N3, >3 areas of lymph node metastasis, high lactate dehydrogenase and serum levels of tumor markers (CEA, NSE, CA125) before treatment were significantly associated with BM (P<.05). In multivariate analysis, age ≤60 years (P=.004, hazard ratio [HR] = 0.491), non-squamous cell carcinoma (P=.000, HR=3.726), NSE >18 ng/mL (P=.008, HR=1.968) and CA125 ≥ 35 U/mL (P=.002, HR=2.129) were independent risk factors for BM. For patients with 0, 1, 2, and 3 to 4 risk factors, the 3-year BM rates were 7.3%, 18.9%, 35.8%, and 70.3%, respectively (P<.001). CONCLUSIONS Age ≤60 years, non-squamous cell carcinoma, serum NSE >18 ng/mL, and CA125 ≥ 35 U/mL were independent risk factors for brain metastasis. The possibilities of selectively using prophylactic cranial irradiation in higher-risk patients with LA-NSCLC should be further explored in the future.
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Affiliation(s)
- Zhe Ji
- Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Nan Bi
- Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Jingbo Wang
- Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Zhouguang Hui
- Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Zefen Xiao
- Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Qinfu Feng
- Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Zongmei Zhou
- Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Dongfu Chen
- Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Jima Lv
- Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Jun Liang
- Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Chengcheng Fan
- Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Lipin Liu
- Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Luhua Wang
- Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China.
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Palmieri D, Duchnowska R, Woditschka S, Hua E, Qian Y, Biernat W, Sosińska-Mielcarek K, Gril B, Stark AM, Hewitt SM, Liewehr DJ, Steinberg SM, Jassem J, Steeg PS. Profound prevention of experimental brain metastases of breast cancer by temozolomide in an MGMT-dependent manner. Clin Cancer Res 2014; 20:2727-39. [PMID: 24634373 DOI: 10.1158/1078-0432.ccr-13-2588] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE Brain metastases of breast cancer cause neurocognitive damage and are incurable. We evaluated a role for temozolomide in the prevention of brain metastases of breast cancer in experimental brain metastasis models. EXPERIMENTAL DESIGN Temozolomide was administered in mice following earlier injection of brain-tropic HER2-positive JIMT-1-BR3 and triple-negative 231-BR-EGFP sublines, the latter with and without expression of O(6)-methylguanine-DNA methyltransferase (MGMT). In addition, the percentage of MGMT-positive tumor cells in 62 patient-matched sets of breast cancer primary tumors and resected brain metastases was determined immunohistochemically. RESULTS Temozolomide, when dosed at 50, 25, 10, or 5 mg/kg, 5 days per week, beginning 3 days after inoculation, completely prevented the formation of experimental brain metastases from MGMT-negative 231-BR-EGFP cells. At a 1 mg/kg dose, temozolomide prevented 68% of large brain metastases, and was ineffective at a dose of 0.5 mg/kg. When the 50 mg/kg dose was administered beginning on days 18 or 24, temozolomide efficacy was reduced or absent. Temozolomide was ineffective at preventing brain metastases in MGMT-transduced 231-BR-EGFP and MGMT-expressing JIMT-1-BR3 sublines. In 62 patient-matched sets of primary breast tumors and resected brain metastases, 43.5% of the specimens had concordant low MGMT expression, whereas in another 14.5% of sets high MGMT staining in the primary tumor corresponded with low staining in the brain metastasis. CONCLUSIONS Temozolomide profoundly prevented the outgrowth of experimental brain metastases of breast cancer in an MGMT-dependent manner. These data provide compelling rationale for investigating the preventive efficacy of temozolomide in a clinical setting.
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Affiliation(s)
- Diane Palmieri
- Authors' Affiliations: Women's Malignancies Branch; Laboratory of Pathology, Center for Cancer Research; Biostatistics and Data Management Section, NCI, NIH, Bethesda; Laboratory Animal Sciences Program, SAIC-Frederick, NCI, NIH, Frederick, Maryland; Department of Oncology, Military Institute of Medicine, Warsaw; Departments of Pathomorphology, and Oncology and Radiotherapy, Medical University; Regional Cancer Center, Gdańsk, Poland; and Klinik fur Neurochirurgie UKSH Campus Kiel, Kiel, Germany
| | - Renata Duchnowska
- Authors' Affiliations: Women's Malignancies Branch; Laboratory of Pathology, Center for Cancer Research; Biostatistics and Data Management Section, NCI, NIH, Bethesda; Laboratory Animal Sciences Program, SAIC-Frederick, NCI, NIH, Frederick, Maryland; Department of Oncology, Military Institute of Medicine, Warsaw; Departments of Pathomorphology, and Oncology and Radiotherapy, Medical University; Regional Cancer Center, Gdańsk, Poland; and Klinik fur Neurochirurgie UKSH Campus Kiel, Kiel, Germany
| | - Stephan Woditschka
- Authors' Affiliations: Women's Malignancies Branch; Laboratory of Pathology, Center for Cancer Research; Biostatistics and Data Management Section, NCI, NIH, Bethesda; Laboratory Animal Sciences Program, SAIC-Frederick, NCI, NIH, Frederick, Maryland; Department of Oncology, Military Institute of Medicine, Warsaw; Departments of Pathomorphology, and Oncology and Radiotherapy, Medical University; Regional Cancer Center, Gdańsk, Poland; and Klinik fur Neurochirurgie UKSH Campus Kiel, Kiel, Germany
| | - Emily Hua
- Authors' Affiliations: Women's Malignancies Branch; Laboratory of Pathology, Center for Cancer Research; Biostatistics and Data Management Section, NCI, NIH, Bethesda; Laboratory Animal Sciences Program, SAIC-Frederick, NCI, NIH, Frederick, Maryland; Department of Oncology, Military Institute of Medicine, Warsaw; Departments of Pathomorphology, and Oncology and Radiotherapy, Medical University; Regional Cancer Center, Gdańsk, Poland; and Klinik fur Neurochirurgie UKSH Campus Kiel, Kiel, Germany
| | - Yongzhen Qian
- Authors' Affiliations: Women's Malignancies Branch; Laboratory of Pathology, Center for Cancer Research; Biostatistics and Data Management Section, NCI, NIH, Bethesda; Laboratory Animal Sciences Program, SAIC-Frederick, NCI, NIH, Frederick, Maryland; Department of Oncology, Military Institute of Medicine, Warsaw; Departments of Pathomorphology, and Oncology and Radiotherapy, Medical University; Regional Cancer Center, Gdańsk, Poland; and Klinik fur Neurochirurgie UKSH Campus Kiel, Kiel, Germany
| | - Wojciech Biernat
- Authors' Affiliations: Women's Malignancies Branch; Laboratory of Pathology, Center for Cancer Research; Biostatistics and Data Management Section, NCI, NIH, Bethesda; Laboratory Animal Sciences Program, SAIC-Frederick, NCI, NIH, Frederick, Maryland; Department of Oncology, Military Institute of Medicine, Warsaw; Departments of Pathomorphology, and Oncology and Radiotherapy, Medical University; Regional Cancer Center, Gdańsk, Poland; and Klinik fur Neurochirurgie UKSH Campus Kiel, Kiel, Germany
| | - Katarzyna Sosińska-Mielcarek
- Authors' Affiliations: Women's Malignancies Branch; Laboratory of Pathology, Center for Cancer Research; Biostatistics and Data Management Section, NCI, NIH, Bethesda; Laboratory Animal Sciences Program, SAIC-Frederick, NCI, NIH, Frederick, Maryland; Department of Oncology, Military Institute of Medicine, Warsaw; Departments of Pathomorphology, and Oncology and Radiotherapy, Medical University; Regional Cancer Center, Gdańsk, Poland; and Klinik fur Neurochirurgie UKSH Campus Kiel, Kiel, Germany
| | - Brunilde Gril
- Authors' Affiliations: Women's Malignancies Branch; Laboratory of Pathology, Center for Cancer Research; Biostatistics and Data Management Section, NCI, NIH, Bethesda; Laboratory Animal Sciences Program, SAIC-Frederick, NCI, NIH, Frederick, Maryland; Department of Oncology, Military Institute of Medicine, Warsaw; Departments of Pathomorphology, and Oncology and Radiotherapy, Medical University; Regional Cancer Center, Gdańsk, Poland; and Klinik fur Neurochirurgie UKSH Campus Kiel, Kiel, Germany
| | - Andreas M Stark
- Authors' Affiliations: Women's Malignancies Branch; Laboratory of Pathology, Center for Cancer Research; Biostatistics and Data Management Section, NCI, NIH, Bethesda; Laboratory Animal Sciences Program, SAIC-Frederick, NCI, NIH, Frederick, Maryland; Department of Oncology, Military Institute of Medicine, Warsaw; Departments of Pathomorphology, and Oncology and Radiotherapy, Medical University; Regional Cancer Center, Gdańsk, Poland; and Klinik fur Neurochirurgie UKSH Campus Kiel, Kiel, Germany
| | - Stephen M Hewitt
- Authors' Affiliations: Women's Malignancies Branch; Laboratory of Pathology, Center for Cancer Research; Biostatistics and Data Management Section, NCI, NIH, Bethesda; Laboratory Animal Sciences Program, SAIC-Frederick, NCI, NIH, Frederick, Maryland; Department of Oncology, Military Institute of Medicine, Warsaw; Departments of Pathomorphology, and Oncology and Radiotherapy, Medical University; Regional Cancer Center, Gdańsk, Poland; and Klinik fur Neurochirurgie UKSH Campus Kiel, Kiel, Germany
| | - David J Liewehr
- Authors' Affiliations: Women's Malignancies Branch; Laboratory of Pathology, Center for Cancer Research; Biostatistics and Data Management Section, NCI, NIH, Bethesda; Laboratory Animal Sciences Program, SAIC-Frederick, NCI, NIH, Frederick, Maryland; Department of Oncology, Military Institute of Medicine, Warsaw; Departments of Pathomorphology, and Oncology and Radiotherapy, Medical University; Regional Cancer Center, Gdańsk, Poland; and Klinik fur Neurochirurgie UKSH Campus Kiel, Kiel, Germany
| | - Seth M Steinberg
- Authors' Affiliations: Women's Malignancies Branch; Laboratory of Pathology, Center for Cancer Research; Biostatistics and Data Management Section, NCI, NIH, Bethesda; Laboratory Animal Sciences Program, SAIC-Frederick, NCI, NIH, Frederick, Maryland; Department of Oncology, Military Institute of Medicine, Warsaw; Departments of Pathomorphology, and Oncology and Radiotherapy, Medical University; Regional Cancer Center, Gdańsk, Poland; and Klinik fur Neurochirurgie UKSH Campus Kiel, Kiel, Germany
| | - Jacek Jassem
- Authors' Affiliations: Women's Malignancies Branch; Laboratory of Pathology, Center for Cancer Research; Biostatistics and Data Management Section, NCI, NIH, Bethesda; Laboratory Animal Sciences Program, SAIC-Frederick, NCI, NIH, Frederick, Maryland; Department of Oncology, Military Institute of Medicine, Warsaw; Departments of Pathomorphology, and Oncology and Radiotherapy, Medical University; Regional Cancer Center, Gdańsk, Poland; and Klinik fur Neurochirurgie UKSH Campus Kiel, Kiel, GermanyAuthors' Affiliations: Women's Malignancies Branch; Laboratory of Pathology, Center for Cancer Research; Biostatistics and Data Management Section, NCI, NIH, Bethesda; Laboratory Animal Sciences Program, SAIC-Frederick, NCI, NIH, Frederick, Maryland; Department of Oncology, Military Institute of Medicine, Warsaw; Departments of Pathomorphology, and Oncology and Radiotherapy, Medical University; Regional Cancer Center, Gdańsk, Poland; and Klinik fur Neurochirurgie UKSH Campus Kiel, Kiel, Germany
| | - Patricia S Steeg
- Authors' Affiliations: Women's Malignancies Branch; Laboratory of Pathology, Center for Cancer Research; Biostatistics and Data Management Section, NCI, NIH, Bethesda; Laboratory Animal Sciences Program, SAIC-Frederick, NCI, NIH, Frederick, Maryland; Department of Oncology, Military Institute of Medicine, Warsaw; Departments of Pathomorphology, and Oncology and Radiotherapy, Medical University; Regional Cancer Center, Gdańsk, Poland; and Klinik fur Neurochirurgie UKSH Campus Kiel, Kiel, Germany
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Chen TC, Cho HY, Wang W, Barath M, Sharma N, Hofman FM, Schönthal AH. A Novel Temozolomide–Perillyl Alcohol Conjugate Exhibits Superior Activity against Breast Cancer Cells In Vitro and Intracranial Triple-Negative Tumor Growth In Vivo. Mol Cancer Ther 2014; 13:1181-93. [DOI: 10.1158/1535-7163.mct-13-0882] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Zhu W, Zhou L, Qian JQ, Qiu TZ, Shu YQ, Liu P. Temozolomide for treatment of brain metastases: A review of 21 clinical trials. World J Clin Oncol 2014; 5:19-27. [PMID: 24527399 PMCID: PMC3920177 DOI: 10.5306/wjco.v5.i1.19] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 11/02/2013] [Accepted: 11/16/2013] [Indexed: 02/06/2023] Open
Abstract
Brain metastases from solid tumours are associated with poor prognosis despite aggressive treatment. Temozolomide can be used for the treatment of glioblastoma multiforme as well as melanoma. It has also been shown to have activity in patients with brain metastases from various malignancies, since it can cross the blood-brain barrier. To better understand the efficacy of temozolomide in the treatment of brain metastases, we carried out a review of 21 published clinical trials to determine whether temozolomide would benefit patients with brain metastases from solid tumours. Information regarding complete response, partial response, stable disease, objective response and objective response rate were collected to assess clinical outcomes. A modest therapeutic effect was observed when temozolomide was used as a single agent, however, the combination of temozolomide with whole-brain radiotherapy and/or other anticancer drugs exhibited encouraging activity. Thus, future high quality studies are warranted to confirm our findings.
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39
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Melisko ME, Kunwar S, Prados M, Berger MS, Park JW. Brain metastases of breast cancer. Expert Rev Anticancer Ther 2014; 5:253-68. [PMID: 15877523 DOI: 10.1586/14737140.5.2.253] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Brain metastases of breast cancer remain a difficult problem for clinical management. Their incidence appears to be increasing, which is likely due to longer survival times for advanced breast cancer patients as well as additional and improved tools for detection. Molecular features of tumors associated with this syndrome are not yet understood. In general, survival may be improving for brain metastases due to better local control in the CNS, as well as improvements in systemic disease management. Selected patients with brain metastases are able to undergo surgical resection, which has been associated with extended disease control in some patients. However, whole-brain radiation has been the mainstay for treatment for most patients. Stereotactic radiosurgery is playing an increasing role in the primary treatment of brain metastases, as well as for salvage after whole-brain radiation. Recent series have reported median survivals of 13 months or longer with stereotactic radiosurgery. Further improvements in radiation-based approaches may come from ongoing studies of radiosensitizing agents. The ability of systemic treatments to impact brain metastases has been debated, and specific treatment regimens have yet to be defined. New approaches include chemotherapy combinations, biologic therapies and novel drug-delivery strategies.
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Affiliation(s)
- Michelle E Melisko
- Division of Hematology-Oncology, University of California at San Francisco, San Francisco, CA 94115, USA.
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41
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Abstract
Brain metastases secondary to primary non-small cell and small cell lung cancer have become an important area of research. The brain is one of the most common sites of failure following treatment for locally advanced non-small cell lung cancer, often as the only site. Treatment strategies and the outcome for brain metastases from lung cancer may differ from brain metastases arising from other primary cancers. This article reviews the prognostic factors associated with brain metastases from lung cancer, as well as current treatment approaches with chemotherapy, surgery and radiation therapy.
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Affiliation(s)
- Laurie E Gaspar
- University of Colorado Health Sciences Center, Department of Radiation Oncology, 1663 N. Ursula Street, Box F-706, Suite 1032, Aurora, CO 80010-0510, USA.
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Chamberlain MC. Brain metastases: a medical neuro-oncology perspective. Expert Rev Neurother 2014; 10:563-73. [DOI: 10.1586/ern.10.30] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Neurologic complications of lung cancer are a frequent cause of morbidity and mortality. Tumor metastasis to the brain parenchyma is the single most common neurologic complication of lung cancer, of any histologic subtype. The goal of radiation therapy and in some cases surgical resection for patients with brain metastases is to improve or maintain neurologic function, and to achieve local control of the brain lesion(s). Metastasis of lung cancer to the spinal epidural space requires urgent evaluation and treatment. Early diagnosis and modern surgical and radiotherapy techniques improve neurologic outcome for most patients. Leptomeningeal metastasis is a less common but ominous occurrence in patients with lung cancer. Lung carcinomas can also occasionally metastasize to the brachial plexus, skull base, dura, or pituitary. Paraneoplastic neurologic disorders are uncommon but important complications of lung carcinoma, and are generally the presenting feature of the tumor. Paraneoplastic disorders are believed to be caused by an autoimmune humoral or cellular attack against shared "onconeural" antigens. The most frequent paraneoplastic disorders in patients with lung cancer are Lambert-Eaton myasthenic syndrome, and multifocal paraneoplastic encephalomyelitis, both mainly occurring in association with small-cell lung carcinoma. There is a variety of other paraneoplastic disorders affecting the central and peripheral nervous systems. Some affected patients have a good neurologic outcome, while others are left with severe permanent neurologic disability.
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Affiliation(s)
- Edward J Dropcho
- Department of Neurology, Indiana University Medical Center, Indianapolis, IN, USA.
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Clinical Trials for Breast Cancer with Brain Metastases: Challenges and New Directions. CURRENT BREAST CANCER REPORTS 2013. [DOI: 10.1007/s12609-013-0120-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Klironomos G, Bernstein M. Salvage stereotactic radiosurgery for brain metastases. Expert Rev Neurother 2013; 13:1285-95. [PMID: 24175726 DOI: 10.1586/14737175.2013.853445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Recurrent or progressive brain metastases after initial treatment represent a common clinical entity mainly due to increased survival of cancer patients. From the various available treatment modalities, salvage stereotactic radiosurgery seems to be the most commonly used. Many clinical studies of class of evidence III have demonstrated satisfied results concerning the local brain control and survival of patients with relapsing brain disease. Also stereotactic radiosurgery is considered a relatively safe modality with low incidence of brain toxicity side effects. It is obvious that well-designed, randomized, prospective studies are necessary for the evaluation of the stereotactic radiosurgery as salvage treatment and for the establishment of guidelines for the selection of patients most suitable for this treatment option. The increasing number of patients with relapsing brain metastatic disease will act as a pressure to this direction.
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Affiliation(s)
- George Klironomos
- Department of surgery, University of Toronto, Clinical Fellow in Neuroncology and Skull Base Neurosurgery, 339 Bathurst Street, Toronto, ON M5T2S8, Canada
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Surgery of recurrent brain metastases: retrospective analysis of 67 patients. Acta Neurochir (Wien) 2013; 155:1823-32. [PMID: 23913109 DOI: 10.1007/s00701-013-1821-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 07/03/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Treatment of patients with recurrent brain metastasis is one of the major challenges in neurooncology. Commonly, WBRT was applied after or as the initial treatment. Many patients received radiosurgery or their lesions were operated on. The question arises of what treatment modalities are appropriate and can be offered to the patients. In our retrospective analysis, we evaluated whether re-operation might be a useful measurement for the patients with respect to overall survival and quality of life. METHODS We included 67 patients who were treated between 1993 and 2008 in our department. The median age was 59 years. Metastases of 11 different primaries were diagnosed. The median OST was 7.5 months. RESULTS Statistically significant prognostic factors for OS were single lesions, completeness of resection, and time to recurrence, which was significantly influenced by WBRT after first operation. The one year survival rate correlated with the RPA classification: class I: 53.3 %, class II: 26.9 %, class III: 12.5 %. In 31.3 %, a second recurrence occurred which was treated by repeated surgery. Six patients survived as long-term survivors (25.7-132.2 months). CONCLUSION Surgery of recurrent brain metastasis is an important therapeutic option. A subgroup of patients, defined by prognostic factors, will profit with improvement of symptoms and prolongation of the overall survival time. Even long-term survivors can be expected.
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Temozolomide added to whole brain radiotherapy in patients with multiple brain metastases of non-small-cell lung cancer: a multicentric Austrian phase II study. Wien Klin Wochenschr 2013; 125:481-6. [PMID: 23907204 DOI: 10.1007/s00508-013-0402-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 07/07/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND This multicentric randomized phase II study investigated the feasibility and toxicity of temozolomide (TMZ) added to whole brain radiotherapy (WBRT) followed by adjuvant TMZ in patients with multiple brain metastases of non-small-cell lung cancer (NSCLC). METHODS Patients with multiple brain metastases from NSCLC aged ≥ 18 years, classified according to recursive partitioning analysis class I or II and with adequate organ functions were eligible. Treatment consisted of WBRT + TMZ 75 mg/m² for 2 weeks followed at day 28 by TMZ 100 mg/m²/day 2 weeks on/2 weeks off for up to 6 months (radiochemotherapy, RCT) or WBRT alone (radiotherapy, RT). RESULTS The study enrolled only 35 patients (22 patients in RCT and 13 in RT) and had to be closed prematurely due to poor accrual. The toxicity was mainly due to TMZ with WHO grade 3 and 4 thrombocytopenia in 3/22 versus 0/13, leucocytopenia in 1/22 versus 0/13 and lymphocytopenia in 7/22 versus 12/13 patients in RCT and RT respectively. Thirteen patients in RCT and six in RT progressed systemically and dropped out before first restaging of the response in brain. Median time to progression (TTP) was 2.4 months (95 % CI: 2-2.6 months) and 2.0 months (95 % CI: 0.5-3.5 months), median overall survival (OAS) was 3 months (95% CI: 1.7-3.1 months) and 6.3.months (95 % CI: 0.2-7.6 months) in RCT and RT, respectively. CONCLUSIONS Like other studies before on patients with brain metastases, insufficient number of recruited patients does not allow conclusions on efficacy and toxicity as the study closed prematurely.
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Kumthekar P, Grimm SA, Avram MJ, Kaklamani V, Helenowski I, Rademaker A, Cianfrocca M, Gradishar W, Patel J, Mulcahy M, McCarthy K, Raizer JJ. Pharmacokinetics and efficacy of pemetrexed in patients with brain or leptomeningeal metastases. J Neurooncol 2013; 112:247-55. [DOI: 10.1007/s11060-013-1055-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 01/14/2013] [Indexed: 11/30/2022]
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[Systemic treatment of brain metastases from breast cancer: cytotoxic chemotherapy and targeted therapies]. Bull Cancer 2013; 100:7-14. [PMID: 23305997 DOI: 10.1684/bdc.2012.1676] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Prevalence of brain metastases is increasing in breast cancer. Brain metastases represent a poor-prognosis disease for which local treatments continue to play a major role. In spite of the presence of a physiological blood-brain barrier limiting their activity, some systemic treatments may display a significant antitumor activity at the central nervous system level. In HER2-positive metastatic breast cancer with brain metastases not previously treated with whole brain radiotherapy, capecitabine and lapatinib combination obtains a volumetric reponse in two thirds of patients (LANDSCAPE study). If confirmed, these results could modify in selected patients the layout of therapeutic strategies. Promoting novel targeted approaches and innovative therapeutic combinations is a critical need to improve survival of breast cancer patients with brain metastases.
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Nieder C, Grosu AL, Mehta MP. Brain metastases research 1990-2010: pattern of citation and systematic review of highly cited articles. ScientificWorldJournal 2012; 2012:721598. [PMID: 23028253 PMCID: PMC3458272 DOI: 10.1100/2012/721598] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 08/26/2012] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND High and continuously increasing research activity related to different aspects of prevention, prediction, diagnosis and treatment of brain metastases has been performed between 1990 and 2010. One of the major databases contains 2695 scientific articles that were published during this time period. Different measures of impact, visibility, and quality of published research are available, each with its own pros and cons. For this overview, article citation rate was chosen. RESULTS Among the 10 most cited articles, 7 reported on randomized clinical trials. Nine covered surgical or radiosurgical approaches and the remaining one a widely adopted prognostic score. Overall, 30 randomized clinical trials were published between 1990 and 2010, including those with phase II design and excluding duplicate publications, for example, after longer followup or with focus on secondary endpoints. Twenty of these randomized clinical trials were published before 2008. Their median number of citations was 110, range 13-1013, compared to 5-6 citations for all types of publications. Annual citation rate appeared to gradually increase during the first 2-3 years after publication before reaching high levels. CONCLUSIONS A large variety of preclinical and clinical topics achieved high numbers of citations. However, areas such as quality of life, side effects, and end-of-life care were underrepresented. Efforts to increase their visibility might be warranted.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodø, Norway.
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