1
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Chen Q, Xiong J, Ma Y, Wei J, Liu C, Zhao Y. Systemic treatments for breast cancer brain metastasis. Front Oncol 2023; 12:1086821. [PMID: 36686840 PMCID: PMC9853531 DOI: 10.3389/fonc.2022.1086821] [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: 11/01/2022] [Accepted: 12/16/2022] [Indexed: 01/07/2023] Open
Abstract
Breast cancer (BC) is the most common cancer in females and BC brain metastasis (BCBM) is considered as the second most frequent brain metastasis. Although the advanced treatment has significantly prolonged the survival in BC patients, the prognosis of BCBM is still poor. The management of BCBM remains challenging. Systemic treatments are important to maintain control of central nervous system disease and improve patients' survival. BCBM medical treatment is a rapidly advancing area of research. With the emergence of new targeted drugs, more options are provided for the treatment of BM. This review features currently available BCBM treatment strategies and outlines novel drugs and ongoing clinical trials that may be available in the future. These treatment strategies are discovered to be more efficacious and potent, and present a paradigm shift in the management of BCBMs.
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Affiliation(s)
| | | | | | | | - Cuiwei Liu
- *Correspondence: Cuiwei Liu, ; Yanxia Zhao,
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2
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Avila J, Leone JP. Advances in the Management of Central Nervous System Metastases from Breast Cancer. Int J Mol Sci 2022; 23:12525. [PMID: 36293379 PMCID: PMC9604332 DOI: 10.3390/ijms232012525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/17/2022] [Accepted: 10/17/2022] [Indexed: 11/24/2022] Open
Abstract
Central nervous system (CNS) metastases are common in breast cancer (BC) patients and are particularly relevant as new treatments for BC are prolonging survival. Here, we review advances in the treatment of CNS metastases from BC, including radiotherapy, systemic therapies, and the evolving role of immunotherapy. The use of radiotherapy and chemotherapy is the cornerstone of treatment for CNS metastases. However, new targeted therapies have recently been developed, including anti-HER2 agents and antibody-drug conjugates that have presented promising results for the treatment of these patients.
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Affiliation(s)
- Jorge Avila
- Department of Internal Medicine, St Elizabeth’s Medical Center, 736 Cambridge St., Boston, MA 02135, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA 02111, USA
| | - José Pablo Leone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Ave., Boston, MA 02215, USA
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3
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Curtaz CJ, Kiesel L, Meybohm P, Wöckel A, Burek M. Anti-Hormonal Therapy in Breast Cancer and Its Effect on the Blood-Brain Barrier. Cancers (Basel) 2022; 14:cancers14205132. [PMID: 36291916 PMCID: PMC9599962 DOI: 10.3390/cancers14205132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
The molecular receptor status of breast cancer has implications for prognosis and long-term metastasis. Although metastatic luminal B-like, hormone-receptor-positive, HER2−negative, breast cancer causes brain metastases less frequently than other subtypes, though tumor metastases in the brain are increasingly being detected of this patient group. Despite the many years of tried and tested use of a wide variety of anti-hormonal therapeutic agents, there is insufficient data on their intracerebral effectiveness and their ability to cross the blood-brain barrier. In this review, we therefore summarize the current state of knowledge on anti-hormonal therapy and its intracerebral impact and effects on the blood-brain barrier in breast cancer.
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Affiliation(s)
- Carolin J. Curtaz
- Department of Gynecology and Obstetrics, University Hospital Würzburg, 97080 Würzburg, Germany
- Correspondence:
| | - Ludwig Kiesel
- Department of Gynecology and Obstetrics, University Hospital of Münster, 48143 Münster, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Achim Wöckel
- Department of Gynecology and Obstetrics, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Malgorzata Burek
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, 97080 Würzburg, Germany
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4
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Salvage Treatment for Progressive Brain Metastases in Breast Cancer. Cancers (Basel) 2022; 14:cancers14041096. [PMID: 35205844 PMCID: PMC8870695 DOI: 10.3390/cancers14041096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/31/2022] [Accepted: 02/17/2022] [Indexed: 11/24/2022] Open
Abstract
Simple Summary Thirty percent of patients with human epidermal growth factor receptor 2-positive breast cancer and triple-negative breast cancer, and 15% of patients with the remaining subtypes of breast cancer will develop brain metastases. Available treatment methods include surgery and radiotherapy. However, some individuals will experience intracranial progression despite prior local treatment. This situation remains a challenge. In the case of progressing lesions amenable to local therapy, the choice of a treatment method must consider performance status, cancer burden, possible toxicity, and previously applied therapy. Stereotactic radiosurgery or fractionated radiotherapy rather than whole-brain radiotherapy should be used only if feasible. If local therapy is unfeasible, selected patients, especially those with human epidermal growth factor receptor 2-positive breast cancer, may benefit from systemic therapy. Abstract Survival of patients with breast cancer has increased in recent years due to the improvement of systemic treatment options. Nevertheless, the occurrence of brain metastases is associated with a poor prognosis. Moreover, most drugs do not penetrate the central nervous system because of the blood–brain barrier. Thus, confirmed intracranial progression after local therapy is especially challenging. The available methods of salvage treatment include surgery, stereotactic radiosurgery (SRS), fractionated stereotactic radiotherapy (FSRT), whole-brain radiotherapy, and systemic therapies. This narrative review discusses possible strategies of salvage treatment for progressive brain metastases in breast cancer. It covers possibilities of repeated local treatment using the same method as applied previously, other methods of local therapy, and options of salvage systemic treatment. Repeated local therapy may provide a significant benefit in intracranial progression-free survival and overall survival. However, it could lead to significant toxicity. Thus, the choice of optimal methods should be carefully discussed within the multidisciplinary tumor board.
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5
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Chew S, Carroll HK, Darwish W, Boychak O, Higgins M, McCaffrey J, Kelly CM. Characterization of Treatments and Disease Course for Women with Breast Cancer Brain Metastases: 5-Year Retrospective Single Institution Experience. Cancer Manag Res 2021; 13:8191-8198. [PMID: 34754239 PMCID: PMC8572013 DOI: 10.2147/cmar.s330829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/22/2021] [Indexed: 11/26/2022] Open
Abstract
Purpose Around 30% of patients with breast cancer will develop brain metastases (BM). We sought to characterize the disease course, treatments and outcome for our patient cohort. Materials and Methods We extracted clinicopathological data from electronic records from January 2015 to December 2020. Results were generated using SPSS statistics v27. Results We identified 98 patients. Median overall survival (OS) from BM diagnosis was 3 months [hormone receptor (HR)+/human epidermal growth factor receptor 2 (HER2)–], 8 months [HR+/HER2+], 7 months [HR–/HER2+] and 2 months [triple negative breast cancer (TNBC)]. Whole brain radiotherapy (WBRT) (n=48, 70%) was most frequently used followed by surgery (n=15, 22%) and stereotactic radiosurgery (n=6, 8%). In patients who received WBRT alone (n=40) the median OS post WBRT was 2.6 months. Conclusion After BM development, half of the patients had systemic therapy and 70% had local therapy, but only the HER2 subgroup had a prolonged OS likely reflecting central nervous system (CNS) activity of anti-HER2 drugs. TNBC patients had the worst prognosis. Although our cohort is small, OS was >1 year for 60% of HER2+ patients who received trastuzumab emtansine after BM development, which is encouraging for antibody drug conjugates and CNS activity. Patients who received WBRT had a higher burden of CNS disease and had an OS of less than 3 months.
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Affiliation(s)
- Sonya Chew
- Department of Medical Oncology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Hailey Kathryn Carroll
- Department of Medical Oncology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Waseem Darwish
- Department of Medical Oncology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Oleksandr Boychak
- Department of Radiation Oncology, St Luke's Radiation Oncology Network, Beaumont Hospital, Dublin, Ireland
| | - Michaela Higgins
- Department of Medical Oncology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - John McCaffrey
- Department of Medical Oncology, Mater Misericordiae University Hospital, Dublin, Ireland
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6
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Wu SY, Sharma S, Wu K, Tyagi A, Zhao D, Deshpande RP, Watabe K. Tamoxifen suppresses brain metastasis of estrogen receptor-deficient breast cancer by skewing microglia polarization and enhancing their immune functions. Breast Cancer Res 2021; 23:35. [PMID: 33736709 PMCID: PMC7977276 DOI: 10.1186/s13058-021-01412-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 02/23/2021] [Indexed: 02/07/2023] Open
Abstract
Background Brain metastasis of breast cancer exhibits exceedingly poor prognosis, and both triple negative (TN) and Her2+ subtypes have the highest incidence of brain metastasis. Although estrogen blockers are considered to be ineffective for their treatment, recent evidence indicates that estrogen blockade using tamoxifen showed certain efficacy. However, how estrogen affects brain metastasis of triple negative breast cancer (TNBC) remains elusive. Methods To examine the effect of estrogen on brain metastasis progression, nude mice were implanted with brain metastatic cells and treated with either estrogen supplement, tamoxifen, or ovariectomy for estrogen depletion. For clinical validation study, brain metastasis specimens from pre- and post-menopause breast cancer patients were examined for microglia polarization by immunohistochemistry. To examine the estrogen-induced M2 microglia polarization, microglia cells were treated with estrogen, and the M1/M2 microglia polarization was detected by qRT-PCR and FACS. The estrogen receptor-deficient brain metastatic cells, SkBrM and 231BrM, were treated with conditioned medium (CM) derived from microglia that were treated with estrogen in the presence or absence of tamoxifen. The effect of microglia-derived CM on tumor cells was examined by colony formation assay and sphere forming ability. Results We found that M2 microglia were abundantly infiltrated in brain metastasis of pre-menopausal breast cancer patients. A similar observation was made in vivo, when we treated mice systemically with estrogen. Blocking of estrogen signaling either by tamoxifen treatment or surgical resection of mice ovaries suppressed M2 microglial polarization and decreased the secretion of C-C motif chemokine ligand 5, resulting in suppression of brain metastasis. The estrogen modulation also suppressed stemness in TNBC cells in vitro. Importantly, estrogen enhanced the expression of signal regulatory protein α on microglia and restricted their phagocytic ability. Conclusions Our results indicate that estrogen promotes brain metastasis by skewing polarity of M2 microglia and inhibiting their phagocytic ability, while tamoxifen suppresses brain metastasis by blocking the M2 polarization of microglia and increasing their anti-tumor phagocytic ability. Our results also highlight a potential therapeutic utility of tamoxifen for treating brain metastasis of hormone receptor-deficient breast cancer. Supplementary Information The online version contains supplementary material available at 10.1186/s13058-021-01412-z.
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Affiliation(s)
- Shih-Ying Wu
- Department of Cancer Biology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA
| | - Sambad Sharma
- Department of Cancer Biology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA
| | - Kerui Wu
- Department of Cancer Biology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA
| | - Abhishek Tyagi
- Department of Cancer Biology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA
| | - Dan Zhao
- Department of Cancer Biology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA
| | - Ravindra Pramod Deshpande
- Department of Cancer Biology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA.
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7
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McMahon JT, Faraj RR, Adamson DC. Emerging and investigational targeted chemotherapy and immunotherapy agents for metastatic brain tumors. Expert Opin Investig Drugs 2020; 29:1389-1406. [PMID: 33040640 DOI: 10.1080/13543784.2020.1836154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Metastases to the central nervous system are the most common cause of malignant intracranial tumors in adults. Current standard of care includes surgery and radiation, but overall survival remains poor. A range of systemic therapies are emerging as promising treatment options for these patients. AREAS COVERED This study reviews novel drug regimens that are under investigation in phase 1 and 2 clinical trials. To identify relevant therapies under clinical investigation, a search was performed on http://clinicaltrials.gov and Pubmed with the keywords brain metastasis, Phase I clinical trial, and Phase II clinical trial from 2016 to 2020. The authors detail the mechanisms of action of all trial agents, outline evidence for their utility, and summarize the current state of the field. EXPERT OPINION Current advancements in the medical management of brain metastases can be categorized into targeted therapies, methods of overcoming treatment resistance, novel combinations of therapies, and modulation of the tumor microenvironment with a specific focus on immunotherapy. Each of these realms holds great promise for the field going forward. A more streamlined structure for enrollment into clinical trials will be a crucial step in accelerating progress in this area.
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Affiliation(s)
| | - Razan R Faraj
- Department of Neurosurgery, Emory University , Atlanta, GA, USA
| | - David Cory Adamson
- Department of Neurosurgery, Emory University , Atlanta, GA, USA.,Department of Neurosurgery, Atlanta VA Medical Center , Decatur, GA
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8
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Systemic therapy for brain metastases. Crit Rev Oncol Hematol 2019; 142:44-50. [PMID: 31357143 DOI: 10.1016/j.critrevonc.2019.07.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 06/30/2019] [Accepted: 07/14/2019] [Indexed: 02/07/2023] Open
Abstract
Metastases from cells outside of the central nervous system are the most common cancer found in the brain and are commonly associated with poor prognosis. Although cancer treatment is improving overall, central nervous system metastases are becoming more prevalent and require finesse to properly treat. Physicians must consider the biology of the primary tumor and the complex neurological environment that the metastasis resides in. This can be further complicated by the fact that the practice of cancer management is constantly evolving and therapy that works outside of the blood-brain barrier may not be effective inside of it. Therefore, this review seeks to update the reader on recent advancements made on the three most common sources of brain metastases: lung cancer, breast cancer, and melanoma. Each of these malignancies has been the subject of intriguing and novel avenues of therapy which are reviewed here.
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9
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The Current and Evolving Role of Radiation Therapy for Central Nervous System Metastases from Breast Cancer. Curr Oncol Rep 2019; 21:50. [DOI: 10.1007/s11912-019-0803-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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10
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Bergen ES, Berghoff AS, Medjedovic M, Rudas M, Fitzal F, Bago-Horvath Z, Dieckmann K, Mader RM, Exner R, Gnant M, Zielinski CC, Steger GG, Preusser M, Bartsch R. Continued Endocrine Therapy Is Associated with Improved Survival in Patients with Breast Cancer Brain Metastases. Clin Cancer Res 2019; 25:2737-2744. [PMID: 30647078 DOI: 10.1158/1078-0432.ccr-18-1968] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/28/2018] [Accepted: 01/11/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Brain metastases (BMs) are a rare but devastating condition in estrogen receptor (ER)-positive metastatic breast cancer (MBC). Although endocrine therapy (ET) is the mainstay of treatment in this disease subtype, only case reports have been published concerning the activity of ET in BMs henceforth. Therefore, we aimed to systematically investigate the impact of ET after diagnosis of BM on outcome and clinical course of disease in patients with ER-positive MBC. EXPERIMENTAL DESIGN Patient characteristics, detailed information about BMs including diagnosis-specific graded prognostic assessment class (DS-GPA), and clinical outcome were obtained by retrospective chart review for all patients treated for ER-positive breast cancer BMs between 1990 and 2017 at an academic care center. Overall survival (OS) was measured as the interval from diagnosis of BM until death or last date of follow-up. RESULTS Overall, 198 patients [female: 195/198 (98.5%); male: 3/198 (1.5%)] with ER-positive breast cancer BMs were available for this analysis. Eighty-eight of 198 patients (44.4%) received ET after diagnosis of BM including aromatase inhibitors (AIs; letrozole, anastrozole, exemestane), tamoxifen, and fulvestrant. Median OS was significantly longer in patients receiving ET after diagnosis of BM compared with patients who did not (15 vs. 4 months, P < 0.001; log-rank test). No significant difference in terms of OS was observed between patients receiving AIs, tamoxifen, or fulvestrant. In patients with concomitant leptomeningeal carcinomatosis (LC), ET prolonged median OS significantly as well (7 vs. 3 months, P = 0.012; log-rank test). In a multivariate analysis including DS-GPA and ET, only treatment with ET after diagnosis of BM (HR, 0.69; 95% confidence interval, 0.48-0.99; P = 0.046) was associated with prognosis (Cox regression model). CONCLUSIONS Continuing ET after BM diagnosis was associated with a significantly prolonged OS in this large single-center cohort. No substantial differences between substances were observed. These findings should be validated in a prospective cohort.
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Affiliation(s)
- Elisabeth S Bergen
- Comprehensive Cancer Center, Vienna, Austria.,Department of Medicine 1, Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Anna S Berghoff
- Comprehensive Cancer Center, Vienna, Austria.,Department of Medicine 1, Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Mela Medjedovic
- Comprehensive Cancer Center, Vienna, Austria.,Department of Medicine 1, Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Margaretha Rudas
- Comprehensive Cancer Center, Vienna, Austria.,Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Florian Fitzal
- Comprehensive Cancer Center, Vienna, Austria.,Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Zsuzsanna Bago-Horvath
- Comprehensive Cancer Center, Vienna, Austria.,Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Karin Dieckmann
- Comprehensive Cancer Center, Vienna, Austria.,Department of Radiotherapy, Medical University of Vienna, Vienna, Austria
| | - Robert M Mader
- Comprehensive Cancer Center, Vienna, Austria.,Department of Medicine 1, Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Ruth Exner
- Comprehensive Cancer Center, Vienna, Austria.,Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Michael Gnant
- Comprehensive Cancer Center, Vienna, Austria.,Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph C Zielinski
- Comprehensive Cancer Center, Vienna, Austria.,Department of Medicine 1, Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Guenther G Steger
- Comprehensive Cancer Center, Vienna, Austria.,Department of Medicine 1, Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Matthias Preusser
- Comprehensive Cancer Center, Vienna, Austria.,Department of Medicine 1, Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Rupert Bartsch
- Comprehensive Cancer Center, Vienna, Austria. .,Department of Medicine 1, Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
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11
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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: 10] [Impact Index Per Article: 1.4] [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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12
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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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13
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Wardell SE, Nelson ER, Chao CA, Alley HM, McDonnell DP. Evaluation of the pharmacological activities of RAD1901, a selective estrogen receptor degrader. Endocr Relat Cancer 2015; 22:713-24. [PMID: 26162914 PMCID: PMC4545300 DOI: 10.1530/erc-15-0287] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2015] [Indexed: 12/14/2022]
Abstract
Endocrine therapy, using tamoxifen or an aromatase inhibitor, remains a first-line treatment for estrogen receptor 1 (ESR1) positive breast cancer. However, tumor resistance limits the duration of response. The clinical efficacy of fulvestrant, a selective ER degrader (SERD) that triggers receptor degradation, has confirmed that ESR1 often remains engaged in endocrine therapy resistant cancers. Recently developed, selective ER modulators (SERMs)/SERD hybrids (SSHs) that facilitate ESR1 degradation in breast cancer cells and reproductive tissues have been advanced as an alternative treatment for advanced breast cancer, particularly in the metastatic setting. RAD1901 is one SSH currently being evaluated clinically that is unique among ESR1 modulators in that it readily enters the brain, a common site of breast cancer metastasis. In this study, RAD1901 inhibited estrogen activation of ESR1 in vitro and in vivo, inhibited estrogen-dependent breast cancer cell proliferation and xenograft tumor growth, and mediated dose-dependent downregulation of ESR1 protein. However, doses of RAD1901 insufficient to induce ESR1 degradation were shown to result in the activation of ESR1 target genes and in the stimulation of xenograft tumor growth. RAD1901 is an SSH that exhibits complex pharmacology in breast cancer models, having dose-dependent agonist/antagonist activity displayed in a tissue-selective manner. It remains unclear how this unique pharmacology will impact the utility of RAD1901 for breast cancer treatment. However, being the only SERD currently known to access the brain, RAD1901 merits evaluation as a targeted therapy for the treatment of breast cancer brain metastases.
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Affiliation(s)
- Suzanne E Wardell
- Department of Pharmacology and Cancer Biology Duke University School of Medicine, Box 3813, Durham, North Carolina 27710, USA
| | - Erik R Nelson
- Department of Pharmacology and Cancer Biology Duke University School of Medicine, Box 3813, Durham, North Carolina 27710, USA
| | - Christina A Chao
- Department of Pharmacology and Cancer Biology Duke University School of Medicine, Box 3813, Durham, North Carolina 27710, USA
| | - Holly M Alley
- Department of Pharmacology and Cancer Biology Duke University School of Medicine, Box 3813, Durham, North Carolina 27710, USA
| | - Donald P McDonnell
- Department of Pharmacology and Cancer Biology Duke University School of Medicine, Box 3813, Durham, North Carolina 27710, USA
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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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16
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Ito KI, Ito T, Okada T, Watanabe T, Gomi K, Kanai T, Mochizuki Y, Amano J. A case of brain metastases from breast cancer that responded to anastrozole monotherapy. Breast J 2009; 15:435-7. [PMID: 19470131 DOI: 10.1111/j.1524-4741.2009.00756.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Harputluoglu H, Dizdar O, Aksoy S, Kilickap S, Dede DS, Ozisik Y, Guler N, Barista I, Gullu I, Hayran M, Selek U, Cengiz M, Zorlu F, Tekuzman G, Altundag K. Characteristics of breast cancer patients with central nervous system metastases: a single-center experience. J Natl Med Assoc 2008; 100:521-6. [PMID: 18507204 DOI: 10.1016/s0027-9684(15)31298-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of this study was to assess the characteristics of breast cancer patients with central nervous system (CNS) metastases and factors associated with survival after development of CNS metastasis. One-hundred-forty-four patients with brain metastases were retrospectively analyzed. Median age at the time of brain metastasis diagnosis was 48.9. Median time between initial diagnosis and development of brain metastasis was 36 months. Fourteen cases had leptomeningeal involvement. Twenty-two patients (15.3%) had single metastasis. Ten percent of the patients had surgery, 94% had radiotherapy and 63% had chemotherapy. Median survival after development of brain metastasis was 7.4 months. Survival of patients with single metastasis was significantly longer than those with multiple metastases (33.5 vs. 6.5 months, p = 0.0006). Survival of patients who received chemotherapy was significantly longer than those who received radiotherapy alone (9.9 vs. 2 months, p < 0.0001). In multivariate Cox regression analyses, presence of single metastasis and application of chemotherapy were the only significant factors associated with better survival (p = 0.047 and p < 0.0001, respectively). Age at initial diagnosis or at the time of brain metastasis, time from initial diagnosis to development of brain metastasis, menopausal status, tumor stage, grade, hormone receptor or HER2 status individually were not associated with survival. In this study, survival after the diagnosis of CNS metastases appeared to be affected by patient characteristics rather than biologic characteristics of the tumor. This is probably secondary to the lack of effective treatment options in these patients and overall poor prognosis.
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Affiliation(s)
- Hakan Harputluoglu
- Hacettepe University Institute of Oncology, Department of Medical Oncology, Ankara, Turkey
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Chemotherapy in breast cancer patients with brain metastases: have new chemotherapic agents changed the clinical outcome? Crit Rev Oncol Hematol 2008; 68:212-21. [PMID: 18550383 DOI: 10.1016/j.critrevonc.2008.04.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Revised: 04/21/2008] [Accepted: 04/23/2008] [Indexed: 11/21/2022] Open
Abstract
Brain metastasis occurs in 15-40% of cancer patients and is present in approximately 10-16% of patients with metastatic breast disease. However, little is known about prognostic factors enabling the early identification of breast cancer patients at risk of CNS metastases. Therapy for brain metastases should be based on several parameters, such as the assessment of prognostic variables, the extent of neurological and systemic disease, and its chemo-sensitivity to previously administered chemotherapy treatments. In view of the known close correlation between metastatic and primary tumor chemosensitivity, the type of chemotherapy chosen should depend more on the tumor histology than on the cerebral distribution of the single drug. More recent drugs with a high impact on the clinical outcome of metastatic breast cancer patients, such as taxanes or trastuzumab, play only a limited role in the treatment of brain metastases.
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Abstract
Brain metastases from breast cancer are a common complication of the disease and alter the management of patients more than any other site of distant progression. Certain subgroups of patients are at high risk for developing CNS disease, warranting targeted research and perhaps screening for occult disease. Data from studies that include other solid tumor histologies provide the bulk of supporting evidence for the use of therapies, such as steroids, antiepileptic drugs, surgery, and radiation. However, there are several issues specific to brain metastases from breast cancer illustrating that this disease should be considered pathophysiologically distinct, and future research should be tailored accordingly.
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Affiliation(s)
- Teri D Nguyen
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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20
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Abstract
As therapy for systemic cancers improves, an increasing number of patients are developing brain metastases. Although conventional therapy with surgery, radiation therapy and radiosurgery has improved the outcome of a significant number of patients, many develop multiple lesions that are not amenable to standard treatments. In this review, the current role of chemotherapy and targeted molecular agents for brain metastases is summarized and future directions are discussed.
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Affiliation(s)
- Jan Drappatz
- Center for Neuro-oncology Dana-Farber/Brigham and Women's Cancer Center, and Division of Neuro-Oncology, Department of Neurology, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Madhup R, Kirti S, Bhatt MLB, Srivastava PK, Srivastava M, Kumar S. Letrozole for brain and scalp metastases from breast cancer—a case report. Breast 2006; 15:440-2. [PMID: 16169225 DOI: 10.1016/j.breast.2005.07.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2005] [Accepted: 07/08/2005] [Indexed: 11/17/2022] Open
Abstract
Brain metastases from breast cancer have a poor prognosis. There have been reports of patients with breast cancer and brain metastases responding well to tamoxifen therapy. We report a very unusual case of intact breast carcinoma with brain as well as scalp metastasis responding well to letrozole (aromatase inhibitor) therapy for a prolonged period of time.
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Affiliation(s)
- R Madhup
- Department of Radiotherapy, King George's Medical University, Chowk, Lucknow-226003, U.P., India.
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Abstract
The use OF chemotherapy to treat patients with brain metastases has been viewed historically with skepticism. To date, a survival benefit has not been demonstrated with the use of systemic chemotherapy in patients with brain metastases. However, the introduction of novel agents and delivery techniques warrants a reexamination of the role of systemic chemotherapy in the management of brain metastases. Temozolomide has shown encouraging results in patients with nonsmall cell lung cancer, and implanted carmustine wafers have demonstrated excellent local tumor control rates. This review discusses clinical data from the past decade with emphasis on trial design, tumor histology, available agents, and multimodality strategies. In addition, delivery techniques that circumvent the blood-brain barrier are reviewed. Although chemotherapy is usually used as a salvage therapy, it may be considered for use in selected patients with newly diagnosed brain metastases. To better evaluate chemotherapy in brain metastases, future trials should evaluate novel agents in the preirradiation setting. Enhanced regional delivery methods warrant further investigation, and Phase III trials of current regimens stratified by histology and by prognostic factors will establish the role of specific chemotherapy regimens in the treatment of patients with brain metastases.
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Affiliation(s)
- David M Peereboom
- Cleveland Clinic Brain Tumor Institute, Hematology/Medical Oncology, Cleveland Clinic Taussig Cancer Center, Cleveland, Ohio 44195, USA.
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Tosoni A, Ermani M, Brandes AA. The pathogenesis and treatment of brain metastases: a comprehensive review. Crit Rev Oncol Hematol 2004; 52:199-215. [PMID: 15582786 DOI: 10.1016/j.critrevonc.2004.08.006] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2004] [Indexed: 12/22/2022] Open
Abstract
Brain metastases are the most common intracranial tumors and their incidence is increasing. Untreated brain metastases are associated with a poor prognosis and a poor performance status. The role of surgery in the management of multiple brain metastases is still controversial. As more than 70% of patients have multiple metastases at the time of diagnosis, whole brain radiotherapy is the treatment of choice in most cases. Brain metastases are an ideal target for stereotactic radiosurgery, as they are better circumscribed than primary brain tumors. Currently, chemotherapy has a limited role in the treatment of most brain metastases. Several new therapies, with a good penetration through the blood brain barrier, such as temozolomide, have been used in brain metastases with different results depending on the histology of the primary tumor. A better understanding of the complex processes underlying the development of brain metastasis will enable us to develop more satisfactory targeted treatments.
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Affiliation(s)
- Alicia Tosoni
- Department of Medical Oncology, University Hospital of Padova, Ospedale Busonera, Via Gattamelata 64, 35100 Padova, Italy
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Abstract
As systemic therapy of metastatic breast cancer improves, CNS involvement is becoming a more widespread problem. This article summarizes the current knowledge regarding the incidence, clinical presentation, diagnosis, prognosis, and treatment of CNS metastases in patients with breast cancer. When available, studies specific to breast cancer are presented; in studies in which many solid tumors were evaluated together, the proportion of patients with breast cancer is noted. On the basis of data from randomized trials and retrospective series, neurosurgery and stereotactic radiosurgery (SRS) may prolong survival in patients with single brain metastases. The treatment of multiple metastases remains controversial, as does the routine use of whole-brain radiotherapy (WBRT) after either surgery or SRS. Although it is widely assumed that chemotherapy is of limited benefit, data from case series and case reports suggest otherwise. WBRT, neurosurgery, SRS, and medical therapy each have a role in the treatment of CNS metastases; however, neurologic symptoms frequently are not fully reversible, even with appropriate therapy. Studies specifically targeted toward this group of patients are needed.
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Affiliation(s)
- Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA
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Evans AJ, James JJ, Cornford EJ, Chan SY, Burrell HC, Pinder SE, Gutteridge E, Robertson JFR, Hornbuckle J, Cheung KL. Brain metastases from breast cancer: identification of a high-risk group. Clin Oncol (R Coll Radiol) 2004; 16:345-9. [PMID: 15341438 DOI: 10.1016/j.clon.2004.03.012] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
AIMS Brain metastases from breast cancer are an uncommon initial presentation of metastatic breast cancer, but brain metastases commonly occur later in women's metastatic illness. The aims of this study were to document the type, frequency, and temporal occurrence of brain metastases from breast cancer as well as the survival of women with such metastases, and to attempt to identify a subgroup of women at high risk of brain metastases who may benefit from pre-emptive medical intervention. MATERIALS AND METHODS The radiological reports of all women presenting with metastases aged under 70 years who had subsequently died were examined. The type, frequency, temporal occurrence and survival with brain metastases were documented. Correlations were sought between the frequency of brain metastases and age at metastatic presentation, tumour grade, histological type and oestrogen receptor (ER) status. RESULTS Of 219 patients who had died with metastatic disease and who were under 70 years of age at metastatic presentation, 49 (22%) developed brain metastases. The development of brain metastases was related to young age (P = 0.0002), with 43% of women under 40 years developing brain metastases. Brain metastases were more common in women whose tumours were ER negative (38%) compared with women with ER-positive disease (14%) (P = 0.0003). By combining age and ER status, it is possible to identify a group of women (age under 50 years and ER negative) with a 53% risk of developing brain metastases. This group included many women who had chemotherapy for visceral metastases, and 68% had either stable disease or disease response at other sites at the time of brain metastases presentation. CONCLUSION It is possible to identify a subgroup of women with metastatic breast cancer at high risk of brain metastases who may benefit from pre-emptive medical intervention, such as screening or prophylactic treatment.
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Affiliation(s)
- A J Evans
- Nottingham Breast Institute, City Hospital, Nottingham, UK.
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Abstract
BACKGROUND Systemic cancer is the second most common cause of death for adults in the United States. Twenty percent of these patients develop neurologic symptoms sometime during their illness. An apparent increase in the incidence of both systemic cancers and resulting brain metastases are posing an increasing challenge to health care providers. Neurologic complications lead to significant morbidity and mortality in these patients. Therefore, it is important to understand the current concepts of diagnosis and treatment of patients with brain metastases. REVIEW SUMMARY This review summarizes the epidemiology, clinical features, pathophysiology, and diagnostic evaluation of brain metastases. The section on current treatments is presented from the perspective of the three most common primary tumor locations along with the treatment approach to other metastatic tumors. This review includes a thorough evaluation of the literature, highlights controversies over treatment options, and provides insight into novel approaches currently under investigation. Clinical studies needed for further study are also discussed. CONCLUSIONS A clearer understanding of the pathophysiology of metastatic tumors and advances in diagnostic technology have paved the road to a better approach to treatment of brain metastases. Although no curative treatments are available to date, significant improvement in a patient's quality of life and life expectancy can be achieved with the available therapy. A better understanding of different primary cancers leading to brain metastases leads to a more effective treatment. More studies are needed to critically analyze the clear benefit of these treatment options in selected patients.
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Abstract
Brain metastases are one of the most feared complications of cancer because even small tumors may cause incapacitating neurologic symptoms. This article reviews the epidemiology, clinical features, treatment, and prognosis of brain metastases from system malignancies.
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Affiliation(s)
- Andrew B Lassman
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Firlik KS, Kondziolka D, Flickinger JC, Lunsford LD. Stereotactic radiosurgery for brain metastases from breast cancer. Ann Surg Oncol 2000; 7:333-8. [PMID: 10864339 DOI: 10.1007/s10434-000-0333-1] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Stereotactic radiosurgery is an alternative to resection or to radiotherapy alone for patients with brain metastases. Outcomes after radiosurgery for patients with brain metastases specifically from breast cancer have not been defined. METHODS We retrospectively studied survival and tumor control for all patients with brain metastases from breast cancer who underwent gamma knife stereotactic radiosurgery at the University of Pittsburgh. Univariate and multivariate analyses were used to determine which prognostic factors significantly affected survival. RESULTS Thirty patients underwent radiosurgery between 1990 and 1997. A total of 58 metastases were treated. The median length of survival for all patients was 13 months from radiosurgery and 18 months from diagnosis of brain metastases. The tumor control rate on follow-up imaging was 93%. On multivariate analysis, the only factor that correlated with longer survival was the absence of multiple brain metastases. Age, presence of systemic disease, previous whole brain radiation, location, and total tumor volume did not significantly affect survival. Four patients had tumors with evidence of radiation-induced edema after radiosurgery but did not require resection. Two patients underwent delayed resection for tumor growth after radiosurgery. CONCLUSIONS Stereotactic radiosurgery is an effective treatment for brain metastases from breast cancer and is associated with a low complication rate.
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Affiliation(s)
- K S Firlik
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pennsylvania 15213-2582, USA.
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Thalacker U, Liszka G, Somogyi A, Németh G. [The observation of edema in the substantia alba during postoperative brain irradiation. The role of computed tomographic studies]. Strahlenther Onkol 1998; 174:14-8. [PMID: 9463559 DOI: 10.1007/bf03038222] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of our study was to determine on CT whether a relation exists between a radiation-induced brain edema, treated with diuretics and its corresponding Houndsfield Units (HU). PATIENTS AND METHODS Seventy-five patients (age 20 to 65 years, suffering from headaches but without hypertension brain tumors or cerebral arteriosclerosis were examined as a reference group. Three slices with 8 mm thickness, 24 mm apart in the upper, middle and lower third of the brain were obtained to measure the HU of the white matter. The second group consisted of 20 patients with brain tumors, which underwent brain surgery. HU of the white matter were measured before radiation and after 10, 20, 30, 40 and 50 Gy. If a reduction in density was detected, diuretic therapy with 40 mg furosemide per o.s. was initiated. If no increase in density was found on follow-up additional therapy with glycerine (4.5 g/kg body weight) was started. In this cases follow-up was on day 4 after initiation of diuretics. If clinical symptoms suggested an increasing in intracranial pressure, CT-examination was performed immediately. Therapy was started according to measurement results. The third group consisted of 64 patients with brain tumors, that underwent postsurgical radiation therapy. Prior to radiation therapy 40 mg furosemide per o.s. were given. CT-examinations, intensified diuretic therapy and follow-up examinations were performed as in group 2. If, despite therapy, the HU decreased, infusion of mannites was added. The second and third group of patients received radiation therapy with telecobalt and/or a linear accelerator (6 and 9 MeV X-ray). RESULTS In the first group white matter density was > 30 HU. In the second group white matter density was between 25 and 29 HU prior to diuretic therapy. Under 25 HU a continuous headache, vertigo and confusion ensued. Diuretic therapy was intensified until the measured values reached 25 to 29 HU. Forty-seven of 64 patients in the third group had 25 to 29 HU prior to radiation therapy. Despite prophylactic diuretic therapy in 28 cases density decreased to 20 to 24 HU. Improvement was achieved with an additional glycerine per o.s. The measured values reached again 25 to 29 HU. In 1 case the values dropped under 20 HU. Additional mannite infusion was necessary. In 17 of 64 patients white matter density was > 30 HU prior to radiation therapy, dropping to 25 to 29 HU during radiation. Prophylactic diuretic administration kept the values in this range. A correlation between age of the patient, radiation source, total dose, tumor histology and degree of change in HU was not found. CONCLUSION Measurements of HU can serve as a good indicator for spontaneous or diuretic induced changes of a white matter edema during radiation therapy.
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Affiliation(s)
- U Thalacker
- Imre-Haynal-Universität für Gesundheitswissenschaften, Strahlentherapeutischer Lehrstuhl, Budapest
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van Rijswijk RE, van Oostenbrugge RJ, Twijnstra A. A case of brain metastases from male breast cancer responding to tamoxifen. Eur J Cancer 1997; 33:2282-3. [PMID: 9470820 DOI: 10.1016/s0959-8049(97)00258-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Pieper DR, Hess KR, Sawaya RE. Role of surgery in the treatment of brain metastases in patients with breast cancer. Ann Surg Oncol 1997; 4:481-90. [PMID: 9309337 DOI: 10.1007/bf02303672] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients whose brain metastases from breast cancer are treated nonsurgically have a median length of survival ranging from 2.5 to 7.5 months, and a median time to recurrence ranging from 2 to 5 months. Patients treated with radiotherapy have a median length of survival ranging from 3 to 4 months. Those treated with chemotherapy have a median length of survival ranging from 5.5 to 7.5 months. METHODS We conducted a retrospective analysis on 63 patients treated over a 10-year period. Only patients who underwent surgery for nonrecurrent brain metastases were studied. Sixty-one patients (97%) underwent surgery within 2 weeks of diagnosis of the brain metastases. RESULTS The median length of survival was 16 months (95% confidence interval [CI] 11 to 22 months), and the 5-year survival rate was 17% (CI 9% to 29%). Brain metastases recurred in 27 patients at a median interval of 15 months (CI 12 to 24 months). Eleven patients had local recurrence, 10 had distal recurrence, and seven developed leptomeningeal disease. Significant prognosticators of length of survival were age (p = 0.011), menopause status (p = 0.10), postoperative radiotherapy (p = 0.054), preoperative neurologic status (p = 0.011), and preoperative systemic disease status (p = 0.0003). Systemic disease status had a significant effect on the length of survival but not on the time to recurrence.
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Affiliation(s)
- D R Pieper
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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