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Wang T, Chen J, Yang J, Fu M, Hua W, Jia W, Liu Y, Wang B, Yan M, Zhou J, Hao C, Chen J, Ou D, Jiang T, Mao Y, Jiang Z. CSCO expert consensus on the diagnosis and treatment of breast cancer brain metastasis. TRANSLATIONAL BREAST CANCER RESEARCH : A JOURNAL FOCUSING ON TRANSLATIONAL RESEARCH IN BREAST CANCER 2022; 3:22. [PMID: 38751521 PMCID: PMC11092996 DOI: 10.21037/tbcr-22-30] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/28/2022] [Indexed: 05/18/2024]
Abstract
Breast cancer is one of the most common malignancies among women worldwide. According to the International Agency for Research on Cancer, breast cancer affected more Chinese women than any other cancer in 2020. The brain is an increasingly common metastatic sites of breast cancer. Although the risk of developing brain metastases (BMs) is lower in breast cancer than in lung cancer and melanoma, due to its high prevalence, it is the second most common cause of BM among solid tumors, being second only to lung cancer. The incidence of breast cancer brain metastasis (BCBM) differs by molecular subtype. Half of patients with advanced human epidermal growth factor receptor-2 (HER2)-positive and one-third of patients with triple-negative breast cancer (TNBC) develop BM. The clinical manifestations of leptomeningeal metastasis (LM) are often non-specific and may manifest as a variety of signs and symptoms, mainly including brain parenchyma involvement and meningeal irritation syndromes cranial nerve involvement, increased intracranial pressure, and progressive brain dysfunction. Therefore, the Chinese Society of Clinical Oncology (CSCO) Breast Cancer Committee has developed this expert consensus on BM, in an effort to improve the overall prognosis of BCBM and promote the standardized diagnosis and treatment of this disease. During the development of this expert consensus, we carried out a comprehensive literature review and referred to some of the most authoritative guidelines in China and abroad. In this consensus, we will discuss clinical manifestations, imaging examinations, pathological diagnosis, treatments, prognosis, follow-up and monitoring. We hope this consensus will be of help to all the clinicians majored in breast cancer and other similar professions.
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Affiliation(s)
- Tao Wang
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Jiayi Chen
- Department of Radiotherapy, Ruijin Affiliated Hospital of Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jin Yang
- Department of Oncology, The First Affiliated Hospital of Xi‘an Jiaotong University, Xi’an, China
| | - Minjie Fu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wei Hua
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wang Jia
- Department of Neurosurgery, Tiantan Hospital, Beijing, China
| | - Yueping Liu
- Department of Pathology, Fourth Hospital Affiliated of Hebei Medical University, Shijiazhuang, China
| | - Biyun Wang
- Department of Oncology, Cancer Hospital Affiliated to Fudan University, ShanghaiChina
| | - Min Yan
- Department of Oncology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Juan Zhou
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Chunfang Hao
- Department of Oncology, Tumor Hospital of Tianjin, Tianjin, China
| | - Jiaxin Chen
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Dan Ou
- Department of Radiotherapy, Ruijin Affiliated Hospital of Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Tao Jiang
- Department of Neurosurgery, Tiantan Hospital, Beijing, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zefei Jiang
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - the CSCO expert panel of breast cancer*TengYueeZhangQingyuanLiManJinFengJiangZefeiWangTaoWenJuyiHaoChunfangGengCuizhiLiuYunjiangLiuYuepingZhangJunYanMinWanHaiboYuZhigangYinYongmeiPanYueyinChenJiayiWangBiyunWangXiaojiaOuyangQuchangLiuJiaLiuShuLiuQiangWangKunWangShusenNieJianyunLiHongyuanLiuXinlanSunGangXueYanYangJin
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing, China
- Department of Radiotherapy, Ruijin Affiliated Hospital of Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Oncology, The First Affiliated Hospital of Xi‘an Jiaotong University, Xi’an, China
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Neurosurgery, Tiantan Hospital, Beijing, China
- Department of Pathology, Fourth Hospital Affiliated of Hebei Medical University, Shijiazhuang, China
- Department of Oncology, Cancer Hospital Affiliated to Fudan University, ShanghaiChina
- Department of Oncology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
- Department of Oncology, Tumor Hospital of Tianjin, Tianjin, China
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Abstract
As novel systemic therapies yield improved survival in metastatic cancer patients, the frequency of brain metastases continues to increase. Over the years, management strategies have continued to evolve. Historically, stereotactic radiosurgery has been used as a boost to whole-brain radiotherapy (WBRT) but is increasingly being used as a replacement for WBRT. Given its capacity to treat both macro- and micro-metastases in the brain, WBRT has been an important management strategy for years, and recent research has identified technologic and pharmacologic approaches to delivering WBRT more safely. In this review, we outline the current landscape of radiotherapeutic treatment options and discuss approaches to integrating radiotherapy advances in the contemporary management of brain metastases.
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Affiliation(s)
- Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville and Proton Center, Warrenville, Illinois, USA
| | | | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Gui C, Grimm J, Kleinberg LR, Zaki P, Spoleti N, Mukherjee D, Bettegowda C, Lim M, Redmond KJ. A Dose-Response Model of Local Tumor Control Probability After Stereotactic Radiosurgery for Brain Metastases Resection Cavities. Adv Radiat Oncol 2020; 5:840-849. [PMID: 33083646 PMCID: PMC7557194 DOI: 10.1016/j.adro.2020.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 05/09/2020] [Accepted: 06/15/2020] [Indexed: 11/09/2022] Open
Abstract
Purpose Recent randomized controlled trials evaluating stereotactic surgery (SRS) for resected brain metastases question the high rates of local control previously reported in retrospective studies. Tumor control probability (TCP) models were developed to quantify the relationship between radiation dose and local control after SRS for resected brain metastases. Methods and Materials Patients with resected brain metastases treated with SRS were evaluated retrospectively. Melanoma, sarcoma, and renal cell carcinoma were considered radio-resistant histologies. The planning target volume (PTV) was the region of enhancement on T1 post-gadolinium magnetic resonance imaging plus a 2-mm uniform margin. The primary outcome was local recurrence, defined as tumor progression within the resection cavity. Cox regression evaluated predictors of local recurrence. Dose-volume histograms for the PTV were obtained from treatment plans and converted to 3-fraction equivalent doses (α/β = 12 Gy). TCP models evaluated local control at 1-year follow-up as a logistic function of dose-volume histogram data. Results Among 150 cavities, 41 (27.3%) were radio-resistant. The median PTV volume was 14.6 mL (range, 1.3-65.3). The median prescription was 21 Gy (range, 15-25) in 3 fractions (range, 1-5). Local control rates at 12 and 24 months were 86% and 82%. On Cox regression, larger cavities (PTV > 12 cm3) predicted increased risk of local recurrence (P = .03). TCP modeling demonstrated relationships between improved 1-year local control and higher radiation doses delivered to radio-resistant cavities. Maximum PTV doses of 30, 35, and 40 Gy predicted 78%, 89%, and 94% local control among all radio-resistant cavities, versus 69%, 79%, and 86% among larger radio-resistant cavities. Conclusions After SRS for resected brain metastases, larger cavities are at greater risk of local recurrence. TCP models suggests that higher radiation doses may improve local control among cavities of radio-resistant histology. Given maximum tolerated doses established for single-fraction SRS, fractionated regimens may be required to optimize local control in large radio-resistant cavities.
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Affiliation(s)
- Chengcheng Gui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Jimm Grimm
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Lawrence Richard Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Peter Zaki
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Nicholas Spoleti
- Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - Michael Lim
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - Kristin Janson Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
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Khattab MH, Sherry AD, Xu MC, Kelly P, Anderson JL, Luo G, Chambless LB, Cmelak AJ, Attia A. Stereotactic Radiosurgery and Hypofractionated Stereotactic Radiotherapy for Nonfunctioning Pituitary Adenoma. J Neurol Surg B Skull Base 2020; 82:e51-e58. [PMID: 34306917 DOI: 10.1055/s-0040-1710518] [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: 10/04/2019] [Accepted: 03/14/2020] [Indexed: 10/24/2022] Open
Abstract
Objectives Hypofractionated stereotactic radiotherapy (HSRT) in two to five fractions may offer patients with large nonfunctioning pituitary adenomas (NFPAs) with chiasm involvement a safe and effective treatment over a single week. However, little has been reported regarding this novel approach. Design We compared the feasibility, outcomes, and toxicity of single-fraction stereotactic radiosurgery and HSRT. Setting This study was conducted at a tertiary academic referral center. Participants After approval by the institutional review board, we performed a retrospective cohort study of patients treated at our institution with stereotactic radiosurgery (SRS) and HSRT for NFPA. Selection for SRS or HSRT was based on clinicopathologic factors including tumor size and cavernous sinus invasion at the discretion of the treating physician. Main Outcome Measures Local control, endocrinopathy, and radiation-associated toxicity were evaluated by binary logistic regression and Cox's proportional hazards regression. Results A total of 45 patients with mean follow-up of 5 years were enrolled including 26 patients treated by HSRT with mean follow-up of 3 years and 19 patients treated by SRS with median follow-up of 6 years. Clinicopathologic characteristics were balanced between cohorts. Local failure at last follow-up was 5% in the SRS cohort and 8% in the HSRT cohort, and rates of post-SRS endocrinopathy were similar between each cohort. Late complications including radionecrosis, visual deficit, and secondary malignancy were minimal in either cohort. Conclusions HSRT is an appropriate treatment strategy for patients with NFPAs, particularly for optic pathway preservation in the setting of large tumors with chiasm involvement. Further studies are needed to optimize fractionated approaches and patient selection.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Alexander D Sherry
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Mark C Xu
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Patrick Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Joshua L Anderson
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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Palmer JD, Greenspoon J, Brown PD, Johnson DR, Roberge D. Neuro-Oncology Practice Clinical Debate: stereotactic radiosurgery or fractionated stereotactic radiotherapy following surgical resection for brain metastasis. Neurooncol Pract 2019; 7:263-267. [PMID: 32537175 DOI: 10.1093/nop/npz047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The treatment of resected brain metastasis has shifted away from the historical use of whole-brain radiotherapy (WBRT) toward adjuvant radiosurgery (stereotactic radiosurgery [SRS]) based on a recent prospective clinical trial demonstrating less cognitive decline with the use of SRS alone and equivalent survival as compared with WBRT. Whereas all level 1 evidence to date concerns single-fraction SRS for postoperative brain metastasis, there is emerging evidence that fractionated stereotactic radiotherapy (FSRT) may improve local control at the resected tumor bed. The lack of direct comparative data for SRS vs FSRT results in a diversity in clinical practice. In this article, Greenspoon and Roberge defend the use of SRS as the standard of care for resected brain metastasis, whereas Palmer and Brown argue for FSRT.
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Affiliation(s)
- Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital at The Ohio State University Wexner Medical Center, Columbus, USA
| | | | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - David Roberge
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Quebec, Canada
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