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Xu D, Hu Z, Wang K, Hu S, Zhou Y, Zhang S, Chen Y, Pan T. Why does HER2-positive breast cancer metastasize to the brain and what can we do about it? Crit Rev Oncol Hematol 2024; 195:104269. [PMID: 38272149 DOI: 10.1016/j.critrevonc.2024.104269] [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: 04/07/2023] [Revised: 12/18/2023] [Accepted: 01/19/2024] [Indexed: 01/27/2024] Open
Abstract
Breast cancer is the most frequent malignancy in women. However, in the middle and late stages, some people develop distant metastases, which considerably lower the quality of life and life expectancy. The brain is one of the sites where metastasis frequently happens. According to epidemiological research, brain metastases occur at a late stage in 30-50% of patients with HER2-positive breast cancer, resulting in a poor prognosis. Additionally, few treatments are available for HER2-positive brain metastatic breast cancer, and the mortality rate is remarkable owing to the complexity of the brain's anatomical structure and physiological function. In this review, we described the stages of the brain metastasis of breast cancer, the relationship between the microenvironment and metastatic cancer cells, and the unique molecular and cellular mechanisms. It involves cancer cells migrating, invading, and adhering to the brain; penetrating the blood-brain barrier; interacting with brain cells; and activating signal pathways once inside the brain. Finally, we reviewed current clinically used treatment approaches for brain metastasis in HER2-positive breast cancer; summarized the traditional treatment, targeted treatment, immunotherapy, and other treatment modalities; compared the benefits and drawbacks of each approach; discussed treatment challenges; and emphasized the importance of identifying potential targets to improve patient survival rates and comprehend brain metastasis in breast cancer.
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Affiliation(s)
- Dongyan Xu
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Zhengfang Hu
- Beijing Tian Tan Hospital, Capital Medical University, Beijing 100050, China
| | - Kaiyue Wang
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Shiyao Hu
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Yunxiang Zhou
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Shizhen Zhang
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Yiding Chen
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Tao Pan
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China.
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2
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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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3
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Viktorsson K, Rieckmann T, Fleischmann M, Diefenhardt M, Hehlgans S, Rödel F. Advances in molecular targeted therapies to increase efficacy of (chemo)radiation therapy. Strahlenther Onkol 2023; 199:1091-1109. [PMID: 37041372 PMCID: PMC10673805 DOI: 10.1007/s00066-023-02064-y] [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: 12/30/2022] [Accepted: 02/19/2023] [Indexed: 04/13/2023]
Abstract
Recent advances in understanding the tumor's biology in line with a constantly growing number of innovative technologies have prompted characterization of patients' individual malignancies and may display a prerequisite to treat cancer at its patient individual tumor vulnerability. In recent decades, radiation- induced signaling and tumor promoting local events for radiation sensitization were explored in detail, resulting the development of novel molecular targets. A multitude of pharmacological, genetic, and immunological principles, including small molecule- and antibody-based targeted strategies, have been developed that are suitable for combined concepts with radiation (RT) or chemoradiation therapy (CRT). Despite a plethora of promising experimental and preclinical findings, however, so far, only a very limited number of clinical trials have demonstrated a better outcome and/or patient benefit when RT or CRT are combined with targeted agents. The current review aims to summarize recent progress in molecular therapies targeting oncogenic drivers, DNA damage and cell cycle response, apoptosis signaling pathways, cell adhesion molecules, hypoxia, and the tumor microenvironment to impact therapy refractoriness and to boost radiation response. In addition, we will discuss recent advances in nanotechnology, e.g., RNA technologies and protein-degrading proteolysis-targeting chimeras (PROTACs) that may open new and innovative ways to benefit from molecular-targeted therapy approaches with improved efficacy.
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Affiliation(s)
- Kristina Viktorsson
- Department of Oncology/Pathology, Karolinska Institutet, Visionsgatan 4, 17164, Solna, Sweden
| | - Thorsten Rieckmann
- Department of Radiation Oncology, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Otolaryngology, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Maximilian Fleischmann
- Department of Radiotherapy and Oncology, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), University of Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Markus Diefenhardt
- Department of Radiotherapy and Oncology, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), University of Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Stephanie Hehlgans
- Department of Radiotherapy and Oncology, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Franz Rödel
- Department of Radiotherapy and Oncology, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
- Frankfurt Cancer Institute (FCI), University of Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
- German Cancer Consortium (DKTK) partner site: Frankfurt, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
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4
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Alzate JD, Mashiach E, Berger A, Bernstein K, Mullen R, Nigris Vasconcellos FD, Qu T, Silverman JS, Donahue BR, Cooper BT, Sulman EP, Golfinos JG, Kondziolka D. Low-Dose Radiosurgery for Brain Metastases in the Era of Modern Systemic Therapy. Neurosurgery 2023; 93:1112-1120. [PMID: 37326435 DOI: 10.1227/neu.0000000000002556] [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: 12/20/2022] [Accepted: 04/17/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Dose selection for brain metastases stereotactic radiosurgery (SRS) classically has been based on tumor diameter with a reduction of dose in the settings of prior brain irradiation, larger tumor volumes, and critical brain location. However, retrospective series have shown local control rates to be suboptimal with reduced doses. We hypothesized that lower doses could be effective for specific tumor biologies with concomitant systemic therapies. This study aims to report the local control (LC) and toxicity when using low-dose SRS in the era of modern systemic therapy. METHODS We reviewed 102 patients with 688 tumors managed between 2014 and 2021 who had low-margin dose radiosurgery, defined as ≤14 Gy. Tumor control was correlated with demographic, clinical, and dosimetric data. RESULTS The main primary cancer types were lung in 48 (47.1%), breast in 31 (30.4%), melanoma in 8 (7.8%), and others in 15 patients (11.7%). The median tumor volume was 0.037cc (0.002-26.31 cm 3 ), and the median margin dose was 14 Gy (range 10-14). The local failure (LF) cumulative incidence at 1 and 2 years was 6% and 12%, respectively. On competing risk regression analysis, larger volume, melanoma histology, and margin dose were predictors of LF. The 1-year and 2-year cumulative incidence of adverse radiation effects (ARE: an adverse imaging-defined response includes increased enhancement and peritumoral edema) was 0.8% and 2%. CONCLUSION It is feasible to achieve acceptable LC in BMs with low-dose SRS. Volume, melanoma histology, and margin dose seem to be predictors for LF. The value of a low-dose approach may be in the management of patients with higher numbers of small or adjacent tumors with a history of whole brain radio therapy or multiple SRS sessions and in tumors in critical locations with the aim of LC and preservation of neurological function.
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Affiliation(s)
- Juan Diego Alzate
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | - Elad Mashiach
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | - Assaf Berger
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Reed Mullen
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | | | - Tanxia Qu
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Joshua S Silverman
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Bernadine R Donahue
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Benjamin T Cooper
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Erik P Sulman
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - John G Golfinos
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | - Douglas Kondziolka
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
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Vaios EJ, Winter SF, Shih HA, Dietrich J, Peters KB, Floyd SR, Kirkpatrick JP, Reitman ZJ. Novel Mechanisms and Future Opportunities for the Management of Radiation Necrosis in Patients Treated for Brain Metastases in the Era of Immunotherapy. Cancers (Basel) 2023; 15:2432. [PMID: 37173897 PMCID: PMC10177360 DOI: 10.3390/cancers15092432] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/12/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
Radiation necrosis, also known as treatment-induced necrosis, has emerged as an important adverse effect following stereotactic radiotherapy (SRS) for brain metastases. The improved survival of patients with brain metastases and increased use of combined systemic therapy and SRS have contributed to a growing incidence of necrosis. The cyclic GMP-AMP (cGAMP) synthase (cGAS) and stimulator of interferon genes (STING) pathway (cGAS-STING) represents a key biological mechanism linking radiation-induced DNA damage to pro-inflammatory effects and innate immunity. By recognizing cytosolic double-stranded DNA, cGAS induces a signaling cascade that results in the upregulation of type 1 interferons and dendritic cell activation. This pathway could play a key role in the pathogenesis of necrosis and provides attractive targets for therapeutic development. Immunotherapy and other novel systemic agents may potentiate activation of cGAS-STING signaling following radiotherapy and increase necrosis risk. Advancements in dosimetric strategies, novel imaging modalities, artificial intelligence, and circulating biomarkers could improve the management of necrosis. This review provides new insights into the pathophysiology of necrosis and synthesizes our current understanding regarding the diagnosis, risk factors, and management options of necrosis while highlighting novel avenues for discovery.
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Affiliation(s)
- Eugene J. Vaios
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
| | - Sebastian F. Winter
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Helen A. Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jorg Dietrich
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Katherine B. Peters
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Scott R. Floyd
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
| | - John P. Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Zachary J. Reitman
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
- Department of Pathology, Duke University Medical Center, Durham, NC 27710, USA
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6
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Debbi K, Grellier N, Loganadane G, Boukhobza C, Mahé M, Cherif MA, Rida H, Gligorov J, Belkacemi Y. Interaction between Radiation Therapy and Targeted Therapies in HER2-Positive Breast Cancer: Literature Review, Levels of Evidence for Safety and Recommendations for Optimal Treatment Sequence. Cancers (Basel) 2023; 15:cancers15082278. [PMID: 37190205 DOI: 10.3390/cancers15082278] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/03/2023] [Accepted: 04/10/2023] [Indexed: 05/17/2023] Open
Abstract
Purpose: Over the past twenty years, anti-HER2 targeted therapies have proven to be a revolution in the management of human epidermal growth receptor 2 (HER2)-positive breast cancers. Anti-HER2 therapies administered alone or in combination with chemotherapy have been specifically studied. Unfortunately, the safety of anti-HER2 therapies in combination with radiation remains largely unknown. Thus, we propose a literature review of the risks and safety of combining radiotherapy with anti-HER2 therapies. We will focus on the benefit/risk rationale and try to understand the risk of toxicity in early-stage and advanced breast cancer. Methods: Research was carried out on the following databases: PubMed, EMBASE, ClinicalTrial.gov, Medline, and Web of Science for the terms "radiotherapy", "radiation therapy", "radiosurgery", "local ablative therapy", and "stereotactic", combined with "trastuzumab", "pertuzumab", "trastuzumab emtansine", "TDM-1", "T-Dxd", "trastuzumab deruxtecan", "tucatinib", "lapatinib", "immune checkpoint inhibitors", "atezolizumab", "pembrolizumab", "nivolumab", "E75 vaccine", "interferon", "anti-IL-2", "anti-IL 12", and "ADC". Results: Association of radiation and monoclonal antibodies such as trastuzumab and pertuzumab (with limited data) seems to be safe, with no excess risk of toxicity. Preliminary data with radiation and of antibody-drug conjugate of trastuzumab combined cytotoxic (trastuzumab emtansine, trastuzumab deruxtecan), given the underlying mechanism of action, suggest that one must be particularly cautious with the association. The safety of the combination of a tyrosine kinase inhibitor (lapatinib, tucatinib) and radiation remains under-studied. The available evidence suggests that checkpoint inhibitors can be safely administrated with radiation. Conclusions: HER2-targeting monoclonal antibodies and checkpoint inhibitors can be combined with radiation, apparently with no excess toxicities. Caution is required when associating radiation with TKI and antibody drugs, considering the limited evidence.
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Affiliation(s)
- Kamel Debbi
- APHP-Radiation Oncology Department and Henri Mondor Breast Center, Henri Mondor University Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
- Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, i-Biot, UPEC, 94000 Créteil, France
| | - Noémie Grellier
- APHP-Radiation Oncology Department and Henri Mondor Breast Center, Henri Mondor University Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Gokoulakrichenane Loganadane
- APHP-Radiation Oncology Department and Henri Mondor Breast Center, Henri Mondor University Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
- Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, i-Biot, UPEC, 94000 Créteil, France
| | - Chahrazed Boukhobza
- APHP-Radiation Oncology Department and Henri Mondor Breast Center, Henri Mondor University Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Mathilde Mahé
- APHP-Radiation Oncology Department and Henri Mondor Breast Center, Henri Mondor University Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Mohamed Aziz Cherif
- APHP-Radiation Oncology Department and Henri Mondor Breast Center, Henri Mondor University Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Hanan Rida
- APHP-Radiation Oncology Department and Henri Mondor Breast Center, Henri Mondor University Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Joseph Gligorov
- APHP-Medical Oncology Department, Institut Universitaire de Cancérologie, Sorbonne Université, 75013 Paris, France
| | - Yazid Belkacemi
- APHP-Radiation Oncology Department and Henri Mondor Breast Center, Henri Mondor University Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
- Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, i-Biot, UPEC, 94000 Créteil, France
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7
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Hintelmann K, Petersen C, Borgmann K. Radiotherapeutic Strategies to Overcome Resistance of Breast Cancer Brain Metastases by Considering Immunogenic Aspects of Cancer Stem Cells. Cancers (Basel) 2022; 15:211. [PMID: 36612206 PMCID: PMC9818478 DOI: 10.3390/cancers15010211] [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] [Received: 12/01/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022] Open
Abstract
Breast cancer is the most diagnosed cancer in women, and symptomatic brain metastases (BCBMs) occur in 15-20% of metastatic breast cancer cases. Despite technological advances in radiation therapy (RT), the prognosis of patients is limited. This has been attributed to radioresistant breast cancer stem cells (BCSCs), among other factors. The aim of this review article is to summarize the evidence of cancer-stem-cell-mediated radioresistance in brain metastases of breast cancer from radiobiologic and radiation oncologic perspectives to allow for the better interpretability of preclinical and clinical evidence and to facilitate its translation into new therapeutic strategies. To this end, the etiology of brain metastasis in breast cancer, its radiotherapeutic treatment options, resistance mechanisms in BCSCs, and effects of molecularly targeted therapies in combination with radiotherapy involving immune checkpoint inhibitors are described and classified. This is considered in the context of the central nervous system (CNS) as a particular metastatic niche involving the blood-brain barrier and the CNS immune system. The compilation of this existing knowledge serves to identify possible synergistic effects between systemic molecularly targeted therapies and ionizing radiation (IR) by considering both BCSCs' relevant resistance mechanisms and effects on normal tissue of the CNS.
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Affiliation(s)
- Katharina Hintelmann
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
- Laboratory of Radiobiology and Experimental Radiooncology, Center of Oncology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Cordula Petersen
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Kerstin Borgmann
- Laboratory of Radiobiology and Experimental Radiooncology, Center of Oncology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
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8
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Singh K, Saxena S, Khosla AA, McDermott MW, Kotecha RR, Ahluwalia MS. Update on the Management of Brain Metastasis. Neurotherapeutics 2022; 19:1772-1781. [PMID: 36422836 PMCID: PMC9723062 DOI: 10.1007/s13311-022-01312-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2022] [Indexed: 11/27/2022] Open
Abstract
Brain metastases occur in almost one-third of adult patients with solid tumor malignancies and lead to considerable patient morbidity and mortality. The rising incidence of brain metastases has been ascribed to the development of better imaging and screening techniques and the formulation of better systemic therapies. Until recently, the multimodal management of brain metastases focused primarily on the utilization of neurosurgical techniques, with varying combinations of whole-brain radiation therapy and stereotactic radio-surgical procedures. Over the past 2 decades, in particular, the increment in knowledge pertaining to molecular genetics and the pathogenesis of brain metastases has led to significant developments in targeted therapies and immunotherapies. This review article highlights the recent updates in the management of brain metastases with an emphasis on novel systemic therapies.
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Affiliation(s)
- Karanvir Singh
- Division of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Shreya Saxena
- Division of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Atulya A Khosla
- Division of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Michael W McDermott
- Division of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, USA
| | - Rupesh R Kotecha
- Division of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, USA
| | - Manmeet S Ahluwalia
- Division of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA.
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, USA.
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9
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Aristei C, Bölükbaşı Y, Kaidar-Person O, Pfeffer R, Arenas M, Boersma LJ, Ciabattoni A, Coles CE, Franco P, Krengli M, Leonardi MC, Marazzi F, Masiello V, Meattini I, Montero A, Offersen B, Trigo ML, Bourgier C, Genovesi D, Kouloulias V, Morganti AG, Meduri B, Pasinetti N, Pedretti S, Perrucci E, Rivera S, Tombolini V, Vidali C, Valentini V, Poortmans P. Ways to improve breast cancer patients' management and clinical outcome: The 2020 Assisi Think Tank Meeting. Crit Rev Oncol Hematol 2022; 177:103774. [PMID: 35917884 DOI: 10.1016/j.critrevonc.2022.103774] [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: 06/08/2021] [Revised: 07/19/2022] [Accepted: 07/29/2022] [Indexed: 10/16/2022] Open
Abstract
We report on the third Assisi Think Tank Meeting (ATTM) on breast cancer, a brainstorming project which involved European radiation and clinical oncologists who were dedicated to breast cancer research and treatment. Held on February 2020, the ATTM aimed at identifying key clinical questions in current clinical practice and "grey" areas requiring research to improve management and outcomes. Before the meeting, three key topics were selected: 1) managing patients with frailty due to either age and/or multi-morbidity; 2) stereotactic radiation therapy and systemic therapy in the management of oligometastatic disease; 3) contralateral breast tumour prevention in BCRA-mutated patients. Clinical practice in these areas was investigated by means of an online questionnaire. In the lapse period between the survey and the meeting, the working groups reviewed data, on-going studies and the clinical challenges which were then discussed in-depth and subjected to intense brainstorming during the meeting; research protocols were also proposed. Methodology, outcome of discussions, conclusions and study proposals are summarized in the present paper. In conclusion, this report presents an in-depth analysis of the state of the art, grey areas and controversies in breast cancer radiation therapy and discusses how to confront them in the absence of evidence-based data to guide clinical decision-making.
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Affiliation(s)
- Cynthia Aristei
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia and Perugia General Hospital, Perugia, Italy.
| | - Yasemin Bölükbaşı
- Radiation Oncology Acıbadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Orit Kaidar-Person
- Breast Radiation Unit, Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Raphael Pfeffer
- Oncology Institute, Assuta Medical Center, Tel Aviv and Ben Gurion University Medical School, Israel
| | - Meritxell Arenas
- Universitat Rovira I Virgili, Radiation Oncology Department, Hospital Universitari Sant Hoan de Reus, IISPV, Spain
| | - Liesbeth J Boersma
- Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Antonella Ciabattoni
- Department of Radiation Oncology, San Filippo Neri Hospital, ASL Rome 1, Rome, Italy
| | | | - Pierfrancesco Franco
- Depatment of Translational Medicine, University of Eastern Piedmont and Department of Radiation Oncology, 'Maggiore della Carità' University Hospital, Novara, Italy
| | - Marco Krengli
- Depatment of Translational Medicine, University of Eastern Piedmont and Department of Radiation Oncology, 'Maggiore della Carità' University Hospital, Novara, Italy
| | | | - Fabio Marazzi
- Unità Operativa di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagine, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - Valeria Masiello
- Unità Operativa di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagine, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence & Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Angel Montero
- Department of Radiation Oncology, University Hospital HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Birgitte Offersen
- Department of Experimental Clinical Oncology, Department of Oncology, Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Maria Lurdes Trigo
- Service of Brachytherapy, Department of Image and Radioncology, Instituto Português Oncologia Porto Francisco Gentil E.P.E., Portugal
| | - Céline Bourgier
- Radiation Oncology, ICM-Val d'Aurelle, Univ Montpellier, Montpellier, France
| | - Domenico Genovesi
- Radiation Oncology, Ospedale Clinicizzato Chieti and University "G. d'Annunzio", Chieti, Italy
| | - Vassilis Kouloulias
- 2(nd) Department of Radiology, Radiotherapy Unit, Medical School, National and Kapodistrian University of Athens, Greece
| | - Alessio G Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna; DIMES, Alma Mater Studiorum Bologna University; Bologna, Italy
| | - Bruno Meduri
- Radiation Oncology Unit, University Hospital of Modena, Modena, Italy
| | - Nadia Pasinetti
- Radiation Oncology Service, ASST Valcamonica Esine and Brescia University, Brescia, Italy
| | - Sara Pedretti
- Istituto del Radio "O.Alberti" - Spedali Civili Hospital and Brescia University, Brescia
| | | | - Sofia Rivera
- Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Vincenzo Tombolini
- Radiation Oncology, Department of Radiological, Oncological and Pathological Science, University "La Sapienza", Roma, Italy
| | - Cristiana Vidali
- former Senior Assistant Department of Radiation Oncology, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Vincenzo Valentini
- Division of Radiation Oncology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
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10
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Park C, Buckley ED, Van Swearingen AED, Giles W, Herndon JE, Kirkpatrick JP, Anders CK, Floyd SR. Systemic Therapy Type and Timing Effects on Radiation Necrosis Risk in HER2+ Breast Cancer Brain Metastases Patients Treated With Stereotactic Radiosurgery. Front Oncol 2022; 12:854364. [PMID: 35669439 PMCID: PMC9163666 DOI: 10.3389/fonc.2022.854364] [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: 01/13/2022] [Accepted: 04/14/2022] [Indexed: 11/25/2022] Open
Abstract
Background There is a concern that HER2-directed systemic therapies, when administered concurrently with stereotactic radiosurgery (SRS), may increase the risk of radiation necrosis (RN). This study explores the impact of timing and type of systemic therapies on the development of RN in patients treated with SRS for HER2+ breast cancer brain metastasis (BCBrM). Methods This was a single-institution, retrospective study including patients >18 years of age with HER2+ BCBrM who received SRS between 2013 and 2018 and with at least 12-month post-SRS follow-up. Presence of RN was determined via imaging at one-year post-SRS, with confirmation by biopsy in some patients. Demographics, radiotherapy parameters, and timing (“during” defined as four weeks pre- to four weeks post-SRS) and type of systemic therapy (e.g., chemotherapy, HER2-directed) were evaluated. Results Among 46 patients with HER2+ BCBrM who received SRS, 28 (60.9%) developed RN and 18 (39.1%) did not based on imaging criteria. Of the 11 patients who underwent biopsy, 10/10 (100%) who were diagnosed with RN on imaging were confirmed to be RN positive on biopsy and 1/1 (100%) who was not diagnosed with RN was confirmed to be RN negative on biopsy. Age (mean 53.3 vs 50.4 years, respectively), radiotherapy parameters (including total dose, fractionation, CTV and size target volume, all p>0.05), and receipt of any type of systemic therapy during SRS (60.7% vs 55.6%, p=0.97) did not differ between patients who did or did not develop RN. However, there was a trend for patients who developed RN to have received more than one agent of HER2-directed therapy independent of SRS timing compared to those who did not develop RN (75.0% vs 44.4%, p=0.08). Moreover, a significantly higher proportion of those who developed RN received more than one agent of HER2-directed therapy during SRS treatment compared to those who did not develop RN (35.7% vs 5.6%, p=0.047). Conclusions Patients with HER2 BCBrM who receive multiple HER2-directed therapies during SRS for BCBrM may be at higher risk of RN. Collectively, these data suggest that, in the eight-week window around SRS administration, if HER2-directed therapy is medically necessary, it is preferable that patients receive a single agent.
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Affiliation(s)
- Christine Park
- Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Evan D. Buckley
- Duke Cancer Institute Biostatistics, Duke University Medical Center, Durham, NC, United States
| | - Amanda E. D. Van Swearingen
- Department of Medicine, Duke University Medical Center, Durham, NC, United States
- Duke Center for Brain and Spine Metastasis, Duke Cancer Institute, Duke University Medical Center, Durham, NC, United States
| | - Will Giles
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States
| | - James E. Herndon
- Duke Cancer Institute Biostatistics, Duke University Medical Center, Durham, NC, United States
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, United States
| | - John P. Kirkpatrick
- Duke Center for Brain and Spine Metastasis, Duke Cancer Institute, Duke University Medical Center, Durham, NC, United States
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Carey K. Anders
- Department of Medicine, Duke University Medical Center, Durham, NC, United States
- Duke Center for Brain and Spine Metastasis, Duke Cancer Institute, Duke University Medical Center, Durham, NC, United States
| | - Scott R. Floyd
- Duke Center for Brain and Spine Metastasis, Duke Cancer Institute, Duke University Medical Center, Durham, NC, United States
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States
- *Correspondence: Scott R. Floyd,
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11
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Rubino S, Oliver DE, Tran ND, Vogelbaum MA, Forsyth PA, Yu HHM, Ahmed K, Etame AB. Improving Brain Metastases Outcomes Through Therapeutic Synergy Between Stereotactic Radiosurgery and Targeted Cancer Therapies. Front Oncol 2022; 12:854402. [PMID: 35311078 PMCID: PMC8924127 DOI: 10.3389/fonc.2022.854402] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/07/2022] [Indexed: 12/12/2022] Open
Abstract
Brain metastases are the most common form of brain cancer. Increasing knowledge of primary tumor biology, actionable molecular targets and continued improvements in systemic and radiotherapy regimens have helped improve survival but necessitate multidisciplinary collaboration between neurosurgical, medical and radiation oncologists. In this review, we will discuss the advances of targeted therapies to date and discuss findings of studies investigating the synergy between these therapies and stereotactic radiosurgery for non-small cell lung cancer, breast cancer, melanoma, and renal cell carcinoma brain metastases.
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Affiliation(s)
- Sebastian Rubino
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL, United States
| | - Daniel E Oliver
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, United States
| | - Nam D Tran
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL, United States
| | - Michael A Vogelbaum
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL, United States
| | - Peter A Forsyth
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL, United States
| | | | - Kamran Ahmed
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, United States
| | - Arnold B Etame
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL, United States
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12
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Ippolito E, Silipigni S, Matteucci P, Greco C, Carrafiello S, Palumbo V, Tacconi C, Talocco C, Fiore M, D’Angelillo RM, Ramella S. Radiotherapy for HER 2 Positive Brain Metastases: Urgent Need for a Paradigm Shift. Cancers (Basel) 2022; 14:cancers14061514. [PMID: 35326665 PMCID: PMC8946529 DOI: 10.3390/cancers14061514] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 01/09/2023] Open
Abstract
Brain metastases (BMs) are common among patients affected by HER2+ metastatic breast cancer (>30%). The management of BMs is usually multimodal, including surgery, radiotherapy, systemic therapy and palliative care. Standard brain radiotherapy (RT) includes the use of stereotactic radiotherapy (SRT) for limited disease and whole brain radiotherapy (WBRT) for extensive disease. The latter is an effective palliative treatment but has a reduced effect on brain local control and BM overall survival, as it is also associated with severe neurocognitive sequelae. Recent advances both in radiation therapy and systemic treatment may change the paradigm in this subset of patients who can experience long survival notwithstanding BMs. In fact, in recent studies, SRT for multiple BM sites (>4) has shown similar efficacy when compared to irradiation of a limited number of lesions (one to three) without increasing toxicity. These findings, in addition to the introduction of new drugs with recognized intracranial activity, may further limit the use of WBRT in favor of SRT, which should be employed for treatment of both multiple-site BMs and for oligo-progressive brain disease. This review summarizes the supporting literature and highlights the need for optimizing combinations of the available treatments in this setting, with a particular focus on radiation therapy.
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Affiliation(s)
- Edy Ippolito
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
| | - Sonia Silipigni
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
| | - Paolo Matteucci
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
- Correspondence: ; Tel.: +39-06225411708
| | - Carlo Greco
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
| | - Sofia Carrafiello
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
| | - Vincenzo Palumbo
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
| | - Claudia Tacconi
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
| | - Claudia Talocco
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
| | - Michele Fiore
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
| | | | - Sara Ramella
- Radiation Oncology, Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128 Rome, Italy; (E.I.); (S.S.); (C.G.); (S.C.); (V.P.); (C.T.); (C.T.); (M.F.); (S.R.)
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13
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Ganz JC. Cerebral metastases. PROGRESS IN BRAIN RESEARCH 2022; 268:229-258. [PMID: 35074082 DOI: 10.1016/bs.pbr.2021.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Brain metastases are common and deadly. Over the last 25 years GKNS has been established as an invaluable treatment. It may be used as a primary treatment or after either surgery or WBRT. Patients are assessed using one of a number of available scales. GKNS may be repeated for new metastases and for unresponsive tumors. Prescription doses are usually between 18 and 20Gy. The use of advanced MR techniques to highlight sensitive structures like the hippocampi have extended the efficacy of the treatment. More recently GKNS has been used with different target therapies with improved results. More recently frameless treatments have become more popular in this group of very sick patients. GKNS controls tumors in between 80% and over 95% of cases and may even be used for brainstem tumors.
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Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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14
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Ippolito E, Silipigni S, Matteucci P, Greco C, Pantano F, D’Auria G, Quattrocchi CC, Floreno B, Fiore M, Gamucci T, Tonini G, Ramella S. Stereotactic Radiation and Dual Human Epidermal Growth Factor Receptor 2 Blockade with Trastuzumab and Pertuzumab in the Treatment of Breast Cancer Brain Metastases: A Single Institution Series. Cancers (Basel) 2022; 14:cancers14020303. [PMID: 35053467 PMCID: PMC8774076 DOI: 10.3390/cancers14020303] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 01/19/2023] Open
Abstract
(1) Background: This study aims to assess the safety and efficacy of fractionated SRT (fSRT) and pertuzumab-trastuzumab (PT) in patients with breast cancer brain metastases (BCBM). (2) Methods: Patients with HER2+ BCBM who received FSRT from 2015 to 2019 were identified. Patients were included if they were treated with fSRT within 21 days of receiving PT. All lesions were treated with LINAC-based fSRT to a total dose of 27 Gy delivered in three consecutive fractions. All patients received concurrent PT. Patients were evaluated 4-6 weeks after SRS and subsequently every 2-3 months with MRI re-imaging (3) Results: A total of 49 patients with HER2+ brain metastases were identified. Of these patients, a total of 10 patients with 32 HER2+ BCBM were treated with concurrent SRT and PT and included in the analysis. No local progression was observed. Overall response rate was 68.7%. Only one patient developed asymptomatic radionecrosis. Median time to BM occurrence was 15.6 (range: 1-40.5 months). Distant intracranial failure occurred in 4/10 patients (40.0%). Overall BCBM median survival was 33.9 months (95%CI 24.1-43.6). Mean duration of PT treatment was 27.9 months (range: 10.1-53.7 months). (4) Conclusions: In our single institution experience, fSRT and PT showed to be a safe treatment for patients with BCBM with an adequate overall response rate.
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Affiliation(s)
- Edy Ippolito
- Department of Radiation Oncology, Campus Bio-Medico University, 00128 Rome, Italy; (S.S.); (P.M.); (C.G.); (B.F.); (M.F.); (S.R.)
- Correspondence: ; Tel.: +39-06-22541-1708
| | - Sonia Silipigni
- Department of Radiation Oncology, Campus Bio-Medico University, 00128 Rome, Italy; (S.S.); (P.M.); (C.G.); (B.F.); (M.F.); (S.R.)
| | - Paolo Matteucci
- Department of Radiation Oncology, Campus Bio-Medico University, 00128 Rome, Italy; (S.S.); (P.M.); (C.G.); (B.F.); (M.F.); (S.R.)
| | - Carlo Greco
- Department of Radiation Oncology, Campus Bio-Medico University, 00128 Rome, Italy; (S.S.); (P.M.); (C.G.); (B.F.); (M.F.); (S.R.)
| | - Francesco Pantano
- Department of Medical Oncology, Campus Bio-Medico University, 00128 Rome, Italy; (F.P.); (G.T.)
| | - Giuliana D’Auria
- Department of Medical Oncology, Sandro Pertini Hospital, 00157 Rome, Italy; (G.D.); (T.G.)
| | - Carlo Cosimo Quattrocchi
- Department of Diagnostic Imaging and Interventional Radiology, Campus Bio-Medico University, 00128 Rome, Italy;
| | - Barnaba Floreno
- Department of Radiation Oncology, Campus Bio-Medico University, 00128 Rome, Italy; (S.S.); (P.M.); (C.G.); (B.F.); (M.F.); (S.R.)
| | - Michele Fiore
- Department of Radiation Oncology, Campus Bio-Medico University, 00128 Rome, Italy; (S.S.); (P.M.); (C.G.); (B.F.); (M.F.); (S.R.)
| | - Teresa Gamucci
- Department of Medical Oncology, Sandro Pertini Hospital, 00157 Rome, Italy; (G.D.); (T.G.)
| | - Giuseppe Tonini
- Department of Medical Oncology, Campus Bio-Medico University, 00128 Rome, Italy; (F.P.); (G.T.)
| | - Sara Ramella
- Department of Radiation Oncology, Campus Bio-Medico University, 00128 Rome, Italy; (S.S.); (P.M.); (C.G.); (B.F.); (M.F.); (S.R.)
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15
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Effect of molecular subtypes on radiotherapy response in patients with breast cancer brain metastasis. MARMARA MEDICAL JOURNAL 2022. [DOI: 10.5472/marumj.1089686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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16
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Kaul D, Sophie Berghoff A, Grosu AL, Weiss Lucas C, Guckenberger M. Focal Radiotherapy of Brain Metastases in Combination With Immunotherapy and Targeted Drug Therapy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:arztebl.m2021.0332. [PMID: 34730083 PMCID: PMC8841640 DOI: 10.3238/arztebl.m2021.0332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 09/06/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Advances in systemic treatment and in brain imaging have led to a higher incidence of diagnosed brain metastases. In the treatment of brain metastases, stereotactic radiotherapy and radiosurgery, systemic immunotherapy, and targeted drug therapy are important evidence-based options. In this review, we summarize the available evidence on the treatment of brain metastases of the three main types of cancer that give rise to them: non-small-cell lung cancer, breast cancer, and malignant melanoma. METHODS This narrative review is based on pertinent original articles, meta-analyses, and systematic reviews that were retrieved by a selective search in PubMed. These publications were evaluated and discussed by an expert panel including radiation oncologists, neurosurgeons, and oncologists. RESULTS There have not yet been any prospective randomized trials concerning the optimal combination of local stereotactic radiotherapy/radiosurgery and systemic immunotherapy or targeted therapy. Retrospective studies have consistently shown a benefit from early combined treatment with systemic therapy and (in particular) focal radiotherapy, compared to sequential treatment. Two metaanalyses of retrospective data from cohorts consisting mainly of patients with non-small-cell lung cancer and melanoma revealed longer overall survival after combined treatment with focal radiotherapy and checkpoint inhibitor therapy (rate of 12-month overall survival for combined versus non-combined treatment: 64.6% vs. 51.6%, p <0.001). In selected patients with small, asymptomatic brain metastases in non-critical locations, systemic therapy without focal radiotherapy can be considered, as long as follow-up with cranial magnetic resonance imaging can be performed at close intervals. CONCLUSION Brain metastases should be treated by a multidisciplinary team, so that the optimal sequence of local and systemic therapies can be determined for each individual patient.
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Affiliation(s)
- David Kaul
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health
| | - Anna Sophie Berghoff
- Department of Medicine 1 and Comprehensive Cancer Center Vienna, Medical University of Vienna
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Medical Center Freiburg
| | - Carolin Weiss Lucas
- Center of Neurosurgery, University of Cologne, Faculty of Medicine und University Hospital Cologne
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17
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Sammons S, Van Swearingen AED, Chung C, Anders CK. Advances in the management of breast cancer brain metastases. Neurooncol Adv 2021; 3:v63-v74. [PMID: 34859234 PMCID: PMC8633750 DOI: 10.1093/noajnl/vdab119] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The development of breast cancer (BC) brain metastases (BrM) is a common complication of advanced disease, occurring in up to half of the patients with advanced disease depending on the subtype. The management of BCBrM requires complex multidisciplinary care including local therapy, surgical resection and/or radiotherapy, palliative care, and carefully selected systemic therapies. Significant progress has been made in the human epidermal growth factor receptor 2-positive (HER2+) BCBrM population due to novel brain penetrable systemic therapies. Increased inclusion of patients with BCBrM in clinical trials using brain-penetrant systemic therapies recently led to the first FDA approval of a HER2-directed therapy specifically in the BCBrM population in the last year. Advances for the treatment of HR+/HER2- and TNBC BCBrM subgroups continue to evolve. In this review, we will discuss the diagnosis and multidisciplinary care of BCBrM. We focus on recent advances in neurosurgery, radiation therapy, and systemic treatment therapies with intracranial activity. We also provide an overview of the current clinical trial landscape for patients with BCBrM.
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Affiliation(s)
- Sarah Sammons
- Department of Medicine, Division of Medical Oncology, Duke Cancer Institute, Durham, North Carolina, USA
| | | | - Caroline Chung
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carey K Anders
- Department of Medicine, Division of Medical Oncology, Duke Cancer Institute, Durham, North Carolina, USA
- Duke Center for Brain and Spine Metastasis, Duke Cancer Institute, Durham, North Carolina, USA
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18
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Tonse R, Tom MC, Mehta MP, Ahluwalia MS, Kotecha R. Integration of Systemic Therapy and Stereotactic Radiosurgery for Brain Metastases. Cancers (Basel) 2021; 13:cancers13153682. [PMID: 34359583 PMCID: PMC8345095 DOI: 10.3390/cancers13153682] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/16/2021] [Accepted: 07/20/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary In the multi-modal treatment of brain metastasis (BM), the role of systemic therapy has undergone a recent revolution. Due to the development of multiple agents with modest central nervous system penetration of the blood-brain barrier, targeted therapies and immune checkpoint inhibitors are increasingly being utilized alone or in combination with radiation therapy. However, the adoption of sequential or concurrent strategies varies considerably, and treatment strategies employed in clinical practice have rapidly outpaced evidence development. Therefore, this review critically analyzes the data regarding combinatorial approaches for a variety of systemic therapeutics with stereotactic radiosurgery and provides an overview of ongoing clinical trials. Abstract Brain metastasis (BM) represents a common complication of cancer, and in the modern era requires multi-modal management approaches and multi-disciplinary care. Traditionally, due to the limited efficacy of cytotoxic chemotherapy, treatment strategies are focused on local treatments alone, such as whole-brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), and resection. However, the increased availability of molecular-based therapies with central nervous system (CNS) penetration now permits the individualized selection of tailored systemic therapies to be used alongside local treatments. Moreover, the introduction of immune checkpoint inhibitors (ICIs), with demonstrated CNS activity has further revolutionized the management of BM patients. The rapid introduction of these cancer therapeutics into clinical practice, however, has led to a significant dearth in the published literature about the optimal timing, sequencing, and combination of these systemic therapies along with SRS. This manuscript reviews the impact of tumor biology and molecular profiles on the management paradigm for BM patients and critically analyzes the current landscape of SRS, with a specific focus on integration with systemic therapy. We also discuss emerging treatment strategies combining SRS and ICIs, the impact of timing and the sequencing of these therapies around SRS, the effect of corticosteroids, and review post-treatment imaging findings, including pseudo-progression and radiation necrosis.
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Affiliation(s)
- Raees Tonse
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (R.T.); (M.C.T.); (M.P.M.)
| | - Martin C. Tom
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (R.T.); (M.C.T.); (M.P.M.)
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA;
| | - Minesh P. Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (R.T.); (M.C.T.); (M.P.M.)
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA;
| | - Manmeet S. Ahluwalia
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA;
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (R.T.); (M.C.T.); (M.P.M.)
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA;
- Correspondence: ; Tel.: +1-(786)-596-2000
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19
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Fallet V, Matton L, Schernberg A, Canellas A, Cornelis FH, Cadranel J. Local ablative therapy in oncogenic-driven oligometastatic non-small cell lung cancer: present and ongoing strategies-a narrative review. Transl Lung Cancer Res 2021; 10:3457-3472. [PMID: 34430380 PMCID: PMC8350076 DOI: 10.21037/tlcr-20-1152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 04/02/2021] [Indexed: 01/09/2023]
Abstract
Oligometastatic (OM) disease is defined by a low metastatic tumor spread. OM non-small cell lung cancer (NSCLC) treatment aims to improve the patient's prognosis and quality of life, in an attempt-to-cure objective. Oncogenic-driven metastatic NSCLC accounts for about 20-25% of NSCLCs, with an ever-increasing number of potentially druggable molecular alterations. Due to specific targeted therapy, the care and prognosis of mutated NSCLC is quite different from non-oncogenic-driven NSCLC. However, OM-NSCLC treatment guidelines do not specifically discuss oncogenic-driven OM-NSCLC patients. We conducted a narrative review regarding retrospective and prospective studies published from inception to May 2020 dealing with oncogenic-driven OM-NSCLC in order to: (I) describe the specific patterns of metastatic spread of oncogenic-driven NSCLC (i.e., bone and pleural tropism in EGFR mutated NSCLC and serous and brain metastases in ALK NSCLC); (II) review the low level of current evidence for local ablative therapy (LAT) strategies in patients with oncogenic-driven OM-NSCLC, focusing on the benefit/risk of tyrosine kinase inhibitors (TKI) and LATs combination and (III) present strategies to help to select the best candidate for an attempt-to-cure approach. Finally, the optimal strategy may be to introduce a targeted therapy, then treat all tumor sites with LAT, and finally continue TKI for unknown prolonged duration in an attempt to prolong progression free survival in most patients, improve overall survival for some patients, and potentially lead to a cancer cure for a few patients.
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Affiliation(s)
- Vincent Fallet
- Department of Pneumology and Thoracic Oncology, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon and GRC 4, Theranoscan, Sorbonne Université, Paris, France
| | - Lise Matton
- Department of Pneumology and Thoracic Oncology, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon and GRC 4, Theranoscan, Sorbonne Université, Paris, France
| | - Antoine Schernberg
- Department of Radiation Oncology, DMU Orphé, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Anthony Canellas
- Department of Pneumology and Thoracic Oncology, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon and GRC 4, Theranoscan, Sorbonne Université, Paris, France
| | - François H. Cornelis
- Department of Interventional Radiology and Oncology, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Jacques Cadranel
- Department of Pneumology and Thoracic Oncology, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon and GRC 4, Theranoscan, Sorbonne Université, Paris, France
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20
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Validation of the updated renal graded prognostic assessment (GPA) for patients with renal cancer brain metastases treated with gamma knife radiosurgery. J Neurooncol 2021; 153:527-536. [PMID: 34170460 DOI: 10.1007/s11060-021-03793-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/19/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Prognosis of patients with brain metastasis (BM) from renal cell carcinoma (RCC) is relevant for treatment decisions and can be estimated with the Renal Graded Prognostic Assessment (GPA). The aim of this study is to validate the updated version of this instrument in a cohort treated with Gamma Knife radiosurgery (GKRS) without prior local intracerebral therapy. METHODS Between 2007 and 2018, 106 RCC patients with BM were treated with GKRS. They were categorized according to the updated Renal GPA. Overall survival (OS), distant intracranial failure and local failure were estimated using the Kaplan-Meier method and risk factors were identified with Cox proportional hazard regressions. RESULTS Median OS was 8.6 months. Median OS for GPA categories 0.0-1.0 (15%), 1.5-2.0 (12%), 2.5-3.0 (35%) and 3.5-4.0 (29%) was 2.9, 5.5, 8.1 and 20.4 months, respectively. Karnofsky performance status < 90, serum hemoglobin ≤ 12.5 g/dL, age > 65 years and time from primary diagnosis to brain metastasis < 1 year were significantly related with shorter survival, while presence of extracranial disease, the volume and total number of BM had no significant impact on OS. A total count of > 4 BM was the only predictive factor for distant intracranial failure, while none of the investigated factors predicted local failure. CONCLUSIONS This study confirms the updated Renal GPA in an independent cohort as a valuable instrument to estimate survival in patients with BM from RCC treated with GKRS.
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21
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Garcia-Alvarez A, Papakonstantinou A, Oliveira M. Brain Metastases in HER2-Positive Breast Cancer: Current and Novel Treatment Strategies. Cancers (Basel) 2021; 13:2927. [PMID: 34208287 PMCID: PMC8230933 DOI: 10.3390/cancers13122927] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/05/2021] [Accepted: 06/08/2021] [Indexed: 01/08/2023] Open
Abstract
Development of brain metastases can occur in up to 30-50% of patients with breast cancer, representing a significant impact on an individual patient in terms of survival and quality of life. Patients with HER2-positive breast cancer have an increased risk of developing brain metastases; however, screening for brain metastases is not currently recommended due to the lack of robust evidence to support survival benefit. In recent years, several novel anti-HER2 agents have led to significant improvements in the outcomes of HER2-positive metastatic breast cancer. Despite these advances, brain and leptomeningeal metastases from HER2-positive breast cancer remain a significant cause of morbidity and mortality, and their optimal management remains an unmet need. This review presents an update on the current and novel treatment strategies for patients with brain metastases from HER2-positive breast cancer and discusses the open questions in the field.
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Affiliation(s)
| | - Andri Papakonstantinou
- Breast Cancer Group, Vall d’Hebron Institute of Oncology (VHIO), 08035 Barcelona, Spain;
- Department of Oncology-Pathology, Karolinska Institute, 17177 Stockholm, Sweden
- Department of Breast Cancer, Endocrine Tumors and Sarcoma, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Mafalda Oliveira
- Medical Oncology Department, Vall d’Hebron Hospital, 08035 Barcelona, Spain;
- Breast Cancer Group, Vall d’Hebron Institute of Oncology (VHIO), 08035 Barcelona, Spain;
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22
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Breast cancer subtype predicts clinical outcomes after stereotactic radiation for brain metastases. J Neurooncol 2021; 152:591-601. [PMID: 33742358 DOI: 10.1007/s11060-021-03735-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE We investigated the prognostic ability of tumor subtype for patients with breast cancer brain metastases (BCBM) treated with stereotactic radiation (SRT). METHODS This is a retrospective review of 181 patients who underwent SRT to 664 BCBM from 2004 to 2019. Patients were stratified by subtype: hormone receptor (HR)-positive, HER2-negative (HR+/HER2-), HR-positive, HER2-positive (HR+/HER2+), HR-negative, HER2-positive (HR-/HER2+), and triple negative (TN). The Kaplan-Meier method was used to calculate overall survival (OS), local control (LC), and distant intracranial control (DIC) from the date of SRT. Multivariate analysis (MVA) was conducted using the Cox proportional hazards model. RESULTS Median follow up from SRT was 11.4 months. Of the 181 patients, 47 (26%) were HR+/HER2+, 30 (17%) were HR-/HER2+, 60 (33%) were HR+/HER2-, and 44 (24%) were TN. Of the 664 BCBMs, 534 (80%) received single fraction stereotactic radiosurgery (SRS) with a median dose of 21 Gy (range 12-24 Gy), and 130 (20%) received fractionated stereotactic radiation therapy (FSRT), with a median dose of 25 Gy (range 12.5-35 Gy) delivered in 3 to 5 fractions. One-year LC was 90%. Two-year DIC was 35%, 23%, 27%, and 16% (log rank, p = 0.0003) and 2-year OS was 54%, 47%, 24%, and 12% (log rank, p < 0.0001) for HR+/HER2+, HR-/HER2+, HR+/HER2-, and TN subtypes, respectively. On MVA, the TN subtype predicted for inferior DIC (HR 1.62, 95% CI 1.00-2.60, p = 0.049). The modified breast-Graded Prognostic Assessment (GPA) significantly predicted DIC and OS (both p < 0.001). CONCLUSIONS Subtype is prognostic for OS and DIC for patients with BCBM treated with SRT.
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23
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Mills MN, Walker C, Thawani C, Naz A, Figura NB, Kushchayev S, Etame A, Yu HHM, Robinson TJ, Liu J, Vogelbaum MA, Forsyth PA, Czerniecki BJ, Soliman HH, Han HS, Ahmed KA. Trastuzumab Emtansine (T-DM1) and stereotactic radiation in the management of HER2+ breast cancer brain metastases. BMC Cancer 2021; 21:223. [PMID: 33663447 PMCID: PMC7934378 DOI: 10.1186/s12885-021-07971-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/24/2021] [Indexed: 12/21/2022] Open
Abstract
Background Due to recent concerns about the toxicity of trastuzumab emtansine (T-DM1) with stereotactic radiation, we assessed our institutional outcomes treating HER2-positive breast cancer brain metastases (BCBM) with T-DM1 and stereotactic radiation. Methods This is a single institution series of 16 patients with HER2-positive breast cancer who underwent 18 stereotactic sessions to 40 BCBM from 2013 to 2019 with T-DM1 delivered within 6 months. The Kaplan-Meier method was used to calculate overall survival (OS), local control (LC), distant intracranial control (DIC), and systemic progression-free survival (sPFS) from the date of SRS. A neuro-radiologist independently reviewed follow-up imaging. Results One patient had invasive lobular carcinoma, and 15 patients had invasive ductal carcinoma. All cases were HER2-positive, while 10 were hormone receptor (HR) positive. Twenty-four lesions were treated with stereotactic radiosurgery (SRS) to a median dose of 21 Gy (14–24 Gy). Sixteen lesions were treated with fractionated stereotactic radiation (FSRT) with a median dose of 25 Gy (20-30Gy) delivered in 3 to 5 fractions. Stereotactic radiation was delivered concurrently with T-DM1 in 19 lesions (48%). Median follow up time was 13.2 months from stereotactic radiation. The 1-year LC, DIC, sPFS, and OS were 75, 50, 30, and 67%, respectively. There was 1 case of leptomeningeal progression and 1 case (3%) of symptomatic radionecrosis. Conclusions We demonstrate that stereotactic radiation and T-DM1 is well-tolerated and effective for patients with HER2-positive BCBM. An increased risk for symptomatic radiation necrosis was not noted in our series.
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Affiliation(s)
- Matthew N Mills
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA.
| | - Chelsea Walker
- University of South Florida, Morsani College of Medicine, Tampa, FL, 33612, USA
| | - Chetna Thawani
- University of South Florida, Morsani College of Medicine, Tampa, FL, 33612, USA
| | - Afrin Naz
- University of South Florida, Morsani College of Medicine, Tampa, FL, 33612, USA
| | - Nicholas B Figura
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA
| | - Sergiy Kushchayev
- Departments of Radiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Arnold Etame
- Departments of Neuro Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Hsiang-Hsuan Michael Yu
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA
| | - Timothy J Robinson
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA
| | - James Liu
- Departments of Neuro Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Michael A Vogelbaum
- Departments of Neuro Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Peter A Forsyth
- Departments of Neuro Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Brian J Czerniecki
- Departments of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Hatem H Soliman
- Departments of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Hyo S Han
- Departments of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Kamran A Ahmed
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA
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24
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Ratosa I, Vidmar MS. Stereotactic radiosurgery for patients with breast cancer brain oligometastases - molecular subtypes and clinical outcomes. ACTA ACUST UNITED AC 2021; 26:1-11. [PMID: 33948296 DOI: 10.5603/rpor.a2021.0001] [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: 06/26/2020] [Accepted: 12/07/2020] [Indexed: 11/25/2022]
Abstract
Background We sought to determine the clinical outcomes of patients with breast cancer (BC) who had undergone stereotactic radiosurgery (SRS) for a limited number of brain metastases (BM) and to identify factors influencing overall survival (OS) and local control. Materials and methods The records of 45 patients who underwent SRS for 72 brain lesions were retrospectively evaluated. Statistics included the chi-squared test, Kaplan-Meier method, and the multivariate Cox model. Results The median number of treated BM was 2 (range 1-10). Median OS from BM diagnosis and post-SRS were 27.6 [95% confidence interval (CI): 14.8-40.5) and 18.5 months (95% CI: 11.1-25.8), respectively. One-year and two-year survival rates after BM diagnosis were 55% and 41%, respectively. In a univariate analysis, the Luminal-B-human-epidermal-growth-receptor-positive (HER2+) subtype had the longest median OS at 39.1 months (95% CI: 34.1-44.1, p = 0.004). In an adjusted analysis, grade 2 [hazard ratio (HR): 0.1; 95% CI: 0.1-0.6, p = 0.005), craniotomy (HR: 0.3; 95% CI: 0.1-0.7; p = 0.006), and ≥ 2 systemic therapies received (HR: 0.3; 95% CI: 0.1-0.9, p = 0.028) were associated with improved OS. One-year and two-year intracranial progression-free survival rates were 85% and 63%, respectively. Four factors for a higher risk of any intracranial recurrence remained significant in the adjusted analysis, as follows: age < 50 years (HR: 4.2; 95% CI: 1.3-36.3; p = 0.014), grade 3 (HR: 3.7; 95% CI: 1.1-13.2; p = 0.038), HER2+ (HR: 6.9; 95% CI: 1.3-36.3; p = 0.023), and whether the brain was the first metastatic site (HR: 4.7; 95% CI: 1.6-14.5; p = 0.006). Conclusion Intrinsic BC characteristics are important determinants for both survival and intracranial control for patients undergoing SRS for oligometastatic brain disease.
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Affiliation(s)
- Ivica Ratosa
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Marija Skoblar Vidmar
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
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25
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Galldiks N, Kocher M, Ceccon G, Werner JM, Brunn A, Deckert M, Pope WB, Soffietti R, Le Rhun E, Weller M, Tonn JC, Fink GR, Langen KJ. Imaging challenges of immunotherapy and targeted therapy in patients with brain metastases: response, progression, and pseudoprogression. Neuro Oncol 2021; 22:17-30. [PMID: 31437274 DOI: 10.1093/neuonc/noz147] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The advent of immunotherapy using immune checkpoint inhibitors (ICIs) and targeted therapy (TT) has dramatically improved the prognosis of various cancer types. However, following ICI therapy or TT-either alone (especially ICI) or in combination with radiotherapy-imaging findings on anatomical contrast-enhanced MRI can be unpredictable and highly variable, and are often difficult to interpret regarding treatment response and outcome. This review aims at summarizing the imaging challenges related to TT and ICI monotherapy as well as combined with radiotherapy in patients with brain metastases, and to give an overview on advanced imaging techniques which potentially overcome some of these imaging challenges. Currently, major evidence suggests that imaging parameters especially derived from amino acid PET, perfusion-/diffusion-weighted MRI, or MR spectroscopy may provide valuable additional information for the differentiation of treatment-induced changes from brain metastases recurrence and the evaluation of treatment response.
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Affiliation(s)
- Norbert Galldiks
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Institute of Neuroscience and Medicine, Research Center Juelich, Juelich, Germany.,Center of Integrated Oncology, Universities of Aachen, Bonn, Cologne, and Düsseldorf, Germany
| | - Martin Kocher
- Institute of Neuroscience and Medicine, Research Center Juelich, Juelich, Germany.,Department of Stereotaxy and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Garry Ceccon
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jan-Michael Werner
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Anna Brunn
- Institute of Neuropathology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Martina Deckert
- Institute of Neuropathology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Whitney B Pope
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Emilie Le Rhun
- Neuro-Oncology, General and Stereotaxic Neurosurgery Service, University Hospital Lille, Lille, France.,Breast Cancer Department, Oscar Lambret Center, Lille, France.,Department of Neurology & Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology & Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Jörg C Tonn
- Department of Neurosurgery, Ludwig Maximilians University of Munich, Munich, Germany.,German Cancer Consortium, partner site Munich, Germany
| | - Gereon R Fink
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Institute of Neuroscience and Medicine, Research Center Juelich, Juelich, Germany
| | - Karl-Josef Langen
- Institute of Neuroscience and Medicine, Research Center Juelich, Juelich, Germany.,Department of Nuclear Medicine, University Hospital Aachen, Aachen, Germany
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26
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Kotecha R, Tonse R, Rubens M, McDermott MW, Odia Y, Appel H, Mehta MP. Systematic review and meta-analysis of breast cancer brain metastasis and primary tumor receptor expression discordance. Neurooncol Adv 2021; 3:vdab010. [PMID: 33898990 PMCID: PMC8055057 DOI: 10.1093/noajnl/vdab010] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Change in hormone receptor (estrogen [ER] and progesterone [PR]) and/or human epidermal growth factor receptor type 2 (HER2) status during the evolutionary course of metastatic breast cancer and the effect of tumor classification subtype switching remain understudied and underappreciated in brain metastasis patients. Methods Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, a systematic review of series published prior to April 2020 obtained from the Medline database of biopsied or resected breast cancer brain metastasis (BCBM) was performed. Weighted random effects models were used to calculate pooled estimates. Results 15 full-text articles were included with receptor expression analyses on 1373 patients who underwent biopsy or resection of at least one intracranial lesion to compare to the primary tumor. Primary tumor receptor expression immunophenotypes were 45.0% ER+, 41.0% ER−, 31.0% PR+, 51.0% PR−, 35% HER2+, and 47.0% HER2−. Corresponding BCBM immunophenotypes were 19.0% ER+, 31.0% ER−, 13.0% PR+, 40.0% PR−, 21.0% HER2+, and 26.0% HER2−. On primary/BCBM comparison, 540 patients (42.6%) exhibited discordance in any receptor with 17.0% (95% CI: 13.0%–23.0%) discordant on ER, 23.0% (95% CI: 18.0%–30.0%) discordant on PR, and 12.0% (95% CI: 8.0%–16.0%) discordant on HER2 status. The most common receptor conversions found in BCBM were ER loss 11.0% (95% CI: 8.0%–16.0%), PR loss 15.0% (95% CI: 11.0%–21.0%), and HER2 gain 9.0% (95% CI: 7.0%–11.0%). Conclusions BCBM exhibits significant receptor expression discordance in comparison to primary tumors in approximately 40% of patients. Classification patterns need to be analyzed to determine factors predictive of BCBM/primary tumor discordance. Overall, tumor subtype switching and its effect on clinical management remains underappreciated.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Raees Tonse
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Muni Rubens
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Michael W McDermott
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA.,Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Yazmin Odia
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA.,Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA.,Department of Neuro-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Haley Appel
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
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27
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Zeng KL, Sahgal A, Husain ZA, Myrehaug S, Tseng CL, Detsky J, Sarfehnia A, Ruschin M, Campbell M, Foster M, Das S, Lipsman N, Bjarnason GA, Atenafu EG, Maralani PJ, Soliman H. Local control and patterns of failure for "Radioresistant" spinal metastases following stereotactic body radiotherapy compared to a "Radiosensitive" reference. J Neurooncol 2021; 152:173-182. [PMID: 33453002 DOI: 10.1007/s11060-020-03691-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 12/30/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE The concept of a radioresistant (RR) phenotype has been challenged with use of stereotactic body radiotherapy (SBRT). We compared outcomes following SBRT to RR spinal metastases to a radiosensitive cohort. METHODS Renal cell, melanoma, sarcoma, gastro-intestinal, and thyroid spinal metastases were identified as RR and prostate cancer (PCA) as radiosensitive. The primary endpoint was MRI-based local failure (LF). Secondary endpoints included overall survival (OS) and vertebral compression fracture (VCF). RESULTS From a prospectively maintained database of 1394 spinal segments in 605 patients treated with spine SBRT, 173 patients/395 RR spinal segments were compared to 94 patients/185 PCA segments. Most received 24-28 Gy in 2 fractions (68.9%) and median follow-up was 15.5 months (range, 1.4-84.2 months). 1- and 2-year LF rates were 19.2% and 22.4% for RR metastases, respectively, which were significantly greater (p < 0.001) than PCA (3.2% and 8.4%, respectively). Epidural disease (HR: 2.47, 95% CI 1.65-3.71, p < 0.001) and RR histology (HR: 2.41, 95% CI 1.45-3.99, p < 0.001) predicted for greater LF. Median OS was 17.4 and 61.0 months for RR and PCA cohorts, respectively. Lung/liver metastases, polymetastatic disease and epidural disease predicted for worse OS. 2-year VCF rates were ~ 13% in both cohorts. Coverage of the CTV V90 (clinical target volume receiving 90% of prescription dose) by ≥ 87% (HR: 2.32, 95% CI 1.29-4.18, p = 0.005), no prior spine radiotherapy (HR: 1.96, 95% CI 1.09-3.55, p = 0.025), and a greater Spinal Instability Neoplasia Score (p = 0.013) predicted for VCF. CONCLUSIONS Higher rates of LF were observed after spine SBRT in RR metastases. Optimization strategies include dose escalation and aggressive management of epidural disease.
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Affiliation(s)
- K Liang Zeng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Zain A Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Arman Sarfehnia
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Mikki Campbell
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Monica Foster
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Sunit Das
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Georg A Bjarnason
- Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada.
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Borius PY, Régis J, Carpentier A, Kalamarides M, Valery CA, Latorzeff I. Safety of radiosurgery concurrent with systemic therapy (chemotherapy, targeted therapy, and/or immunotherapy) in brain metastases: a systematic review. Cancer Metastasis Rev 2021; 40:341-354. [PMID: 33392851 DOI: 10.1007/s10555-020-09949-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 12/15/2020] [Indexed: 02/07/2023]
Abstract
Stereotactic radiosurgery (SRS) is a standard option for brain metastases (BM). There is lack of consensus when patients have a systemic treatment, if a washout is necessary. The aim of this review is to analyze the toxicity of SRS when it is concurrent with chemotherapies, immunotherapy, and/or targeted therapies. From Medline and Embase databases, we searched for English literature published up to April 2020 according to the PRISMA guidelines, using for key words the list of the main systemic therapies currently in use And "radiosurgery," "SRS," "GKRS," "Gamma Knife," "toxicity," "ARE," "radiation necrosis," "safety," "brain metastases." Studies reporting safety or toxicity with SRS concurrent with systemic treatment for BM were included. Of 852 abstracts recorded, 77 were included. The main cancers were melanoma, lung, breast, and renal carcinoma. These studies cumulate 6384 patients. The median SRS dose prescription was 20 Gy [12-30] .For some, they compared a concurrent arm with a non-concurrent or a SRS-alone arm. There were no skin toxicities, no clearly increased rate of bleeding, or radiation necrosis with significant clinical impact. SRS combined with systemic therapy appears to be safe, allowing the continuation of treatment when brain SRS is considered.
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Affiliation(s)
- Pierre-Yves Borius
- Neurosurgery Department, Pitié Salpêtrière Sorbonne University Hospital, Paris, France.
| | - Jean Régis
- Aix-Marseille Université, Institut de Neuroscience des Systèmes, Functional Neurosurgery and Radiosurgery Department, Hôpital de la Timone, APHM, Marseille, France
| | - Alexandre Carpentier
- Neurosurgery Department, Pitié Salpêtrière Sorbonne University Hospital, Paris, France
| | - Michel Kalamarides
- Neurosurgery Department, Pitié Salpêtrière Sorbonne University Hospital, Paris, France
| | | | - Igor Latorzeff
- Département de radiothérapie-oncologie, bâtiment Atrium, Clinique Pasteur, 1, rue de la Petite-Vitesse, 31300, Toulouse, France
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Samanci Y, Sisman U, Altintas A, Sarioglu S, Sharifi S, Atasoy Aİ, Bolukbasi Y, Peker S. Hypofractionated frameless gamma knife radiosurgery for large metastatic brain tumors. Clin Exp Metastasis 2021; 38:31-46. [PMID: 33389335 DOI: 10.1007/s10585-020-10068-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/29/2020] [Indexed: 12/30/2022]
Abstract
Hypofractionated stereotactic radiosurgery has become an alternative for metastatic brain tumors (METs). We aimed to analyze the efficacy and safety of frameless hypofractionated Gamma Knife radiosurgery (hfGKRS) in the management of unresected, large METs. All patients who were managed with hfGKRS for unresected, large METs (> 4 cm3) between June 2017 and June 2020 at a single center were reviewed in this retrospective study. Local control (LC), progression-free survival (PFS), overall survival (OS), and toxicities were investigated. A total of 58 patients and 76 METs with regular follow-up were analyzed. LC rate was 98.5% at six months, 96.0% at one year, and 90.6% at 2 years during a median follow-up of 12 months (range, 2-37). The log-rank test indicated no difference in the distribution of LC for any clinical or treatment variable. PFS was 86.7% at 6 months, 66.6% at 1 year, and 58.5% at 2 years. OS was 81% at 6 months, 63.6% at one year, and 50.7% at 2 years. On the log-rank test, clinical parameters such as control status of primary cancer, presence of extracranial metastases, RTOG-RPA class, GPA group, and ds-GPA group were significantly associated with PFS and OS. Patients presented with grade 1 (19.0%), grade 2 (3.5%) and grade 3 (5.2%) side effects. Radiation necrosis was not observed in any patients. Our current results suggest that frameless hfGKRS for unresected, large METs is a rational alternative in selected patients with promising results.
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Affiliation(s)
- Yavuz Samanci
- Department of Neurosurgery, Koç University Hospital, Istanbul, Turkey
| | - Uluman Sisman
- School of Medicine, Koç University, Istanbul, Turkey
| | | | | | | | - Ali İhsan Atasoy
- Department of Radiation Oncology, Koç University Hospital, Istanbul, Turkey
| | - Yasemin Bolukbasi
- Department of Radiation Oncology, School of Medicine, Koç University, Istanbul, Turkey
| | - Selcuk Peker
- Department of Neurosurgery, School of Medicine, Koç University, Davutpasa Caddesi No:4, 34010, Zeytinburnu/İstanbul, Turkey.
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Khan M, Zhao Z, Arooj S, Zheng T, Liao G. Lapatinib Plus Local Radiation Therapy for Brain Metastases From HER-2 Positive Breast Cancer Patients and Role of Trastuzumab: A Systematic Review and Meta-Analysis. Front Oncol 2020; 10:576926. [PMID: 33240815 PMCID: PMC7677410 DOI: 10.3389/fonc.2020.576926] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 09/30/2020] [Indexed: 01/11/2023] Open
Abstract
Background Intracranial activity of lapatinib has been demonstrated in several studies in patients with human epidermal growth factor receptor-2 positive breast cancers (HER-2+ BC). Stereotactic radiosurgery (SRS) has been increasingly used as the local therapy for brain metastases in breast cancer patients. Increased objective response rate was observed for lapatinib plus whole brain radiotherapy (WBRT) is such patients with high toxicity. Objective We seek to obtain clinical evidence of synergistic efficacy of lapatinib in combination with radiation therapy, in particular, SRS. Materials and methods We carried out a comprehensive research using the following databases: PubMed; Medline; EMBASE; Cochrane library. These databases were searched until 10 June 2020. PRISMA guidelines were followed step by step for carrying out this systematic review and meta-analysis. Review Manager v 5.4 software was used for statistical evaluation of data. Results Overall 6 studies with 843 HER-2 positive breast cancer patients (442 HER-2 amplified disease, 399 luminal B disease) were included in this systematic review and meta-analysis. A total 279 patients had received lapatinib in addition to HER-2 antibody (trastuzumab) plus/minus chemoradiotherapy, while 610 patients had received trastuzumab-based management or only chemoradiotherapy. Lapatinib-based management of BM was associated with significant increase in overall survival (HR 0.63 [0.52, 0.77], p < 0.00001). Combination of the two (trastuzumab plus lapatinib) was associated with increased survival advantage compared to each agent alone (0.55 [0.32, 0.92], p = 0.02). SRS in combination with lapatinib was associated with increased local control (HR 0.47 [0.33, 0.66], p = 0.0001). Ever use of lapatinib with SRS was associated an increased survival as reported in two studies (Shireen et al.: 27.3 vs. 19.5 months, p = 0.03; Kim et al.: 33.3 vs. 23.6 months, p = 0.009). Kim et al. also revealed significant increase in intracranial activity with concurrent lapatinib reporting 57% complete response compared to 38% (p < 0.001) and lower progressive disease rate of 11 vs. 19% (p < 0.001). Risk of radiation necrosis was decreased with lapatinib use. Conclusions Lapatinib has shown intracranial activity and yielded better survival for HER-2+ BC patients with BMs. SRS in combination with ever use of lapatinib had better local control and were associated with better survival. Radiation necrosis risk was reduced with the use of lapatinib.
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Affiliation(s)
- Muhammad Khan
- Department of Radiation Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China.,Department of Oncology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhihong Zhao
- Department of Nephrology, Shenzhen People's Hospital, Second Clinical Medicine Centre, Jinan University, Shenzhen, China
| | - Sumbal Arooj
- Department of Radiation Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China.,Department of Biochemistry, University of Sialkot, Sialkot, Pakistan
| | - Tao Zheng
- Department of Radiation Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Guixiang Liao
- Department of Radiation Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
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Soffietti R, Ahluwalia M, Lin N, Rudà R. Management of brain metastases according to molecular subtypes. Nat Rev Neurol 2020; 16:557-574. [PMID: 32873927 DOI: 10.1038/s41582-020-0391-x] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2020] [Indexed: 12/25/2022]
Abstract
The incidence of brain metastases has markedly increased in the past 20 years owing to progress in the treatment of malignant solid tumours, earlier diagnosis by MRI and an ageing population. Although local therapies remain the mainstay of treatment for many patients with brain metastases, a growing number of systemic options are now available and/or are under active investigation. HER2-targeted therapies (lapatinib, neratinib, tucatinib and trastuzumab emtansine), alone or in combination, yield a number of intracranial responses in patients with HER2-positive breast cancer brain metastases. New inhibitors are being investigated in brain metastases from ER-positive or triple-negative breast cancer. Several generations of EGFR and ALK inhibitors have shown activity on brain metastases from EGFR and ALK mutant non-small-cell lung cancer. Immune-checkpoint inhibitors (ICIs) hold promise in patients with non-small-cell lung cancer without druggable mutations and in patients with triple-negative breast cancer. The survival of patients with brain metastases from melanoma has substantially improved after the advent of BRAF inhibitors and ICIs (ipilimumab, nivolumab and pembrolizumab). The combination of targeted agents or ICIs with stereotactic radiosurgery could further improve the response rates and survival but the risk of radiation necrosis should be monitored. Advanced neuroimaging and liquid biopsy will hopefully improve response evaluation.
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Affiliation(s)
- Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy.
| | - Manmeet Ahluwalia
- Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Center Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nancy Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
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Abstract
The development of brain metastases occurs in 10–20% of all patients with cancer. Brain metastases portend poor survival and contribute to increased cancer mortality and morbidity. Despite multimodal treatment options, which include surgery, radiotherapy, and chemotherapy, 5-year survival remains low. Besides, our current treatment modalities can have significant neurological comorbidities, which result in neurocognitive decline and a decrease in a patient’s quality of life. However, innovations in technology, improved understanding of tumor biology, and new therapeutic options have led to improved patient care. Novel approaches in radiotherapy are minimizing the neurocognitive decline while providing the same therapeutic benefit. In addition, advances in targeted therapies and immune checkpoint inhibitors are redefining the management of lung and melanoma brain metastases. Similar approaches to brain metastases from other primary tumors promise to lead to new and effective therapies. We are beginning to understand the appropriate combination of these novel approaches with our traditional treatment options. As advances in basic and translational science and innovative technologies enter clinical practice, the prognosis of patients with brain metastases will continue to improve.
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Affiliation(s)
- Adam Lauko
- Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yasmeen Rauf
- Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Manmeet S Ahluwalia
- Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
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Aoyagi K, Higuchi Y, Matsunaga S, Serizawa T, Yomo S, Aiyama H, Nagano O, Kondoh T, Kenai H, Shuto T, Kawagishi J, Jokura H, Sato S, Nakazaki K, Nakaya K, Hasegawa T, Kawashima M, Kawai H, Yamanaka K, Nagatomo Y, Yamamoto M, Sato Y, Aoyagi T, Matsutani T, Iwadate Y. Impact of breast cancer subtype on clinical outcomes after Gamma Knife radiosurgery for brain metastases from breast cancer: a multi-institutional retrospective study (JLGK1702). Breast Cancer Res Treat 2020; 184:149-159. [PMID: 32737714 DOI: 10.1007/s10549-020-05835-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 07/22/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Brain metastasis (BM) is one of the most important issues in the management of breast cancer (BC), since BMs are associated with neurological deficits. However, the importance of BC subtypes remains unclear for BM treated with Gamma Knife radiosurgery (GKS). Thus, we conducted a multicenter retrospective study to compare clinical outcomes based on BC subtypes, with the aim of developing an optimal treatment strategy. METHODS We studied 439 patients with breast cancer and 1-10 BM from 16 GKS facilities in Japan. Overall survival (OS) was analyzed by the Kaplan-Meier method, and cumulative incidences of systemic death (SD), neurologic death (ND), and tumor progression were estimated by competing risk analysis. RESULTS OS differed among subtypes. The median OS time (months) after GKS was 10.4 in triple-negative (TN), 13.7 in Luminal, 31.4 in HER2, and 35.8 in Luminal-HER2 subtype BC (p < 0.0001). On multivariate analysis, poor control of the primary disease (hazard ratio [HR] = 1.84, p < 0.0001), active extracranial disease (HR = 2.76, p < 0.0001), neurological symptoms (HR 1.44, p = 0.01), and HER2 negativity (HR = 2.66, p < 0.0001) were significantly associated with worse OS. HER2 positivity was an independent risk factor for local recurrence (p = 0.03) but associated with lower rates of ND (p = 0.03). TN histology was associated with higher rates of distant brain failure (p = 0.03). CONCLUSIONS HER2 positivity is related to the longer OS after SRS; however, we should pay attention to preventing recurrence in Luminal-HER2 patients. Also, TN patients require meticulous follow-up observation to detect distant metastases and/or LMD.
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Affiliation(s)
- Kyoko Aoyagi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan.
- Gamma Knife House, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba, 290-0512, Japan.
| | - Yoshinori Higuchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shigeo Matsunaga
- Department of Neurosurgery, Yokohama Rosai Hospital, Yokohama, Japan
| | - Toru Serizawa
- Tokyo Gamma Unit Center, Tsukiji Neurological Clinic, Tokyo, Japan
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | | | - Osamu Nagano
- Gamma Knife House, Chiba Cerebral and Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba, 290-0512, Japan
| | - Takeshi Kondoh
- Department of Neurosurgery, Shinsuma General Hospital, Kobe, Japan
| | - Hiroyuki Kenai
- Department of Neurosurgery, Nagatomi Neurosurgical Hospital, Oita, Japan
| | - Takashi Shuto
- Department of Neurosurgery, Yokohama Rosai Hospital, Yokohama, Japan
| | - Jun Kawagishi
- Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Osaki, Japan
| | - Hidefumi Jokura
- Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Osaki, Japan
| | - Sonomi Sato
- Department of Neurosurgery, Southern Tohoku General Hospital, Ōkuma, Fukushima, Japan
| | - Kiyoshi Nakazaki
- Department of Neurosurgery, Brain Attack Center Ota Memorial Hospital, Fukuyama, Japan
| | - Kotaro Nakaya
- Department of Neurosurgery, Atami Tokoro Memorial Hospital, Atami, Japan
| | | | - Mariko Kawashima
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hideya Kawai
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-Akita, Akita, Japan
| | - Kazuhiro Yamanaka
- Department of Neurosurgery, Osaka City General Hospital, Osaka, Japan
| | - Yasushi Nagatomo
- Department of Neurosurgery, Koseikai Takai Hospital, Tenri, Japan
| | | | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Tomoyoshi Aoyagi
- Department of Breast Surgery, Funabashi Municipal Medical Center, Funabashi, Japan
| | - Tomoo Matsutani
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yasuo Iwadate
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
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Khan M, Arooj S, Li R, Tian Y, Zhang J, Lin J, Liang Y, Xu A, Zheng R, Liu M, Yuan Y. Tumor Primary Site and Histology Subtypes Role in Radiotherapeutic Management of Brain Metastases. Front Oncol 2020; 10:781. [PMID: 32733787 PMCID: PMC7358601 DOI: 10.3389/fonc.2020.00781] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 04/22/2020] [Indexed: 12/12/2022] Open
Abstract
Randomized controlled trials have failed to report any survival advantage for WBRT combined with SRS in the management of brain metastases, despite the enhanced local and distant control in comparison to each treatment alone. Literature review have revealed important role of primary histology of the tumor when dealing with brain metastases. NSCLC responds better to combined approach even when there was only single brain metastasis present while breast cancer has registered better survival with SRS alone probably due to better response of primary tumor to advancement in surgical and chemotherapeutic agents. Furthermore, mutation status (EGFR/ALK) in lung cancer and receptor status (ER/PR/HER2) in breast cancer also exhibit diversity in their response to radiotherapy. Radioresistant tumors like renal cell carcinoma and melanoma brain metastases have achieved better results when treated with SRS alone. Secondly, single brain metastasis may benefit from local and distant brain control achieved with combined treatment. These diverse outcomes suggest a primary histology-based analysis of the radiotherapy regimens (WBRT, SRS, or their combination) would more ideally establish the role of radiotherapy in the management of brain metastases. Molecularly targeted therapeutic and immunotherapeutic agents have revealed synergism with radiation therapy particularly SRS in treating cancer patients with brain metastases. Clinical updates in this regard have also been reviewed.
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Affiliation(s)
- Muhammad Khan
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China.,Department of Oncology, First affiliated Hospital of Anhui Medical University, Hefei, China
| | - Sumbal Arooj
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China.,Department of Oncology, First affiliated Hospital of Anhui Medical University, Hefei, China.,Department of Biochemistry, University of Sialkot, Sialkot, Pakistan
| | - Rong Li
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Yunhong Tian
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Jian Zhang
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Jie Lin
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Yingying Liang
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Anan Xu
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Ronghui Zheng
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Mengzhong Liu
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yawei Yuan
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
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Silipigni S, Ippolito E, Matteucci P, Santo B, Gangemi E, La Cesa A, Santini D, Greco C, Ramella S. Repeated courses of radiation treatment in an HER2-positive breast cancer patient with diffuse brain metastases: A case report. Breast J 2020; 26:1370-1371. [PMID: 32279411 DOI: 10.1111/tbj.13844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/18/2020] [Accepted: 03/27/2020] [Indexed: 10/24/2022]
Abstract
In human epidermal growth factor receptor 2 (HER2+) expressing breast cancer subtype, the incidence of brain metastases is common and patients often die due to uncontrolled cranial disease. This is a case report of a HER2+ breast cancer woman with diffuse brain metastases that experienced long survival and clinical benefit from multiple radiotherapy treatments and combined systemic therapy, without increased toxicity.
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Affiliation(s)
- Sonia Silipigni
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Edy Ippolito
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Paolo Matteucci
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Bianca Santo
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Emma Gangemi
- Radiology, Campus Bio-Medico University, Rome, Italy
| | | | | | - Carlo Greco
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Sara Ramella
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
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36
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Eastman BM, Venur VA, Lo SS, Graber JJ. Stereotactic radiosurgery in the treatment of adults with metastatic brain tumors. J Neurosurg Sci 2020; 64:272-286. [PMID: 32270945 DOI: 10.23736/s0390-5616.20.04952-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Brain metastasis is the most common type of intracranial tumor affecting a significant proportion of advanced cancer patients. In recent years, stereotactic radiosurgery (SRS) has become commonly utilized. It has contributed significantly to decreased toxicity, prolonged quality of life and general improvement in outcomes of patients with brain metastases. Frequent imaging and advanced treatment techniques have allowed for the treatment of more patients with large and numerous metastases extending their overall survival. The addition of targeted therapy and immunotherapy to SRS has introduced novel treatment paradigms and has further improved our ability to effectively treat brain lesions. In this review, we examined in detail the available evidence for the use of SRS alone or in combination with surgery and systemic therapies. Given our developing understanding of the importance of primary tumor histology, the use of different treatment strategies for different metastasis is evolving. Combining SRS with immunotherapy and targeted therapy in breast cancer, lung cancer and melanoma as well as the use of preoperative SRS have shown significant promise in recent years and are investigated in multiple ongoing prospective trials. Further research is needed to guide the optimal sequence of therapies and to identify specific patient subgroups that may benefit the most from aggressive, combined treatment approaches.
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Affiliation(s)
- Boryana M Eastman
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Vyshak A Venur
- Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Jerome J Graber
- Department of Neurology and Neurosurgery, Alvord Brain Tumor Center, University of Washington School of Medicine, Seattle, WA, USA -
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37
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Erickson AW, Ghodrati F, Habbous S, Jerzak KJ, Sahgal A, Ahluwalia MS, Das S. HER2-targeted therapy prolongs survival in patients with HER2-positive breast cancer and intracranial metastatic disease: a systematic review and meta-analysis. Neurooncol Adv 2020; 2:vdaa136. [PMID: 33305268 PMCID: PMC7720818 DOI: 10.1093/noajnl/vdaa136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Intracranial metastatic disease (IMD) is a serious and known complication of human epidermal growth factor receptor 2 (HER2)-positive breast cancer. The role of targeted therapy for patients with HER2-positive breast cancer and IMD remains unclear. In this study, we sought to evaluate the effect of HER2-targeted therapy on IMD from HER2-positive breast cancer. METHODS We searched MEDLINE, EMBASE, CENTRAL, and gray literature sources for interventional and observational studies reporting survival, response, and safety outcomes for patients with IMD receiving HER2-targeted therapy. We pooled outcomes through meta-analysis and examined confounder effects through forest plot stratification and meta-regression. Evidence quality was evaluated using GRADE (PROSPERO CRD42020161209). RESULTS A total of 97 studies (37 interventional and 60 observational) were included. HER2-targeted therapy was associated with prolonged overall survival (hazard ratio [HR] 0.47; 95% confidence interval [CI], 0.39-0.56) without significantly prolonged progression-free survival (HR 0.52; 95% CI, 0.27-1.02) versus non-targeted therapy; the intracranial objective response rate was 19% (95% CI, 12-27%), intracranial disease control rate 62% (95% CI, 55-69%), intracranial complete response rate 0% (95% CI, 0-0.01%), and grade 3+ adverse event rate 26% (95% CI, 11-45%). Risk of bias was high in 40% (39/97) of studies. CONCLUSION These findings support a potential role for systemic HER2-targeted therapy in the treatment of patients with IMD from HER2-positive metastatic breast cancer.
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Affiliation(s)
- Anders W Erickson
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Farinaz Ghodrati
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Steven Habbous
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Katarzyna J Jerzak
- Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Hospital, Toronto, Ontario, Canada
| | - Manmeet S Ahluwalia
- Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sunit Das
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
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38
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Lucke-Wold B, Scott K. A Brief Overview of Neurosurgical Management for Breast Cancer Metastasis. SF JOURNAL OF MEDICAL ONCOLOGY AND CANCER 2020; 1:1001. [PMID: 32613208 PMCID: PMC7328909 DOI: pmid/32613208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Despite advances in chemotherapy and radiation, stage IV breast cancer presents a serious challenge to clinicians in light of the continued poor outcomes for patients. Stage IV breast cancer frequently metastasizes to the brain often necessitating neurosurgical intervention. The goals of the neurosurgeon are to adequately address metastatic disease to the central nervous system, limit morbidity for the patients, while preserving as much neurologic function as possible, and to help guide next steps regarding need for radiation and immunotherapy. In this review, we provide a background overview of the role of neurosurgery in managing stage IV metastatic breast cancer involving the brain, discuss what is known about brain metastasis, and highlight avenues for future study and investigation.
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Affiliation(s)
- Brandon Lucke-Wold
- Correspondence: Brandon Lucke-Wold, Department of Neurosurgery, University of Florida, USA.
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