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Upadhyay R, Palmer JD, Klamer BG, Perlow HK, Schoenhals JE, Ghose J, Rajappa P, Blakaj DM, Beyer S, Grecula JC, Sim AJ, Lu L, Zoller W, Elder JB, Chakravarti A, Thomas E, Raval RR. Safety and Feasibility of Stereotactic Radiosurgery for Patients with 15 or more Brain Metastases. Adv Radiat Oncol 2024; 9:101509. [PMID: 38799108 PMCID: PMC11127210 DOI: 10.1016/j.adro.2024.101509] [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: 11/26/2023] [Accepted: 04/01/2024] [Indexed: 05/29/2024] Open
Abstract
Background Current standard of care treatment for patients with ≥15 brain metastases (BM) is whole brain radiation therapy (WBRT), despite poor neurocognitive outcomes. We analyzed our institutional experience of treating these patients with stereotactic radiosurgery (SRS), with the aim of evaluating safety, cognitive outcomes, and survival metrics. Methods Patients who received SRS for ≥15 BMs in 1 to 5 fractions from 2014 to 2022 were included. Cognitive outcomes were objectively evaluated using serial Patient-Reported Outcome Measurement Information System (PROMIS) scores. The Kaplan-Meier method was used for survival analysis and log-rank test for intergroup comparisons. Results Overall, 118 patients underwent 124 courses of LINAC-based SRS. The median number of lesions treated per course was 20 (range, 15-94). Most patients received fractionated SRS to a dose of 24 Gy in 3 fractions (81.5%). At the time of SRS, 19.4% patients had received prior WBRT, and 24.2% had received prior SRS. The rate of any grade radiation necrosis (RN) and grade ≥3 RN were 15.3% and 3.2%, respectively. When evaluating longitudinal PROMIS score trends, 25 of 31 patients had a stable/improved PROMIS score. Patients who did not receive prior brain RT had a longer median survival (7.4 months vs 4.6 months, P = .034). The 12m local control was 97.6%, and the cumulative incidence of distant intracranial failure, with death as a competing event, was 46% (95% CI, 36%, 55%). One year freedom from neurologic death, leptomeningeal disease, and salvage WBRT were 89%, 94.6%, and 84%, respectively. Conclusion We present here one of the largest studies evaluating SRS for patients with ≥15 BMs. SRS was safe, had favorable cognitive outcomes, and had comparable survival outcomes to contemporary studies evaluating WBRT in this population. Treatment-naïve patients had a median survival of >6 months, long enough to benefit from cognitive sparing with SRS. Our study supports randomized studies comparing SRS and hippocampal avoidance WBRT approaches for these patients.
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Affiliation(s)
- Rituraj Upadhyay
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Joshua D. Palmer
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Brett G. Klamer
- Center for Biostatistics, The Ohio State University, Columbus, Ohio
| | - Haley K. Perlow
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Jonathan E. Schoenhals
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Jayeeta Ghose
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Prajwal Rajappa
- Department of Pediatrics and Neurological Surgery, The Ohio State University James Cancer Center, Columbus, OH and Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Sasha Beyer
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - John C. Grecula
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Austin J. Sim
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Lanchun Lu
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Wesley Zoller
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - James B. Elder
- Department of Neurological Surgery, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Evan Thomas
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Raju R. Raval
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
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Amouzegar A, Haig S, Kahn AM, Tawbi HA, Jones JA, Goldberg SB. Navigating the Complexities of Brain Metastases Management. Am Soc Clin Oncol Educ Book 2024; 44:e433694. [PMID: 38781565 DOI: 10.1200/edbk_433694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
The management of brain metastases, a potentially devastating complication of advanced cancers, has become increasingly complex with advancements in local and systemic therapies. Improved outcomes and extended survival for patients with metastatic solid tumors have led to a surge in the prevalence and possibly incidence of brain metastases, affecting up to 40% of individuals with solid tumors. Enhanced imaging technologies contribute to more accurate and early detection, shaping the understanding of the intricate landscape of this condition. Traditionally, surgery and radiation stood as the mainstays of treatment because of the limited efficacy of systemic therapies within the brain. However, emerging clinical data, particularly in melanoma, lung, and breast cancers, reveal promising results with novel systemic treatments such as immunotherapy and targeted therapies. Despite the historical exclusion of patients with active brain metastases from clinical trials, a shift is occurring toward a more inclusive approach. This chapter delves into the multifaceted challenges associated with managing brain metastases, with a focus on the evolving landscape of systemic approaches as well as the intricacies of shared decision making, providing a comprehensive overview of the current state and future directions in navigating the complexities of brain metastases management.
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Affiliation(s)
- Afsaneh Amouzegar
- Department of Melanoma Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shannon Haig
- Lake Erie College of Osteopathic Medicine, Greensburg, PA
| | - Adriana M Kahn
- Section of Medical Oncology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Hussein A Tawbi
- Department of Melanoma Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joshua A Jones
- Department of Oncology, Division of Radiation Oncology and Division of Palliative Medicine, Rochester Regional Health System, Rochester, NY
| | - Sarah B Goldberg
- Section of Medical Oncology, Department of Medicine, Yale School of Medicine, New Haven, CT
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Leng JX, Carpenter DJ, Huang C, Qazi J, Arshad M, Mullikin TC, Reitman ZJ, Kirkpatrick JP, Floyd SR, Fecci PE, Chmura SJ, Hong JC, Salama JK. Determinants of Symptomatic Intracranial Progression After an Initial Stereotactic Radiosurgery Course. Adv Radiat Oncol 2024; 9:101475. [PMID: 38690297 PMCID: PMC11059392 DOI: 10.1016/j.adro.2024.101475] [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: 11/28/2023] [Accepted: 02/04/2024] [Indexed: 05/02/2024] Open
Abstract
Purpose Clinical and imaging surveillance of patients with brain metastases is important after stereotactic radiosurgery (SRS) because many will experience intracranial progression (ITCP) requiring multidisciplinary management. The prognostic significance of neurologic symptoms at the time of ITCP is poorly understood. Methods and Materials This was a multi-institutional, retrospective cohort study from 2015 to 2020, including all patients with brain metastases completing an initial course of SRS. The primary outcome was overall survival (OS) by presence of neurologic symptoms at ITCP. OS, freedom from ITCP (FF-ITCP), and freedom from symptomatic ITCP (FF-SITCP) were assessed via Kaplan-Meier method. Cox proportional hazard models tested parameters impacting FF-ITCP and FF-SITCP. Results Among 1383 patients, median age was 63.4 years, 55% were female, and common primaries were non-small cell lung (49%), breast (15%), and melanoma (9%). At a median follow-up of 8.72 months, asymptomatic and symptomatic ITCP were observed in 504 (36%) and 194 (14%) patients, respectively. The majority of ITCP were distant ITCP (79.5%). OS was worse with SITCP (median, 10.2 vs 17.9 months, P < .001). SITCP was associated with clinical factors including total treatment volume (P = .012), melanoma histology (P = .001), prior whole brain radiation therapy (P = .003), number of brain metastases (P < .001), interval of 1 to 2 years from primary and brain metastasis diagnosis (P = .012), controlled extracranial disease (P = .042), and receipt of pre-SRS chemotherapy (P = .015). Patients who were younger and received post-SRS chemotherapy (P = .001), immunotherapy (P < .001), and targeted or small-molecule inhibitor therapy (P < .026) had better FF-SITCP. Conclusions In this cohort study of patients with brain metastases completing SRS, neurologic symptoms at ITCP is prognostic for OS. This data informs post-SRS surveillance in clinical practice as well as future prospective studies needed in the modern management of brain metastases.
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Affiliation(s)
- Jim X. Leng
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - David J. Carpenter
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
- Department of Radiation Oncology, Wellstar Paulding Hospital, Hiram, Georgia
| | - Christina Huang
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Jamiluddin Qazi
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Muzamil Arshad
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Trey C. Mullikin
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Zachary J. Reitman
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - John P. Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Scott R. Floyd
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Peter E. Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Steven J. Chmura
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Julian C. Hong
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, California
- Joint Program in Computational Precision Health, University of California, San Francisco, California and University of California, Berkeley, California
| | - Joseph K. Salama
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
- Radiation Oncology Clinical Service, Durham VA Health Care System, Durham, North Carolina
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Simon AB, Quezada J, Mohyeldin A, Harris J, Shi M, Seyedin S, Sehgal V, Chen AM. Integrating Overall Survival and Tumor Control Probability Models to Predict Local Progression After Brain Metastasis Radiosurgery. Adv Radiat Oncol 2024; 9:101474. [PMID: 38681893 PMCID: PMC11043807 DOI: 10.1016/j.adro.2024.101474] [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: 08/21/2023] [Accepted: 02/04/2024] [Indexed: 05/01/2024] Open
Abstract
Purpose Stereotactic radiosurgery (SRS) for brain metastases is frequently prescribed to the maximum tolerated dose to minimize the probability of local progression. However, many patients die from extracranial disease prior to local progression and may not require maximally aggressive treatment. Recently, improvements in models of SRS tumor control probability (TCP) and overall survival (OS) have been made. We predicted that by combining models of OS and TCP, we could better predict the true risk of local progression after SRS than by using TCP modeling alone. Methods and Materials Records of patients undergoing SRS at a single institution were reviewed retrospectively. Using established TCP and OS models, for each patient, the probability of 1-year survival [p ( O S ) ] was calculated, as was the probability of 1-year local progression [p ( L P ) ]) for each treated lesion. Joint-probability was used to combine the models [p ( L P , O S ) = p ( L P ) * p ( O S ) ]. Analyses were conducted at the individual metastasis and whole-patient levels. Fine-Gray regression was used to model p ( L P ) or p ( L P , O S ) on the risk of local progression after SRS, with death as a competing risk. Results At the patient level, 1-year local progression was 0.08 (95% CI, 0.03-0.15), median p ( L P , O S ) was 0.13 (95% CI, 0.07-0.2), and median p ( L P ) was 0.29 (95% CI, 0.22-0.38). At the metastasis level, 1-year local progression was 0.02 (95% CI, 0.01-0.04), median p ( L P , O S ) was 0.05 (95% CI, 0.02-0.07), and median p ( L P ) was 0.10 (95% CI, 0.07-0.13). p ( L P , O S ) was found to be significantly associated with the risk of local progression at the patient level (P = .048) and metastasis level (P = .007); however, p ( L P ) was not (P = .16 and P = .28, respectively). Conclusions Simultaneous modeling of OS and TCP more accurately predicted local progression than TCP modeling alone. Better understanding which patients with brain metastases are at risk of local progression after SRS may help personalize treatment to minimize risk without sacrificing efficacy.
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Affiliation(s)
- Aaron B. Simon
- Department of Radiation Oncology, University of California Irvine, Irvine, California
| | - Jeffrey Quezada
- University of California Irvine School of Medicine, Irvine, California
| | - Ahmed Mohyeldin
- Department of Neurosurgery, University of California Irvine, Irvine, California
| | - Jeremy Harris
- Department of Radiation Oncology, University of California Irvine, Irvine, California
| | - Mengying Shi
- Department of Radiation Oncology, University of California Irvine, Irvine, California
| | - Steven Seyedin
- Department of Radiation Oncology, University of California Irvine, Irvine, California
| | - Varun Sehgal
- Department of Radiation Oncology, University of California Irvine, Irvine, California
| | - Allen M. Chen
- Department of Radiation Oncology, University of California Irvine, Irvine, California
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5
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Goyette MA, Stevens LE, DePinho CR, Seehawer M, Nishida J, Li Z, Wilde CM, Li R, Qiu X, Pyke AL, Zhao S, Lim K, Tender GS, Northey JJ, Riley NM, Long HW, Bertozzi CR, Weaver VM, Polyak K. Cancer-stromal cell interactions in breast cancer brain metastases induce glycocalyx-mediated resistance to HER2-targeting therapies. Proc Natl Acad Sci U S A 2024; 121:e2322688121. [PMID: 38709925 PMCID: PMC11098130 DOI: 10.1073/pnas.2322688121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/27/2024] [Indexed: 05/08/2024] Open
Abstract
Brain metastatic breast cancer is particularly lethal largely due to therapeutic resistance. Almost half of the patients with metastatic HER2-positive breast cancer develop brain metastases, representing a major clinical challenge. We previously described that cancer-associated fibroblasts are an important source of resistance in primary tumors. Here, we report that breast cancer brain metastasis stromal cell interactions in 3D cocultures induce therapeutic resistance to HER2-targeting agents, particularly to the small molecule inhibitor of HER2/EGFR neratinib. We investigated the underlying mechanisms using a synthetic Notch reporter system enabling the sorting of cancer cells that directly interact with stromal cells. We identified mucins and bulky glycoprotein synthesis as top-up-regulated genes and pathways by comparing the gene expression and chromatin profiles of stroma-contact and no-contact cancer cells before and after neratinib treatment. Glycoprotein gene signatures were also enriched in human brain metastases compared to primary tumors. We confirmed increased glycocalyx surrounding cocultures by immunofluorescence and showed that mucinase treatment increased sensitivity to neratinib by enabling a more efficient inhibition of EGFR/HER2 signaling in cancer cells. Overexpression of truncated MUC1 lacking the intracellular domain as a model of increased glycocalyx-induced resistance to neratinib both in cell culture and in experimental brain metastases in immunodeficient mice. Our results highlight the importance of glycoproteins as a resistance mechanism to HER2-targeting therapies in breast cancer brain metastases.
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Affiliation(s)
- Marie-Anne Goyette
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215
- Department of Medicine, Harvard Medical School, Boston, MA 02115
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115
| | - Laura E Stevens
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215
- Department of Medicine, Harvard Medical School, Boston, MA 02115
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115
| | - Carolyn R DePinho
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215
| | - Marco Seehawer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215
- Department of Medicine, Harvard Medical School, Boston, MA 02115
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115
| | - Jun Nishida
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215
- Department of Medicine, Harvard Medical School, Boston, MA 02115
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115
| | - Zheqi Li
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215
- Department of Medicine, Harvard Medical School, Boston, MA 02115
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115
| | - Callahan M Wilde
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215
| | - Rong Li
- Center for Functional Cancer Epigenetics, Dana-Farber Cancer Institute, Boston, MA 02215
| | - Xintao Qiu
- Center for Functional Cancer Epigenetics, Dana-Farber Cancer Institute, Boston, MA 02215
| | - Alanna L Pyke
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215
| | - Stephanie Zhao
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215
| | - Klothilda Lim
- Center for Functional Cancer Epigenetics, Dana-Farber Cancer Institute, Boston, MA 02215
| | | | - Jason J Northey
- Center for Bioengineering and Tissue Regeneration, University of California San Francisco, San Francisco, CA 94143
| | - Nicholas M Riley
- Department of Chemistry, Stanford University, Stanford, CA 94305
| | - Henry W Long
- Center for Functional Cancer Epigenetics, Dana-Farber Cancer Institute, Boston, MA 02215
| | - Carolyn R Bertozzi
- Department of Chemistry, Stanford University, Stanford, CA 94305
- HHMI, Stanford University, Stanford, CA 94305
- Sarafan ChEM-H, Stanford University, Stanford, CA 94305
| | - Valerie M Weaver
- Center for Bioengineering and Tissue Regeneration, University of California San Francisco, San Francisco, CA 94143
- Helen Diller Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA 94143
- Department of Surgery, University of California San Francisco, San Francisco, CA 94143
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA 94143
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA 94143
- Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA 94143
| | - Kornelia Polyak
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215
- Department of Medicine, Harvard Medical School, Boston, MA 02115
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115
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Cherng HRR, Sun K, Bentzen S, Armstrong TS, Gondi V, Brown PD, Mehta M, Mishra MV. Evaluating the heterogeneity of hippocampal avoidant whole brain radiotherapy treatment effect: A secondary analysis of NRG CC001. Neuro Oncol 2024; 26:911-921. [PMID: 38069666 PMCID: PMC11066939 DOI: 10.1093/neuonc/noad226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024] Open
Abstract
BACKGROUND Hippocampal avoidant whole brain radiotherapy (HA-WBRT) is the standard of care for patients needing WBRT for brain metastases. This study, using existing data from NRG Oncology CC001 including baseline tumor characteristics and patient-reported MD Anderson Symptom Inventory-Brain Tumor (MDASI-BT) scores, sought to identify subgroups of patients that demonstrate differential neuroprotective treatment response to HA-WBRT. METHODS An exploratory analysis of NRG CC001, a phase 3 trial in which 518 patients were randomly assigned to WBRT plus memantine or HA-WBRT plus memantine, was performed. Rates of neurocognitive function failure (NCFF) were estimated between subgroups and stratified by arm. Covariate and subgroup interaction with differential treatment response were calculated. RESULTS The benefit of HA-WBRT on decreasing NCFF was seen in patients living ≥ 4 months (HR 0.75, 95% CI: 0.58-0.97, P = .03), whereas patients living < 4 months derived no significant neurocognitive benefit. A significant association between baseline MDASI-BT cognitive factor and treatment response (interaction P = .03) was identified. Patients with lower MDASI-BT scores (less patient-reported cognitive impairment) derived significantly greater benefit (HR = 0.64, 95% CI: 0.48-0.85, P = .002) compared to those with highest MDASI-BT scores (HR = 1.24, 95% CI: 0.76-2.04, P = .39). Tumor histology also had a significant interaction (P = .01) with treatment response. Primary lung histology patients derived cognitive failure risk reduction (HR = 0.58, 95% CI: 0.43-0.77, P = .0007) from HA-WBRT, in contrast to nonlung primary histology patients (HR = 1.15, 95% CI: 0.78-1.50, P = .48). CONCLUSIONS Differential neuroprotective response to HA-WBRT was identified in this analysis. Patients surviving ≥ 4 months derived benefit from HA-WBRT. There is evidence of heterogeneity of treatment effect for patients with less severe patient-reported cognitive impairment at baseline and those with primary lung histology.
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Affiliation(s)
- Hua-Ren R Cherng
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Kai Sun
- Division of Biostatistics and Bioinformatics, University of Maryland Greenebaum Cancer Center, Baltimore, Maryland, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Søren Bentzen
- Division of Biostatistics and Bioinformatics, University of Maryland Greenebaum Cancer Center, Baltimore, Maryland, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Terri S Armstrong
- National Cancer Institute Center for Cancer Research, Bethesda, Maryland, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center and Proton Center, Warrenville, Illinois, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Minesh Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Fittall MW, Brewer M, de Boisanger J, Kviat L, Babiker A, Taylor H, Saran F, Konadu J, Solda F, Creak A, Welsh LC, Rosenfelder N. Predicting Survival with Brain Metastases in the Stereotactic Radiosurgery Era: are Existing Prognostic Scores Still Relevant? Or Can we do Better? Clin Oncol (R Coll Radiol) 2024; 36:307-317. [PMID: 38368229 DOI: 10.1016/j.clon.2024.01.037] [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: 06/01/2023] [Revised: 11/20/2023] [Accepted: 01/30/2024] [Indexed: 02/19/2024]
Abstract
Predicting survival is essential to tailoring treatment for patients diagnosed with brain metastases. We have evaluated the performance of widely used, validated prognostic scoring systems (Graded Prognostic Assessment and diagnosis-specific Graded Prognostic Assessment) in over 1000 'real-world' patients treated with stereotactic radiosurgery to the brain, selected according to National Health Service commissioning criteria. Survival outcomes from our dataset were consistent with those predicted by the prognostic systems, but with certain cancer subtypes showing a significantly better survival than predicted. Although performance status remains the simplest tool for prediction, total brain tumour volume emerges as an independent prognostic factor, and a new, improved, prognostic scoring system incorporating this has been developed.
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Affiliation(s)
- M W Fittall
- Cancer Institute, University College London, London, UK
| | - M Brewer
- The Department of Neuro-oncology, Royal Marsden NHS Foundation Trust, London, UK
| | - J de Boisanger
- The Department of Neuro-oncology, Royal Marsden NHS Foundation Trust, London, UK
| | - L Kviat
- The Department of Neuro-oncology, Royal Marsden NHS Foundation Trust, London, UK
| | - A Babiker
- The Department of Neuro-oncology, Royal Marsden NHS Foundation Trust, London, UK
| | - H Taylor
- The Department of Neuro-oncology, Royal Marsden NHS Foundation Trust, London, UK
| | - F Saran
- Cancer and Blood Service, Auckland City Hospital, Auckland, New Zealand
| | - J Konadu
- The Department of Neuro-oncology, Royal Marsden NHS Foundation Trust, London, UK
| | - F Solda
- The Department of Neuro-oncology, Royal Marsden NHS Foundation Trust, London, UK
| | - A Creak
- The Department of Neuro-oncology, Royal Marsden NHS Foundation Trust, London, UK
| | - L C Welsh
- The Department of Neuro-oncology, Royal Marsden NHS Foundation Trust, London, UK
| | - N Rosenfelder
- The Department of Neuro-oncology, Royal Marsden NHS Foundation Trust, London, UK.
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8
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Flores-Paco P, Vargas-Aliaga A, Guevara MG, Lopera I, Ruiz LR, López-Herrero M, Camús JA, López-González J, Inga-Saavedra E, Montero M, Barneto I, Gómez-España MA, Ruiz E, Ruza M, Armenta A, Palacios A, De La Haba-Rodríguez JR, Aranda E. A new updated prognostic index for patients with brain metastases (BMs) treated with palliative whole brain radiotherapy (WBRT) in the era of precision oncology. METASNCore project. J Neurooncol 2024; 167:407-413. [PMID: 38539006 DOI: 10.1007/s11060-024-04618-1] [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: 02/04/2024] [Accepted: 02/22/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Palliative WBRT is the main treatment for multiple BMs. Recent studies report no benefit in survival after WBRT compared to palliative supportive care in patients (pts) with poor prognosis. A new era of systemic treatment strategies based on targeted therapies are improving the prognosis of patients with BMs. The purpose of this study is to develop a prognostic score in palliative pts with BMs who undergo WBRT in this new setting. METHODS 239 pts with BMs who received palliative WBRT between 2013-2022 in our center were analyzed retrospectively. The score was designed according to the value of the β coefficient of each variable with statistical significance in the multivariate model using Cox regression. Once the score was established, a comparison was performed according to Kaplan-Meier and was analyzed by log-rank test. RESULTS 149 pts (62.3%) were male and median (m) age was 60 years. 139 (58,2%) were lung cancer and 35 (14,6%) breast cancer. All patients received 30Gys in 10 sessions. m overall survival (OS) was 3,74 months (ms). 37 pts (15,5%) had a specific target mutation. We found that 62 pts were in group < 4 points with mOS 6,89 ms (CI 95% 3,18-10,62), 84 in group 4-7 points with mOS 4,01 ms (CI 95% 3,40-4,62) and 92 pts in group > 7 points with mOS 2,72 ms (CI 95% 1,93-3,52) (p < 0,001). CONCLUSIONS METASNCore items are associated with OS and they could be useful to select palliative pts to receive WBRT. More studies are necessary to corroborate our findings.
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Affiliation(s)
- Pablo Flores-Paco
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Alicia Vargas-Aliaga
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - María Geraldina Guevara
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | | | - Lucía Rodríguez Ruiz
- Radiation Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - María López-Herrero
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Juan Adrián Camús
- Radiation Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Javier López-González
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Elizabeth Inga-Saavedra
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Marina Montero
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Isidoro Barneto
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Mª Auxiliadora Gómez-España
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Estela Ruiz
- Radiation Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Marta Ruza
- Radiation Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Ana Armenta
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Amalia Palacios
- Radiation Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
| | - Juan R De La Haba-Rodríguez
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain.
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain.
- Medical School, University of Cordoba, Cordoba, Spain.
- Medical Oncology Department, Hospital Universitario Reina Sofía, Av. Menendez Pidal, s/n, 14004, Córdoba, Spain.
| | - Enrique Aranda
- Medical Oncology Department, University Hospital Reina Sofia, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- Medical School, University of Cordoba, Cordoba, Spain
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9
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Habibi MA, Rashidi F, Habibzadeh A, Mehrtabar E, Arshadi MR, Mirjani MS. Prediction of the treatment response and local failure of patients with brain metastasis treated with stereotactic radiosurgery using machine learning: A systematic review and meta-analysis. Neurosurg Rev 2024; 47:199. [PMID: 38684566 DOI: 10.1007/s10143-024-02391-3] [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: 01/20/2024] [Revised: 04/01/2024] [Accepted: 04/07/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) effectively treats brain metastases. It can provide local control, symptom relief, and improved survival rates, but it poses challenges in selecting optimal candidates, determining dose and fractionation, monitoring for toxicity, and integrating with other modalities. Practical tools to predict patient outcomes are also needed. Machine learning (ML) is currently used to predict treatment outcomes. We aim to investigate the accuracy of ML in predicting treatment response and local failure of brain metastasis treated with SRS. METHODS PubMed, Scopus, Web of Science (WoS), and Embase were searched until April 16th, which was repeated on October 17th, 2023 to find possible relevant papers. The study preparation adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The statistical analysis was performed by the MIDAS package of STATA v.17. RESULTS A total of 17 articles were reviewed, of which seven and eleven were related to the clinical use of ML in predicting local failure and treatment response. The ML algorithms showed sensitivity and specificity of 0.89 (95% CI: 0.84-0.93) and 0.87 (95% CI: 0.81-0.92) for predicting treatment response. The positive likelihood ratio was 7.1 (95% CI: 4.5-11.1), the negative likelihood ratio was 0.13 (95% CI: 0.08-0.19), and the diagnostic odds ratio was 56 (95% CI: 25-125). Moreover, the pooled estimates for sensitivity and specificity of ML algorithms for predicting local failure were 0.93 (95% CI: 0.76-0.98) and 0.80 (95% CI: 0.53-0.94). The positive likelihood ratio was 4.7 (95% CI: 1.6-14.0), the negative likelihood ratio was 0.09 (95% CI: 0.02-0.39), and the diagnostic odds ratio was 53 (95% CI: 5-606). CONCLUSION ML holds promise in predicting treatment response and local failure in brain metastasis patients receiving SRS. However, further studies and improvements in the treatment process can refine the models and effectively integrate them into clinical practice.
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Affiliation(s)
- Mohammad Amin Habibi
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Farhang Rashidi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Adriana Habibzadeh
- Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran
| | - Ehsan Mehrtabar
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Arshadi
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Sina Mirjani
- Student Research Committee, Faculty of Medicine, Qom University of Medical Science, Qom, Iran
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10
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Hijazi A, Mohanna M, Sabbagh S, Herrán M, Dominguez B, Sarna K, Nahleh Z. Clinico-pathologic factors and survival of patients with breast cancer diagnosed with de novo brain metastasis: a national cancer database analysis. Breast Cancer Res Treat 2024:10.1007/s10549-024-07321-x. [PMID: 38683296 DOI: 10.1007/s10549-024-07321-x] [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: 12/26/2023] [Accepted: 03/28/2024] [Indexed: 05/01/2024]
Abstract
PURPOSE Patients with Breast Cancer (BC) with Brain Metastasis (BCBM) have poor survival outcomes. We aimed to explore the clinico-pathologic and therapeutic factors predicting the survival in patients with de novo BCBM using the National Cancer Database (NCDB). PATIENTS AND METHODS The NCDB was queried for patients with BC between 2010 and 2020. Survival analysis with Kaplan-Meier curves and log rank tests were used to find median overall survival (OS) in months (95% CI) across the different variables. A multivariate cox regression model was computed to identify significant predictors of survival. RESULTS Out of n = 2,610,598 patients, n = 9005 (0.34%) had de novo BCBM. A trend of decreasing OS was observed with increasing age, Charlson-Deyo score (CDS), and number of extracranial metastatic sites. The highest median OS was observed in the Triple Positive and the lowest OS in the Triple Negative subgroup. Based on treatment regimen, combination of systemic therapy and local therapy achieved the highest OS. A positive trend in OS was observed in the BC subgroup analysis with targeted therapy demonstrating a survival benefit when added to systemic therapy. The multivariate cox regression model showed that age, race, ethnicity, insurance, median income, facility type, CDS, BC subtype, metastatic location sites, and treatment combinations received were significantly associated with risk of death. Receiving only local treatment for BM without systemic therapy more than doubled the risk of death compared to combining it with systemic therapy. CONCLUSIONS This analysis suggests that treatment of systemic disease is the major factor influencing survival in patients with BCBM. Moreover, targeted therapy with anti-HER2 increased survival when added to systemic therapy explaining the highest median OS noted in the Triple Positive subgroup.
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Affiliation(s)
- Ali Hijazi
- Department of Hematology and Oncology, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA.
| | - Mohamed Mohanna
- Department of Hematology and Oncology, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Saad Sabbagh
- Department of Hematology and Oncology, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - María Herrán
- Department of Hematology and Oncology, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Barbara Dominguez
- Department of Hematology and Oncology, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Kaylee Sarna
- Center for Clinical Research, Cleveland Clinic Foundation, Weston, FL, 33331, USA
| | - Zeina Nahleh
- Department of Hematology and Oncology, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
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11
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Kim IA, Winter KA, Sperduto PW, De Los Santos JF, Peereboom DM, Ogunleye T, Boulter D, Fritz JM, Cho KH, Shin KH, Zoberi I, Choi S, Palmer JD, Liem B, Kim YB, Anderson BM, Thakrar AW, Muanza TM, Kim MM, Choi DH, Mehta MP, White JR. Concurrent Lapatinib With Brain Radiation Therapy in Patients With HER2+ Breast Cancer With Brain Metastases: NRG Oncology-KROG/RTOG 1119 Phase 2 Randomized Trial. Int J Radiat Oncol Biol Phys 2024; 118:1391-1401. [PMID: 37506981 PMCID: PMC10811275 DOI: 10.1016/j.ijrobp.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/03/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023]
Abstract
PURPOSE Lapatinib plus whole brain radiation therapy (WBRT) or stereotactic radiosurgery (SRS) was hypothesized to improve the 12-week intracranial complete response (CR) rate compared with either option of radiation therapy (RT) alone for patients with brain metastases (BM) from human epidermal growth factor receptor 2-positive (HER2+) breast cancer. METHODS AND MATERIALS This study included patients with HER2+ breast cancer with ≥1 measurable, unirradiated BM. Patients were randomized to WBRT (37.5 Gy/3 wk)/SRS (size-based dosing) ± concurrent lapatinib (1000 mg daily for 6 weeks). Secondary endpoints included objective response rate (ORR), lesion-specific response, central nervous system progression-free survival, and overall survival. RESULTS From July 2012 to September 2019, 143 patients were randomized, with 116 analyzable for the primary endpoint. RT + lapatinib did not improve 12-week CR (0% vs 6% for RT alone, 1-sided P = .97), or ORR at 12 weeks. At 4 weeks, RT + lapatinib showed higher ORR (55% vs 42%). Higher graded prognostic assessment and ≤10 lesions were associated with higher 12-week ORR. Grade 3 and 4 adverse event rates were 8% and 0% for RT and 28% and 6% for RT + lapatinib. CONCLUSIONS The addition of 6 weeks of concomitant lapatinib to WBRT/SRS did not improve the primary endpoint of 12-week CR rate or 12-week ORR. Adding lapatinib to WBRT/SRS showed improvement of 4-week ORR, suggesting a short-term benefit from concomitant therapy.
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Affiliation(s)
- In Ah Kim
- Department of Radiation Oncology, Seoul National University, Seoul, South Korea.
| | - Kathryn A Winter
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Paul W Sperduto
- Radiation Oncologist, Minneapolis Radiation Oncology, Minneapolis, Minnesota
| | | | - David M Peereboom
- Brain Tumor & Neuro-Oncology Cleveland Clinic Main Campus, Cleveland, Ohio
| | - Tomi Ogunleye
- Medical Physics Department, Northside Hospital Cancer Institute, Atlanta, Georgia
| | - Daniel Boulter
- Department of Radiology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joel M Fritz
- Department of Radiology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kwan Ho Cho
- Department of Radiation Oncology, Seoul National University, Seoul, South Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University, Seoul, South Korea
| | - Imran Zoberi
- Department of Radiology Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Serah Choi
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center and Case Comprehensive Cancer Center, Cleveland, Ohio
| | - Joshua D Palmer
- Department of Radiology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ben Liem
- Department of Internal Medicine, Division of Hematology/Oncology, New Mexico Minority Underserved NCORP, Albuquerque, New Mexico
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei University Health System-Severance Hospital, Seoul, South Korea
| | - Bethany M Anderson
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Anupama W Thakrar
- Department of Radiation Oncology, Stroger Hospital of Cook County Minority Underserved NCORP, Chicago, Illinois
| | - Thierry M Muanza
- Department of Radiation Oncology, Jewish General Hospital, Montreal, Quebec, Canada
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Seoul, South Korea
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida
| | - Julia R White
- Department of Radiation Oncology, University of Kansas, Kansas City, Kansas
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12
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Borm KJ, Behzadi ST, Hörner-Rieber J, Krug D, Baumann R, Corradini S, Duma MN, Dunst J, Fastner G, Feyer P, Fietkau R, Haase W, Harms W, Hehr T, Matuschek C, Piroth MD, Schmeel LC, Souchon R, Strnad V, Budach W, Combs SE. DEGRO guideline for personalized radiotherapy of brain metastases and leptomeningeal carcinomatosis in patients with breast cancer. Strahlenther Onkol 2024; 200:259-275. [PMID: 38488902 DOI: 10.1007/s00066-024-02202-0] [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: 01/03/2024] [Accepted: 01/07/2024] [Indexed: 03/17/2024]
Abstract
PURPOSE The aim of this review was to evaluate the existing evidence for radiotherapy for brain metastases in breast cancer patients and provide recommendations for the use of radiotherapy for brain metastases and leptomeningeal carcinomatosis. MATERIALS AND METHODS For the current review, a PubMed search was conducted including articles from 01/1985 to 05/2023. The search was performed using the following terms: (brain metastases OR leptomeningeal carcinomatosis) AND (breast cancer OR breast) AND (radiotherapy OR ablative radiotherapy OR radiosurgery OR stereotactic OR radiation). CONCLUSION AND RECOMMENDATIONS Despite the fact that the biological subtype of breast cancer influences both the occurrence and relapse patterns of breast cancer brain metastases (BCBM), for most scenarios, no specific recommendations regarding radiotherapy can be made based on the existing evidence. For a limited number of BCBM (1-4), stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (SRT) is generally recommended irrespective of molecular subtype and concurrent/planned systemic therapy. In patients with 5-10 oligo-brain metastases, these techniques can also be conditionally recommended. For multiple, especially symptomatic BCBM, whole-brain radiotherapy (WBRT), if possible with hippocampal sparing, is recommended. In cases of multiple asymptomatic BCBM (≥ 5), if SRS/SRT is not feasible or in disseminated brain metastases (> 10), postponing WBRT with early reassessment and reevaluation of local treatment options (8-12 weeks) may be discussed if a HER2/Neu-targeting systemic therapy with significant response rates in the central nervous system (CNS) is being used. In symptomatic leptomeningeal carcinomatosis, local radiotherapy (WBRT or local spinal irradiation) should be performed in addition to systemic therapy. In patients with disseminated leptomeningeal carcinomatosis in good clinical condition and with only limited or stable extra-CNS disease, craniospinal irradiation (CSI) may be considered. Data regarding the toxicity of combining systemic therapies with cranial and spinal radiotherapy are sparse. Therefore, no clear recommendations can be given, and each case should be discussed individually in an interdisciplinary setting.
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Affiliation(s)
- Kai J Borm
- TUM School of Medicine, Department of Radiation Oncology, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Sophie T Behzadi
- TUM School of Medicine, Department of Radiation Oncology, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Rene Baumann
- Department of Radiation Oncology, St. Marien-Krankenhaus, Siegen, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, Helios Clinics of Schwerin-University Campus of MSH Medical School Hamburg, Schwerin, Germany
- Department for Human Medicine, MSH Medical School Hamburg, Hamburg, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Gerd Fastner
- Department of Radiotherapy and Radio-Oncology, University Hospital Salzburg, Landeskrankenhaus, Paracelsus Medical University, Salzburg, Austria
| | - Petra Feyer
- Formerly Department of Radiation Oncology, Vivantes Hospital Neukölln, Berlin, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Wulf Haase
- Formerly Department of Radiation Oncology, St.-Vincentius-Hospital Karlsruhe, Karlsruhe, Germany
| | - Wolfgang Harms
- Department of Radiation Oncology, St. Claraspital, Basel, Switzerland
| | - Thomas Hehr
- Department of Radiation Oncology, Marienhospital Stuttgart, Stuttgart, Germany
| | - Christiane Matuschek
- Department of Radiation Oncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Marc D Piroth
- Department of Radiation Oncology, HELIOS University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | | | - Rainer Souchon
- Formerly Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Vratislav Strnad
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Wilfried Budach
- Department of Radiation Oncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Stephanie E Combs
- TUM School of Medicine, Department of Radiation Oncology, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.
- Partner Site Munich, Deutsches Konsortium für Translationale Krebsforschung (DKTK), Munich, Germany.
- Department of Radiation Medicine (IRM), Helmholtz Zentrum München (HMGU), Neuherberg, Germany.
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13
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Hügel M, Stöhr J, Kuhnt T, Nägler F, Papsdorf K, Klagges S, Hambsch P, Güresir E, Nicolay NH, Seidel C. Long-term survival in patients with brain metastases-clinical characterization of a rare scenario. Strahlenther Onkol 2024; 200:335-345. [PMID: 37646818 DOI: 10.1007/s00066-023-02123-4] [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: 02/01/2023] [Accepted: 07/10/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE This study aimed to assess clinical, treatment, and prognostic features in patients with brain metastases (BM) from solid tumors achieving long-term survival (LTS). Further, the accuracy of diagnosis-specific Graded Prognostic Assessment scores (ds-GPA) to predict LTS was evaluated. METHODS Patients admitted for radiotherapy of BM between 2010 and 2020 at a large tertiary cancer center with survival of at least 3 years from diagnosis of BM were included. Patient, tumor, treatment characteristics and ds-GPA were compiled retrospectively. RESULTS From a total of 1248 patients with BM, 61 (4.9%) survived ≥ 3 years. In 40 patients, detailed patient charts were available. Among LTS patients, median survival time from diagnosis of BM was 51.5 months. Most frequent primary tumors were lung cancer (45%), melanoma (20%), and breast cancer (17.5%). At the time of diagnosis of BM, 11/40 patients (27.5%) had oligometastatic disease. Estimated mean survival time based on ds-GPA was 19.7 months (in 8 cases estimated survival < 12 months). Resection followed by focal or whole-brain radiotherapy (WBRT) was often applied (60%), followed by primary stereotactic radiotherapy (SRT) (20%) or WBRT (20%). 80% of patients received systemic treatment, appearing particularly active in specifically altered non-small lung cancer (NSCLC), melanoma, and HER2-positive breast cancer. Karnofsky performance score (KPS) and the presence of oligometastatic disease at BM diagnosis were persisting prognostic factors in LTS patients. CONCLUSION In this monocentric setting reflecting daily pattern of care, LTS with BM is heterogeneous and difficult to predict. Effective local treatment and modern systemic therapies often appear crucial for LTS. The impact of concomitant diseases and frailty is not clear.
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Affiliation(s)
- M Hügel
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - J Stöhr
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - T Kuhnt
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - F Nägler
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - K Papsdorf
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - S Klagges
- Clinical Cancer Registry, Leipzig, Germany
| | - P Hambsch
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - E Güresir
- Department of Neurosurgery, University of Leipzig Medical Center, Leipzig, Germany
| | - N H Nicolay
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - C Seidel
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany.
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14
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Maemoto H, Kushi K, Owan I, Ariga T, Heianna J, Nishie A. Deterioration of Performance Status during Palliative Radiotherapy Suggests a Significant Short Survival Duration: Indicating the Necessities for Considering Radiotherapy Discontinuation. Curr Oncol 2024; 31:1752-1761. [PMID: 38668036 PMCID: PMC11049355 DOI: 10.3390/curroncol31040133] [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: 02/20/2024] [Revised: 03/11/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Discontinuation of palliative radiotherapy due to a patient's declining general condition poses a clinical dilemma for palliative care physicians. This study aimed to investigate the survival duration of patients whose performance status (PS) deteriorated during palliative radiotherapy and inform decisions regarding early treatment discontinuation. We retrospectively analyzed data from patients referred from our institute's palliative care department who underwent ≥10 fractions of palliative radiotherapy between March 2017 and December 2021. PS was assessed using the Eastern Cooperative Oncology Group (ECOG) scale. Survival duration was calculated from the final day of palliative radiotherapy to death using the Kaplan-Meier method. A total of 35 patients underwent palliative radiotherapy. Seven (20%) experienced deterioration in ECOG PS during treatment. Their median survival duration was significantly shorter at 22 days (95% confidence interval: 1-94 days) compared to 125 days (95% confidence interval: 82-150 days) for the 28 patients whose PS remained stable (p = 0.0007). Deterioration in ECOG PS during palliative radiotherapy signifies a markedly shorter survival duration. Careful assessment of a patient's condition throughout treatment is crucial, and early discontinuation should be considered if their general health worsens rather than strictly adhering to the initial schedule.
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Affiliation(s)
- Hitoshi Maemoto
- Division of Radiation Oncology, NHO Okinawa Hospital, Okinawa 901-2214, Japan
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0213, Japan; (T.A.); (J.H.); (A.N.)
| | - Kazuaki Kushi
- Division of Palliative Care, NHO Okinawa Hospital, Okinawa 901-2214, Japan
| | - Isoko Owan
- Division of Pulmonary Medicine, NHO Okinawa Hospital, Okinawa 901-2214, Japan;
| | - Takuro Ariga
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0213, Japan; (T.A.); (J.H.); (A.N.)
- Health Information Management Center, University of the Ryukyus Hospital, Okinawa 903-0213, Japan
| | - Joichi Heianna
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0213, Japan; (T.A.); (J.H.); (A.N.)
| | - Akihiro Nishie
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0213, Japan; (T.A.); (J.H.); (A.N.)
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15
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Mangesius J, Seppi T, Arnold CR, Mangesius S, Kerschbaumer J, Demetz M, Minasch D, Vorbach SM, Sarcletti M, Lukas P, Nevinny-Stickel M, Ganswindt U. Prognosis versus Actual Outcomes in Stereotactic Radiosurgery of Brain Metastases: Reliability of Common Prognostic Parameters and Indices. Curr Oncol 2024; 31:1739-1751. [PMID: 38668035 PMCID: PMC11049204 DOI: 10.3390/curroncol31040132] [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: 01/31/2024] [Revised: 03/11/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
This study aims to evaluate the clinical outcome of stereotactic radiosurgery as the sole treatment for brain metastases and to assess prognostic factors influencing survival. A total of 108 consecutive patients with 213 metastases were retrospectively analyzed. Treatment was determined with close-meshed MRI follow-up. Various prognostic factors were assessed, and several prognostic indices were compared regarding their reliability to estimate overall survival. Median overall survival was 15 months; one-year overall survival was 50.5%. Both one- and two-year local controls were 90.9%. The rate of new metastases after SRS was 49.1%. Multivariate analysis of prognostic factors revealed that the presence of extracranial metastases, male sex, lower KPI, and progressive extracranial disease were significant risk factors for decreased survival. Of all evaluated prognostic indices, the Basic Score for Brain Metastases (BSBMs) showed the best correlation with overall survival. A substantial survival advantage was found for female patients after SRS when compared to male patients (18 versus 9 months, p = 0.003). SRS of brain metastasis is a safe and effective treatment option when frequent monitoring for new metastases with MRI is performed. Common prognostic scores lack reliable estimation of survival times. Female sex should be considered as an additional independent positive prognostic factor influencing survival.
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Affiliation(s)
- Julian Mangesius
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Thomas Seppi
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | | | - Stephanie Mangesius
- Department of Neuroradiology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Johannes Kerschbaumer
- Department of Neurosurgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Matthias Demetz
- Department of Neurosurgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Danijela Minasch
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Samuel Moritz Vorbach
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Manuel Sarcletti
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Peter Lukas
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | | | - Ute Ganswindt
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
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16
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Nannini S, Guisier F, Curcio H, Ricordel C, Demontrond P, Abdallahoui S, Baloglu S, Greillier L, Chouaid C, Schott R. Outcomes of Patients with Non-Small Cell Lung Cancer and Brain Metastases Treated with the Upfront Single Agent Pembrolizumab: A Retrospective and Multicentric Study of the ESCKEYP GFPC Cohort. Curr Oncol 2024; 31:1656-1666. [PMID: 38534959 PMCID: PMC10969391 DOI: 10.3390/curroncol31030126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 03/10/2024] [Accepted: 03/20/2024] [Indexed: 05/26/2024] Open
Abstract
Non-small cell lung cancer (NSCLC) is the most common cause of brain metastasis (BM). Little is known about immune checkpoint inhibitor activity in the central nervous system, especially in patients receiving monotherapy for tumors with a tumor proportion score (TPS) ≥ 50%. This noninterventional, retrospective, multicenter study, conducted with the GFPC, included treatment-naïve patients strongly positive for PD-L1 (TPS ≥ 50%) with BM receiving first-line single-agent pembrolizumab treatment between May 2017 and November 2019. The primary endpoints were centrally reviewed intracranial overall response rates (ORRs), centrally reviewed intracranial progression-free survival (cPFS), extracranial PFS, and overall survival were secondary endpoints. Forty-three patients from five centers were included. Surgical or local radiation therapy was administered to 31 (72%) patients, mostly before initiating ICI therapy (25/31). Among 38/43 (88.4%) evaluable patients, the intracranial ORR was 73%. The median PFS was 8.3 months. The cerebral and extracerebral median PFS times were 9.2 and 5.3 months, respectively. The median OS was 25.5 months. According to multivariate analysis, BM surgery before ICI therapy was the only factor significantly associated with both improved PFS (HR = 0.44) and OS (HR = 0.45). This study revealed the feasibility and outcome of front-line pembrolizumab treatment in this population with BM.
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Affiliation(s)
- Simon Nannini
- Department of Oncology, Institut de Cancérologie Strasbourg Europe, 67200 Strasbourg, France; (S.N.); (S.A.)
| | - Florian Guisier
- Department of Pneumology, UNIROUEN, LITIS Lab QuantIF Team EA4108, CHU Rouen, Normandie University, Rouen and Inserm CIC-CRB 1404, 76000 Rouen, France
| | - Hubert Curcio
- Department of Pneumology, Centre Régionale de Lutte Contre le Cancer François Baclesse, 14000 Caen, France
| | - Charles Ricordel
- Department of Pneumology, Centre Hospitalier Universitaire, 35000 Rennes, France
| | - Pierre Demontrond
- Department of Pneumology, Centre Régionale de Lutte Contre le Cancer François Baclesse, 14000 Caen, France
| | - Safa Abdallahoui
- Department of Oncology, Institut de Cancérologie Strasbourg Europe, 67200 Strasbourg, France; (S.N.); (S.A.)
| | - Seyyid Baloglu
- Department of Radiological, Centre Hospitalier Universitaire de Strasbourg, 67200 Strasbourg, France
| | - Laurent Greillier
- Multidisciplinary Oncology and Therapeutic Innovations, APHM, INSERM, CNRS, CRCM, Hôpital Nord, Aix Marseille University, 13015 Marseille, France
| | - Christos Chouaid
- Department of Pneumology, Centre Hospitalier, 94000 Créteil, France
| | - Roland Schott
- Department of Oncology, Institut de Cancérologie Strasbourg Europe, 67200 Strasbourg, France; (S.N.); (S.A.)
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17
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Lehrer EJ, Breen WG, Singh R, Palmer JD, Brown PD, Trifiletti DM, Sheehan JP. Hypofractionated Stereotactic Radiosurgery in the Management of Brain Metastases. Neurosurgery 2024:00006123-990000000-01093. [PMID: 38511946 DOI: 10.1227/neu.0000000000002897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 01/09/2024] [Indexed: 03/22/2024] Open
Abstract
Stereotactic radiosurgery (SRS) is an important weapon in the management of brain metastases. Single-fraction SRS is associated with local control rates ranging from approximately 70% to 100%, which are largely dependent on lesion and postoperative cavity size. The rates of local control and improved neurocognitive outcomes compared with conventional whole-brain radiation therapy have led to increased adoption of SRS in these settings. However, when treating larger targets and/or targets located in eloquent locations, the risk of normal tissue toxicity and adverse radiation effects within healthy brain tissue becomes significantly higher. Thus, hypofractionated SRS has become a widely adopted approach, which allows for the delivery of ablative doses of radiation while also minimizing the risk of toxicity. This approach has been studied in multiple retrospective reports in both the postoperative and intact settings. While there are no reported randomized data to date, there are trials underway evaluating this paradigm. In this article, we review the role of hypofractionated SRS in the management of brain metastases and emerging data that will serve to validate this treatment approach. Pertinent articles and references were obtained from a comprehensive search of PubMed/MEDLINE and clinicaltrials.gov.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - William G Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Raj Singh
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
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18
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Lehrer EJ, Breen WG, Sener U, Campian JL. Editorial: Radiotherapy strategies for precise treatment on brain metastases. Front Oncol 2024; 14:1366261. [PMID: 38571498 PMCID: PMC10989057 DOI: 10.3389/fonc.2024.1366261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/14/2024] [Indexed: 04/05/2024] Open
Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - William G. Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Ugur Sener
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Jian L. Campian
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States
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19
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Lehrer EJ, Trifiletti DM, Fadul CE, Brown PD, Sheehan JP. Chemoimmunotherapy for Untreated Lung Cancer Brain Metastases: A Reason for Optimism While Avoiding Overreaching Interpretations. J Clin Oncol 2024; 42:857-858. [PMID: 38079583 DOI: 10.1200/jco.23.01876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/16/2023] [Indexed: 02/29/2024] Open
Affiliation(s)
- Eric J Lehrer
- Eric J. Lehrer, MD, Department of Radiation Oncology, Mayo Clinic, Rochester, MN; Daniel M. Trifiletti, MD, Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL; Camilo E. Fadul, MD, Division of Neuro-Oncology, Department of Neurology, University of Virginia, Charlottesville, VA; Paul D. Brown, MD, Department of Radiation Oncology, Mayo Clinic, Rochester, MN; and Jason P. Sheehan, MD, PhD, Department of Neurological Surgery, University of Virginia, Charlottesville, VA
| | - Daniel M Trifiletti
- Eric J. Lehrer, MD, Department of Radiation Oncology, Mayo Clinic, Rochester, MN; Daniel M. Trifiletti, MD, Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL; Camilo E. Fadul, MD, Division of Neuro-Oncology, Department of Neurology, University of Virginia, Charlottesville, VA; Paul D. Brown, MD, Department of Radiation Oncology, Mayo Clinic, Rochester, MN; and Jason P. Sheehan, MD, PhD, Department of Neurological Surgery, University of Virginia, Charlottesville, VA
| | - Camilo E Fadul
- Eric J. Lehrer, MD, Department of Radiation Oncology, Mayo Clinic, Rochester, MN; Daniel M. Trifiletti, MD, Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL; Camilo E. Fadul, MD, Division of Neuro-Oncology, Department of Neurology, University of Virginia, Charlottesville, VA; Paul D. Brown, MD, Department of Radiation Oncology, Mayo Clinic, Rochester, MN; and Jason P. Sheehan, MD, PhD, Department of Neurological Surgery, University of Virginia, Charlottesville, VA
| | - Paul D Brown
- Eric J. Lehrer, MD, Department of Radiation Oncology, Mayo Clinic, Rochester, MN; Daniel M. Trifiletti, MD, Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL; Camilo E. Fadul, MD, Division of Neuro-Oncology, Department of Neurology, University of Virginia, Charlottesville, VA; Paul D. Brown, MD, Department of Radiation Oncology, Mayo Clinic, Rochester, MN; and Jason P. Sheehan, MD, PhD, Department of Neurological Surgery, University of Virginia, Charlottesville, VA
| | - Jason P Sheehan
- Eric J. Lehrer, MD, Department of Radiation Oncology, Mayo Clinic, Rochester, MN; Daniel M. Trifiletti, MD, Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL; Camilo E. Fadul, MD, Division of Neuro-Oncology, Department of Neurology, University of Virginia, Charlottesville, VA; Paul D. Brown, MD, Department of Radiation Oncology, Mayo Clinic, Rochester, MN; and Jason P. Sheehan, MD, PhD, Department of Neurological Surgery, University of Virginia, Charlottesville, VA
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20
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Miccio JA, Tian Z, Mahase SS, Lin C, Choi S, Zacharia BE, Sheehan JP, Brown PD, Trifiletti DM, Palmer JD, Wang M, Zaorsky NG. Estimating the risk of brain metastasis for patients newly diagnosed with cancer. COMMUNICATIONS MEDICINE 2024; 4:27. [PMID: 38388667 PMCID: PMC10883934 DOI: 10.1038/s43856-024-00445-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 01/31/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Brain metastases (BM) affect clinical management and prognosis but limited resources exist to estimate BM risk in newly diagnosed cancer patients. Additionally, guidelines for brain MRI screening are limited. We aimed to develop and validate models to predict risk of BM at diagnosis for the most common cancer types that spread to the brain. METHODS Breast cancer, melanoma, kidney cancer, colorectal cancer (CRC), small cell lung cancer (SCLC), and non-small cell lung cancer (NSCLC) data were extracted from the National Cancer Database to evaluate for the variables associated with the presence of BM at diagnosis. Multivariable logistic regression (LR) models were developed and performance was evaluated with Area Under the Receiver Operating Characteristic Curve (AUC) and random-split training and testing datasets. Nomograms and a Webtool were created for each cancer type. RESULTS We identify 4,828,305 patients from 2010-2018 (2,095,339 breast cancer, 472,611 melanoma, 407,627 kidney cancer, 627,090 CRC, 164,864 SCLC, and 1,060,774 NSCLC). The proportion of patients with BM at diagnosis is 0.3%, 1.5%, 1.3%, 0.3%, 16.0%, and 10.3% for breast cancer, melanoma, kidney cancer, CRC, SCLC, and NSCLC, respectively. The average AUC over 100 random splitting for the LR models is 0.9534 for breast cancer, 0.9420 for melanoma, 0.8785 for CRC, 0.9054 for kidney cancer, 0.7759 for NSCLC, and 0.6180 for SCLC. CONCLUSIONS We develop accurate models that predict the BM risk at diagnosis for multiple cancer types. The nomograms and Webtool may aid clinicians in considering brain MRI at the time of initial cancer diagnosis.
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Affiliation(s)
- Joseph A Miccio
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Zizhong Tian
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Sean S Mahase
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Christine Lin
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Serah Choi
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Brad E Zacharia
- Department of Neurosurgery, Penn State Cancer Institute, Hershey, PA, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University James Comprehensive Cancer Center, Columbus, OH, USA
| | - Ming Wang
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve School of Medicine, Cleveland, OH, USA.
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21
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Antoni D, Mesny E, El Kabbaj O, Josset S, Noël G, Biau J, Feuvret L, Latorzeff I. Role of radiotherapy in the management of brain oligometastases. Cancer Radiother 2024; 28:103-110. [PMID: 37802747 DOI: 10.1016/j.canrad.2023.03.005] [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: 01/06/2023] [Revised: 02/27/2023] [Accepted: 03/29/2023] [Indexed: 10/08/2023]
Abstract
The management of patients with brain oligometastases is complex and relies on specific reasoning compared to extracranial oligometastases. The levels of evidence are still low because patients with brain oligometastases are frequently excluded from randomized clinical trials. Stereotactic radiotherapy should be preferred in this indication over whole brain irradiation, both for patients with metastases in place and for those who have undergone surgery. The decision of local treatment and its timing must be a multidisciplinary reflection taking into account the histological and molecular characteristics of the tumor as well as the intracranial efficacy of the prescribed systemic treatments. Great caution must be observed when using stereotactic radiotherapy and concomitant systemic treatments because interactions are still poorly documented. We present the recommendations of the French society of radiation oncology on the management of brain oligometastatic patients with radiotherapy.
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Affiliation(s)
- D Antoni
- Radiation Therapy Department, Institut de cancérologie Strasbourg Europe, 67033 Strasbourg, France.
| | - E Mesny
- Radiation Therapy Department, Hospices civils de Lyon, 69000 Lyon, France
| | - O El Kabbaj
- Radiation Therapy Department, hôpital privé Océane, 56000 Vannes, France
| | - S Josset
- Medical Physics, Institut de cancérologie de l'Ouest, 44800 Saint-Herblain, France
| | - G Noël
- Radiation Therapy Department, Institut de cancérologie Strasbourg Europe, 67033 Strasbourg, France
| | - J Biau
- Radiation Therapy Department, centre Jean-Perrin, 63011 Clermont-Ferrand, France
| | - L Feuvret
- Radiation Therapy Department, Hospices civils de Lyon, 69000 Lyon, France
| | - I Latorzeff
- Radiation Therapy Department, clinique Pasteur, 31300 Toulouse, France
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22
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Goldberg M, Mondragon-Soto MG, Altawalbeh G, Meyer B, Aftahy AK. New Breakthroughs in the Diagnosis of Leptomeningeal Carcinomatosis: A Review of Liquid Biopsies of Cerebrospinal Fluid. Cureus 2024; 16:e55187. [PMID: 38558729 PMCID: PMC10980855 DOI: 10.7759/cureus.55187] [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] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Leptomeningeal carcinomatosis represents a terminal stage and is a devastating complication of cancer. Despite its high incidence, current diagnostic methods fail to accurately detect this condition in a timely manner. This failure to diagnose leads to the refusal of treatment and the absence of clinical trials, hampering the development of new therapy strategies. The use of liquid biopsy is revolutionizing the field of diagnostic oncology. The dynamic and non-invasive detection of tumor markers has enormous potential in cancer diagnostics and treatment. Leptomeningeal carcinomatosis is a condition where invasive tissue biopsy is not part of the routine diagnostic analysis, making liquid biopsy an essential diagnostic tool. Several elements in cerebrospinal fluid (CSF) have been investigated as potential targets of liquid biopsy, including free circulating tumor cells, free circulating nucleic acids, proteins, exosomes, and even non-tumor cells as part of the dynamic tumor microenvironment. This review aims to summarize current breakthroughs in the research on liquid biopsy, including the latest breakthroughs in the identification of tumor cells and nucleic acids, and give an overview of future directions in the diagnosis of leptomeningeal carcinomatosis.
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Affiliation(s)
- Maria Goldberg
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, DEU
| | | | - Ghaith Altawalbeh
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, DEU
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, DEU
| | - Amir Kaywan Aftahy
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, DEU
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23
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Xu H, Wang Y, Li L, Han Y, Wu Y, Sa Q, Xu B, Wang J. New insights into HER2-low breast cancer brain metastasis: A retrospective analysis. Breast 2024; 73:103669. [PMID: 38176304 PMCID: PMC10791565 DOI: 10.1016/j.breast.2023.103669] [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: 07/07/2023] [Revised: 11/17/2023] [Accepted: 12/30/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND A considerable number of patients with breast cancer will suffer from brain metastasis in the advanced setting. The HER2 status serves as a significant prognostic factor and the reference of applying treatment for patients with breast cancer brain metastasis (BCBM). METHODS Between January 2010 and July 2021, patients with BCBM who had available HER2 status were identified. The patients with HER2 1+ in immunohistochemistry (IHC) or IHC 2+ and fluorescence in situ hybridization (FISH) negative were categorized as HER2-low. Comparisons were conducted between the HER2-low and HER2-zero population. The primary endpoint was overall survival (OS) after the diagnosis of BCBM. Survival outcomes were assessed using Kaplan-Meier curves with log-rank test and Cox proportional hazards model. RESULTS In this study, we analyzed 71 patients with the HER2-low breast cancer subtype and 64 patients with the HER2-zero subtype. Despite the limited sample size, our findings revealed a significantly better OS for patients with HER2-low cancer compared to their HER2-zero counterparts (26 m vs 20 m, p = 0.0017). This trend was particularly notable in the HR-negative group (26 m vs 13 m, p = 0.0078), whereas no significant difference was observed among the HR-positive patients. Furthermore, Cox regression analysis revealed that the HER2-low status was an independent prognostic factor for better survival in the HR-negative patients (p = 0.046 in multivariate analysis). CONCLUSIONS Patients diagnosed with HER2-low BCBM exhibited a more favorable prognosis than those with HER2-zero BCBM, particularly within the HR-negative subgroup. The low expression of HER2 is supposed to be linked to the prolonged survival of BCBM patients.
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Affiliation(s)
- Hangcheng Xu
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Yan Wang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Li Li
- Department of Medical Records, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Yiqun Han
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Yun Wu
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Qiang Sa
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Binghe Xu
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China.
| | - Jiayu Wang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China.
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Dipasquale A, Barigazzi C, Losurdo A, Persico P, Di Muzio A, Navarria P, Pessina F, van den Bent M, Santoro A, Simonelli M. Brain metastases and next-generation anticancer therapies: a survival guide for clinicians. Crit Rev Oncol Hematol 2024; 194:104239. [PMID: 38128629 DOI: 10.1016/j.critrevonc.2023.104239] [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: 09/04/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023] Open
Abstract
Historically, patients with brain metastases (BMs) have been characterized by few systemic treatment options and poor prognosis. The recent introduction of next-generation anticancer therapies such as molecular targeted agents and immunotherapy have revolutionized the clinical decision-making process of this sub-population, posing new challenges to physicians. In this review, current evidence for the use of checkpoint inhibitors and targeted therapies in patients with BMs are discussed, with a focus on lung cancer, breast cancer, melanoma and renal cell carcinoma, providing suggestions and potential workflows for daily clinical practice. Several other on-going and future challenges, such as clinical trials design, ways to improve CNS penetration of novel drugs and unique molecular characteristics of BMs, are also discussed. The aim is producing an updated and easy-to-read guide for physicians, to improve decision-making in clinical practice.
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Affiliation(s)
- Angelo Dipasquale
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Chiara Barigazzi
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Agnese Losurdo
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Pasquale Persico
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Antonio Di Muzio
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Piera Navarria
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Federico Pessina
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Armando Santoro
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Matteo Simonelli
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
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25
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Averbuch I, Tschernichovsky R, Yust-Katz S, Rotem O, Limon D, Kurman N, Icht O, Reinhorn D, Moskovitz M, Hanovich E, Benouaich-Amiel A, Siegal T, Zer A, Gal O. Converging survival trends in non-small cell lung cancer patients with and without brain metastasis receiving state-of-the-art treatment. J Neurooncol 2024; 166:461-469. [PMID: 38324192 PMCID: PMC10876498 DOI: 10.1007/s11060-024-04562-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 01/02/2024] [Indexed: 02/08/2024]
Abstract
INTRODUCTION Historically, patients with brain metastasis (BM) have been excluded from clinical trials investigating treatments for non-small cell lung cancer (NSCLC) due to their unfavorable prognosis. Advanced treatments have increased survival prospects for NSCLC patients with BM. This study evaluated the life expectancy of NSCLC patients with and without BM in the context of contemporary treatments. METHODS Outcome data were collected for patients with advanced NSCLC attending a tertiary medical center between 2015 and 2020. Patients were stratified according to BM status and compared for overall survival (OS) using log-rank and Cox regression analyses. RESULTS The cohort included 360 patients with NSCLC of whom 134 (37.2%) had BM. Most (95%) of cases of BM developed within the first two years: 63% at diagnosis, 18% during the first year, 14% during the second year. There was no significant difference in OS between patients without BM and those with BM (median 23.7 vs. 22.3 months, HR = 0.97, p = 0.82); patients with BM and a targetable or non-targetable mutation (40.2 vs. 31.4 months, HR = 0.93, p = 0.84, and 20.7 vs. 19.87 months, HR = 0.95, p = 0.75, respectively); and patients with symptomatic BM (23.7 vs. 19.8 months, HR = 0.95, p = 0.78). Treatment for BM (95% of patients) consisted of stereotactic radiosurgery or tyrosine kinase inhibitors, with corresponding intracranial control rates of 90% and 86%. CONCLUSION The results imply that the presence of BM has no impact on the prognosis of NSCLC. The practice of excluding NSCLC patients with BM from clinical trials warrants reconsideration.
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Affiliation(s)
- Itamar Averbuch
- Davidoff Cancer Center, Rabin Medical Center- Beilinson Hospital, 39 Jabotinsky St, Petach Tikva, 4941492, Israel.
- Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel.
| | - Roi Tschernichovsky
- Davidoff Cancer Center, Rabin Medical Center- Beilinson Hospital, 39 Jabotinsky St, Petach Tikva, 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Shlomit Yust-Katz
- Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
- Neuro-Oncology Unit, Davidoff Cancer Center at Rabin Medical Center, Petach Tikva, 4941492, Israel
| | - Ofer Rotem
- Davidoff Cancer Center, Rabin Medical Center- Beilinson Hospital, 39 Jabotinsky St, Petach Tikva, 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
| | - Dror Limon
- Davidoff Cancer Center, Rabin Medical Center- Beilinson Hospital, 39 Jabotinsky St, Petach Tikva, 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
| | - Noga Kurman
- Davidoff Cancer Center, Rabin Medical Center- Beilinson Hospital, 39 Jabotinsky St, Petach Tikva, 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
| | - Oded Icht
- Davidoff Cancer Center, Rabin Medical Center- Beilinson Hospital, 39 Jabotinsky St, Petach Tikva, 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
| | - Daniel Reinhorn
- Davidoff Cancer Center, Rabin Medical Center- Beilinson Hospital, 39 Jabotinsky St, Petach Tikva, 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
| | - Mor Moskovitz
- Davidoff Cancer Center, Rabin Medical Center- Beilinson Hospital, 39 Jabotinsky St, Petach Tikva, 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
| | - Ekaterina Hanovich
- Davidoff Cancer Center, Rabin Medical Center- Beilinson Hospital, 39 Jabotinsky St, Petach Tikva, 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
| | - Alexandra Benouaich-Amiel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
- Neuro-Oncology Unit, Davidoff Cancer Center at Rabin Medical Center, Petach Tikva, 4941492, Israel
| | - Tali Siegal
- Neuro-Oncology Unit, Davidoff Cancer Center at Rabin Medical Center, Petach Tikva, 4941492, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Alona Zer
- Fishman Oncology Institute, Rambam Health Care Campus, Haifa, Israel
| | - Omer Gal
- Davidoff Cancer Center, Rabin Medical Center- Beilinson Hospital, 39 Jabotinsky St, Petach Tikva, 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
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Harrison RA, Tang M, Shih KK, Khan M, Pham L, De Moraes AR, O'Brien BJ, Bassett R, Bruera E. Characterization of patients with brain metastases referred to palliative care. BMC Palliat Care 2024; 23:13. [PMID: 38212765 PMCID: PMC10782691 DOI: 10.1186/s12904-023-01320-3] [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: 01/04/2023] [Accepted: 12/04/2023] [Indexed: 01/13/2024] Open
Abstract
PURPOSE In this study, we aimed to assess the clinical characteristics, reasons for referral, and outcomes of patients with brain metastases (BM) referred to the supportive care center. METHODS Equal numbers of patients with melanoma, breast cancer, and lung cancer with (N = 90) and without (N = 90) BM were retrospectively identified from the supportive care database for study. Descriptive statistics were used to analyze demographic, disease, and clinical data. Kaplan Meier method was used to evaluate survival outcomes. RESULTS While physical symptom management was the most common reason for referral to supportive care for both patients with and without BM, patients with BM had significantly lower pain scores on ESAS at time of referral (p = 0.002). They had greater interaction with acute care in the last weeks of life, with higher rates of ICU admission, emergency room visits, and hospitalizations after initial supportive care (SC) visit. The median survival time from referral to Supportive Care Center (SCC) was 0.90 years (95% CI 0.73, 1.40) for the brain metastasis group and 1.29 years (95% CI 0.91, 2.29) for the group without BM. CONCLUSIONS Patients with BM have shorter survival and greater interaction with acute care in the last weeks of life. This population also has distinct symptom burdens from patients without BM. Strategies to optimize integration of SC for patients with BM warrant ongoing study.
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Affiliation(s)
- Rebecca A Harrison
- Division of Neurology, BC Cancer, The University of British Columbia, Vancouver, BC, Canada.
| | - Michael Tang
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kaoswi Karina Shih
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria Khan
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lily Pham
- Department of Neurology, University of Maryland School or Medicine, Baltimore, MD, USA
| | - Aline Rozman De Moraes
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Barbara J O'Brien
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roland Bassett
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Goldberg M, Mondragon-Soto MG, Altawalbeh G, Baumgart L, Gempt J, Bernhardt D, Combs SE, Meyer B, Aftahy AK. Enhancing outcomes: neurosurgical resection in brain metastasis patients with poor Karnofsky performance score - a comprehensive survival analysis. Front Oncol 2024; 13:1343500. [PMID: 38269027 PMCID: PMC10806166 DOI: 10.3389/fonc.2023.1343500] [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: 11/23/2023] [Accepted: 12/21/2023] [Indexed: 01/26/2024] Open
Abstract
Background A reduced Karnofsky performance score (KPS) often leads to the discontinuation of surgical and adjuvant therapy, owing to a lack of evidence of survival and quality of life benefits. This study aimed to examine the clinical and treatment outcomes of patients with KPS < 70 after neurosurgical resection and identify prognostic factors associated with better survival. Methods Patients with a preoperative KPS < 70 who underwent surgical resection for newly diagnosed brain metastases (BM) between 2007 and 2020 were retrospectively analyzed. The KPS, age, sex, tumor localization, cumulative tumor volume, number of lesions, extent of resection, prognostic assessment scores, adjuvant radiotherapy and systemic therapy, and presence of disease progression were analyzed. Univariate and multivariate logistic regression analyses were performed to determine the factors associated with better survival. Survival > 3 months was considered favorable and ≤ 3 months as poor. Results A total of 140 patients were identified. Median overall survival was 5.6 months (range 0-58). There was no difference in the preoperative KPS between the groups of > 3 and ≤ 3 months (50; range, 20-60 vs. 50; range, 10-60, p = 0.077). There was a significant improvement in KPS after surgery in patients with a preoperative KPS of 20% (20 vs 40 ± 20, p = 0.048). In the other groups, no significant changes in KPS were observed. Adjuvant radiotherapy was associated with better survival (44 [84.6%] vs. 32 [36.4%]; hazard ratio [HR], 0.0363; confidence interval [CI], 0.197-0.670, p = 0.00199). Adjuvant chemotherapy and immunotherapy resulted in prolonged survival (24 [46.2%] vs. 12 [13.6%]; HR 0.474, CI 0.263-0.854, p = 0.013]. Systemic disease progression was associated with poor survival (36 [50%] vs. 71 [80.7%]; HR 5.975, CI 2.610-13.677, p < 0.001]. Conclusion Neurosurgical resection is an appropriate treatment modality for patients with low KPS. Surgery may improve functional status and facilitate further tumor-specific treatment. Combined treatment with adjuvant radiotherapy and systemic therapy was associated with improved survival in this cohort of patients. Systemic tumor progression has been identified as an independent factor for a poor prognosis. There is almost no information regarding surgical and adjuvant treatment in patients with low KPS. Our paper provides novel data on clinical outcome and survival analysis of patients with BM who underwent surgical treatment.
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Affiliation(s)
- Maria Goldberg
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Michel G. Mondragon-Soto
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Ghaith Altawalbeh
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Lea Baumgart
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- Department of Radiation Sciences (DRS), Helmholtz Zentrum Munich, Institute of Innovative Radiotherapy (iRT), Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Amir Kaywan Aftahy
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
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Goldberg M, Mondragon-Soto MG, Dieringer L, Altawalbeh G, Pöser P, Baumgart L, Wiestler B, Gempt J, Meyer B, Aftahy AK. Navigating Post-Operative Outcomes: A Comprehensive Reframing of an Original Graded Prognostic Assessment in Patients with Brain Metastases. Cancers (Basel) 2024; 16:291. [PMID: 38254781 PMCID: PMC10813622 DOI: 10.3390/cancers16020291] [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: 12/19/2023] [Revised: 12/28/2023] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Graded Prognostic Assessment (GPA) has been proposed for various brain metastases (BMs) tailored to the primary histology and molecular profiles. However, it does not consider whether patients have been operated on or not and does not include surgical outcomes as prognostic factors. The residual tumor burden (RTB) is a strong predictor of overall survival. We validated the GPA score and introduced "volumetric GPA" in the largest cohort of operated patients and further explored the role of RTB as an additional prognostic factor. METHODS A total of 630 patients with BMs between 2007 and 2020 were included. The four GPA components were analyzed. The validity of the original score was assessed using Cox regression, and a modified index incorporating RTB was developed by comparing the accuracy, sensitivity, specificity, F1-score, and AUC parameters. RESULTS GPA categories showed an association with survival: age (p < 0.001, hazard ratio (HR) 2.9, 95% confidence interval (CI) 2.5-3.3), Karnofsky performance status (KPS) (p < 0.001, HR 1.3, 95% CI 1.2-1.5), number of BMs (p = 0.019, HR 1.4, 95% CI 1.1-1.8), and the presence of extracranial manifestation (p < 0.001, HR 3, 95% CI 1.6-2.5). The median survival for GPA 0-1 was 4 months; for GPA 1.5-2, it was 12 months; for GPA 2.5-3, it was 21 months; and for GPA 3.5-4, it was 38 months (p < 0.001). RTB was identified as an independent prognostic factor. A cut-off of 2 cm3 was used for further analysis, which showed a median survival of 6 months (95% CI 4-8) vs. 13 months (95% CI 11-14, p < 0.001) for patients with RTB > 2 cm3 and <2 cm3, respectively. RTB was added as an additional component for a modified volumetric GPA score. The survival rates with the modified GPA score were: GPA 0-1: 4 months, GPA 1.5-2: 7 months, GPA 2.5-3: 18 months, and GPA 3.5-4: 34 months. Both scores showed good stratification, with the new score showed a trend towards better discrimination in patients with more favorable prognoses. CONCLUSION The prognostic value of the original GPA was confirmed in our cohort of patients who underwent surgery for BM. The RTB was identified as a parameter of high prognostic significance and was incorporated into an updated "volumetric GPA". This score provides a novel tool for prognosis and clinical decision making in patients undergoing surgery. This method may be useful for stratification and patient selection for further treatment and in future clinical trials.
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Affiliation(s)
- Maria Goldberg
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University Munich, 80333 Munich, Germany; (L.D.); (G.A.); (B.M.); (A.K.A.)
| | - Michel G. Mondragon-Soto
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico City 14269, Mexico;
| | - Laura Dieringer
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University Munich, 80333 Munich, Germany; (L.D.); (G.A.); (B.M.); (A.K.A.)
| | - Ghaith Altawalbeh
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University Munich, 80333 Munich, Germany; (L.D.); (G.A.); (B.M.); (A.K.A.)
| | - Paul Pöser
- Department of Neurosurgery, Charite–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany
| | - Lea Baumgart
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Benedikt Wiestler
- Department of Neuroradiology, School of Medicine, Klinikum Rechts der Isar, Technical University Munich, 80333 Munich, Germany;
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University Munich, 80333 Munich, Germany; (L.D.); (G.A.); (B.M.); (A.K.A.)
| | - Amir Kaywan Aftahy
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University Munich, 80333 Munich, Germany; (L.D.); (G.A.); (B.M.); (A.K.A.)
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Wang TW, Chao HS, Chiu HY, Lu CF, Liao CY, Lee Y, Chen JR, Shiao TH, Chen YM, Wu YT. Radiomics of metastatic brain tumor as a predictive image biomarker of progression-free survival in patients with non-small-cell lung cancer with brain metastasis receiving tyrosine kinase inhibitors. Transl Oncol 2024; 39:101826. [PMID: 37984256 PMCID: PMC10689936 DOI: 10.1016/j.tranon.2023.101826] [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: 07/15/2023] [Revised: 10/18/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Epidermal growth factor receptor (EGFR)-targeted tyrosine kinase inhibitors (TKIs) are the first-line therapy for EGFR-mutant non-small-cell lung cancer (NSCLC). Early prediction of treatment failure in patients with brain metastases treated with EGFR-TKIs may help in making decisions for systemic drug therapy or local brain tumor control. This study examined the predictive power of the radiomics of both brain metastasis tumors and primary lung tumors. We propose a deep learning based CoxCC model based on quantitative brain magnetic resonance imaging (MRI), a prognostic index and clinical data; the model can be used to predict progression-free survival (PFS) after EGFR-TKI therapy in advanced EGFR-mutant NSCLC. METHODS This retrospective single-center study included 271 patients receiving first-line EGFR-TKI targeted therapy in 2018-2019. Among them, 72 patients who had brain metastases before receiving first-line EGFR-TKI treatment. Three radiomic features were extracted from pretreatment brain MRI images. A CoxCC model for the progression risk stratification of EGFR-TKI treatment was proposed on the basis of MRI radiomics, clinical features, and a prognostic index. We performed time-dependent PFS predictions to evaluate the performance of the CoxCC model. RESULTS The CoxCC model based on a prognostic index, clinical features, and radiomic features of brain metastasis exhibited higher performance than clinical features combined with indexes previously proposed for determining the prognosis of brain metastasis, including recursive partitioning analysis, diagnostic-specific graded prognostic assessment, graded prognostic assessment for lung cancer using molecular markers (lung-molGPA), and modified lung-molGPA, with c-index values of 0.75, 0.67, 0.66, 0.65, and 0.65, respectively. The model achieved areas under the curve of 0.88, 0.73, 0.92, and 0.90 for predicting PFS at 3, 6, 9 and 12 months, respectively. PFS significantly differed between the high- and low-risk groups (p < 0.001). CONCLUSIONS For patients with advanced-stage NSCLC with brain metastasis, MRI radiomics of brain metastases may predict PFS. The CoxCC model integrating brain metastasis radiomics, clinical features, and a prognostic index provided reliable multi-time-point PFS predictions for patients with advanced NSCLC and brain metastases receiving EGFR-TKI treatment.
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Affiliation(s)
- Ting-Wei Wang
- Institute of Biophotonics, National Yang Ming Chiao Tung University, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Heng-Sheng Chao
- Department of Chest Medicine, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Hwa-Yen Chiu
- Institute of Biophotonics, National Yang Ming Chiao Tung University, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Chest Medicine, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Chia-Feng Lu
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Yi Liao
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen Lee
- Institute of Biophotonics, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jyun-Ru Chen
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tsu-Hui Shiao
- Department of Chest Medicine, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Yuh-Min Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Chest Medicine, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Yu-Te Wu
- Institute of Biophotonics, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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30
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Smith EJ, Naik A, Goel M, Wen PY, Lim M, Chang SM, Germano IM. Adult neuro-oncology trials in the United States over 5 decades: Analysis of trials completion rate to guide the path forward. Neurooncol Adv 2024; 6:vdad169. [PMID: 38312230 PMCID: PMC10838133 DOI: 10.1093/noajnl/vdad169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background Clinical trials are important to close the gap between therapeutic unmet needs and scientific advances in neuro-oncology. This study analyzes the landscape of neuro-oncology trials to identify completion rates and guide strategies for the path forward. Methods US-registered adult neuro-oncology clinical trials were extracted from www.clinicaltrials.gov (1966-2019), including funding source, trial type, scope, phase, and subjects' demographics. Completed trials defined as those that had completed participants' examinations or intervention administration for the purpose of the final collection of data for the primary outcome were dichotomized against those that failed to reach completion. Univariate and multivariate analyses were used to detect differences across factors comparing the last 2 decades (2000-2009, 2010-2019). Results Our search yielded 4522 trials, of which 1257 are eligible for this study. In 25 US states, neuro-oncology trial availability is <0.85/100,000 population. Comparing the past 2 decades, trial completion rate decreased from 88% to 64% (P < .001) and National Institutes of Health funding decreased from 47% to 24% (P < .001). Inclusion of subjects >65-year-old and women increased, while inclusion of Hispanic subjects decreased (P < .001). The top 2 reasons for lack of completion included accrual and operational difficulties. A larger proportion of women, non-Hispanic subjects, and older adults were enrolled in completed trials than in those that failed completion. Conclusions Our study is the first report on the neuro-oncology clinical trial landscape in the United States and supports the development of strategies to further improve access to these trials. Additionally, attention is needed to identify and modify other factors contributing to lack of completion.
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Affiliation(s)
- Emily J Smith
- Carle Illinois College of Medicine, Urbana, Illinois, USA
| | - Anant Naik
- Carle Illinois College of Medicine, Urbana, Illinois, USA
| | - Mahima Goel
- Carle Illinois College of Medicine, Urbana, Illinois, USA
| | - Patrick Y Wen
- Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Lim
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Susan M Chang
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Isabelle M Germano
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Chyrmang D, Devi YS, Baidya K, Singh LJ, Nongrum DL, Devi ND. A comparative study of whole brain radiotherapy with concomitant thalidomide versus whole brain radiotherapy alone in brain metastases. J Cancer Res Ther 2024; 20:255-260. [PMID: 38554330 DOI: 10.4103/jcrt.jcrt_1724_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/21/2022] [Indexed: 04/01/2024]
Abstract
BACKGROUND Brain metastasis increases morbidity and mortality in cancer patients. This study was undertaken to compare tumor response and treatment-related toxicities in patients treated with orally administered thalidomide concomitantly with whole brain radiotherapy to whole brain radiotherapy alone in brain metastases. METHODS This randomized control trial was conducted in radiation oncology department, RIMS among 42 patients of brain metastases distributed in two study arms during the period August 2018 to July 2020. Twenty patients in Arm-A received whole brain radiotherapy to a dose of 3,750 cGy in 15 fractions with concomitant oral thalidomide 200 mg daily in first week and 400 mg/day from second week of radiation onward till the end of radiotherapy, whereas 20 patients of Arm-B received whole brain radiation of 3,750 cGy in 15 fractions alone. RESULTS Patient characteristics were comparable. Median central nervous system progression free survival was 2 months for Arm-A and 3 months for Arm-B, whereas median overall survival study was 4 months for Arm-A and 3 months for Arm-B. Overall response rate in Arm-A was 56% and in Arm-B was 44%. Treatment-related toxicities were more in arm-A but were manageable. CONCLUSION Addition of thalidomide to whole brain radiotherapy makes no significant difference. Though not statistically significant, but still, Arm-A had shown some percentage benefits. Further studies with larger sample sizes should be done.
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Affiliation(s)
- Deiwakor Chyrmang
- Department of Radiation Oncology, NEIGRIHMS, Shillong, Meghalaya, India
| | | | - Kishalay Baidya
- Department of Radiation Oncology, RIMS, Imphal, Manipur, India
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Jia C, Xu Q, Zhao L, Kong F, Jia Y. Therapeutic role of EGFR - Tyrosine kinase inhibitors in non-small cell lung cancer with leptomeningeal metastasis. Transl Oncol 2024; 39:101832. [PMID: 38006761 PMCID: PMC10728707 DOI: 10.1016/j.tranon.2023.101832] [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: 09/14/2023] [Revised: 10/28/2023] [Accepted: 11/14/2023] [Indexed: 11/27/2023] Open
Abstract
Leptomeningeal metastasis (LM) is a significant complication that advances fast and has a poor prognosis for patients with advanced non-small cell lung cancer (NSCLC) who have epidermal growth factor receptor (EGFR) mutations. Current therapies for LM are inconsistent and ineffective, and established techniques such as radiation, chemotherapy, and surgery continue to fall short of potential outcomes. Nonetheless, EGFR tyrosine kinase inhibitors (TKIs) exhibit potent anti-tumor activity and hold considerable promise for NSCLC patients with EGFR mutations. Thus, assessing EGFR-TKIs effectiveness in treating these central nervous system (CNS) problems is crucial. This review integrates current literature on the intracranial efficacy of EGFR-TKIs to explore the varying impacts of approved EGFR-TKIs in LM patients and the therapeutic possibilities presented by other EGFR-TKIs in development. To delineate the optimal clinical treatment strategy, further exploration is needed regarding the optimal sequencing of EGFR-TKIs and the selection of alternative therapy options following initial treatment failure with EGFR-TKIs.
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Affiliation(s)
- Caiyan Jia
- Department of Oncology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300381, PR China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, PR China
| | - Qian Xu
- Department of Oncology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300381, PR China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, PR China
| | - Lu Zhao
- Department of Oncology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300381, PR China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, PR China
| | - Fanming Kong
- Department of Oncology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300381, PR China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, PR China.
| | - Yingjie Jia
- Department of Oncology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300381, PR China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, PR China.
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Wefel JS, Deshmukh S, Brown PD, Grosshans DR, Sulman EP, Cerhan JH, Mehta MP, Khuntia D, Shi W, Mishra MV, Suh JH, Laack NN, Chen Y, Curtis AA, Laba JM, Elsayed A, Thakrar A, Pugh SL, Bruner DW. Impact of Apolipoprotein E Genotype on Neurocognitive Function in Patients With Brain Metastases: An Analysis of NRG Oncology's RTOG 0614. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)08238-X. [PMID: 38101486 DOI: 10.1016/j.ijrobp.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 11/28/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE Whole-brain radiation therapy (WBRT) is a common treatment for brain metastases and is frequently associated with decline in neurocognitive functioning (NCF). The e4 allele of the apolipoprotein E (APOE) gene is associated with increased risk of Alzheimer disease and NCF decline associated with a variety of neurologic diseases and insults. APOE carrier status has not been evaluated as a risk factor for onset time or extent of NCF impairment in patients with brain metastases treated with WBRT. METHODS AND MATERIALS NRG/Radiation Therapy Oncology Group 0614 treated adult patients with brain metastases with 37.5 Gy of WBRT (+/- memantine), performed longitudinal NCF testing, and included an optional blood draw for APOE analysis. NCF test results were compared at baseline and over time with mixed-effects models. A cause-specific Cox model for time to NCF failure was performed to assess the effects of treatment arm and APOE carrier status. RESULTS APOE results were available for 45% of patients (n = 227/508). NCF did not differ by APOE e4 carrier status at baseline. Mixed-effects modeling showed that APOE e4 carriers had worse memory after WBRT compared with APOE e4 noncarriers (Hopkins Verbal Learning Test-Revised total recall [least square mean difference, 0.63; P = .0074], delayed recognition [least square mean difference, 0.75; P = .023]). However, APOE e4 carrier status was not associated with time to NCF failure (hazard ratio, 0.86; 95% CI, 0.60-1.23; P = .40). Memantine delayed the time to NCF failure, regardless of carrier status (hazard ratio, 0.72; 95% CI, 0.52-1.01; P = .054). CONCLUSIONS APOE e4 carriers with brain metastases exhibited greater decline in learning and memory, executive function, and the Clinical Trial Battery Composite score after treatment with WBRT (+/- memantine), without acceleration of onset of difference in time to NCF failure.
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Affiliation(s)
- Jeffrey S Wefel
- University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Snehal Deshmukh
- NRG Oncology Statistics and Data Management Center/American College of Radiology, Philadelphia, Pennsylvania
| | | | | | - Erik P Sulman
- Laura and Isaac Perlmutter Cancer Center, New York University Langone, New York, New York
| | | | - Minesh P Mehta
- Baptist Hospital of Miami and Florida International University, Miami, Florida
| | | | - Wenyin Shi
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Mark V Mishra
- University of Maryland Medical Systems, Baltimore, Maryland
| | - John H Suh
- Cleveland Clinic Foundation, Cleveland, Ohio
| | | | | | - Amarinthia Amy Curtis
- Spartanburg Medical Center, Accruals for Upstate Carolina NCORP-Gibbs Regional Cancer Center, Spartanburg, South Carolina
| | - Joanna M Laba
- London Regional Cancer Program, Accruals for University of Western Ontario, London, Ontario, Canada
| | - Ahmed Elsayed
- Toledo Community Hospital Oncology Program CCOP, Toledo, Ohio
| | - Anu Thakrar
- John H. Stroger Jr Hospital of Cook County MBCCOP, Chicago, Illinois
| | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center/American College of Radiology, Philadelphia, Pennsylvania
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Khalaveh F, Cho A, Shaltout A, Untersteiner H, Kranawetter B, Hirschmann D, Göbl P, Marik W, Gatterbauer B, Rössler K, Dorfer C, Frischer JM. Concomitant radiosurgical and targeted oncological treatment improves the outcome of patients with brain metastases from gastrointestinal cancer. Radiat Oncol 2023; 18:197. [PMID: 38071299 PMCID: PMC10710706 DOI: 10.1186/s13014-023-02383-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND So far, only limited studies exist that evaluate patients with brain metastases (BM) from GI cancer and associated primary cancers who were treated by Gamma Knife Radiosurgery (GKRS) and concomitant immunotherapy (IT) or targeted therapy (TT). METHODS Survival after GKRS was compared to the general and specific Graded Prognostic Assessment (GPA) and Score Index for Radiosurgery (SIR). Further, the influence of age, sex, Karnofsky Performance Status Scale (KPS), extracranial metastases (ECM) status at BM diagnosis, number of BM, the Recursive Partitioning Analysis (RPA) classes, GKRS1 treatment mode and concomitant treatment with IT or TT on the survival after GKRS was analyzed. Moreover, complication rates after concomitant GKRS and mainly TT treatment are reported. RESULTS Multivariate Cox regression analysis revealed IT or TT at or after the first Gamma Knife Radiosurgery (GKRS1) treatment as the only significant predictor for overall survival after GKRS1, even after adjusting for sex, KPS group, age group, number of BM at GKRS1, RPA class, ECM status at BM diagnosis and GKRS treatment mode. Concomitant treatment with IT or TT did not increase the rate of adverse radiation effects. There was no significant difference in local BM progression after GKRS between patients who received IT or TT and patients without IT or TT. CONCLUSION Good local tumor control rates and low rates of side effects demonstrate the safety and efficacy of GKRS in patients with BM from GI cancers. The concomitant radiosurgical and targeted oncological treatment significantly improves the survival after GKRS without increasing the rate of adverse radiation effects. To provide local tumor control, radiosurgery remains of utmost importance in modern GI BM management.
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Affiliation(s)
- Farjad Khalaveh
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Anna Cho
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Abdallah Shaltout
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Helena Untersteiner
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Beate Kranawetter
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Dorian Hirschmann
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Philipp Göbl
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Wolfgang Marik
- Department of Radiology, Division of Neuro- and Musculoskeletal Radiology, Medical University of Vienna, Vienna, Austria
| | - Brigitte Gatterbauer
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Karl Rössler
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Christian Dorfer
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Josa M Frischer
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria.
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Ribeiro LM, Bomtempo FF, Rocha RB, Telles JPM, Neto EB, Figueiredo EG. Development and adaptations of the Graded Prognostic Assessment (GPA) scale: a systematic review. Clin Exp Metastasis 2023; 40:445-463. [PMID: 37819546 DOI: 10.1007/s10585-023-10237-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023]
Abstract
The Graded Prognostic Assessment (GPA) score has the best accuracy among prognostic scales for patients with brain metastases (BM). A wide range of GPA-derived scales have been established to different types of primary tumor BM. However, there is a high variability between them, and their characteristics have not been described altogether yet. We aim to summarize the features of the existent GPA-derived scales and to compare their predictor factors and their uses in clinical setting. Medline was searched from inception until January 2023 to identify studies related to the development, update, or validation of GPA. The initial search yielded 1,083 results. 16 original studies and 16 validation studies were included, comprising a total of 33,348 patients. 13 different scales were assessed, including: GPA, Diagnosis-Specific GPA, Extracranial Score, Lung-molGPA, Updated Renal GPA, Updated Gastrointestinal GPA, Modified Breast GPA, Integrated Melanoma GPA, Melanoma Mol GPA, Sarcoma GPA, Hepatocellular Carcinoma GPA, Colorectal Cancer GPA, and Uterine Cancer GPA. The most prevalent prognostic predictors were age, Karnofsky Performance Status, number of BM, and presence or absence of extracranial metastases. Treatment modalities consisted of whole brain radiation therapy, stereotactic radiosurgery, surgery, cranial radiotherapy, gamma knife radiosurgery, and BRAF inhibitor therapy. Median survival rates with no treatment and with a specific treatment ranged from 6.1 weeks to 33 months and from 3.1 to 21 months, respectively. Original GPA and GPA-derived scales are valid prognostic tools, but with heterogeneous survival results when compared to each other. More studies are needed to improve scientific evidence of these scales.
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Affiliation(s)
| | | | | | | | - Eliseu Becco Neto
- Division of Neurosurgery, University of São Paulo, São Paulo, Brazil
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Bellur S, Khosla AA, Ozair A, Kotecha R, McDermott MW, Ahluwalia MS. Management of Brain Metastases: A Review of Novel Therapies. Semin Neurol 2023; 43:845-858. [PMID: 38011864 DOI: 10.1055/s-0043-1776782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Brain metastases (BMs) represent the most common intracranial tumors in adults, and most commonly originate from lung, followed by breast, melanoma, kidney, and colorectal cancer. Management of BM is individualized based on the size and number of brain metastases, the extent of extracranial disease, the primary tumor subtype, neurological symptoms, and prior lines of therapy. Until recently, treatment strategies were limited to local therapies, like surgical resection and radiotherapy, the latter in the form of whole-brain radiotherapy or stereotactic radiosurgery. The next generation of local strategies includes laser interstitial thermal therapy, magnetic hyperthermic therapy, post-resection brachytherapy, and focused ultrasound. New targeted therapies and immunotherapies with documented intracranial activity have transformed clinical outcomes. Novel systemic therapies with intracranial utility include new anaplastic lymphoma kinase inhibitors like brigatinib and ensartinib; selective "rearranged during transfection" inhibitors like selpercatinib and pralsetinib; B-raf proto-oncogene inhibitors like encorafenib and vemurafenib; Kirsten rat sarcoma viral oncogene inhibitors like sotorasib and adagrasib; ROS1 gene rearrangement (ROS1) inhibitors, anti-neurotrophic tyrosine receptor kinase agents like larotrectinib and entrectinib; anti-human epidermal growth factor receptor 2/epidermal growth factor receptor exon 20 agent like poziotinib; and antibody-drug conjugates like trastuzumab-emtansine and trastuzumab-deruxtecan. This review highlights the modern multidisciplinary management of BM, emphasizing the integration of systemic and local therapies.
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Affiliation(s)
- Shreyas Bellur
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | | | - Ahmad Ozair
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Rupesh Kotecha
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Michael W McDermott
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida
| | - Manmeet S Ahluwalia
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
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Cuthbert H, Riley M, Bhatt S, Au-Yeung CK, Arshad A, Eladawi S, Zisakis A, Tsermoulas G, Watts C, Wykes V. Utility of a prognostic assessment tool to predict survival following surgery for brain metastases. Neurooncol Pract 2023; 10:586-591. [PMID: 38026583 PMCID: PMC10666803 DOI: 10.1093/nop/npad047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Background Brain metastases account for more than 50% of all intracranial tumors and are associated with poor outcomes. Treatment decisions in this highly heterogenous cohort remain controversial due to the myriad of treatment options available, and there is no clearly defined standard of care. The prognosis in brain metastasis patients varies widely with tumor type, extracranial disease burden and patient performance status. Decision-making regarding treatment is, therefore, tailored to each patient and their disease. Methods This is a retrospective cohort study assessing survival outcomes following surgery for brain metastases over a 50-month period (April 1, 2014-June 30, 2018). We compared predicted survival using the diagnosis-specific Graded Prognostic Assessment (ds-GPA) with actual survival. Results A total of 186 patients were included in our cohort. Regression analysis demonstrated no significant correlation between actual and predicted outcome. The most common reason for exclusion was insufficient information being available to the neuro-oncology multidisciplinary team (MDT) meeting to allow GPA calculation. Conclusions In this study, we demonstrate that "predicted survival" using the ds-GPA does not correlate with "actual survival" in our operated patient cohort. We also identify a shortcoming in the amount of information available at MDT in order to implement the GPA appropriately. Patient selection for aggressive therapies is crucial, and this study emphasizes the need for treatment decisions to be individualized based on patient and cancer clinical characteristics.
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Affiliation(s)
- Hadleigh Cuthbert
- Department of Neurosurgery, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, UK
| | - Max Riley
- University of Birmingham Medical School, Birmingham, UK
| | - Shreya Bhatt
- University of Birmingham Medical School, Birmingham, UK
| | | | - Ayesha Arshad
- Department of Neurosurgery, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, UK
| | - Sondos Eladawi
- Department of Neurosurgery, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, UK
| | - Athanasios Zisakis
- Department of Neurosurgery, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, UK
| | - Georgios Tsermoulas
- Department of Neurosurgery, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, UK
| | - Colin Watts
- Department of Neurosurgery, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Victoria Wykes
- Department of Neurosurgery, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
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Verheijen EJ, Taal W, Tewari RDN, Giessen MC, Roshani H. Isolated cerebellar metastasis from urothelial carcinoma: A case report of a rare phenomenon. BRAIN & SPINE 2023; 3:102716. [PMID: 38105804 PMCID: PMC10724209 DOI: 10.1016/j.bas.2023.102716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 11/18/2023] [Accepted: 11/25/2023] [Indexed: 12/19/2023]
Abstract
Introduction Although urothelial carcinoma (UC) generally is non-invasive, contrastingly in 25% of patients UC metastasizes. Isolated central nervous system (CNS) metastasis from UC without other distant metastases are considered rare. In this report we describe a patient with an isolated and solitary cerebellar metastasis from UC. Research question In this case report we explore the value of histological analysis of CNS metastases, imaging, treatment options and survival. Material and methods A rare case is presented of a patient diagnosed with an isolated CNS metastasis originating from UC. Through a systematic review of literature route of dissemination, current imaging and treatment options, and survival are discussed. Results A 77-year-old male was diagnosed with a pT2N0M0 high-grade UC and treated with transurethral resection and chemoradiation therapy. Several months later, the patient presented with neurological symptoms, and radiological imaging revealed a solitary cerebellar mass. A body CT scan showed no other metastasis. After surgical resection, histology confirmed urothelial origin of the mass, matching his primary UC and the patient received post-operative stereotactic radiotherapy at the surgical site. Recurrence of the cerebellar mass occurred after 6 months for which the patient received re-resection. The patient died 5.5 months after re-resection. Discussion and conclusion Isolated brain metastases without other distant metastases from UC are rare, so histologic confirmation of the brain metastasis is essential, particularly when the time interval between diagnosis of the UC and brain metastasis increases. Early brain CT is not recommended. PET CT may have additional value in detection of other distant metastases from UC. Despite advancements in treatments, prognosis for CNS metastasis from UC remains poor.
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Affiliation(s)
| | - Walter Taal
- Neurology, Haga Teaching Hospital, The Hague, the Netherlands
- Department of Neurology/Neuro-Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | | | - Hossain Roshani
- Departments of Urology, Haga Teaching Hospital, The Hague, the Netherlands
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DeVries DA, Tang T, Albweady A, Leung A, Laba J, Johnson C, Lagerwaard F, Zindler J, Hajdok G, Ward AD. Predicting stereotactic radiosurgery outcomes with multi-observer qualitative appearance labelling versus MRI radiomics. Sci Rep 2023; 13:20977. [PMID: 38017055 PMCID: PMC10684869 DOI: 10.1038/s41598-023-47702-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 11/17/2023] [Indexed: 11/30/2023] Open
Abstract
Qualitative observer-based and quantitative radiomics-based analyses of T1w contrast-enhanced magnetic resonance imaging (T1w-CE MRI) have both been shown to predict the outcomes of brain metastasis (BM) stereotactic radiosurgery (SRS). Comparison of these methods and interpretation of radiomics-based machine learning (ML) models remains limited. To address this need, we collected a dataset of n = 123 BMs from 99 patients including 12 clinical features, 107 pre-treatment T1w-CE MRI radiomic features, and BM post-SRS progression scores. A previously published outcome model using SRS dose prescription and five-way BM qualitative appearance scoring was evaluated. We found high qualitative scoring interobserver variability across five observers that negatively impacted the model's risk stratification. Radiomics-based ML models trained to replicate the qualitative scoring did so with high accuracy (bootstrap-corrected AUC = 0.84-0.94), but risk stratification using these replicated qualitative scores remained poor. Radiomics-based ML models trained to directly predict post-SRS progression offered enhanced risk stratification (Kaplan-Meier rank-sum p = 0.0003) compared to using qualitative appearance. The qualitative appearance scoring enabled interpretation of the progression radiomics-based ML model, with necrotic BMs and a subset of heterogeneous BMs predicted as being at high-risk of post-SRS progression, in agreement with current radiobiological understanding. Our study's results show that while radiomics-based SRS outcome models out-perform qualitative appearance analysis, qualitative appearance still provides critical insight into ML model operation.
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Affiliation(s)
- David A DeVries
- Department of Medical Biophysics, Western University, London, N6A 3K7, Canada.
- Gerald C. Baines Centre, London Health Sciences Centre, London, N6A 5W9, Canada.
| | - Terence Tang
- Department of Radiation Oncology, London Health Sciences Centre, London, N6A 5W9, Canada
| | - Ali Albweady
- Department of Radiology, Unaizah College of Medicine and Medical Sciences, Qassim University, 56219, Buraidah, Saudi Arabia
| | - Andrew Leung
- Department of Medical Imaging, Western University, London, N6A 3K7, Canada
| | - Joanna Laba
- Department of Radiation Oncology, London Health Sciences Centre, London, N6A 5W9, Canada
- Department of Oncology, Western University, London, N6A 3K7, Canada
| | - Carol Johnson
- Gerald C. Baines Centre, London Health Sciences Centre, London, N6A 5W9, Canada
| | - Frank Lagerwaard
- Department of Radiation Oncology, Amsterdam University Medical Centre, Amsterdam, 1081, The Netherlands
| | - Jaap Zindler
- Department of Radiation Oncology, Haaglanden Medical Centre, Den Hague, 2512VA, The Netherlands
- Holland Proton Centre, Delft, 2629JA, The Netherlands
| | - George Hajdok
- Department of Medical Biophysics, Western University, London, N6A 3K7, Canada
| | - Aaron D Ward
- Department of Medical Biophysics, Western University, London, N6A 3K7, Canada
- Gerald C. Baines Centre, London Health Sciences Centre, London, N6A 5W9, Canada
- Department of Oncology, Western University, London, N6A 3K7, Canada
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Fantin J, Toutain J, Pérès EA, Bernay B, Mehani SM, Helaine C, Bourgeois M, Brunaud C, Chazalviel L, Pontin J, Corroyer-Dulmont A, Valable S, Cherel M, Bernaudin M. Assessment of hypoxia and oxidative-related changes in a lung-derived brain metastasis model by [ 64Cu][Cu(ATSM)] PET and proteomic studies. EJNMMI Res 2023; 13:102. [PMID: 38006431 PMCID: PMC10676347 DOI: 10.1186/s13550-023-01052-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/19/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND Brain metastases (BM) are the most frequent malignant brain tumors. The aim of this study was to characterize the tumor microenvironment (TME) of BM and particularly hypoxia and redox state, known to play a role in tumor growth and treatment resistance with multimodal PET and MRI imaging, immunohistochemical and proteomic approaches in a human lung cancer (H2030-BrM3)-derived BM model in rats. RESULTS First, in vitro studies confirmed that H2030-BrM3 cells respond to hypoxia with increasing expression of HIF-1, HIF-2 and their target genes. Proteomic analyses revealed, among expression changes, proteins associated with metabolism, oxidative stress, metal response and hypoxia signaling in particular in cortical BM. [64Cu][Cu(ATSM)] PET revealed a significant uptake by cortical BM (p < 0.01), while no uptake is observed in striatal BM 23 days after tumor implantation. Pimonidazole, HIF-1α, HIF-2α, CA-IX as well as GFAP, CTR1 and DMT1 immunostainings are positive in both BM. CONCLUSION Overall, [64Cu][Cu(ATSM)] imaging and proteomic results showed the presence of hypoxia and protein expression changes linked to hypoxia and oxidative stress in BM, which are more pronounced in cortical BM compared to striatal BM. Moreover, it emphasized the interest of [64Cu][Cu(ATSM)] PET to characterize TME of BM and depict inter-metastasis heterogeneity that could be useful to guide treatments.
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Affiliation(s)
- Jade Fantin
- Université de Caen Normandie, CNRS, Normandie Univ., ISTCT UMR6030, GIP CYCERON, F-14000, Caen, France
| | - Jérôme Toutain
- Université de Caen Normandie, CNRS, Normandie Univ., ISTCT UMR6030, GIP CYCERON, F-14000, Caen, France
| | - Elodie A Pérès
- Université de Caen Normandie, CNRS, Normandie Univ., ISTCT UMR6030, GIP CYCERON, F-14000, Caen, France
| | - Benoit Bernay
- Université de Caen Normandie, Normandie Univ., US EMerode, Plateforme Proteogen, F-14000, Caen, France
| | - Sarina Maya Mehani
- Université de Caen Normandie, CNRS, Normandie Univ., ISTCT UMR6030, GIP CYCERON, F-14000, Caen, France
| | - Charly Helaine
- Université de Caen Normandie, CNRS, Normandie Univ., ISTCT UMR6030, GIP CYCERON, F-14000, Caen, France
| | - Mickael Bourgeois
- CRCI2NA, INSERM UMR1307, CNRS-ERL6075, Université d'Angers, Université de Nantes, F-44000, Nantes, France
- GIP ARRONAX, F-44800, Saint-Herblain, France
| | - Carole Brunaud
- Université de Caen Normandie, CNRS, Normandie Univ., ISTCT UMR6030, GIP CYCERON, F-14000, Caen, France
| | - Laurent Chazalviel
- Université de Caen Normandie, CNRS, Normandie Univ., ISTCT UMR6030, GIP CYCERON, F-14000, Caen, France
| | - Julien Pontin
- Université de Caen Normandie, Normandie Univ., US EMerode, Plateforme Proteogen, F-14000, Caen, France
| | - Aurélien Corroyer-Dulmont
- Université de Caen Normandie, CNRS, Normandie Univ., ISTCT UMR6030, GIP CYCERON, F-14000, Caen, France
- Medical Physics Department, CLCC François Baclesse, F-14000, Caen, France
| | - Samuel Valable
- Université de Caen Normandie, CNRS, Normandie Univ., ISTCT UMR6030, GIP CYCERON, F-14000, Caen, France
| | - Michel Cherel
- CRCI2NA, INSERM UMR1307, CNRS-ERL6075, Université d'Angers, Université de Nantes, F-44000, Nantes, France
- GIP ARRONAX, F-44800, Saint-Herblain, France
| | - Myriam Bernaudin
- Université de Caen Normandie, CNRS, Normandie Univ., ISTCT UMR6030, GIP CYCERON, F-14000, Caen, France.
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Burney IA, Aal Hamad AH, Hashmi SFA, Ahmad N, Pervez N. Evolution of the Management of Brain Metastases: A Bibliometric Analysis. Cancers (Basel) 2023; 15:5570. [PMID: 38067273 PMCID: PMC10705608 DOI: 10.3390/cancers15235570] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/03/2023] [Accepted: 11/10/2023] [Indexed: 05/04/2024] Open
Abstract
A systematic review of the published literature was conducted to analyze the management evolution of brain metastases from different cancers. Using the keywords "brain metastasis", "brain metastases", "CNS metastasis", "CNS metastases", "phase III" AND/OR "Randomized Controlled Trial" (RCT), relevant articles were searched for on the SCOPUS database. A total of 1986 articles were retrieved, published over a 45-year period (1977-2022). Relevant articles were defined as clinical studies describing the treatment or prevention of brain metastases from any cancer. Articles on imaging, quality of life, cognitive impairment after treatment, or primary brain tumors were excluded. After a secondary analysis, reviewing the abstracts and/or full texts, 724 articles were found to be relevant. Publications significantly increased in the last 10 years. A total of 252 articles (34.8%) were published in 12 core journals, receiving 50% of the citations. The number of publications in Frontiers in Oncology, BMC Cancer, and Radiotherapy and Oncology have increased considerably over the last few years. There were 111 randomized controlled trials, 128 review articles, and 63 meta-analyses. Most randomized trials reported on brain metastases management from unselected tumors (49), lung cancer (47), or breast cancer (11). In the last 5 years (2017 to 2022), management of brain metastasis has moved on from WBRT, the use of chemotherapy, and radio-sensitization to three directions. First, Radiosurgery or Radiotherapy (SRS/SRT), or hippocampal-sparing WBRT is employed to reduce radiation toxicity. Second, it has moved to the use of novel agents, such as tyrosine kinase inhibitors (TKI) and immune checkpoint inhibitors (ICI) and third, to the use of molecularly directed therapy such as TKIs, in asymptomatic low volume metastasis, obviating the need for WBRT.
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Affiliation(s)
- Ikram A. Burney
- Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat 123, Oman; (I.A.B.); (S.F.A.H.)
- Panjwani Center for Molecular Medicine & Drug Research, International Center of Chemical and Biological Sciences, Karachi University, Karachi 75270, Pakistan
| | | | - Syed F. A. Hashmi
- Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat 123, Oman; (I.A.B.); (S.F.A.H.)
| | - Nisar Ahmad
- Department of Economics and Finance, College of Economics and Political Science, Sultan Qaboos University, Muscat 123, Oman;
| | - Nadeem Pervez
- Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat 123, Oman; (I.A.B.); (S.F.A.H.)
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Schnurman Z, Mashiach E, Link KE, Donahue B, Sulman E, Silverman J, Golfinos JG, Oermann EK, Kondziolka D. Causes of Death in Patients With Brain Metastases. Neurosurgery 2023; 93:986-993. [PMID: 37255296 DOI: 10.1227/neu.0000000000002542] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/04/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Advances in targeted therapies and wider application of stereotactic radiosurgery (SRS) have redefined outcomes of patients with brain metastases. Under modern treatment paradigms, there remains limited characterization of which aspects of disease drive demise and in what frequencies. This study aims to characterize the primary causes of terminal decline and evaluate differences in underlying intracranial tumor dynamics in patients with metastatic brain cancer. These fundamental details may help guide management, patient counseling, and research priorities. METHODS Using NYUMets-Brain-the largest, longitudinal, real-world, open data set of patients with brain metastases-patients treated at New York University Langone Health between 2012 and 2021 with SRS were evaluated. A review of electronic health records allowed for the determination of a primary cause of death in patients who died during the study period. Causes were classified in mutually exclusive, but collectively exhaustive, categories. Multilevel models evaluated for differences in dynamics of intracranial tumors, including changes in volume and number. RESULTS Of 439 patients with end-of-life data, 73.1% died secondary to systemic disease, 10.3% died secondary to central nervous system (CNS) disease, and 16.6% died because of other causes. CNS deaths were driven by acute increases in intracranial pressure (11%), development of focal neurological deficits (18%), treatment-resistant seizures (11%), and global decline driven by increased intracranial tumor burden (60%). Rate of influx of new intracranial tumors was almost twice as high in patients who died compared with those who survived ( P < .001), but there was no difference in rates of volume change per intracranial tumor ( P = .95). CONCLUSION Most patients with brain metastases die secondary to systemic disease progression. For patients who die because of neurological disease, tumor dynamics and cause of death mechanisms indicate that the primary driver of decline for many may be unchecked systemic disease with unrelenting spread of new tumors to the CNS rather than failure of local growth control.
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Affiliation(s)
- Zane Schnurman
- Department of Neurosurgery, NYU Langone Health, New York , New York , USA
| | - Elad Mashiach
- Department of Neurosurgery, NYU Langone Health, New York , New York , USA
| | - Katherine E Link
- Department of Neurosurgery, NYU Langone Health, New York , New York , USA
| | - Bernadine Donahue
- Department of Radiation Oncology, NYU Langone Health, New York , New York , USA
| | - Erik Sulman
- Department of Radiation Oncology, NYU Langone Health, New York , New York , USA
| | - Joshua Silverman
- Department of Radiation Oncology, NYU Langone Health, New York , New York , USA
| | - John G Golfinos
- Department of Neurosurgery, NYU Langone Health, New York , New York , USA
| | - Eric Karl Oermann
- Department of Neurosurgery, NYU Langone Health, New York , New York , USA
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Health, New York , New York , USA
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Alexopoulos G, Zhang J, Karampelas I, Patel M, Mercier P. Prognostics of Systemic Malignancy ICD-O Topography and Morphology Types on Brain Metastases: An NCDB Time-to-event Cohort. Am J Clin Oncol 2023; 46:475-485. [PMID: 37561070 DOI: 10.1097/coc.0000000000001034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
BACKGROUND The primary site and histology of systemic malignancy are known predictors of progression to brain metastases (BM). We investigated the combinational interactions of International Classification of Diseases for Oncology (ICD-O) primary topography and morphology types on the survival of BM after adjusting for relevant clinical and demographic prognostic factors. METHODS The cohort included all adult patients with BM at diagnosis of an invasive malignancy in the National Cancer Database (2010 to 2018). The sample consisted of 180,150 entries out of 14,279,749 cancer patients screened. A survival analysis of the topography-specific and histology-specific time to death was performed. Multivariate Cox regression revealed violations of the proportional hazard assumption for multiple covariates. Parametric models using a log-logistic distribution best described the population survival pattern. RESULTS The primary topography "prostate" and morphology "choriocarcinoma" provided the strongest survival benefit among ICD-O types, whereas BM from prostate demonstrated a 14-month median overall increase in survival probability. Favorable prognostics were BM from breast, bone/joints, and testis; also, the morphologies of carcinoid tumor, mature B-cell lymphoma, and papillary adenocarcinoma. Poor prognostics were BM from gastrointestinal (liver, biliary tree, pancreas, and gallbladder) and gynecologic malignancies. All morphologies of spindle cell carcinoma, hemangiosarcoma, undifferentiated carcinoma, Ewing sarcoma, pseudosarcomatous carcinoma, renal cell carcinoma/sarcomatoid, signet ring cell carcinoma, spindle cell sarcoma, and squamous cell carcinoma/spindle cell were associated with poor survival. CONCLUSIONS This is the largest cohort providing an unbiased estimate of the adjusted ICD-O topography and morphology effect sizes. The results can be summarized as a booklet for prognostic classification of disease in patients with BM secondary to systemic malignancy.
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Affiliation(s)
- Georgios Alexopoulos
- Department of Neurosurgery, Saint Louis University Hospital
- Graduate School of Biomedical Science and Engineering, The University of Maine, Orono, ME
| | - Justin Zhang
- School of Medicine, Saint Louis University, St. Louis, MO
| | - Ioannis Karampelas
- Department of Neurosurgery, Banner Neurological Surgery Clinic, Greeley, CO
| | - Mayur Patel
- School of Medicine, Saint Louis University, St. Louis, MO
| | - Philippe Mercier
- Department of Neurosurgery, Saint Louis University Hospital
- School of Medicine, Saint Louis University, St. Louis, MO
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Halil E, Viteva E, Vasilev G, Shukerski K, Atanassova P. Atypical clinical and radiologic findings in a patient with brain metastatic lesions. Folia Med (Plovdiv) 2023; 65:844-848. [PMID: 38351770 DOI: 10.3897/folmed.65.e84810] [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: 04/03/2022] [Accepted: 06/30/2022] [Indexed: 02/16/2024] Open
Abstract
We report the case of a 47-year-old man who was admitted to our clinic with an intractable headache, nausea, and sporadic vomiting, as well as speech difficulties and a 'floating' sensation. This man had no prior medical history. MRI of the brain showed evidence of over 20 supra- and infratentorial capsulated ring-enhancing lesions. All other paraclinical investigations done in our clinic were unremarkable and we excluded our first assumption of neurocysticercosis, as well as other parasitic infections. The patient was then referred to the Oral and Maxillofacial Surgery Clinic for an excisional biopsy of a submandibular formation, which was later verified to represent a lymph node metastasis from a poorly differentiated adenocarcinoma. A chest X-ray failed to demonstrate any significant pathology and the immunohistochemical constellation of the lymph node metastasis excluded the possibility of the primary tumor originating in the lung or the prostate. Due to the unresolved diagnostic query, a whole-body PET/CT was performed demonstrating a formation with malignant characteristics in the basal segment of the left lung, reaching the pleura and the left hilum, as well as solitary enlarged mesenteric and mediastinal lymph nodes. Following clinical consultations, it was determined that the patient was inoperable and chemotherapy and palliative CNS irradiation were recommended.
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Affiliation(s)
- Eray Halil
- St George University Hospital, Plovdiv, Bulgaria
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Rozati H, Chen J, Williams M. Overall survival following stereotactic radiosurgery for ten or more brain metastases: a systematic review and meta-analysis. BMC Cancer 2023; 23:1004. [PMID: 37858075 PMCID: PMC10585836 DOI: 10.1186/s12885-023-11452-7] [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: 12/14/2022] [Accepted: 09/26/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Brain metastases are the most common intracranial tumours. Variation exists in the use of stereotactic radiosurgery for patients with 10 or more brain metastases. Concerns include an increasing number of brain metastases being associated with poor survival, the lack of prospective, randomised data and an increased risk of toxicity. METHODS We performed a systematic review and meta-analysis to assess overall survival of patients with ten or more brain metastases treated with stereotactic radiosurgery as primary therapy. The search strings were applied to MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL). Log hazard ratios and standard errors were estimated from each included study. A random-effects meta-analysis using the DerSimonian and Laird method was applied using the derived log hazard ratios and standard errors on studies which included a control group. RESULTS 15 studies were included for systematic review. 12 studies were used for pooled analysis for overall survival at set time points, with a predicted 12 month survival of 20-40%. The random-effects meta-analysis in five studies of overall survival comparing ten or greater metastases against control showed statistically worse overall survival in the 10 + metastases group (1.10, 95% confidence interval 1.03-1.18, p-value = < 0.01, I2 = 6%). A funnel plot showed no evidence of bias. There was insufficient information for a meta-analysis of toxicity. DISCUSSION Overall survival outcomes of patients with ten or more brain metastases treated with SRS is acceptable and should not be a deterrent for its use. There is a lack of prospective data and insufficient real-world data to draw conclusions on toxicity. PROSPERO ID CRD42021246115.
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Affiliation(s)
- Hamoun Rozati
- London Gamma Knife Centre, Platinum Medical Centre, Wellington Hospital, Lodge Road, London, UK
- Computational Oncology Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jiarong Chen
- Computational Oncology Group, Department of Surgery and Cancer, Imperial College London, London, UK
- Clinical Experimental Center, Jiangmen Key Laboratory of Clinical Biobanks and Translational Research, Jiangmen Central Hospital, Jiangmen, 529030, China
| | - Matt Williams
- Computational Oncology Group, Department of Surgery and Cancer, Imperial College London, London, UK.
- Department of Radiotherapy, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK.
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Maas RR, Soukup K, Fournier N, Massara M, Galland S, Kornete M, Wischnewski V, Lourenco J, Croci D, Álvarez-Prado ÁF, Marie DN, Lilja J, Marcone R, Calvo GF, Santalla Mendez R, Aubel P, Bejarano L, Wirapati P, Ballesteros I, Hidalgo A, Hottinger AF, Brouland JP, Daniel RT, Hegi ME, Joyce JA. The local microenvironment drives activation of neutrophils in human brain tumors. Cell 2023; 186:4546-4566.e27. [PMID: 37769657 DOI: 10.1016/j.cell.2023.08.043] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 07/11/2023] [Accepted: 08/31/2023] [Indexed: 10/03/2023]
Abstract
Neutrophils are abundant immune cells in the circulation and frequently infiltrate tumors in substantial numbers. However, their precise functions in different cancer types remain incompletely understood, including in the brain microenvironment. We therefore investigated neutrophils in tumor tissue of glioma and brain metastasis patients, with matched peripheral blood, and herein describe the first in-depth analysis of neutrophil phenotypes and functions in these tissues. Orthogonal profiling strategies in humans and mice revealed that brain tumor-associated neutrophils (TANs) differ significantly from blood neutrophils and have a prolonged lifespan and immune-suppressive and pro-angiogenic capacity. TANs exhibit a distinct inflammatory signature, driven by a combination of soluble inflammatory mediators including tumor necrosis factor alpha (TNF-ɑ) and Ceruloplasmin, which is more pronounced in TANs from brain metastasis versus glioma. Myeloid cells, including tumor-associated macrophages, emerge at the core of this network of pro-inflammatory mediators, supporting the concept of a critical myeloid niche regulating overall immune suppression in human brain tumors.
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Affiliation(s)
- Roeltje R Maas
- Department of Oncology, University of Lausanne, Lausanne 1011, Switzerland; Ludwig Institute for Cancer Research, University of Lausanne, Lausanne 1011, Switzerland; Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland; L. Lundin and Family Brain Tumor Research Center, Departments of Oncology and Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland; Neuroscience Research Center, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland; Department of Neurosurgery, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland
| | - Klara Soukup
- Department of Oncology, University of Lausanne, Lausanne 1011, Switzerland; Ludwig Institute for Cancer Research, University of Lausanne, Lausanne 1011, Switzerland; Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland
| | - Nadine Fournier
- Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland; Translational Data Science Group, Swiss Institute of Bioinformatics, Lausanne 1011, Switzerland; Bioinformatics Core Facility, Swiss Institute of Bioinformatics, Lausanne 1011, Switzerland
| | - Matteo Massara
- Department of Oncology, University of Lausanne, Lausanne 1011, Switzerland; Ludwig Institute for Cancer Research, University of Lausanne, Lausanne 1011, Switzerland; Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland; L. Lundin and Family Brain Tumor Research Center, Departments of Oncology and Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland
| | - Sabine Galland
- Department of Oncology, University of Lausanne, Lausanne 1011, Switzerland; Ludwig Institute for Cancer Research, University of Lausanne, Lausanne 1011, Switzerland; Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland; L. Lundin and Family Brain Tumor Research Center, Departments of Oncology and Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland; Department of Oncology, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland
| | - Mara Kornete
- Department of Oncology, University of Lausanne, Lausanne 1011, Switzerland; Ludwig Institute for Cancer Research, University of Lausanne, Lausanne 1011, Switzerland; Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland
| | - Vladimir Wischnewski
- Department of Oncology, University of Lausanne, Lausanne 1011, Switzerland; Ludwig Institute for Cancer Research, University of Lausanne, Lausanne 1011, Switzerland; Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland; L. Lundin and Family Brain Tumor Research Center, Departments of Oncology and Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland
| | - Joao Lourenco
- Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland; Translational Data Science Group, Swiss Institute of Bioinformatics, Lausanne 1011, Switzerland
| | - Davide Croci
- Department of Oncology, University of Lausanne, Lausanne 1011, Switzerland; Ludwig Institute for Cancer Research, University of Lausanne, Lausanne 1011, Switzerland; Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland
| | - Ángel F Álvarez-Prado
- Department of Oncology, University of Lausanne, Lausanne 1011, Switzerland; Ludwig Institute for Cancer Research, University of Lausanne, Lausanne 1011, Switzerland; Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland; L. Lundin and Family Brain Tumor Research Center, Departments of Oncology and Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland
| | - Damien N Marie
- Department of Oncology, University of Lausanne, Lausanne 1011, Switzerland; Ludwig Institute for Cancer Research, University of Lausanne, Lausanne 1011, Switzerland; Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland
| | - Johanna Lilja
- Department of Oncology, University of Lausanne, Lausanne 1011, Switzerland; Ludwig Institute for Cancer Research, University of Lausanne, Lausanne 1011, Switzerland; Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland
| | - Rachel Marcone
- Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland; Translational Data Science Group, Swiss Institute of Bioinformatics, Lausanne 1011, Switzerland
| | - Gabriel F Calvo
- Department of Mathematics & MOLAB-Mathematical Oncology Laboratory, University of Castilla-La Mancha, Ciudad Real 13071, Spain
| | - Rui Santalla Mendez
- Department of Oncology, University of Lausanne, Lausanne 1011, Switzerland; Ludwig Institute for Cancer Research, University of Lausanne, Lausanne 1011, Switzerland; Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland; L. Lundin and Family Brain Tumor Research Center, Departments of Oncology and Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland
| | - Pauline Aubel
- Department of Oncology, University of Lausanne, Lausanne 1011, Switzerland; Ludwig Institute for Cancer Research, University of Lausanne, Lausanne 1011, Switzerland; Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland; L. Lundin and Family Brain Tumor Research Center, Departments of Oncology and Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland
| | - Leire Bejarano
- Department of Oncology, University of Lausanne, Lausanne 1011, Switzerland; Ludwig Institute for Cancer Research, University of Lausanne, Lausanne 1011, Switzerland; Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland; L. Lundin and Family Brain Tumor Research Center, Departments of Oncology and Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland
| | - Pratyaksha Wirapati
- Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland; Bioinformatics Core Facility, Swiss Institute of Bioinformatics, Lausanne 1011, Switzerland
| | - Iván Ballesteros
- Program of Cardiovascular Regeneration, Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid 28029, Spain
| | - Andrés Hidalgo
- Program of Cardiovascular Regeneration, Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid 28029, Spain; Vascular Biology and Therapeutics Program and Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06519, USA
| | - Andreas F Hottinger
- Department of Oncology, University of Lausanne, Lausanne 1011, Switzerland; Ludwig Institute for Cancer Research, University of Lausanne, Lausanne 1011, Switzerland; Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland; Department of Oncology, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland
| | - Jean-Philippe Brouland
- Department of Pathology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne 1011, Switzerland
| | - Roy T Daniel
- L. Lundin and Family Brain Tumor Research Center, Departments of Oncology and Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland; Department of Neurosurgery, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland
| | - Monika E Hegi
- L. Lundin and Family Brain Tumor Research Center, Departments of Oncology and Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland; Neuroscience Research Center, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland; Department of Neurosurgery, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland
| | - Johanna A Joyce
- Department of Oncology, University of Lausanne, Lausanne 1011, Switzerland; Ludwig Institute for Cancer Research, University of Lausanne, Lausanne 1011, Switzerland; Agora Cancer Research Centre Lausanne, Lausanne 1011, Switzerland; L. Lundin and Family Brain Tumor Research Center, Departments of Oncology and Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne 1011, Switzerland.
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Bander ED, El Ahmadieh TY, Chen J, Reiner AS, Brown S, Giantini-Larsen AM, Young RJ, Beal K, Imber BS, Pike LRG, Brennan CW, Tabar V, Panageas KS, Moss NS. Outcomes Following Early Postoperative Adjuvant Radiosurgery for Brain Metastases. JAMA Netw Open 2023; 6:e2340654. [PMID: 37906192 PMCID: PMC10618851 DOI: 10.1001/jamanetworkopen.2023.40654] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/19/2023] [Indexed: 11/02/2023] Open
Abstract
Importance Adjuvant stereotactic radiosurgery (SRS) enhances the local control of resected brain metastases (BrM). However, the risks of local failure (LF) and potential for posttreatment adverse radiation effects (PTRE) after early postoperative adjuvant SRS have not yet been established. Objective To evaluate whether adjuvant SRS delivered within a median of 14 days after surgery is associated with improved LF without a concomitant increase in PTRE. Design, Setting, and Participants This prospective cohort study examines a clinical workflow (RapidRT) that was implemented from 2019 to 2022 to deliver SRS to surgical patients within a median of 14 days, ensuring all patients were treated within 30 days postoperatively. This prospective cohort was compared with a historical cohort (StanRT) of patients with BrM resected between 2013 and 2019 to assess the association of the RapidRT workflow with LF and PTRE. The 2 cohorts were combined to identify optimal SRS timing, with a median follow-up of 3.3 years for survivors. Exposure Timing of adjuvant SRS (14, 21, and 30 days postoperatively). Main Outcomes and Measures LF and PTRE, according to modified Response Assessment in Neuro-Oncology Brain Metastases criteria. Results There were 438 patients (265 [60.5%] female patients; 23 [5.3%] Asian, 27 [6.2%] Black, and 364 [83.1%] White patients) with a mean (SD) age of 62 (13) years; 377 were in the StanRT cohort and 61 in the RapidRT cohort. LF and PTRE rates at 1 year were not significantly different between RapidRT and StanRT cohorts. Timing of SRS was associated with radiographic PTRE. Patients receiving radiation within 14 days had the highest 1-year PTRE rate (18.08%; 95% CI, 8.31%-30.86%), and patients receiving radiation between 22 and 30 days had the lowest 1-year PTRE rate (4.10%; 95% CI, 1.52%-8.73%; P = .03). LF rates were highest for patients receiving radiation more than 30 days from surgery (10.65%; 95% CI, 6.90%-15.32%) but comparable for patients receiving radiation within 14 days, between 15 and 21 days, and between 22 and 30 days (≤14 days: 5.12%; 95% CI, 0.86%-15.60%; 15 to ≤21 days: 3.21%; 95% CI, 0.59%-9.99%; 22 to ≤30 days: 6.58%; 95% CI, 3.06%-11.94%; P = .20). Conclusions and Relevance In this cohort study of adjuvant SRS timing following surgical resection of BrM, the optimal timing for adjuvant SRS appears to be within 22 to 30 days following surgery. The findings of this study suggest that this timing allows for a balanced approach that minimizes the risks associated with LF and PTRE.
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Affiliation(s)
- Evan D. Bander
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York
| | - Tarek Y. El Ahmadieh
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurosurgery, Loma Linda University Health, Loma Linda, California
| | - Justin Chen
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne S. Reiner
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Samantha Brown
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alexandra M. Giantini-Larsen
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York
| | - Robert J. Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- Department of Radiation Oncology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Brandon S. Imber
- Department of Radiation Oncology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luke R. G. Pike
- Department of Radiation Oncology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cameron W. Brennan
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Viviane Tabar
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine S. Panageas
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nelson S. Moss
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
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Zheng Y, Zhang Z, Zhao J, Teo K, Nga VDW, Yeo TT, Lim MJR. Effect of blood type on mortality among patients with brain metastases. Clin Neurol Neurosurg 2023; 233:107963. [PMID: 37703616 DOI: 10.1016/j.clineuro.2023.107963] [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: 07/24/2023] [Revised: 09/01/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVE ABO blood type has been associated with mortality among patients with cancer, but this association has thus far not been investigated among patients with brain metastases. Hence, we aimed to investigate the association between ABO blood type and mortality among patients who underwent surgical resection of brain metastases. METHODS A single-center retrospective study of patients who underwent surgical resection of brain metastases between 2011 and 2019 was conducted. Cox proportional hazards models were constructed, adjusting for potential confounders, to evaluate whether blood type was independently associated with overall mortality. RESULTS A total of 158 patients were included in the analysis. The mean (SD) age of the cohort was 59.3 (12.0) years, and 67.7% of patients were female. The median overall survival of patients with blood type AB was 11.2 months, while the median overall survival of patients with blood types O, B, and A were 11.7, 13.5, and 14.4 months respectively. On univariate analysis, patients with blood type AB had a higher risk of overall mortality (p = 0.017). On multivariate analysis adjusting for potential confounders, blood type AB was again associated with a higher risk of overall mortality (HR: 2.29, 95% CI: 1.11-4.72, p = 0.025). CONCLUSION Blood type AB was independently associated with a higher risk of overall mortality among patients who underwent surgical resection of brain metastases, indicating the potential prognostic value of ABO blood type in brain metastases.
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Affiliation(s)
- Yilong Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Zheting Zhang
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Jiashen Zhao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kejia Teo
- Division of Neurosurgery, National University Hospital, Singapore
| | | | - Tseng Tsai Yeo
- Division of Neurosurgery, National University Hospital, Singapore
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49
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Lehrer EJ, Khosla AA, Ozair A, Gurewitz J, Bernstein K, Kondziolka D, Niranjan A, Wei Z, Lunsford LD, Mathieu D, Trudel C, Deibert CP, Malouff TD, Ruiz-Garcia H, Peterson JL, Patel S, Bonney P, Hwang L, Yu C, Zada G, Picozzi P, Franzini A, Attuati L, Prasad RN, Raval RR, Palmer JD, Lee CC, Yang HC, Fakhoury KR, Rusthoven CG, Dickstein DR, Sheehan JP, Trifiletti DM, Ahluwalia MS. Immune checkpoint inhibition and single fraction stereotactic radiosurgery in brain metastases from non-small cell lung cancer: an international multicenter study of 395 patients. J Neurooncol 2023; 165:63-77. [PMID: 37889444 DOI: 10.1007/s11060-023-04413-4] [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: 04/23/2023] [Accepted: 08/02/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE Approximately 80% of brain metastases originate from non-small cell lung cancer (NSCLC). Immune checkpoint inhibitors (ICI) and stereotactic radiosurgery (SRS) are frequently utilized in this setting. However, concerns remain regarding the risk of radiation necrosis (RN) when SRS and ICI are administered concurrently. METHODS A retrospective study was conducted through the International Radiosurgery Research Foundation. Logistic regression models and competing risks analyses were utilized to identify predictors of any grade RN and symptomatic RN (SRN). RESULTS The study included 395 patients with 2,540 brain metastases treated with single fraction SRS and ICI across 11 institutions in four countries with a median follow-up of 14.2 months. The median age was 67 years. The median margin SRS dose was 19 Gy; 36.5% of patients had a V12 Gy ≥ 10 cm3. On multivariable analysis, V12 Gy ≥ 10 cm3 was a significant predictor of developing any grade RN (OR: 2.18) and SRN (OR: 3.95). At 1-year, the cumulative incidence of any grade and SRN for all patients was 4.8% and 3.8%, respectively. For concurrent and non-concurrent groups, the cumulative incidence of any grade RN was 3.8% versus 5.3%, respectively (p = 0.35); and for SRN was 3.8% vs. 3.6%, respectively (p = 0.95). CONCLUSION The risk of any grade RN and symptomatic RN following single fraction SRS and ICI for NSCLC brain metastases increases as V12 Gy exceeds 10 cm3. Concurrent ICI and SRS do not appear to increase this risk. Radiosurgical planning techniques should aim to minimize V12 Gy.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA.
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Atulya A Khosla
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Ahmad Ozair
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Jason Gurewitz
- Department of Radiation Oncology, NYU Langone Medical Center, New York, NY, USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Medical Center, New York, NY, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - Claire Trudel
- Department of Medicine, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | | | - Timothy D Malouff
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Phillip Bonney
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Lindsay Hwang
- Department of Radiation Oncology, University of Southern California, Los Angeles, CA, USA
| | - Cheng Yu
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Piero Picozzi
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano (Mi), Italy
| | - Andrea Franzini
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano (Mi), Italy
| | - Luca Attuati
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano (Mi), Italy
| | - Rahul N Prasad
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Raju R Raval
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Kareem R Fakhoury
- Department of Radiation Oncology, University of Colorado, Denver, CO, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Denver, CO, USA
| | - Daniel R Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
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Zubaľ M, Výmolová B, Matrasová I, Výmola P, Vepřková J, Syrůček M, Tomáš R, Vaníčková Z, Křepela E, Konečná D, Bušek P, Šedo A. Fibroblast activation protein as a potential theranostic target in brain metastases of diverse solid tumours. Pathology 2023; 55:806-817. [PMID: 37419841 DOI: 10.1016/j.pathol.2023.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 03/30/2023] [Accepted: 05/30/2023] [Indexed: 07/09/2023]
Abstract
Brain metastases are a very common and serious complication of oncological diseases. Despite the vast progress in multimodality treatment, brain metastases significantly decrease the quality of life and prognosis of patients. Therefore, identifying new targets in the microenvironment of brain metastases is desirable. Fibroblast activation protein (FAP) is a transmembrane serine protease typically expressed in tumour-associated stromal cells. Due to its characteristic presence in the tumour microenvironment, FAP represents an attractive theranostic target in oncology. However, there is little information on FAP expression in brain metastases. In this study, we quantified FAP expression in samples of brain metastases of various primary origin and characterised FAP-expressing cells. We have shown that FAP expression is significantly higher in brain metastases in comparison to non-tumorous brain tissues, both at the protein and enzymatic activity levels. FAP immunopositivity was localised in regions rich in collagen and containing blood vessels. We have further shown that FAP is predominantly confined to stromal cells expressing markers typical of cancer-associated fibroblasts (CAFs). We have also observed FAP immunopositivity on tumour cells in a portion of brain metastases, mainly originating from melanoma, lung, breast, and renal cancer, and sarcoma. There were no significant differences in the quantity of FAP protein, enzymatic activity, and FAP+ stromal cells among brain metastasis samples of various origins, suggesting that there is no association of FAP expression and/or presence of FAP+ stromal cells with the histological type of brain metastases. In summary, we are the first to establish the expression of FAP and characterise FAP-expressing cells in the microenvironment of brain metastases. The frequent upregulation of FAP and its presence on both stromal and tumour cells support the use of FAP as a promising theranostic target in brain metastases.
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Affiliation(s)
- Michal Zubaľ
- Laboratory of Cancer Cell Biology, Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Barbora Výmolová
- Laboratory of Cancer Cell Biology, Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ivana Matrasová
- Laboratory of Cancer Cell Biology, Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Petr Výmola
- Laboratory of Cancer Cell Biology, Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jana Vepřková
- Laboratory of Cancer Cell Biology, Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Martin Syrůček
- Department of Pathology, Na Homolce Hospital, Prague, Czech Republic
| | - Robert Tomáš
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Zdislava Vaníčková
- Laboratory of Cancer Cell Biology, Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Evžen Křepela
- Laboratory of Cancer Cell Biology, Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Dora Konečná
- Laboratory of Cancer Cell Biology, Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University, Prague, Czech Republic; Departments of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - Petr Bušek
- Laboratory of Cancer Cell Biology, Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Aleksi Šedo
- Laboratory of Cancer Cell Biology, Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University, Prague, Czech Republic
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