Prophylactic Cranial Irradiation for Patients with Lung Cancer

Machine-Learning-Aided Prediction of Brain Metastases Development in Non-Small-Cell Lung Cancers

PURPOSE

Non-small-cell lung cancer (NSCLC) shows a high incidence of brain metastases (BM). Early detection is crucial to improve clinical prospects. We trained and validated classifier models to identify patients with a high risk of developing BM, as they could potentially benefit from surveillance brain MRI.

METHODS

Consecutive patients with an initial diagnosis of NSCLC from January 2011 to April 2019 and an in-house chest-CT scan (staging) were retrospectively recruited at a German lung cancer center. Brain imaging was performed at initial diagnosis and in case of neurological symptoms (follow-up). Subjects lost to follow-up or still alive without BM at the data cut-off point (12/2020) were excluded. Covariates included clinical and/or 3D-radiomics-features of the primary tumor from staging chest-CT. Four machine learning models for prediction (80/20 training) were compared. Gini Importance and SHAP were used as measures of importance; sensitivity, specificity, area under the precision-recall curve, and Matthew's Correlation Coefficient as evaluation metrics.

RESULTS

Three hundred and ninety-five patients compromised the clinical cohort. Predictive models based on clinical features offered the best performance (tuned to maximize recall: sensitivity∼70%, specificity∼60%). Radiomics features failed to provide sufficient information, likely due to the heterogeneity of imaging data. Adenocarcinoma histology, lymph node invasion, and histological tumor grade were positively correlated with the prediction of BM, age, and squamous cell carcinoma histology were negatively correlated. A subgroup discovery analysis identified 2 candidate patient subpopulations appearing to present a higher risk of BM (female patients + adenocarcinoma histology, adenocarcinoma patients + no other distant metastases).

CONCLUSION

Analysis of the importance of input features suggests that the models are learning the relevant relationships between clinical features/development of BM. A higher number of samples is to be prioritized to improve performance. Employed prospectively at initial diagnosis, such models can help select high-risk subgroups for surveillance brain MRI.

18F-FDG PET/CT radiomics predicts brain metastasis in I-IIIA resected Non-Small cell lung cancer

OBJECTIVE

To establish ¹⁸F-FDG PET/CT radiomics model for predicting brain metastasis in non-small cell lung cancer (NSCLC) patients.

METHODS

This research comprised 203 NSCLC patients who had received surgical therapy at two institutions. To identify independent predictive factors of brain metastasis, metabolic indicators, CT features, and clinical features were investigated. A prediction model was established by incorporating radiomics signature and clinicopathological risk variables. The suggested model's performance was assessed from the perspective of discrimination, calibration, and clinical application.

RESULTS

The C-indices of the PET/CT radiomics model in the training, internal validation, and external validation cohorts were 0.911, 0.825 and 0.800, respectively. According to the multivariate analysis, neuron-specific enolase (NSE) and air bronchogram were independent risk factors for brain metastasis (BM). Furthermore, the combined model integrating radiomics and clinicopathological characteristics related to brain metastasis performed better in terms of prediction, with C-indices of 0.927, 0.861, and 0.860 in the training, internal validation, and external validation cohorts, respectively. The decision curve analysis (DCA) suggested that the PET/CT nomogram was clinically beneficial.

CONCLUSIONS

A predictive algorithm based on PET/CT imaging information and clinicopathological features may accurately predict the probability of brain metastasis in NSCLC patients following surgery. This presented doctors with a unique technique for screening NSCLC patients at high risk of brain metastasis.

A Novel Score Combining Magnetic Resonance Spectroscopy Parameters and Systemic Immune-Inflammation Index Improves Prognosis Prediction in Non-Small Cell Lung Cancer Patients With Brain Metastases After Stereotactic Radiotherapy

Objective

The aim of this study was to evaluate the prognostic significance of the combination of the magnetic resonance spectroscopy (MRS) parameters and systemic immune-inflammation index (SII) in patients with brain metastases (BMs) from non-small cell lung cancer (NSCLC) treated with stereotactic radiotherapy.

Methods

A total of 118 NSCLC patients with BM who were treated with stereotactic radiotherapy were retrospectively enrolled in this study. All patients underwent MRS and blood samples test for SII analysis before the initiation of stereotactic radiotherapy. The correlation between the parameters of MRS and SII level was assessed using Spearman's correlation coefficient. The cutoff values for the parameters of MRS, SII, and clinical laboratory variables were defined by the receiver operating characteristic (ROC) curve analysis to quantify these predictive values. The prognostic factors of overall survival (OS) and progression-free survival (PFS) curves were assessed using the Kaplan-Meier and Cox proportional hazards models.

Results

The median follow-up time was 25 months (range, 12-49 months). The optimal cutoff point for the choline/creatine (Cho/Cr) ratio and SII were 1.50 and 480, respectively. The Cho/Cr ratio was negatively correlated with SII (rs = 0.164, p = 0.075), but there was a trend. The C-SII score was established by combining the Cho/Cr ratio and SII. Patients with both an elevated Cho/Cr ratio (>1.50) and an elevated SII (>480) were given a C-SII score of 2, and patients with one or neither were given a C-SII score of 1 or 0, respectively. The Kaplan-Meier analysis showed that a C-SII score of 2 was significantly linked with poor OS and PFS (p < 0.001 and p < 0.001, respectively). In the Cox proportional hazards model, the C-SII score independently predicted OS [hazard ratio (HR), 1.749; 95% CI, 1.176-2.601; p = 0.006] and PFS (HR, 2.472; 95% CI, 1.624-3.763; p < 0.001).

Conclusion

The C-SII score was more accurate for predicting the clinical outcomes of NSCLC patients with BM who underwent stereotactic radiotherapy. The C-SII score, which was superior to either score alone, could be used to identify BM in NSCLC patients with poor outcomes.

[Research Progress on Risk Factors of Brain Metastasis in Non-small Cell Lung Cancer]

Brain metastasis of non-small cell lung cancer (NSCLC) is a common treatment failure mode, and the median survival time of NSCLC patients with brain metastasis is only 1 mon-2 mon. Prophylactic cranial irradiation (PCI) can delay the occurrence of brain metastasis, but the survival benefits of NSCLC patients are still controversial. It is particularly important to identify the patients who are most likely to benefit from PCI. This article reviews the high risk factors of brain metastasis in NSCLC.
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Risk Factors, Prognosis, and a New Nomogram for Predicting Cancer-Specific Survival Among Lung Cancer Patients with Brain Metastasis: A Retrospective Study Based on SEER

PURPOSE

To make a comprehensive population-based study on risk and prognostic factors of brain metastasis from lung cancer.

METHODS

A total of 91,643 patients diagnosed with lung cancer from 2010 to 2018 were collected from the Surveillance, Epidemiology and End results (SEER) database. To analyze the risk and prognostic factors of brain metastasis among lung cancer patients, both Logistic and Cox regression methods were applied, respectively. Also, the competing risk regression model was performed to establish a new nomogram to predict cancer-specific survival (CSS).

RESULTS

Among the 91,643 lung cancer patients, 10,855 were found to have brain metastasis, with the incidence of 11.84%. The residence, age, race, income, primary site, histological type, extracranial metastasis, T stage, and N stage were all found to be independent risk factors of brain metastasis. The median overall survival (OS) of brain metastasis patients was limited to 6.08 months. By dividing patients randomly into a primary cohort with 7237 patients and a validation cohort with 3618 patients, a conclusion that the income, race, gender, age, histological type, extracranial metastasis, T stage, and N stage were all associated with the prognosis of brain metastasis was drawn. Our established primary-cohort-based new nomogram showed a good discriminative ability in predicting the probability of CSS among patients with brain metastasis, and the C-index was 0.62. Besides, the calibration curves for CSS also showed that the predicted survival by nomogram was consistent with the actual survival in the validation cohort.

CONCLUSION

Our study shall provide a deeper insight into the risk factors and prognosis of brain metastasis among lung cancer patients.

NFAT as a Biomarker and Therapeutic Target in Non-Small Cell Lung Cancer-Related Brain Metastasis

Background

Brain metastases (BMs) are associated with poor prognosis and significant mortality, and approximately 25% of patients with non-small cell lung cancer (NSCLC) develop BMs. The present study was aimed to understand the relationships between BM and NSCLC and reveal potential biomarkers and therapeutic targets in NSCLC-related BM.

Methods

The differentially expressed genes (DEGs) expressed during NSCLC and BM development were predicted by bioinformatics analysis, and the expression of the upstream transcription factor nuclear factor of activated T cells (NFAT) was confirmed as a differential gene expressed in both NSCLC and BM. In addition, the expression of proteins encoded by these DEGs was verified by immunohistochemical experiments examining normal lung tissue, lung cancer tissue, and brain metastasis tissue from 30 patients with NSCLC related BM.

Results

The co-DEGs interleukin (IL)-11, cadherin 5 (CDH5) and C-C motif chemokine 2 (CCL2) link NSCLC and BM in the Gene Expression Omnibus (GEO) database, and NFAT may target the expression of these co-DEGs. In the GEO database, NFATc1 and NFATc3 were significantly downregulated in NSCLC tissues (P <.05), whereas NFATc1, NFATc2, NFATc3, and NFATc4 were significantly downregulated in BMs (P <.05). Consistent findings were observed in the immunohistochemical analysis.

Conclusion

NFATc1 and NFATc3 may play important roles in the occurrence of NSCLC and BM by regulating IL-11, CDH5, and CCL2.

CT-based radiomics for predicting brain metastases as the first failure in patients with curatively resected locally advanced non-small cell lung cancer

PURPOSE

Brain metastasis (BM) is the primary first failure pattern in patients with curatively resected locally advanced non-small cell lung cancer (LA-NSCLC). It is not yet possible to accurately predict the occurrence of BM. The purpose of the research is to develop and validate a prediction model of BM-free survival based on radiomics characterising the primary lesions combined with clinical characteristics in patients with curatively resected LA-NSCLC.

METHODS

This study consisted of 124 patients with curatively resected stage IIB-IIIB NSCLC in our institution between January 2014 and June 2018. Patients were randomly divided into training and validation cohorts using a 4:1 ratio. Radiomics features were selected from the chest CT images before surgery. A radiomics signature was constructed using the LASSO algorithm based on the training cohort. Clinical model was developed using the Cox proportional hazards model. The clinical, radiomics, and integrated nomograms were constructed. The prediction performance of the models was assessed based on its discrimination, calibration, and clinical utility.

RESULTS

The radiomics signature is significantly associated with BM-free survival in the overall cohort. The discrimination performance of the integrated nomogram, with the C-indexes 0.889 (0.872-0.906, 95 % CI) and 0.853 (0.788-0.918, 95 % CI) in the training and validation cohorts, respectively, is significantly better than the clinical nomogram (p < 0.0001 for the training cohort, p = 0.0008 for the validation cohort). Compared with the radiomics nomogram, the integrated nomogram is also improved to varying degrees, but not apparent in the validation cohort (p = 0.0007 for the training cohort, p = 0.0554 for the validation cohort). The calibration curve and decision curve analysis demonstrated that the integrated nomogram exceeded the clinical or radiomics nomograms in predicting BM-free survival.

CONCLUSIONS

Compared with the clinical or radiomics nomograms, the predictive performance of the integrated nomogram is significantly improved. The integrated nomogram is most suitable for predicting BM-free survival in patients with curatively resected LA-NSCLC.

Risk factors for brain metastases in patients with non-small-cell lung cancer

Brain metastases (BM) are severe incidents in patients with non-small-cell lung cancer (NSCLC). The controversial value of prophylactic cranial irradiation (PCI) in NSCLC in terms of survival benefit prompted us to explore the possible risk factors for BM in NSCLC and identify the potential population most likely to benefit from PCI. Risk factors for brain metastases in NSCLC are reviewed in this article. Identifying patients with a higher risk of BM could possibly increase the benefit of PCI while reducing the discomfort and risks caused by unnecessary invasive procedures in the NSCLC patient population. Future studies might focus on finding a solid basis for the prediction of the occurrence of brain metastases and for the therapeutic decision on the use of PCI.

MiR-423-5p in brain metastasis: potential role in diagnostics and molecular biology

During the last several years, a growing number of studies have shown that microRNAs (miRNAs) participate in cancer metastasis. Brain metastasis (BM) is a frequent complication of lung adenocarcinoma (LAD), and the incidence of locally advanced LAD with BM can be as high as 30-50%. This study was performed to identify the miRNA expression patterns of LAD with BM and to determine the biological role that miRNAs play in tumorigenesis. To this end, we conducted microarray and quantitative PCR analyses to evaluate BM-related miRNAs independently validated from a total of 155 patients with LAD. A series of in vivo and in vitro assays were also conducted to verify the impact of miRNAs on BM. We found significantly increased expression of miR-423-5p, and BM was predicted in non-small cell lung cancer when compared to LAD without BM. We next examined the function of miR-423-5p and discovered that it significantly promoted colony formation, cell motility, migration, and invasion in vitro. We computationally and experimentally confirmed that metastasis suppressor 1 (MTSS1) was a direct miR-423-5p target. Through a combination of image, histological, and molecular analyses, we found that miR-423-5p overexpression significantly increased tumor burden, local invasion, and distant BM. The level of MTSS1 expression was inversely correlated with miR-423-5p upregulation in the LAD specimens and was associated with survival of patients with BM. MiR-423-5p promoted BM in LAD and inhibited MTSS1 expression. Together, these results show that MiR-423-5p has the potential to be a marker of BM and/or a therapeutic target in LAD.

Targeted DNA sequencing of non-small cell lung cancer identifies mutations associated with brain metastases

Introduction

This study explores the hypothesis that dominant molecular oncogenes in non-small cell lung cancer (NSCLC) are associated with metastatic spread to the brain.

Methods

NSCLC patient groups with no evidence of metastasis, with metastatic disease to a non-CNS site, who developed brain metastasis after diagnosis, and patients with simultaneous diagnosis of NSCLC and metastatic brain lesions were studied using targeted sequencing.

Results

In patients with brain metastasis versus those without, only 2 variants (one each in BCL6 and NOTHC2) were identified that occurred in ≥ 4 NSCLC of patients with brain metastases but ≤ 1 of the NSCLC samples without brain metastases. At the gene level, 20 genes were found to have unique variants in more than 33% of the patients with brain metastases. When analyzed at the patient level, these 20 genes formed the basis of a predictive test to discriminate those with brain metastasis. Further analysis showed that PI3K/AKT signaling is altered in both the primary and metastases of NSCLC patients with brain lesions.

Conclusion

While no single variant was associated with brain metastasis, this study describes a potential gene panel for the identification of patients at risk and implicates PI3K/AKT signaling as a therapeutic target.

The Road Less Traveled: Should We Omit Prophylactic Cranial Irradiation for Patients With Small Cell Lung Cancer?

New randomized data from Japan have raised questions regarding the use of prophylactic cranial irradiation for patients with extensive-stage small-cell lung cancer but without detectable brain metastases on magnetic resonance imaging. In the present focused review, we examine the general role of prophylactic cranial irradiation in the management of small-cell lung cancer and present relevant controversies from both sides of the discussion. Future directions for clinical investigation and research are also highlighted. Strategies for neurocognitive protection, including memantine use and hippocampal sparing using modulated radiotherapy techniques, are also presented.

A Nomogram to Predict Brain Metastases of Resected Non-Small Cell Lung Cancer Patients

PURPOSE

Brain metastasis is a major cause leading to the failure of treatment management for non-small cell lung cancer (NSCLC) patients. The goal of this study was to establish an effective nomogram for prediction of brain metastases of resected NSCLC patients.

METHODS

We retrospectively investigated 637 operable NSCLC patients who received treatment at Zhejiang Cancer Hospital, China. A Cox proportional hazards regression model was performed to identify significant risk factors, and a nomogram was developed for predicting 3- and 5-year brain metastases rates.

RESULTS

Multivariate analysis identified four independent risk factors: neuron-specific enolase, histological type, number of metastatic lymph nodes, and tumor grade, and a nomogram was developed based on these factors. The effectiveness of the nomogram was validated using an internal bootstrap resampling approach, showing that the nomogram exhibited a sufficient level of discrimination according to the C-index (0.74, 95 % confidence interval 0.67-0.82).

CONCLUSIONS

The nomogram developed in this study demonstrated its discrimination capability for predicting 3- and 5-year occurrence of brain metastases, and can be used to identify high-risk patients.

Intracranial Hemangiopericytoma and the Role of Radiation Therapy A Population Based Analysis

BACKGROUND:

Intracranial hemangiopericytoma (HPC) is a rare malignancy for which treatment recommendations vary.

OBJECTIVE:

We sought to characterize outcomes of HPC patients treated with postoperative external beam radiotherapy (PORT).

METHODS:

A retrospective analysis was conducted using the Surveillance, Epidemiology and End Results (SEER) Program of the US National Cancer Institute. We identified patients with intracranial hemangiopericytoma who underwent surgery alone or PORT.

RESULTS:

We identified 88 patients with a diagnosis of HPC between 1982 and 2009 treated with surgery alone or PORT. The majority of patients were female (53%) and white (84%) with a median age of 50.5 years (range, 0–92 years). Gross total resection (GTR) was achieved in 55%, and PORT was delivered to 48% of the entire cohort. The median overall survival (OS) and cause-specific survival (CSS) were 111 months and 161 months, respectively. On univariate analysis, age older than 50 years correlated with poor OS (hazard ratio [HR]: 3.43; 95% confidence interval [CI]: 1.70-6.95; P = .001) and CSS (HR: 2.77; 95% CI: 1.18-6.48; P = .019). On multivariate analysis (MVA), age &gt;50 years correlated with poor OS (HR: 3.69; 95% CI: 1.72-7.93; P = .001) and CSS (HR: 2.67; 95% CI: 1.08-6.59; P = .034). On MVA, GTR correlated with improved OS (HR: 0.28; 95% CI: 0.11-0.71; P = .007) and CSS (HR: 0.23; 95% CI: 0.07-0.76; P = .016). In addition, PORT correlated with improved OS (MVA HR: 0.02; 95% CI: 0.00-0.31; P = .005) and CSS (MVA HR: 0.02; 95% CI: 0.00-0.45; P = .015). Patients undergoing STR with PORT compared favorably with those undergoing GTR alone with respect to OS (HR: 0.43; 95% CI: 0.15-1.26; P = .13) and CSS (HR: 0.51; 95% CI: 0.15-1.78; P = .29).

CONCLUSION:

In intracranial HPC, both PORT and GTR independently correlate with improved OS and CSS.

MicroRNA-378 is associated with non-small cell lung cancer brain metastasis by promoting cell migration, invasion and tumor angiogenesis

Lung cancer is the leading cause of cancer deaths in the world. Brain metastasis (BM) can affect about 25% of non-small cell lung cancer (NSCLC) patients during their lifetime. Efforts to characterize patients that will develop BM have been disappointing. MicroRNAs (miRNAs) play a role in regulating a variety of targets and, consequently, multiple pathways, which make them a powerful tool for early detection of disease, risk assessment and prognosis. In this study, using RT-PCR and further northern blot validation, we confirmed that miR-378 was significantly differentially expressed in the matched NSCLC from 8 patients with BM and 21 without BM. Our study showed evidences that miR-378 is associated with non-small cell lung cancer brain metastasis by promoting cell migration, invasion and tumor angiogenesis. MiR-378 may be a potential biomarker for characterizing non-small cell lung cancer brain metastasis and assisting clinicians in stratifying the high-risk patients on a clinical trial for either prophylactic cranial irradiation or a new intervention that may mitigate BM development, ultimately leading to a new standard of care for NSCLC patients.

MicroRNA-328 is associated with (non-small) cell lung cancer (NSCLC) brain metastasis and mediates NSCLC migration

Brain metastasis (BM) can affect ∼ 25% of nonsmall cell lung cancer (NSCLC) patients during their lifetime. Efforts to characterize patients that will develop BM have been disappointing. microRNAs (miRNAs) regulate the expression of target mRNAs. miRNAs play a role in regulating a variety of targets and, consequently, multiple pathways, which make them a powerful tool for early detection of disease, risk assessment, and prognosis. We investigated miRNAs that may serve as biomarkers to differentiate between NSCLC patients with and without BM. miRNA microarray profiling was performed on samples from clinically matched NSCLC from seven patients with BM (BM+) and six without BM (BM-). Using t-test and further qRT-PCR validation, eight miRNAs were confirmed to be significantly differentially expressed. Of these, expression of miR-328 and miR-330-3p were able to correctly classify BM+ vs. BM- patients. This classifier was used on a validation cohort (n = 15), and it correctly classified 12/15 patients. Gene expression analysis comparing A549 parental and A549 cells stably transfected to over-express miR-328 (A549-328) identified several significantly differentially expressed genes. PRKCA was one of the genes over-expressed in A549-328 cells. Additionally, A549-328 cells had significantly increased cell migration compared to A549 cells, which was significantly reduced upon PRKCA knockdown. In summary, miR-328 has a role in conferring migratory potential to NSCLC cells working in part through PRKCA and with further corroboration in additional independent cohorts, these miRNAs may be incorporated into clinical treatment decision making to stratify NSCLC patients at higher risk for developing BM.

MicroRNA-328 is associated with (non-small) cell lung cancer (NSCLC) brain metastasis and mediates NSCLC migration

Brain metastasis (BM) can affect ∼ 25% of nonsmall cell lung cancer (NSCLC) patients during their lifetime. Efforts to characterize patients that will develop BM have been disappointing. microRNAs (miRNAs) regulate the expression of target mRNAs. miRNAs play a role in regulating a variety of targets and, consequently, multiple pathways, which make them a powerful tool for early detection of disease, risk assessment, and prognosis. We investigated miRNAs that may serve as biomarkers to differentiate between NSCLC patients with and without BM. miRNA microarray profiling was performed on samples from clinically matched NSCLC from seven patients with BM (BM+) and six without BM (BM-). Using t-test and further qRT-PCR validation, eight miRNAs were confirmed to be significantly differentially expressed. Of these, expression of miR-328 and miR-330-3p were able to correctly classify BM+ vs. BM- patients. This classifier was used on a validation cohort (n = 15), and it correctly classified 12/15 patients. Gene expression analysis comparing A549 parental and A549 cells stably transfected to over-express miR-328 (A549-328) identified several significantly differentially expressed genes. PRKCA was one of the genes over-expressed in A549-328 cells. Additionally, A549-328 cells had significantly increased cell migration compared to A549 cells, which was significantly reduced upon PRKCA knockdown. In summary, miR-328 has a role in conferring migratory potential to NSCLC cells working in part through PRKCA and with further corroboration in additional independent cohorts, these miRNAs may be incorporated into clinical treatment decision making to stratify NSCLC patients at higher risk for developing BM.

Pancoast tumors

Pancoast tumors (superior sulcus tumors or apical lung tumors) typically invade structures at the thoracic outlet, including the inferior elements of the brachial plexus (C8, T1 nerve roots and lower trunk). Historically, these tumors are rapidly fatal, but newer treatment with induction chemotherapy and radiotherapy, followed by surgical resection of the tumor has resulted in improved patient survival. To accomplish oncologic excision, resection of the involved brachial plexus elements is still standard practice in most centers, resulting in loss of hand function and/or development of neuropathic pain. We present a modification of this protocol that incorporates induction chemoradiation, surgical resection of the lung tumor by a thoracic surgeon, and neurolysis and preservation of the brachial plexus by a neurosurgeon. Improved survival outcome, especially in patients demonstrating a pathologic complete response, with preservation of hand function, supports our hypothesis that involved brachial plexus does not need resection in these patients.

Long-term follow-up of a phase I/II trial of dose escalating three-dimensional conformal thoracic radiation therapy with induction and concurrent carboplatin and paclitaxel in unresectable stage IIIA/B non-small cell lung cancer

BACKGROUND

We conducted a modified phase I/II trial investigating the incorporation of three-dimensional conformal thoracic radiation therapy (TCRT) into the treatment paradigm of induction and concurrent carboplatin and paclitaxel in patients with unresectable stage IIIA/B non-small cell lung cancer.

METHODS

Patients received 2 cycles of induction carboplatin (area under the curve of 6) and paclitaxel (225 mg/m) on days 1, and 22. On day 43 concurrent TCRT and weekly x6 of carboplatin (area under the curve = 2) and paclitaxel (45 mg/m) was initiated. The TCRT dose was escalated from 60 to 74 Gy in 4 cohorts (60, 66, 70, and 74 Gy), and the 74 Gy cohort was expanded into a phase II trial.

RESULTS

Sixty-two patients were enrolled; the median age 57 years (range, 36-82), 39 were male (63%), 61 (98%) had a performance status of 0 or 1, 28 (45%) had stage IIIA disease, 21 (34%) had >5% weight loss, and the median forced expiratory volume 1 = 2.10 liters (range, 1.02-3.75). With a median follow-up for survivors of approximately 9 years (range, 7-11 years) the median progression-free survival, time to tumor progression, and overall survival (OS) (with 95% confidence intervals) were 10 (8.5-17), 15 (9-50), and 25 months (18-37), respectively. The 5-year progression-free survival and OS rates were 21% (12-32%) and 27% (17-39%), respectively. The 10-year OS rate was 14% (7-25%).

CONCLUSION

The long term survival rate compares favorably to other treatment approaches for stage III non-small cell lung cancer.

Prophylactic cranial irradiation in advanced breast cancer: a case for caution

PURPOSE

Prophylactic cranial irradiation (PCI) has a well-recognized role in the treatment of leukemia and small-cell lung cancer. Clinical utility has yet to be determined for breast cancer, where an emerging group at high risk of brain metastasis has fuelled consideration of PCI.

METHODS AND MATERIALS

In reviewing our experience with PCI as part of a complex protocol for advanced breast cancer, we present descriptive data on late central nervous system outcomes in those receiving PCI. After high-dose anthracycline-based induction chemotherapy, Stage IIIB/IV breast cancer responders underwent tandem autologous marrow transplantation. Those in continued remission were referred for PCI. Whole-brain radiotherapy was delivered by usual means, at 36 Gy in 20 fractions.

RESULTS

Twenty-four women, with median age 45 (28-61), were enrolled between 1995 and 1998. Disease was largely metastatic (79%), and 75% were previously exposed to chemotherapy or hormonotherapy. Ten patients received PCI, at a median of 13.4 (11.8-16.5) months from study entry. Six patients developed brain metastases, 2 despite PCI. Striking functional decline was documented in 3 patients (at 9 months, 4 years, and 5 years post-PCI), including one previously high-functioning woman requiring full care for posttreatment dementia.

CONCLUSIONS

We present a series of advanced breast cancer patients treated prophylactically with whole-brain radiotherapy following an aggressive chemotherapy regimen. Although the therapeutic benefit of PCI is not ascertainable here, we describe brain metastases occurring despite PCI and serious long-term neurobehavioral sequelae in PCI-treated patients. Any further investigation of PCI in high-risk breast cancer will need to be approached with caution.