Clinical Recommendations of DEGRO and AGO on Preferred Standard Palliative Radiotherapy of Bone and Cerebral Metastases, Metastatic Spinal Cord Compression, and Leptomeningeal Carcinomatosis in Breast Cancer

How has the field of metastatic breast cancer in bones evolved over the past 22 years?

Background

Although knowledge on metastatic breast cancer in bones (MBCB) has increased rapidly over the past 22 years, a comprehensive and objective bibliometric analysis is still lacking.

Materials and methods

We used R, VOSviewer, and Citespace software to conduct a bibliometric analysis of 5,497 papers on MBCB from the Web of Science Core Collection (WOSCC) using author, institution, country/region, citation, and keyword indicators.

Results

A general strong sense of scholarly collaboration was noted in the MBCB field at the author, research institution, and country/region levels. We discovered some outstanding authors and highly productive institutions, but with less collaboration with other academic groups. Unbalanced and uncoordinated developments were observed among countries/regions in the field of MBCB research. We also found that by using various indicators and applying different analysis methods to them, we were able to broadly identify primary clinical practices, relevant clinical experiments, and directions for bioinformatics regarding MBCB, changes over the past 22 years, and current challenges in the field. The development of knowledge on MBCB is progressing greatly; however, MBCB is still incurable.

Conclusion

This study is the first to use bibliometrics to provide an overall analysis of the scientific output of MBCB studies. Palliative therapies for MBCB are mostly in a mature state. However, research on the molecular mechanisms and immune response to tumors related to the development of treatments to cure MBCB remains relatively immature. Therefore, further research should be undertaken in this area.

Primary neuroendocrine carcinoma of the breast with leptomeninges metastasis: A case report and literature review

Primary neuroendocrine carcinoma of the breast (NECB) is a rare tumour with an incident rate of 0.3-0.5%. The most common metastatic sites of NECB are liver, bones, lung, pancreas, soft tissues and brain, while leptomeninges metastasis (LM) is reported rarely. This current case report describes a 50-year-old female patient with NECB and LM whose overall survival was 2 months. The report also presents the current literature regarding the knowledge of this unusual tumour and metastatic type. The current patient was diagnosed with NECB with right cerebellar metastasis, followed by LM. She underwent modified radical mastectomy of the left breast, left whole breast radiation therapy and incomplete adjuvant chemotherapy until the metastasis occurred. Whole-brain radiation therapy and a first-line salvage regimen of etoposide and cis-platinum were then undertaken. The patient died 2 months after their LM diagnosis. Primary NECB with LM is sporadic, devoid of effective treatment and associated with a poor prognosis. Consequently, it is vitally important to identify LM in order to achieve longer patient survival.

Radiotherapy for Leptomeningeal Carcinomatosis in Breast Cancer Patients: A Narrative Review

Simple Summary

Leptomeningeal carcinomatosis (LC) is a rare event in breast cancer (BC) patients that carries an abysmal prognosis. Little progress has been made in this field in the last few decades. Despite innovations in radiotherapy (RT), there is no univocal evidence of its impact on survival. Due to the rarity of the diagnosis, only a few prospective trials have evaluated the role of RT for LC in BC. Nonetheless, most BC patients with LC currently receive RT, depending on local protocols and individual convictions. This review presents the current knowledge on the indications and feasibility of RT for LC in BC, focusing on new technologies and perspectives.

Abstract

Leptomeningeal carcinomatosis (LC), defined as the infiltration of the leptomeninges by cancer cells, is a rare oncological event with the most common etiology being breast cancer (BC), lung cancer, and melanoma. Despite innovations in radiotherapy (RT), firm evidence of its impact on survival is lacking, and concerns are related to its possible neurotoxicity. Owing to a paucity of data, the optimal treatment strategy for LC remains unknown. This review discusses current approaches, indications, and contraindications for various forms of RT for LC in BC. A separate section is dedicated to new RT techniques, such as proton therapy. We also summarize ongoing clinical trials evaluating the role of RT in patients with LC.

Analysis of Short-Term versus Long-Term Readmission-Free Survival After Metastatic Spine Tumor Surgery

BACKGROUND

Readmission-free survival (ReAFS) is a novel clinical and quality metric after metastatic spine tumor surgery (MSTS). We believe that factors influencing ReAFS after index MSTS vary based on time. We considered 2 time frames and defined short-term ReAFS as survival without an unplanned hospital readmission up to 90 days and long-term ReAFS as survival without unplanned hospital readmission up to 1 year after MSTS.

METHODS

We retrospectively analyzed 266 patients who underwent MSTS between 2005 and 2016. All relevant oncologic, surgical and follow-up data were collected. Multivariate logistic regression analysis was used to analyze prognostic factors associated with higher probability of short-term ReAFS and long-term ReAFS.

RESULTS

Multivariate analysis showed that Eastern Cooperative Oncology Group score ≤2 (P = 0.011), preoperative hemoglobin (Hb) level >12 g/dL (P = 0.008), ≤3 comorbidities (P = 0.052), shorter index length of stay ≤10 days (P = 0.007), and absence of neurologic/hematologic complications during index stay (P = 0.015) significantly increased the probability of short-term ReAFS, whereas preoperative Hb level >12 g/dL (P = 0.003) or tumor primaries with advanced treatment modalities such as breast (P = 0.012), hematologic (P = 0.006), prostate (P = 0.004), and renal/thyroid (P = 0.038) as opposed to aggressive lung tumor primaries were associated with significantly higher probability of long-term ReAFS.

CONCLUSIONS

Patient and treatment factors predominantly influence ReAFS up to 90 days, whereas primary tumor-related factors alongside general health influence ReAFS beyond 90 days after index MSTS. Awareness of these factors may help oncologists and surgeons optimize treatment planning. The clinical significance of this study will continue to evolve, because we have been witnessing over the past decade that patients are becoming more involved in both their general health and understanding the natural history of the diseases that affect them.

Leptomeningeal Carcinomatosis: Molecular Landscape, Current Management, and Emerging Therapies

Leptomeningeal carcinomatosis is a devastating consequence of late-stage cancer, and despite multimodal treatment, remains rapidly fatal. Definitive diagnosis requires identification of malignant cells in the cerebrospinal fluid (CSF), or frank disease on MRI. Therapy is generally palliative and consists primarily of radiotherapy and/or chemotherapy, which is administered intrathecally or systemically. Immunotherapies and novel experimental therapies have emerged as promising options for decreasing patient morbidity and mortality. In this review, the authors discuss a refined view of the molecular pathophysiology of leptomeningeal carcinomatosis, current approaches to disease management, and emerging therapies.

Complete Eye Ophthalmoplegia: the unusual initial presentation of Leptomeningeal Carcinomatosis

Ophthalmoplegia is a paralysis or weakness of extraocular muscles that have a variety of different etiologies including and not limited to Leptomeningeal Carcinomatosis (LC). LC is caused mainly by metastatic cancers and can cause a wide variety of symptoms. We present a case of LC with no preexisting condition who presented with a unilateral ophthalmoplegia as initial presentation who was found to have LC secondary to large B-cell lymphoma.

Leptomeningeal carcinomatosis in patients with breast cancer

Leptomeningeal carcinomatosis (LC) is defined as infiltration of the leptomeninges by metastatic carcinoma, a relatively uncommon but devastating complication of many malignancies. Although only 5% of patients with breast cancer develop leptomeningeal involvement, it remains the most common etiology of LC. It can occur as a late-stage complication of systemic progression or present as the first sign of metastatic disease, with or without parenchymal brain metastases. Lobular carcinomas have a higher propensity to metastasize into the meninges when compared to ductal carcinoma, especially the triple-negative subtype, which usually is associated with a shorter interval between metastatic breast cancer diagnosis and the development of LC. Prognosis remains poor, with median survival of 4 months for patients receiving state-of-the-art treatment. The main factors associated with survival are performance status at diagnosis, CSF protein level and triple-negative subtype. Headache is commonly the first clinical presentation of LC, and the diagnostic workup usually requires CSF-cytological analysis and or/MRI. The current management of LC consists of a combination of intra-CSF chemotherapy, systemic therapy, radiotherapy and/or best-supportive care. The standard intra-CSF chemotherapy regimen is methotrexate. Radiotherapy is used for relieving obstruction points on CSF-outflow channels due to ependymal nodules, tumor deposits or bulky disease. Objective responses have been reported with intrathecal administration of trastuzumab for HER2-positive disease, yet this strategy is still under investigation. Further prospective trials are needed to better address the impact of these treatment modalities on overall survival and quality of life.

Leptomeningeal metastasis from systemic cancer: Review and update on management

Leptomeningeal metastasis is an uncommon and typically late complication of cancer with a poor prognosis and limited treatment options. Diagnosis is often challenging, with nonspecific presenting symptoms ranging from headache and confusion to focal neurologic deficits, such as cranial nerve palsies. Standard diagnostic evaluation involves a neurologic examination, magnetic resonance imaging of the brain and spine with gadolinium, and cytologic evaluation of the cerebral spinal fluid. Therapy entails a multimodal approach focused on palliation with surgery, radiation, and/or chemotherapy, which may be administered systemically or directly into the cerebral spinal fluid. Limited trial data exist to guide treatment, and current regimens are based primarily on expert opinion. Although newer targeted and immunotherapeutic agents are under investigation and have shown promise, an improved understanding of the biology of leptomeningeal metastasis and treatment resistance as well as additional randomized controlled studies are needed to guide the optimal treatment of this devastating disease. Cancer 2018;124:21-35. © 2017 American Cancer Society.

A review of patterns of practice and clinical guidelines in the palliative radiation treatment of uncomplicated bone metastases

BACKGROUND AND PURPOSE

Single fraction radiation treatment (SFRT) is recommended for its equivalence to multiple-fraction (MF) RT in the palliation of uncomplicated bone metastases (BM). However, adoption of SFRT has been slow.

MATERIALS AND METHODS

Literature searches for studies published following 2014 were conducted using online repositories of gray literature, Ovid MEDLINE, Embase and Embase Classic, and the Cochrane Central Register of Controlled Trials databases.

RESULTS

A total of 32 articles detailing patterns of practice and clinical practice guidelines were included for final synthesis. The majority of organizations have released high level recommendations for SFRT use in treatment of uncomplicated BM, based on evidence of non-inferiority to MFRT. There are key differences between guidelines, such as varying strengths of recommendation for SFRT use over MFRT; contraindication in vertebral sites for SFRT; and risk estimation of pathologic fractures after SFRT. Differences in guidelines may be influenced by committee composition and organization mandate. Differences in patterns of practice may be influenced by individual center policies, payment modalities and consideration of patient factors such as age, prognosis, and performance status.

CONCLUSION

Although there is some variation between groups, the majority of guidelines recommend use of SFRT and others consider it to be a reasonable alternative to MFRT.

Incidence and treatment patterns of complicated bone metastases in a population-based radiotherapy program

INTRODUCTION

There is abundant evidence in support of single fraction (SF) radiation therapy (RT) for uncomplicated bone metastases (BoM). We sought to determine the proportion of BoM that is complicated in a population-based RT program in order to act as a potential guide for assessing SFRT utilization rates.

MATERIALS AND METHODS

A total of 3200 RT courses were prescribed to 1880 consecutive patients diagnosed with BoM in 2013. Associations between choice of RT fractionation and BoM characterization, whether complicated or not, were assessed with logistic regression.

RESULTS

The incidence of complicated BoM was 34.4%, resulting most often from adverse features of actual pathological fracture (42.1%), and neurological compromise (36.3%). Complicated BoM were most common in lung cancers (24.2%) and in the spine (68.5%), followed by extremity (15.2%) and pelvis (14.4%). SFRT was prescribed less commonly in complicated versus un-complicated BoM (39.4% vs. 70.4%; p<0.001), which was confirmed on multivariable analysis (OR 0.32; 95% CI 0.28-0.61; p<0.001).

CONCLUSIONS

This study found that 34.4% of BoM are complicated by fracture, or neurological compromise (i.e. 65.6% were un-complicated), and that they were less likely to receive SFRT. A reasonable benchmark for SFRT utilization should be at least 60%.

Prognostic factors for survival of women with unstable spinal bone metastases from breast cancer

BACKGROUND

Bone metastases are an important clinical issue in women with breast cancer. Particularly, unstable spinal bone metastases (SBM) are a major cause of severe morbidity and reduced quality of life (QoL) due to frequent immobilization. Radiotherapy (RT) is the major treatment modality and is capable of promoting re-ossification and improving stability. Since local therapy response is excellent, survival of these patients with unstable SBM is of high clinical importance. We therefore conducted this analysis to assess survival and to determine prognostic factors for bone survival (BS) in women with breast cancer and unstable SBM.

METHODS

A total population of 92 women with unstable SBM from breast cancer who were treated with RT at our department between January 2000 and January 2012 was retrospectively investigated. We calculated overall survival (OS) and BS (time between first diagnosis of bone metastases until death) with the Kaplan-Meier method and assessed prognostic factors for BS with a Cox regression model.

RESULTS

Mean age at first diagnosis of breast cancer was 60.8 years ± SD 12.4 years. OS after 1, 2 and 5 years was 84.8, 66.3 and 50 %, respectively. BS after 1, 2 and 5 years was 62.0, 33.7 and 12 %, respectively. An age > 50 years (p < .001; HR 1.036 [CI 1.015-1.057]), the presence of a single bone metastasis (p = .002; HR 0.469 [CI 0.292-0.753]) and triple negative phenotype (p < .001; HR 1.068 [CI 0.933-1.125]) were identified as independent prognostic factors for BS.

CONCLUSIONS

Our analysis demonstrated a short survival of women with breast cancer and unstable SBM. Age, presence of a solitary SBM and triple-negative phenotype correlated with survival. Our results may have an impact on therapeutic decisions in the future and offer a rationale for future prospective investigations.

Bone density as a marker for local response to radiotherapy of spinal bone metastases in women with breast cancer: a retrospective analysis

BACKGROUND

We designed this study to quantify the effects of radiotherapy (RT) on bone density as a local response in spinal bone metastases of women with breast cancer and, secondly, to establish bone density as an accurate and reproducible marker for assessment of local response to RT in spinal bone metastases.

METHODS

We retrospectively assessed 135 osteolytic spinal metastases in 115 women with metastatic breast cancer treated at our department between January 2000 and January 2012. Primary endpoint was to compare bone density in the bone metastases before, 3 months after and 6 months after RT. Bone density was measured in Hounsfield units (HU) in computed tomography scans. We calculated mean values in HU and the standard deviation (SD) as a measurement of bone density before, 3 months and 6 months after RT. T-test was used for statistical analysis of difference in bone density as well as for univariate analysis of prognostic factors for difference in bone density 3 and 6 months after RT.

RESULTS

Mean bone density was 194.8 HU ± SD 123.0 at baseline. Bone density increased significantly by a mean of 145.8 HU ± SD 139.4 after 3 months (p = .0001) and by 250.3 HU ± SD 147.1 after 6 months (p < .0001). Women receiving bisphosphonates showed a tendency towards higher increase in bone density in the metastases after 3 months (152.6 HU ± SD 141.9 vs. 76.0 HU ± SD 86.1; p = .069) and pathological fractures before RT were associated with a significantly higher increase in bone density after 3 months (202.3 HU ± SD 161.9 vs. 130.3 HU ± SD 129.2; p = .013). Concomitant chemotherapy (ChT) or endocrine therapy (ET), hormone receptor status, performance score, applied overall RT dose and prescription of a surgical corset did not correlate with a difference in bone density after RT.

CONCLUSIONS

Bone density measurement in HU is a practicable and reproducible method for assessment of local RT response in osteolytic metastases in breast cancer. Our analysis demonstrated an excellent local response within metastases after palliative RT.

Stability of spinal bone metastases in breast cancer after radiotherapy: a retrospective analysis of 157 cases

PURPOSE

This retrospective analysis was performed to evaluate osteolytic bone lesions of breast cancer in the thoracic and lumbar spine after radiotherapy (RT) in terms of stability using a validated scoring system.

METHODS

The stability of 157 osteolytic metastases, treated from January 2000 to January 2012, in 115 patients with breast cancer was evaluated retrospectively using the Taneichi score. Predictive factors for stability were analyzed and survival rates were calculated.

RESULTS

Eighty-five (54%) lesions were classified as unstable prior to RT. After 3 and 6 months, 109 (70%) and 124 (79%) lesions, respectively, were classified as stable. Thirty fractures were detected prior to RT, and after RT seven cases (4.5%) with pathologic fractures were found within 6 months. None of the examined predictive factors showed significant correlation with stability 6 months after RT. After a median follow-up of 16.7 months, Kaplan-Meier estimates revealed an overall survival of 83% after 5 years.

CONCLUSION

The majority of patients showed an improved or unchanged stability of the involved vertebral bodies after 6 months. The patients showed only minor cancer-related morbidity during follow-up and reached comparably high survival rates.

Atypical presentation of a cervical breast-cancer metastasis mimicking a dumbbell-shaped neurinoma

INTRODUCTION

Spinal metastases are frequently encountered in patients with breast cancer. Because of recent improvements in oncologic therapies a growing incidence of symptomatic leptomeningeal metastases (LM) should be expected. The differential diagnosis of LM comprises a wide range of conditions, including neurinoma. The radiologic discrimination between metastases and neurinomas is primarily based on distinct neuroimaging features, particularly number, size and growth pattern.

PRESENTATION OF CASE

We report the first case of a solitary leptomeningeal metastasis of a cervical nerve-root, which mimicked a benign dumbbell-shaped neurinoma, using neuroimaging and visualized intraoperatively. The tumor was successfully treated with surgery followed by adjuvant radiochemotherapy (RCT).

DISCUSSION

While the patient history directs towards a metastasis, the localization, growth pattern and MRI signal were concordant with a cervical neurinoma. The current literature is not conclusive concerning the optimal choice of treatment; the therapy is strictly palliative and indications for surgery remain individual decisions. However, due to recent improvements in survival of patients with LM require reconsideration of established strategies.

CONCLUSION

The present case report and the reviewed literature point towards a growing clinical relevance of symptomatic LM in cancer patients and their possible atypical presentations and locations.

Estimation of intracranial failure risk following hippocampal-sparing whole brain radiotherapy

PURPOSE

To estimate the risk of undertreatment in hippocampal-sparing whole brain radiotherapy (HS-WBRT).

METHODS

Eight hundred and fifty six metastases were contoured together with the hippocampi in cranial MRIs of 100 patients. For each metastasis, the distance to the closest hippocampus was calculated. Treatment plans for 10 patients were calculated and linear dose profiles were established. For SCLC and NSCLC, dose-response curves were created based on data from studies on prophylactic cranial irradiation, allowing estimating the risk for intracranial failure.

RESULTS

Only 0.4% of metastases were located inside a hippocampus in 3% of all patients. SCLC showed a relatively high rate of hippocampal metastasis (18.2% of all SCLC patients) and HS-WBRT in a commonly applied fractionation scheme would increase the risk for brain relapse by ∼4% compared to conventional WBRT. NSCLC showed a lower rate of brain metastasis in the hippocampi (2.8%) and HS-WBRT would account for a slightly increased absolute risk of 0.2%.

CONCLUSIONS

Prophylactic or therapeutic HS-WBRT is expected to be associated with a low risk of undertreatment. For SCLC, it bears a minimally elevated risk of failure compared to standard WBRT. In NSCLC, HS-WBRT is most likely not associated with a clinically relevant increase in risk of failure.

Epidemiologic study of radiotherapy use in China in patients with breast cancer between 1999 and 2008

BACKGROUND

To investigate the use of radiotherapy (RT) in China in patients with breast cancer over a 10-year period. A hospital-based, nationwide, multicenter, retrospective epidemiologic study of women with primary breast cancer was conducted.

PATIENTS AND METHODS

Patients were selected randomly in 7 hospitals from 1999 to 2008. Data on overall RT, postmastectomy RT (PMRT), RT after conservative breast surgery (PBRT) and palliative RT (PRT) were recorded. RT use was analyzed, and differences were compared by using the Cochran-Armitage trend test and the χ(2) test. A total of 3732 patients were included: 1009 (27%) received RT, including 688 (18.4%) PMRT, 170 (4.6%) PBRT, 86 (2.3%) PRT, 47 (1.3%) both PMRT and PRT, and 18 (0.5%) other RT.

RESULTS

Overall use of RT increased significantly from 1999 to 2008 (2P < .001). There was a slight but significant increase in PMRT (2P = .012) and a 10-fold increase in PBRT (2P < .001); use of PRT was relatively constant (2P = .777). There was a significant difference among regions in the use of RT, PMRT, PBRT, and PRT (2P < .01). Of patients with stage III disease, 51.6% and of those with node-positive stage II disease treated by radical mastectomy, 21% had received PMRT. In patients treated by using breast conservative surgery, 83.7% received PBRT, which was not affected by stage.

CONCLUSION

In summary, in China, the overall use of RT in patients with breast cancer was quite low, but there was an increasing trend in those treated between 1999 and 2008.

Radiotherapy of Bone Metastasis in Breast Cancer Patients - Current Approaches

Bone metastases (BM) represent the most frequent indication for palliative radiotherapy in patients with breast cancer. BM increase the risk of skeletal-related events defined as pathological fractures, spinal cord compression, and, most frequently, bone pain. The therapeutic goals of palliative radiotherapy for BM are pain relief, recalcification, and stabilization, reducing spinal cord compression and minimizing the risk of paraplegia. In advanced tumor stages radiotherapy may also be used to alleviate symptoms of generalized bone metastasis. This requires an individual approach including factors, such as life expectancy and tumor progression at different sites. Side effects of radiation therapy of the middle and lower spine may include nausea and emesis requiring adequate antiemetic prophylaxis. Irradiation of large bone marrow areas may cause myelotoxicity making monitoring of blood cell counts mandatory. Radiotherapy is an effective tool in palliation treatment of BM and is part of an interdisciplinary approach. Preferred technique, targeting, and different dose schedules are described in the guidelines of the German Society for Radiooncology (DEGRO) which are also integrated in 2012 recommendations of the Working Group Gynecologic Oncology (AGO).