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Dharnipragada R, Shah RA, Reynolds M, Dusenbery K, Chen CC. Laser interstitial thermal therapy followed by consolidation stereotactic radiosurgery (LITT-cSRS) in patients with newly diagnosed brain metastasis. J Neurooncol 2024; 169:155-163. [PMID: 38865010 DOI: 10.1007/s11060-024-04712-4] [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] [Received: 02/09/2024] [Accepted: 05/09/2024] [Indexed: 06/13/2024]
Abstract
INTRODUCTION The efficacy and safety of laser interstitial thermal therapy followed by consolidation radiosurgery (LITT-cSRS) was previously studied in brain metastasis that recurs locally after initial radiosurgery (BMRS). Here, we characterize the clinical outcome of LITT-cSRS in patients with newly diagnosed brain metastasis. METHODS Between 2017 and 2023, ten consecutive cancer patients with newly diagnosed brain mass of unclear etiology who underwent stereotactic needle biopsy (SNB) and LITT in the same setting followed by consolidation SRS (cSRS) with > 6 months follow-up were identified retrospectively. Clinical and imaging outcomes were collected. RESULTS The histology of the BM were: breast cancer (n = 3), melanoma (n = 3), non-cell cell lung cancer (n = 3), colon (n = 1). There were no wound or procedural complications. All patients were discharged home, with a median one-day hospital stay (range: 1-2 days). All patients were off corticosteroid therapy by the one-month follow-up. cSRS were carried out 12-27 days (median of 19 days) after SNB + LITT. There were no subsequent emergency room presentation, 30-day or 90-day re-admission. The Karnofsky Performance Score (KPS) remains stable or improved at the 3 months-follow-up. With a median follow-up of 416 days (13.8 mo; range: 199-1,096 days), there was one local recurrence at 384 days (12.8 mo) post-LITT-cSRS. With exception of this patient with local recurrence, all patients showed decreased FLAIR volume surrounding the LITT-cSRS treated BMRS by the six-month follow-up. CONCLUSIONS To our awareness, this case series represent the first to describe LITT-cSRS in the setting of newly diagnosed BM. The results presented here provide pilot data to support the safety and efficacy of LITT-cSRS and lay the foundation for future studies.
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Affiliation(s)
- Rajiv Dharnipragada
- Medical School, University of Minnesota, University of Minnesota Twin-Cities, Minneapolis, MN, 55455, USA
| | - Rena A Shah
- Oncology & Hematology, Health Partners Park Nicollet, Minneapolis, MN, USA
| | - Margaret Reynolds
- Department of Radiation Oncology, University of Minnesota Twin Cities, Minneapolis, MN, 55455, USA
| | - Kathryn Dusenbery
- Department of Radiation Oncology, University of Minnesota Twin Cities, Minneapolis, MN, 55455, USA
| | - Clark C Chen
- Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA.
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2
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Zhu Y, Zhou M, Li C, Kong W, Hu Y. Gastric cancer with brain metastasis: from molecular characteristics and treatment. Front Oncol 2024; 14:1310325. [PMID: 38577333 PMCID: PMC10991736 DOI: 10.3389/fonc.2024.1310325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 03/12/2024] [Indexed: 04/06/2024] Open
Abstract
Gastric cancer is one of the cancers with increasing incidence and ranks fourth globally among the most frequent causes of cancer-related mortality. Early gastric cancer is often asymptomatic or presents with atypical symptoms, and the majority of patients present with advanced disease upon diagnosis. Brain metastases are present in approximately 1% of gastric cancer patients at the time of diagnosis, which significantly contributed to the overall mortality of the disease worldwide. Conventional therapies for patients with brain metastases remain limited and the median overall survival of patients is only 8 months in advanced cases. Recent studies have improved our understanding of the molecular mechanisms underlying gastric cancer brain metastases, and immunotherapy has become an important treatment option in combination with radiotherapy, chemotherapy, targeted therapy and surgery. This review aims to provide insight into the cellular processes involved in gastric cancer brain metastases, discuss diagnostic approaches, evaluate the integration of immune checkpoint inhibitors into treatment and prognosis, and explore the predictive value of biomarkers in immunotherapy.
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Affiliation(s)
- Yingze Zhu
- Department of Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Miao Zhou
- Department of Oncology, Tang Shan Central Hospital, Tangshan, China
| | - Congling Li
- School of Clinical Medicine, Affiliated Hospital, North China University of Science and Technology, Tangshan, China
| | - Wenyue Kong
- School of Clinical Medicine, Affiliated Hospital, North China University of Science and Technology, Tangshan, China
| | - Yuning Hu
- School of Clinical Medicine, Affiliated Hospital, North China University of Science and Technology, Tangshan, China
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3
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Dharnipragada R, Dusenbery K, Watanabe Y, Ferreira C, Chen CC. Comparison of Gamma Knife (GK) and Linear Accelerator (LINAC) radiosurgery of brain metastasis resection cavity: a systematic review and proportional meta-analysis. Clin Exp Metastasis 2024; 41:1-8. [PMID: 37943360 DOI: 10.1007/s10585-023-10240-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) to the resection cavity is essential in the treatment of brain metastasis (BM) amenable to surgical resection. The two most common platforms for SRS delivery include Gamma Knife (GK) and LINAC. Here we collated the available peer-reviewed literature and performed a meta-analysis on clinical outcomes after GK or LINAC resection cavity SRS. METHODS Following PRISMA Guidelines, a search on PUBMED and MEDLINE was performed to include all studies evaluating each post-operative SRS modality. Local control, overall survival, radiation necrosis, and leptomeningeal disease were evaluated from the available data. A proportional meta-analysis was performed via R using the metafor package to pool the outcomes of studies and a moderator effect to assess the significance between groups. RESULTS We identified 21 GK studies (n = 2009) and 28 LINAC studies (n = 2219). The radiosurgery doses employed were comparable between GK and LINAC studies. The pooled estimate of 1-year local control, 1-year overall survival, and risk of leptomeningeal disease were statistically comparable between GK and LINAC (81.7 v 85.8%; 61.4 v 62.7%; 10.6 v 12.5%, respectively). However, the risk of radiation necrosis (RN) was higher for LINAC resection cavity SRS (5.4% vs. 10%, p = 0.036). The volume of the resection cavity was a significant modifying factor for RN in both modalities (p = 0.007) with a 0.5% and 0.7% increase in RN risk with every 1 cm3 increase in tumor volume for GK and LINAC, respectively. CONCLUSIONS Our meta-analysis suggests that GK and LINAC SRS of resection cavity achieve comparable 1-year local control and survival. However, resection cavity treated with GK SRS was associated with lowered RN risk relative to those treated with LINAC SRS.
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Affiliation(s)
- Rajiv Dharnipragada
- University of Minnesota Medical School, University of Minnesota Twin-Cities, 420 Delaware Street SE, Minneapolis, MN, 55455, USA.
- University of Minnesota Medical School, University of Minnesota Twin-Cities, 420 Delaware Street SE, Minneapolis, MN, 55455, USA.
| | - Kathryn Dusenbery
- Department of Radiation Oncology, University of Minnesota Twin Cities, Minneapolis, MN, 55455, USA
| | - Yoichi Watanabe
- Department of Radiation Oncology, University of Minnesota Twin Cities, Minneapolis, MN, 55455, USA
| | - Clara Ferreira
- Department of Radiation Oncology, University of Minnesota Twin Cities, Minneapolis, MN, 55455, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota Twin-Cities, Minneapolis, MN, 55455, USA
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4
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Limon D, Shachar E, Wolf I, Adar L, Peleg Hasson S, Ferro L, Safra T. Brain metastases in patients with ovarian cancer. Acta Oncol 2022; 61:757-763. [PMID: 35485453 DOI: 10.1080/0284186x.2022.2066985] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Brain metastasis (BM) are uncommon among women with epithelial ovarian cancer (EOC). The frequency, risk factors and clinical repercussions of BM in these patients are not well described. METHODS We retrospectively evaluated EOC patients treated at our center from 2002 to 2020 and assessed their clinical parameters, risk for BM development and association with overall survival (OS). This cohort has a known high frequency of BRCA mutation carriers (BRCAm) due to women of Ashkenazi Jewish descent. RESULTS Among 1035 EOC patients, 29 (2.8%) were diagnosed with BM. The prevalence of BRCA mutations was more common among women with BM (56.5% vs. 34.3%, p = 0.033). The BM rate in patients with BRCAm was higher than the BM rate in those with wildtype BRCA (BRCAw; 5.1% vs. 2.1%, OR = 2.6; 95% CI: 1.2-5.4, p = 0.013). Median time from diagnosis to BM and from disease recurrence to BM was longer among patients with BRCAm. Median OS was not significantly different among patients with BM versus those without BM (59.4 vs. 73.4 months, p = 0.243). After BM diagnosis, median OS was not statistically significantly different between patients with BRCAm and those with BRCAw (20.6 vs. 12.3 months, p = 0.441). Treatment with poly (ADP-ribose) polymerase inhibitors and bevacizumab had no impact on subsequent development of BM. CONCLUSIONS BM are rare among EOC patients. However, the risk is three-fold higher among patients with BRCAm. BM do not significantly alter OS among EOC patients. The higher rate of BM in patients with BRCAm may be related to longer OS in this subpopulation.
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Affiliation(s)
- Dror Limon
- Oncology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eliya Shachar
- Oncology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ido Wolf
- Oncology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lyri Adar
- Oncology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shira Peleg Hasson
- Oncology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leora Ferro
- Oncology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tamar Safra
- Oncology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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5
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Smith DL, Debeb BG, Diagaradjane P, Larson R, Kumar S, Ning J, Lacerda L, Li L, Woodward WA. Prophylactic cranial irradiation reduces the incidence of brain metastasis in a mouse model of metastatic, HER2-positive breast cancer. Genes Cancer 2021; 12:28-38. [PMID: 33884104 PMCID: PMC8045965 DOI: 10.18632/genesandcancer.212] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/21/2021] [Indexed: 12/02/2022] Open
Abstract
Prophylactic cranial irradiation (PCI) can reduce the incidence of brain metastasis and
improve overall survival in some patients with acute lymphoblastic leukemia or small-cell
lung cancer. We examined the potential effects of PCI in a mouse model of breast cancer
brain metastasis. The HER2+ inflammatory breast cancer cell line MDA-IBC3 was labeled with
green fluorescent protein and injected via tail-vein into female SCID/Beige mice. Mice
were then given 0 Gy or 4 Gy of whole-brain irradiation 2 days before tumor-cell injection
or 5 days, 3 weeks, or 6 weeks after tumor-cell injection. Mice were sacrificed 4-weeks or
8-weeks after injection and brain tissues were examined for metastasis by fluorescent
stereomicroscopy. In the unirradiated control group, brain metastases were present in 77%
of mice at 4 weeks and in 90% of mice at 8 weeks; by comparison, rates for the group given
PCI at 5 days after tumor-cell injection were 20% at 4 weeks (p=0.01) and
30% at 8 weeks (p=0.02). The PCI group also had fewer brain metastases
per mouse at 4 weeks (p=0.03) and 8 weeks (p=0.006)
versus the unirradiated control as well as a lower metastatic burden
(p=0.01). Irradiation given either before tumor-cell injection or 3-6
weeks afterward had no significant effect on brain metastases compared to the unirradiated
control. These results underscore the importance of timing for irradiating subclinical
disease. Clinical whole brain strategies to target subclinical brain disease as safely as
possible may warrant further study.
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Affiliation(s)
- Daniel L Smith
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bisrat G Debeb
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Parmeswaran Diagaradjane
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard Larson
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Swaminathan Kumar
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,The University of Texas MD Anderson Cancer Center, UTHealth Graduate School of Biomedical Sciences, Houston, TX, USA
| | - Jing Ning
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lara Lacerda
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Li Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wendy A Woodward
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abstract
Impaired neurocognitive function is an increasingly recognized morbidity in patients who have cancer. Cancer treatments, psychosocial stressors, and the malignancy itself can alter brain function. The mechanisms by which this occurs are under active investigation. Although there is a growing appreciation of its prevalence and causes, there remain limited therapeutic options for the treatment of neurocognitive dysfunction in this population. A persistent scientific and clinical effort to understand its mechanisms and impact is critical to the care of oncology patients.
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Affiliation(s)
- Rebecca A Harrison
- Department of Neuro-Oncology, The University of Texas M.D. Anderson Cancer Center, 1400 Holcombe Boulevard, Unit 0431, Houston, TX 77030, USA.
| | - Jeffrey S Wefel
- Section of Neuropsychology, Department of Neuro-Oncology, The University of Texas M.D. Anderson Cancer Center, 1400 Holcombe Boulevard, Unit 0431, Houston, TX 77030, USA
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7
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Soffietti R, Abacioglu U, Baumert B, Combs SE, Kinhult S, Kros JM, Marosi C, Metellus P, Radbruch A, Villa Freixa SS, Brada M, Carapella CM, Preusser M, Le Rhun E, Rudà R, Tonn JC, Weber DC, Weller M. Diagnosis and treatment of brain metastases from solid tumors: guidelines from the European Association of Neuro-Oncology (EANO). Neuro Oncol 2017; 19:162-174. [PMID: 28391295 DOI: 10.1093/neuonc/now241] [Citation(s) in RCA: 304] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The management of patients with brain metastases has become a major issue due to the increasing frequency and complexity of the diagnostic and therapeutic approaches. In 2014, the European Association of Neuro-Oncology (EANO) created a multidisciplinary Task Force to draw evidence-based guidelines for patients with brain metastases from solid tumors. Here, we present these guidelines, which provide a consensus review of evidence and recommendations for diagnosis by neuroimaging and neuropathology, staging, prognostic factors, and different treatment options. Specifically, we addressed options such as surgery, stereotactic radiosurgery/stereotactic fractionated radiotherapy, whole-brain radiotherapy, chemotherapy and targeted therapy (with particular attention to brain metastases from non-small cell lung cancer, melanoma and breast and renal cancer), and supportive care.
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Affiliation(s)
- Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Ufuk Abacioglu
- Department of Radiation Oncology, Neolife Medical Center, Istanbul, Turkey
| | - Brigitta Baumert
- Department of Radiation-Oncology, MediClin Robert-Janker-Klinik, Bonn, Germany
| | - Stephanie E Combs
- Department of Innovative Radiation Oncology and Radiation Sciences, Munich, Germany
| | - Sara Kinhult
- Department of Oncology, Skane University Hospital, Lund, Sweden
| | - Johan M Kros
- Department of Pathology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Christine Marosi
- Department of Internal Medicine, Division of Oncology, Medical University, Vienna, Austria
| | - Philippe Metellus
- Department of Internal Medicine, Division of Oncology, Medical University, Vienna, Austria.,Department of Neurosurgery, Clairval Hospital Center, Generale de Santé, Marseille, France
| | - Alexander Radbruch
- Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Salvador S Villa Freixa
- Department of Radiation Oncology, Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Michael Brada
- Department of Molecular and Clinical Cancer Medicine & Radiation Oncology, Liverpool, United Kingdom
| | - Carmine M Carapella
- Department of Neuroscience, Division of Neurosurgery, Regina Elena Nat Cancer Institute, Rome, Italy
| | - Matthias Preusser
- Department of Medicine I and Comprehensive Cancer Center CNS Unit (CCC-CNS), Medical University of Vienna, Vienna, Austria
| | - Emilie Le Rhun
- Department of Neurosurgery, Neuro-oncology, University Hospital, Lille, France
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Joerg C Tonn
- Department of Neurosurgery, University of Munich LMU, Munich, Germany
| | - Damien C Weber
- Centre for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Michael Weller
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
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8
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Fan Y, Xu Y, Gong L, Fang L, Lu H, Qin J, Han N, Xie F, Qiu G, Huang Z. Effects of icotinib with and without radiation therapy on patients with EGFR mutant non-small cell lung cancer and brain metastases. Sci Rep 2017; 7:45193. [PMID: 28332624 PMCID: PMC5362911 DOI: 10.1038/srep45193] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 02/20/2017] [Indexed: 12/25/2022] Open
Abstract
EGFR-TKIs and radiation therapy (RT) are the principal treatment for patients with brain metastases (BM) and EGFR mutant NSCLC. However, the optimal use of brain RT for patients with asymptomatic BM remains undefined. A total of 152 patients were identified. 58 patients were excluded. Of the remaining 97 patients, 56 patients received upfront RT followed by icotinib, including WBRT or SRS. 41 patients received icotinib therapy alone. The mOS from diagnosis of BM was 27.0 months for the whole cohort (95% CI, 23.9–30.1 months). There was no difference in OS between the RT followed by icotinib group and the icotinib alone group (31.9 vs. 27.9 months, P = 0.237), and similar results were found in the SRS subgroup (35.5 vs. 27.9 months, P = 0.12). Patients with the EGFR Del19 mutation had a longer OS than patients with the exon 21 L858R mutation (32.7 vs. 27.4, P = 0.037). Intracranial progression-free survival (PFS) was improved in the patients who received RT followed by icotinib compared to those receiving icotinib alone (22.4 vs. 13.9 months, P = 0.043). Patients with EGFR-mutant adenocarcinoma and BM treated with icotinib exhibited prolonged survival. A longer duration of intracranial control was observed with brain RT.
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Affiliation(s)
- Yun Fan
- Wenzhou Medical University, Wenzhou, China.,Department of Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou, China.,Key Laboratory Diagnosis and Treatment Technology on Thoracic Oncology and Cancer Research Institute, Hangzhou, China
| | - Yanjun Xu
- Department of Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Lei Gong
- Department of Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Luo Fang
- Department of Pharmacy, Zhejiang Cancer Hospital, Hangzhou, China
| | - Hongyang Lu
- Department of Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Jing Qin
- Department of Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Na Han
- Department of Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Fajun Xie
- Department of Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Guoqin Qiu
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Zhiyu Huang
- Department of Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou, China
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9
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More than Just the Number of Brain Metastases: Evaluating the Impact of Brain Metastasis Location and Relative Volume on Overall Survival After Stereotactic Radiosurgery. World Neurosurg 2017; 99:111-117. [DOI: 10.1016/j.wneu.2016.11.119] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 11/22/2016] [Accepted: 11/23/2016] [Indexed: 11/23/2022]
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10
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Chamberlain MC, Baik CS, Gadi VK, Bhatia S, Chow LQM. Systemic therapy of brain metastases: non-small cell lung cancer, breast cancer, and melanoma. Neuro Oncol 2017; 19:i1-i24. [PMID: 28031389 PMCID: PMC5193029 DOI: 10.1093/neuonc/now197] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Brain metastases (BM) occur frequently in many cancers, particularly non-small cell lung cancer (NSCLC), breast cancer, and melanoma. The development of BM is associated with poor prognosis and has an adverse impact on survival and quality of life. Commonly used therapies for BM such as surgery or radiotherapy are associated with only modest benefits. However, recent advances in systemic therapy of many cancers have generated considerable interest in exploration of those therapies for treatment of intracranial metastases.This review discusses the epidemiology of BM from the aforementioned primary tumors and the challenges of using systemic therapies for metastatic disease located within the central nervous system. Cumulative data from several retrospective and small prospective studies suggest that molecularly targeted systemic therapies may be an effective option for the treatment of BM from NSCLC, breast cancer, and melanoma, either as monotherapy or in conjunction with other therapies. Larger prospective studies are warranted to further characterize the efficacy and safety profiles of these targeted agents for the treatment of BM.
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Affiliation(s)
- Marc C Chamberlain
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| | - Christina S Baik
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| | - Vijayakrishna K Gadi
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| | - Shailender Bhatia
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| | - Laura Q M Chow
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
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11
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Patel KR, Burri SH, Boselli D, Symanowski JT, Asher AL, Sumrall A, Fraser RW, Press RH, Zhong J, Cassidy RJ, Olson JJ, Curran WJ, Shu HKG, Crocker IR, Prabhu RS. Comparing pre-operative stereotactic radiosurgery (SRS) to post-operative whole brain radiation therapy (WBRT) for resectable brain metastases: a multi-institutional analysis. J Neurooncol 2016; 131:611-618. [PMID: 28000105 DOI: 10.1007/s11060-016-2334-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/12/2016] [Indexed: 12/11/2022]
Abstract
Pre-operative stereotactic radiosurgery (pre-SRS) has been shown as a viable treatment option for resectable brain metastases (BM). The aim of this study is to compare oncologic outcomes and toxicities for pre-SRS and post-operative WBRT (post-WBRT) for resectable BM. We reviewed records of consecutive patients who underwent resection of BM and either pre-SRS or post-WBRT between 2005 and 2013 at two institutions. Overall survival (OS) was calculated using the Kaplan-Meier method. Cumulative incidence was used for intracranial outcomes. Multivariate analysis (MVA) was performed using the Cox and Fine and Gray models, respectively. Overall, 102 patients underwent surgical resection of BM; 66 patients with 71 lesions received pre-SRS while 36 patients with 42 cavities received post-WBRT. Baseline characteristics were similar except for the pre-SRS cohort having more single lesions (65.2% vs. 38.9%, p = 0.001) and smaller median lesion volume (8.3 cc vs. 15.3 cc, p = 0.006). 1-year OS was similar between cohorts (58% vs. 56%, respectively) (p = 0.43). Intracranial outcomes were also similar (2-year outcomes, pre-SRS vs. post-WBRT): local recurrence: 24.5% vs. 25% (p = 0.81), distant brain failure (DBF): 53.2% vs. 45% (p = 0.66), and leptomeningeal disease (LMD) recurrence: 3.5% vs. 9.0% (p = 0.66). On MVA, radiation cohort was not independently associated with OS or any intracranial outcome. Crude rates of symptomatic radiation necrosis were 5.6 and 0%, respectively. OS and intracranial outcomes were similar for patients treated with pre-SRS or post-WBRT for resected BM. Pre-SRS is a viable alternative to post-WBRT for resected BM. Further confirmatory studies with neuro-cognitive outcomes comparing these two treatment paradigms are needed.
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Affiliation(s)
- Kirtesh R Patel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA.
| | - Stuart H Burri
- Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - Danielle Boselli
- Department of Cancer Biostatistics, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - James T Symanowski
- Department of Cancer Biostatistics, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - Anthony L Asher
- Carolina Neurosurgery and Spine Associates, Levine Cancer Institute, Charlotte, NC, USA
| | - Ashley Sumrall
- Department of Oncology, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - Robert W Fraser
- Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - Robert H Press
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Jim Zhong
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Richard J Cassidy
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Jeffrey J Olson
- Department of Neurosurgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Walter J Curran
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Hui-Kuo G Shu
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Ian R Crocker
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
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12
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Cohen-Inbar O, Melmer P, Lee CC, Xu Z, Schlesinger D, Sheehan JP. Leukoencephalopathy in long term brain metastases survivors treated with radiosurgery. J Neurooncol 2016; 126:289-98. [PMID: 26468138 DOI: 10.1007/s11060-015-1962-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/10/2015] [Indexed: 12/28/2022]
Abstract
Brain metastases (BM) develop in 10-30 % of patients. Stereotactic radiosurgery (SRS) was shown to improve local control, and performance status, in certain cohorts of brain metastasis patients. The cumulative neurocognitive effect of numerous SRS sessions remains unknown. Leukoencephalopathy is significant diffuse white matter changes and it usually implies a neurocognitive decline. We report patients with BM who survived >2 years after SRS. Clinical and treatment parameters were analyzed for development of leukoencephalopathy. Multiple parameters as well as leukoencephalopathy grade changes were recorded. The median clinical and radiological follow-up was 42 and 41 months (range 24–115 and 24–115) respectively. The cohort included 92 patients and 704 lesions. The most common malignancies were non-small cell lung carcinoma (44.5 % n = 41), breast adenocarcinoma (23.9 %, n = 22) and melanoma (16.3 %,n = 15). 27.6 % (n = 26) of patients underwent adjuvant WBRT. At last follow up, local tumor control was achieved in 76.3 % (n = 61) of patients and 71.8 % (n = 461) of lesions. Overall prevalence of leukoencephalopathy was 42, 60, 73 and 84 % at 1, 2, 3, and 4 years after SRS. Moderate-severe leukoencephalopathy development was related to an integral dose to skull >3 Joules (p = 0.012) at any radiosurgical treatment and prior WBRT (p<0.042). Leukoencephalopathy incidence was consistently higher in the WBRT + SRS group at each following year of survival from initial SRS. Long-term BM survivors treated with SRS are at progressive risk for developing leukoencephalopathy.Those with a higher BM burden, higher integral SRS dose to the skull, and treatment with WBRT are at increased risk of leukoencephalopathy.
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13
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Soffietti R, Rudà R, Trakul N, Chang EL. Point/Counterpoint: Is stereotactic radiosurgery needed following resection of brain metastasis? Neuro Oncol 2016; 18:12-5. [PMID: 26667138 DOI: 10.1093/neuonc/nov286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy (R.S., R.R.); Department of Radiation Oncology, University of Southern California and Norris Cancer Hospital, Los Angeles, California (N.T., E.L.C.)
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy (R.S., R.R.); Department of Radiation Oncology, University of Southern California and Norris Cancer Hospital, Los Angeles, California (N.T., E.L.C.)
| | - Nicholas Trakul
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy (R.S., R.R.); Department of Radiation Oncology, University of Southern California and Norris Cancer Hospital, Los Angeles, California (N.T., E.L.C.)
| | - Eric L Chang
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy (R.S., R.R.); Department of Radiation Oncology, University of Southern California and Norris Cancer Hospital, Los Angeles, California (N.T., E.L.C.)
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14
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Shen CJ, Lim M, Kleinberg LR. Controversies in the Therapy of Brain Metastases: Shifting Paradigms in an Era of Effective Systemic Therapy and Longer-Term Survivorship. Curr Treat Options Oncol 2016; 17:46. [DOI: 10.1007/s11864-016-0423-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Chamberlain MC. A selected review of abstracts from the 20th Annual Meeting of the Society for Neuro-Oncology (SNO). CNS Oncol 2016; 5:115-9. [PMID: 27230972 PMCID: PMC6042634 DOI: 10.2217/cns-2016-0014] [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: 03/20/2016] [Accepted: 03/23/2016] [Indexed: 11/21/2022] Open
Abstract
20th Annual Meeting of the Society for Neuro-Oncology, San Antonio, TX, USA, 18-22 November 2015 The Society for Neuro-Oncology is the largest neuro-oncology meeting in the USA that meets annually and provides a multiday venue that showcases new brain cancer clinical trial results and basic research primarily pertaining to gliomas. The Society for Neuro-Oncology 2015 meeting comprising one education day, 2 days of premeetings and 3 days of presentation, over 200 oral presentations and 900 abstracts provides an overview of contemporary neuro-oncology that includes metastatic disease of the central nervous system as well as primary brain tumors. This review attempts to highlight select abstracts presented at this year's meeting in a short summary that provides a synopsis of a large and multifaceted meeting.
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Affiliation(s)
- Marc C Chamberlain
- Department of Neurology/Division of Neuro-Oncology, University of Washington, Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, 825 Eastlake Avenue E, POB 19023, MS G4940, Seattle, WA 98109-1023, USA
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16
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Bauman G, Yartsev S, Roberge D, MacRae R, Roa W, Panet-Raymond V, Masucci L, Yaremko B, D'Souza D, Palma D, Sexton T, Yu E, Pantarotto JR, Ahmad B, Fisher B, Dar AR, Lambert C, Pond G, Stitt L, Tay KY, Rodrigues G. Assessment of function and quality of life in a phase II multi-institutional clinical trial of fractionated simultaneous in-field boost radiotherapy for patients with 1-3 metastases. J Neurooncol 2016; 128:431-6. [PMID: 27084705 DOI: 10.1007/s11060-016-2128-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 04/07/2016] [Indexed: 11/28/2022]
Abstract
We examined functional outcomes and quality of life of whole brain radiotherapy (WBRT) with integrated fractionated stereotactic radiotherapy boost (FSRT) for brain metastases treatment. Eighty seven people with 1-3 brain metastases (54/87 lung primary, 42/87 single brain metastases) were enrolled on this Phase II trial of WBRT (30 Gy/10) + simultaneous FSRT, (60 Gy/10). Median overall follow-up and survival was 5.4 months, 6 month actuarial intra-lesional control was 78 %; only 1 patient exhibited grade 4 toxicity (worsened seizures); most treatment related toxicity was grade 1 or 2; 2/87 patients demonstrated asymptomatic radiation necrosis on follow-up imaging. Mean (Min-Max) baseline KPS, Mini Mental Status Exam (MMSE) and FACT-BR quality of life were 83 (70-100), 28 (21-30) and 143 (98-153). Lower baseline MMSE (but not KPS or FACT-Br) was associated with worse survival after adjusting for age, number of metastases, primary and extra-cranial disease status. Crude rates of deterioration (>10 points decrease from baseline for KPS and FACT-Br, MMSE fall to <27) ranged from 26 to 38 % for KPS, 32-59 % for FACT-Br and 0-16 % for MMSE depending on the time-point assessed with higher rates generally noted at earlier time points (≤6 months post-treatment). Using a linear mixed models analysis, significant declines from baseline were noted for KPS and FACT-Br (largest effects at 6 weeks to 3 months) with no significant change in MMSE. The effects on function and quality of life of this integrated treatment of WBRT + simultaneous FSRT were similar to other published series combining WBRT + radiosurgery.
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Affiliation(s)
- Glenn Bauman
- Division of Radiation Oncology, London Health Sciences Centre, A4-901B, 790 Commissioners Rd. E, London, ON, N6A4L6, Canada.
| | - Slav Yartsev
- Division of Radiation Oncology, London Health Sciences Centre, A4-901B, 790 Commissioners Rd. E, London, ON, N6A4L6, Canada
| | - David Roberge
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Robert MacRae
- Division of Radiation Oncology, University of Ottawa, Ottawa, ON, Canada
| | - Wilson Roa
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada
| | - Valerie Panet-Raymond
- Department of Radiation Oncology, McGill University Health Centre, Montreal, QC, Canada
| | - Laura Masucci
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Brian Yaremko
- Division of Radiation Oncology, London Health Sciences Centre, A4-901B, 790 Commissioners Rd. E, London, ON, N6A4L6, Canada
| | - David D'Souza
- Division of Radiation Oncology, London Health Sciences Centre, A4-901B, 790 Commissioners Rd. E, London, ON, N6A4L6, Canada
| | - David Palma
- Division of Radiation Oncology, London Health Sciences Centre, A4-901B, 790 Commissioners Rd. E, London, ON, N6A4L6, Canada
| | - Tracy Sexton
- Division of Radiation Oncology, London Health Sciences Centre, A4-901B, 790 Commissioners Rd. E, London, ON, N6A4L6, Canada
| | - Edward Yu
- Division of Radiation Oncology, London Health Sciences Centre, A4-901B, 790 Commissioners Rd. E, London, ON, N6A4L6, Canada
| | - Jason R Pantarotto
- Division of Radiation Oncology, University of Ottawa, Ottawa, ON, Canada
| | - Belal Ahmad
- Division of Radiation Oncology, London Health Sciences Centre, A4-901B, 790 Commissioners Rd. E, London, ON, N6A4L6, Canada
| | - Barbara Fisher
- Division of Radiation Oncology, London Health Sciences Centre, A4-901B, 790 Commissioners Rd. E, London, ON, N6A4L6, Canada
| | - A Rashid Dar
- Division of Radiation Oncology, London Health Sciences Centre, A4-901B, 790 Commissioners Rd. E, London, ON, N6A4L6, Canada
| | - Carole Lambert
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Gregory Pond
- Department of Oncology, Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Larry Stitt
- Division of Radiation Oncology, London Health Sciences Centre, A4-901B, 790 Commissioners Rd. E, London, ON, N6A4L6, Canada
| | - Keng Yeow Tay
- Department of Diagnostic Radiology, London Health Sciences Centre, London, ON, Canada
| | - George Rodrigues
- Division of Radiation Oncology, London Health Sciences Centre, A4-901B, 790 Commissioners Rd. E, London, ON, N6A4L6, Canada
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17
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Optimizing the Management of Metastatic HER2-Positive Breast Cancer. CURRENT BREAST CANCER REPORTS 2015. [DOI: 10.1007/s12609-015-0191-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Leone JP, Leone BA. Breast cancer brain metastases: the last frontier. Exp Hematol Oncol 2015; 4:33. [PMID: 26605131 PMCID: PMC4657380 DOI: 10.1186/s40164-015-0028-8] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 11/09/2015] [Indexed: 01/16/2023] Open
Abstract
Breast cancer is a common cause of brain metastases, with metastases occurring in at least 10–16 % of patients. Longer survival of patients with metastatic breast cancer and the use of better imaging techniques are associated with an increased incidence of brain metastases. Unfortunately, patients who develop brain metastases tend to have poor prognosis with short overall survival. In addition, brain metastases are a major cause of morbidity, associated with progressive neurologic deficits that result in a reduced quality of life. Tumor subtypes play a key role in prognosis and treatment selection. Current therapies include surgery, whole-brain radiation therapy, stereotactic radiosurgery, chemotherapy and targeted therapies. However, the timing and appropriate use of these therapies is controversial and careful patient selection by using available prognostic tools is extremely important. This review will focus on current treatment options, novel therapies, future approaches and ongoing clinical trials for patients with breast cancer brain metastases.
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Affiliation(s)
- José Pablo Leone
- University of Iowa Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, C32 GH, 200 Hawkins Drive, Iowa City, IA 52242 USA
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19
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Brain metastasis from melanoma: the prognostic value of varying sites of extracranial disease. J Neurooncol 2015; 125:411-8. [PMID: 26354772 DOI: 10.1007/s11060-015-1932-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 09/06/2015] [Indexed: 12/27/2022]
Abstract
Patients with brain metastasis from melanoma have poor outcomes. Radiation is used both for prognostic and symptomatic value. We aimed to further clarify the role of stereotactic radiosurgery (SRS) and whole brain radiotherapy (WBRT) as well as the prognostic implication of various sites of extracranial disease. The records of 73 consecutive patients treated at the University of Rochester Medical Center for brain-metastatic melanoma from January 2004 to October 2013 were reviewed. The median overall survival (OS) was 3.0 months. Patients treated with WBRT alone had decreased OS compared to those treated with SRS alone (HR = 0.38, p = 0.001) or WBRT and SRS (HR = 0.51, p = 0.039). The mean number of brain metastasis differed (p = 0.002) in patients in patients who received WBRT (4.0) compared to those who did not (2.0). Among patients with extracranial disease (n = 63), bone metastasis (HR = 1.86, p = 0.047, n = 15) was a negative prognostic factor; liver (HR = 1.59, p = 0.113, n = 17), lung (HR = 1.51, p = 0.23, n = 51) and adrenal metastasis (HR = 1.70, p = 0.15, n = 10) were not. In patients with concurrent brain and lung metastasis, those with disease limited to those two sites (OS = 8.7 mo, n = 13) had improved OS (HR = 0.44, p = 0.014) compared to those with additional disease (OS = 1.8 mo, n = 50). Based on this hypothesis-generating retrospective analysis, SRS may offer survival benefit compared to WBRT alone in patients with brain metastatic melanoma. Bone metastasis appears to confer a particularly poor prognosis. Those with disease confined to the lung and brain may represent a population with improved prognosis.
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