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Rahman F, Bhat V, Ozair A, Detchou DKE, Ahluwalia MS. Financial barriers and inequity in medical education in India: challenges to training a diverse and representative healthcare workforce. Med Educ Online 2024; 29:2302232. [PMID: 38194431 PMCID: PMC10778416 DOI: 10.1080/10872981.2024.2302232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 01/02/2024] [Indexed: 01/11/2024]
Abstract
India has been historically challenged by an insufficient and heterogeneously clustered distribution of healthcare infrastructure. While resource-limited healthcare settings, such as major parts of India, require multidisciplinary approaches for improvement, one key approach is the recruitment and training of a healthcare workforce representative of its population. This requires overcoming barriers to equity and representation in Indian medical education that are multi-faceted, historical, and rooted in inequality. However, literature is lacking regarding the financial or economic barriers, and their implications on equity and representation in the Indian allopathic physician workforce, which this review sought to describe. Keyword-based searches were carried out in PubMed, Google Scholar, and Scopus in order to identify relevant literature published till November 2023. This state-of-the-art narrative review describes the existing multi-pronged economic barriers, recent and forthcoming changes deepening these barriers, and how these may limit opportunities for having a diverse workforce. Three sets of major economic barriers exist to becoming a specialized medical practitioner in India - resources required to get selected into an Indian medical school, resources required to pursue medical school, and resources required to get a residency position. The resources in this endeavor have historically included substantial efforts, finances, and privilege, but rising barriers in the medical education system have worsened the state of inequity. Preparation costs for medical school and residency entrance tests have risen steadily, which may be further exacerbated by recent major policy changes regarding licensing and residency selection. Additionally, considerable increases in direct and indirect costs of medical education have recently occurred. Urgent action in these areas may help the Indian population get access to a diverse and representative healthcare workforce and also help alleviate the shortage of primary care physicians in the country. Discussed are the reasons for rural healthcare disparities in India and potential solutions related to medical education.
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Affiliation(s)
- Faique Rahman
- Faculty of Medicine, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University (AMU), Aligarh, UP, India
| | - Vivek Bhat
- St. John’s Medical College, Bangalore, KA, India
| | - Ahmad Ozair
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Faculty of Medicine, King George’s Medical University, Lucknow, UP, India
| | - Donald K. E. Detchou
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Manmeet S. Ahluwalia
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
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Murphy ES, Yang K, Suh JH, Yu JS, Stevens G, Angelov L, Vogelbaum MA, Barnett GH, Ahluwalia MS, Neyman G, Mohammadi AM, Chao ST. Phase I trial of dose escalation for preoperative stereotactic radiosurgery for patients with large brain metastases. Neuro Oncol 2024:noae076. [PMID: 38656347 DOI: 10.1093/neuonc/noae076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Single session stereotactic radiosurgery (SRS) or surgical resection alone for brain metastases larger than 2 cm results in unsatisfactory local control. We conducted a phase I trial for brain metastases(>2cm) to determine the safety of preoperative SRS at escalating doses. METHODS Radiosurgery dose was escalated at 3 Gy increments for 3 cohorts based on maximum tumor dimension starting at: 18 Gy for >2-3 cm, 15 Gy for >3-4 cm, and 12 Gy for >4-6 cm. Dose limiting toxicity (DLT) was defined as grade III or greater acute toxicity. RESULTS A total of 35 patients/36 lesions were enrolled. For tumor size >2-3 cm, patients were enrolled up to the second dose level (21 Gy); for >3-4 cm and >4-6 cm cohorts the third dose level (21 Gy and 18 Gy, respectively) was reached. There were 2 DLTs in the >3-4 cm arm at 21Gy. The maximum tolerated dose (MTD) of SRS for >2-3 cm was not reached; and was 18 Gy for both >3-4 cm arm and >4-6 cm arm. With a median follow-up of 64.0 months, the 6- and 12-month local control rates were 85.9% and 76.6%, respectively. One patient developed grade 3 radiation necrosis at 5 months. The 2-year rate of leptomeningeal disease (LMD) was 0%. CONCLUSION Preoperative SRS with dose escalation followed by surgical resection for brain metastases greater than 2 cm in size demonstrates acceptable acute toxicity. The phase II portion of the trial will be conducted at the maximum tolerated SRS doses.
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Affiliation(s)
- Erin S Murphy
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic , Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic , Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University , Cleveland, Ohio
| | - Kailin Yang
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic , Cleveland, Ohio
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic , Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic , Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University , Cleveland, Ohio
| | - Jennifer S Yu
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic , Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic , Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University , Cleveland, Ohio
| | - Glen Stevens
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic , Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic , Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University , Cleveland, Ohio
| | - Lilyana Angelov
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic , Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic , Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University , Cleveland, Ohio
| | | | - Gene H Barnett
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic , Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic , Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University , Cleveland, Ohio
| | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida , Miami, Florida
| | - Gennady Neyman
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic , Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University , Cleveland, Ohio
| | - Alireza M Mohammadi
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic , Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic , Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University , Cleveland, Ohio
| | - Samuel T Chao
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic , Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic , Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University , Cleveland, Ohio
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Mikolajewicz N, Yee PP, Bhanja D, Trifoi M, Miller AM, Metellus P, Bagley SJ, Balaj L, de Macedo Filho LJM, Zacharia BE, Aregawi D, Glantz M, Weller M, Ahluwalia MS, Kislinger T, Mansouri A. Systematic Review of Cerebrospinal Fluid Biomarker Discovery in Neuro-Oncology: A Roadmap to Standardization and Clinical Application. J Clin Oncol 2024:JCO2301621. [PMID: 38608213 DOI: 10.1200/jco.23.01621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 01/17/2024] [Accepted: 02/26/2024] [Indexed: 04/14/2024] Open
Abstract
Effective diagnosis, prognostication, and management of CNS malignancies traditionally involves invasive brain biopsies that pose significant risk to the patient. Sampling and molecular profiling of cerebrospinal fluid (CSF) is a safer, rapid, and noninvasive alternative that offers a snapshot of the intracranial milieu while overcoming the challenge of sampling error that plagues conventional brain biopsy. Although numerous biomarkers have been identified, translational challenges remain, and standardization of protocols is necessary. Here, we systematically reviewed 141 studies (Medline, SCOPUS, and Biosis databases; between January 2000 and September 29, 2022) that molecularly profiled CSF from adults with brain malignancies including glioma, brain metastasis, and primary and secondary CNS lymphomas. We provide an overview of promising CSF biomarkers, propose CSF reporting guidelines, and discuss the various considerations that go into biomarker discovery, including the influence of blood-brain barrier disruption, cell of origin, and site of CSF acquisition (eg, lumbar and ventricular). We also performed a meta-analysis of proteomic data sets, identifying biomarkers in CNS malignancies and establishing a resource for the research community.
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Affiliation(s)
- Nicholas Mikolajewicz
- Peter Gilgan Centre for Research and Learning, Hospital for Sick Children, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Patricia P Yee
- Medical Scientist Training Program, Penn State College of Medicine, Hershey, PA
| | - Debarati Bhanja
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Mara Trifoi
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Alexandra M Miller
- Departments of Neurology and Pediatrics, Memorial Sloan Kettering Cancer Center, Manhattan, NY
| | - Philippe Metellus
- Department of Neurosurgery, Ramsay Santé, Hôpital Privé Clairval, Marseille, France
| | - Stephen J Bagley
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Leonora Balaj
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Brad E Zacharia
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Dawit Aregawi
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Michael Glantz
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Michael Weller
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Department of Neurology, University of Zurich, Zurich, Switzerland
| | - Manmeet S Ahluwalia
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Thomas Kislinger
- Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
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Barnett AE, Ozair A, Bamashmos AS, Li H, Bosler DS, Yeaney G, Ali A, Peereboom DM, Lathia JD, Ahluwalia MS. MGMT Methylation and Differential Survival Impact by Sex in Glioblastoma. Cancers (Basel) 2024; 16:1374. [PMID: 38611052 PMCID: PMC11011031 DOI: 10.3390/cancers16071374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
Introduction: Sex differences in glioblastoma (GBM) have been observed in incidence, genetic and epigenetic alterations, and immune response. These differences have extended to the methylation of the MGMT promoter, which critically impacts temozolomide resistance. However, the association between sex, MGMT methylation, and survival is poorly understood, which this study sought to evaluate. Methods: A retrospective cohort study was conducted and reported following STROBE guidelines, based on adults with newly diagnosed GBM who received their first surgical intervention at Cleveland Clinic (Ohio, USA) between 2012 and 2018. Kaplan-Meier and multivariable Cox proportional hazards models were used to analyze the association between sex and MGMT promoter methylation status on overall survival (OS). MGMT was defined as methylated if the mean of CpG 1-5 ≥ 12. Propensity score matching was performed on a subset of patients to evaluate the effect of individual CpG site methylation. Results: A total of 464 patients had documented MGMT methylation status with a mean age of 63.4 (range 19-93) years. A total of 170 (36.6%) were female, and 133 (28.7%) received gross total resection as a first intervention. A total of 42.5% were MGMT methylated, with females more often having MGMT methylation than males (52.1% vs. 37.4%, p = 0.004). In univariable analysis, OS was significantly longer for MGMT promoter methylated than un-methylated groups for females (2 yr: 36.8% vs. 11.1%; median: 18.7 vs. 9.5 months; p = 0.001) but not for males (2 yr: 24.3% vs. 12.2%; median: 12.4 vs. 11.3 months; p = 0.22, p for MGMT-sex interaction = 0.02). In multivariable analysis, MGMT un-methylated versus methylated promoter females (2.07; 95% CI, 1.45-2.95; p < 0.0001) and males (1.51; 95% CI, 1.14-2.00; p = 0.004) had worse OS. Within the MGMT promoter methylated group, males had significantly worse OS than females (1.42; 95% CI: 1.01-1.99; p = 0.04). Amongst patients with data on MGMT CpG promoter site methylation values (n = 304), the median (IQR) of CpG mean methylation was 3.0% (2.0, 30.5). Females had greater mean CpG methylation than males (11.0 vs. 3.0, p < 0.002) and higher per-site CpG methylation with a significant difference at CPG 1, 2, and 4 (p < 0.008). After propensity score matching, females maintained a significant survival benefit (18.7 vs. 10.0 months, p = 0.004) compared to males (13.0 vs. 13.6 months, p = 0.76), and the pattern of difference was significant (P for CpG-sex interaction = 0.03). Conclusions: In this study, females had higher mean and individual CpG site methylation and received a greater PFS and OS benefit by MGMT methylation that was not seen in males despite equal degrees of CpG methylation.
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Affiliation(s)
- Addison E. Barnett
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44106, USA; (A.E.B.); (A.S.B.); (A.A.); (D.M.P.); (J.D.L.)
| | - Ahmad Ozair
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA;
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Anas S. Bamashmos
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44106, USA; (A.E.B.); (A.S.B.); (A.A.); (D.M.P.); (J.D.L.)
- NYU Langone Health, New York, NY 10016, USA
| | - Hong Li
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH 44106, USA;
| | - David S. Bosler
- Robert J. Tomisch Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH 44106, USA; (D.S.B.); (G.Y.)
| | - Gabrielle Yeaney
- Robert J. Tomisch Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH 44106, USA; (D.S.B.); (G.Y.)
| | - Assad Ali
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44106, USA; (A.E.B.); (A.S.B.); (A.A.); (D.M.P.); (J.D.L.)
| | - David M. Peereboom
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44106, USA; (A.E.B.); (A.S.B.); (A.A.); (D.M.P.); (J.D.L.)
| | - Justin D. Lathia
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44106, USA; (A.E.B.); (A.S.B.); (A.A.); (D.M.P.); (J.D.L.)
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - Manmeet S. Ahluwalia
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44106, USA; (A.E.B.); (A.S.B.); (A.A.); (D.M.P.); (J.D.L.)
- 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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Nagpal S, Milano MT, Chiang VL, Soltys SG, Brackett A, Halasz LM, Garg AK, Sahgal A, Ahluwalia MS, Tom MC, Palmer JD, Knisley JPS, Chao ST, Gephart MH, Wang TJC, Lo SS, Chang EL. Executive Summary of the American Radium Society Appropriate Use Criteria for Brain Metastases in EGFR-mutated and ALK-fusion Non-Small Cell Lung Cancer. Neuro Oncol 2024:noae041. [PMID: 38459978 DOI: 10.1093/neuonc/noae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Indexed: 03/11/2024] Open
Abstract
BACKGROUND The American Radium Society (ARS) Central Nervous System (CNS) committee reviewed literature on epidermal growth factor receptor mutated (EGFRm) and ALK-fusion (ALK+) tyrosine kinase inhibitors (TKIs) for the treatment of brain metastases (BrMs) from non-small cell lung cancers (NSCLC) to generate appropriate use guidelines addressing use of TKIs in conjunction with or in lieu of radiotherapy (RT). METHODS The panel developed three key questions to guide systematic review: can radiotherapy be deferred in patients receiving EGFR or ALK TKIs at 1) diagnosis or 2) recurrence? Should TKI be administered concurrently with RT (3)? Two literature searches were performed (May 2019 and December 2023). The panel developed 8 model cases and voted on treatment options using a 9-point scale, with 1-3, 4-6 and 7-9 corresponding to usually not appropriate, may be appropriate, and usually appropriate (respectively), per the UCLA/RAND Appropriateness Method. RESULTS Consensus was achieved in only 4 treatment scenarios, all consistent with existing ARS-AUC guidelines for multiple BrM. The panel did not reach consensus that RT can be appropriately deferred in patients with BrM receiving CNS penetrant ALK or EGFR TKIs, though median scores indicated deferral may be appropriate under most circumstances. Whole brain RT with concurrent TKI generated broad disagreement except in cases with 2-4 BrM, where it was considered usually not appropriate. CONCLUSIONS We identified no definitive studies dictating optimal sequencing of TKIs and RT for EGFRm and ALK+ BrM. Until such studies are completed, the committee hopes these cases guide decision-making in this complex clinical space.
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Affiliation(s)
| | | | | | | | | | - Lia M Halasz
- University of Washington, Department of Radiation Oncology
| | - Amit K Garg
- Presbyterian Healthcare Services Albuquerque, NM, Department of Radiation Oncology
| | - Arjun Sahgal
- Sunnybrook Research Institute, Department of Radiation Oncology
| | | | | | | | | | - Samuel T Chao
- Case Western University, Department of Radiation Oncology
| | | | - Tony J C Wang
- Columbia University, Department of Radiation Oncology
| | - Simon S Lo
- University of Washington, Department of Radiation Oncology
| | - Eric L Chang
- University of Southern California, Department of Radiation Oncology
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Mohammed NBB, Lau LS, Souchak J, Qiu S, Ahluwalia MS, Osman I, Dimitroff CJ. Tumor-Intrinsic Galectin-3 Suppresses Melanoma Metastasis. J Invest Dermatol 2024:S0022-202X(24)00169-6. [PMID: 38458429 DOI: 10.1016/j.jid.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/24/2024] [Accepted: 02/03/2024] [Indexed: 03/10/2024]
Abstract
Melanoma poses a poor prognosis with high mortality rates upon metastasis. Exploring the molecular mechanisms governing melanoma progression paves the way for developing novel approaches to control melanoma metastasis and ultimately enhance patient survival rates. Extracellular galectin-3 (Gal-3) has emerged as a pleiotropic promoter of melanoma metastasis, exerting varying activities depending on its interacting partner. However, whether intracellular Gal-3 promotes melanoma aggressive behavior remains unknown. In this study, we explored Gal-3 expression in human melanoma tissues as well as in murine melanoma models to examine its causal role in metastatic behavior. We found that Gal-3 expression is downregulated in metastatic melanoma tissues compared with its levels in primary melanomas. Enforced silencing of Gal-3 in melanoma cells promoted migration, invasion, colony formation, in vivo xenograft growth, and metastasis and activated canonical oncogenic signaling pathways. Moreover, loss of Gal-3 in melanoma cells resulted in upregulated the expression of the prometastatic transcription factor NFAT1 and its downstream metastasis-associated proteins, matrix metalloproteinase 3, and IL-8. Overall, our findings implicate melanoma intracellular Gal-3 as a major determinant of its metastatic behavior and reveal a negative regulatory role for Gal-3 on the expression of NFAT1 in melanoma cells.
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Affiliation(s)
- Norhan B B Mohammed
- Translational Glycobiology Institute at FIU, Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA; Department of Medical Biochemistry, Faculty of Medicine, South Valley University, Qena, Egypt
| | - Lee Seng Lau
- Translational Glycobiology Institute at FIU, Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Joseph Souchak
- Translational Glycobiology Institute at FIU, Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Shi Qiu
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York, USA
| | - Manmeet S Ahluwalia
- Translational Glycobiology Institute at FIU, Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA; Department of Medical Oncology, Miami Cancer Institute, Baptist Health-South Florida, Miami, Florida, USA
| | - Iman Osman
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York, USA
| | - Charles J Dimitroff
- Translational Glycobiology Institute at FIU, Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA.
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Ahluwalia MS, Khosla AA, Ozair A, Gouda MA, Subbiah V. Impact of tissue-agnostic approvals on management of primary brain tumors. Trends Cancer 2024; 10:256-274. [PMID: 38245379 DOI: 10.1016/j.trecan.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/11/2023] [Accepted: 11/17/2023] [Indexed: 01/22/2024]
Abstract
Novel tissue-agnostic therapeutics targeting driver mutations in tumor cells have been recently approved by FDA, driven by basket trials that have demonstrated their efficacy and safety across diverse tumor histology. However, the relative rarity of primary brain tumors (PBTs) has limited their representation in early trials of tissue-agnostic medications. Thus, consensus continues to evolve regarding utility of tissue-agnostic medications in routine practice for PBTs, a diverse group of neoplasms characterized by limited treatment options and unfavorable prognoses. We describe current and potential impact of tissue-agnostic approvals on management of PBTs. We discuss data from clinical trials for PBTs regarding tissue-agnostic targets, including BRAFV600E, neurotrophic tyrosine receptor kinase (NTRK) fusions, microsatellite instability-high (MSI-High), mismatch repair deficiency (dMMR), and high tumor mutational burden (TMB-H), in context of challenges in managing PBTs. Described are additional tissue-agnostic targets that hold promise for benefiting patients with PBTs, including RET fusion, fibroblast growth factor receptor (FGFR), ERBB2/HER2, and KRASG12C, and TP53Y220C.
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Affiliation(s)
- Manmeet S Ahluwalia
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Atulya A Khosla
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Internal Medicine, William Beaumont University Hospital, Royal Oak, MI, USA
| | - Ahmad Ozair
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Mohamed A Gouda
- Department of Investigational Cancer Therapeutics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vivek Subbiah
- Early Phase Drug Development Program, Sarah Cannon Research Institute, Nashville, TN, USA.
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Sharma M, Papisetty S, Dhawan S, Ahluwalia MS, Venteicher AS, Chen CC. Comparison of Stereotactic Radiosurgery and Hypofractionated Radiosurgery for Vestibular Schwannomas: A Meta-Analysis of Available Literature. World Neurosurg 2024; 182:e742-e754. [PMID: 38092351 DOI: 10.1016/j.wneu.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) and recently, hypofractionated radiosurgery (hSRS) are increasingly utilized as treatment for vestibular schwannomas (VS). We performed a meta-analysis of literature comparing these modalities. METHODS The PubMed database of articles was searched for studies that compared SRS and hSRS in patients with VS. Variables analyzed include tumor control, hearing preservation, facial nerve preservation, trigeminal nerve preservation, and total complications. Heterogeneity across the studies was gauged using Higgins's inconsistency index. Funnel plots and Egger's regression intercept test were used to address the publication bias. RESULTS Thirteen studies that satisfied the search criteria were selected for meta-analysis. The studies identified in our study included 353 SRS and 511 hSRS-treated patients. Analysis of heterogeneity showed that hSRS is employed for relatively larger tumor sizes in comparison to SRS. Pooled meta-analysis estimates showed no significant differences between SRS and hSRS in terms of tumor control (odds ratio [OR], 0.620; 95% confidence interval [CI], 0.21-1.86, P = 0.39), hearing preservation (OR, 1.07; 95% CI, 0.59-1.93, P = 0.83), facial nerve preservation (OR, 0.53; 5% CI, 0.23-1.21, P = 0.13), or trigeminal nerve preservation (OR, 0.67; 95% CI, 0.24-1.89, P = 0.49) at a mean follow-up of 39 months. Statistically significant heterogeneity was found across the studies only for tumor diameter (Higgins's inconsistency index = 65.69%, P = 0.003) but not for other variables. CONCLUSIONS Meta-analysis of thirteen studies comparing SRS and hSRS as treatment for VS showed comparable tumor control, hearing preservation, facial nerve preservation, and trigeminal nerve preservation.
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Affiliation(s)
- Mayur Sharma
- Department of Neurosurgery, University of Minnesota, MMC 96, Minneapolis, Minnesota, USA.
| | - Saikarthik Papisetty
- Department of Neurosurgery, University of Minnesota, MMC 96, Minneapolis, Minnesota, USA
| | - Sanjay Dhawan
- Department of Neurosurgery, University of Minnesota, MMC 96, Minneapolis, Minnesota, USA
| | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Andrew S Venteicher
- Department of Neurosurgery, University of Minnesota, MMC 96, Minneapolis, Minnesota, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, MMC 96, Minneapolis, Minnesota, USA
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Rothrock RJ, Ozair A, Avendano MC, Herrera S, Appel H, Ramos S, Starosciak AK, Leon-Ariza DS, Rubens M, McDermott MW, Ahluwalia MS, Mehta MP, Kotecha RR. Prophylactic Radiotherapy Of MInimally Symptomatic Spinal Disease (PROMISSeD): study protocol for a randomized controlled trial. Trials 2024; 25:41. [PMID: 38217032 PMCID: PMC10785467 DOI: 10.1186/s13063-023-07850-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 12/03/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Early palliative/pre-emptive intervention improves clinical outcomes and quality of life for patients with metastatic cancer. A previous signal-seeking randomized controlled trial (RCT) demonstrated that early upfront radiotherapy to asymptomatic or minimally symptomatic high-risk osseous metastases led to reduction in skeletal-related events (SREs), a benefit driven primarily by subgroup of high-risk spine metastasis. The current RCT aims to determine whether early palliative/pre-emptive radiotherapy in patients with high-risk, asymptomatic or minimally symptomatic spine metastases will lead to fewer SREs within 1 year. METHODS This is a single-center, parallel-arm, in-progress RCT in adults (≥ 18 years) with ECOG performance status 0-2 and asymptomatic or minimally symptomatic (not requiring opioids) high-risk spine metastases from histologically confirmed solid tumor malignancies with > 5 sites of metastatic disease on cross-sectional imaging. High-risk spine metastases are defined by the following: (a) bulkiest disease sites ≥ 2 cm; (b) junctional disease (occiput to C2, C7-T1, T12-L2, L5-S1); (c) posterior element involvement; or (d) vertebral body compression deformity > 50%. Patients are randomized 1:1 to receive either standard-of-care systemic therapy (arm 1) or upfront, early radiotherapy to ≤ 5 high-risk spine lesions plus standard-of-care systemic therapy (arm 2), in the form of 20-30 Gy of radiation in 2-10 fractions. The primary endpoint is SRE, a composite outcome including spinal fracture, spinal cord compression, need for palliative radiotherapy, interventional procedures, or spinal surgery. Secondary endpoints include (1) surrogates of health care cost, including the number and duration of SRE-related hospitalizations; (2) overall survival; (3) pain-free survival; and (4) quality of life. Study instruments will be captured pre-treatment, at baseline, during treatment, and at 1, 3, 6, 12, and 24 months post-treatment. The trial aims to accrue 74 patients over 2 years to achieve > 80% power in detecting difference using two-sample proportion test with alpha < 0.05. DISCUSSION The results of this RCT will demonstrate the value, if any, of early radiotherapy for high-risk spine metastases. The trial has received IRB approval, funding, and prospective registration (NCT05534321) and has been open to accrual since August 19, 2022. If positive, the trial will expand the scope and utility of spine radiotherapy. TRIAL REGISTRATION ClinicalTrials.Gov NCT05534321 . Registered September 9, 2022. TRIAL STATUS Version 2.0 of the protocol (2021-KOT-002), revised last on September 2, 2022, was approved by the WCG institutional review board (Study Number 1337188, IRB tracking number 20223735). The trial was first posted on ClinicalTrials.Gov on September 9, 2022 (NCT05534321). Patient enrollment commenced on August 19, 2022, and is expected to be completed in 2 years, likely by August 2024.
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Affiliation(s)
- Robert J Rothrock
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Ahmad Ozair
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Maria C Avendano
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Susana Herrera
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Haley Appel
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Suyen Ramos
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Amy K Starosciak
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Daniel S Leon-Ariza
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Muni Rubens
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Michael W McDermott
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Manmeet S Ahluwalia
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Minesh P Mehta
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Rupesh R Kotecha
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA.
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
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10
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Bardhan M, Dey D, Suresh V, Javed B, Venur VA, Joe N, Kalidindi R, Ozair A, Khan M, Mahtani R, Lo S, Odia Y, Ahluwalia MS. An overview of the therapeutic strategies for neoplastic meningitis due to breast cancer: when and why? Expert Rev Neurother 2024; 24:77-103. [PMID: 38145503 DOI: 10.1080/14737175.2023.2293223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/06/2023] [Indexed: 12/27/2023]
Abstract
INTRODUCTION Neoplastic meningitis (NM), also known as leptomeningeal carcinomatosis, is characterized by the infiltration of tumor cells into the meninges, and poses a significant therapeutic challenge owing to its aggressive nature and limited treatment options. Breast cancer is a common cause of NM among solid tumors, further highlighting the urgent need to explore effective therapeutic strategies. This review aims to provide insights into the evolving landscape of NM therapy in breast cancer by collating existing research, evaluating current treatments, and identifying potential emerging therapeutic options. AREAS COVERED This review explores the clinical features, therapeutic strategies, recent advances, and challenges of managing NM in patients with breast cancer. Its management includes multimodal strategies, including systemic and intrathecal chemotherapy, radiation therapy, and supportive care. This review also emphasizes targeted drug options and optimal drug concentrations, and discusses emerging therapies. Additionally, it highlights the variability in treatment outcomes and the potential of combination regimens to effectively manage NM in breast cancer. EXPERT OPINION Challenges in treating NM include debates over clinical trial end points and the management of adverse effects. Drug resistance and low response rates are significant hurdles, particularly inHER2-negative breast cancer. The development of more precise and cost-effective medications with improved selectivity is crucial. Additionally, global efforts are needed for infrastructure development and cancer control considering the diverse nature of the disease.
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Affiliation(s)
- Mainak Bardhan
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | | | - Vinay Suresh
- King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Binish Javed
- Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Vyshak Alva Venur
- Seattle Cancer Care Alliance, Fred Hutchinson Cancer Center, University of Washington, Seattle, WA, USA
| | - Neha Joe
- St John's Medical College Hospital, Bengaluru, India
| | | | - Ahmad Ozair
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Reshma Mahtani
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Simon Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Yazmin Odia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
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11
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Rahman R, Trippa L, Lee EQ, Arrillaga-Romany I, Fell G, Touat M, McCluskey C, Wiley J, Gaffey S, Drappatz J, Welch MR, Galanis E, Ahluwalia MS, Colman H, Nabors LB, Hepel J, Elinzano H, Schiff D, Chukwueke UN, Beroukhim R, Nayak L, McFaline-Figueroa JR, Batchelor TT, Rinne ML, Kaley TJ, Lu-Emerson C, Mellinghoff IK, Bi WL, Arnaout O, Peruzzi PP, Haas-Kogan D, Tanguturi S, Cagney D, Aizer A, Doherty L, Lavallee M, Fisher-Longden B, Dowling S, Geduldig J, Watkinson F, Pisano W, Malinowski S, Ramkissoon S, Santagata S, Meredith DM, Chiocca EA, Reardon DA, Alexander BM, Ligon KL, Wen PY. Inaugural Results of the Individualized Screening Trial of Innovative Glioblastoma Therapy: A Phase II Platform Trial for Newly Diagnosed Glioblastoma Using Bayesian Adaptive Randomization. J Clin Oncol 2023; 41:5524-5535. [PMID: 37722087 DOI: 10.1200/jco.23.00493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/17/2023] [Accepted: 07/24/2023] [Indexed: 09/20/2023] Open
Abstract
PURPOSE The Individualized Screening Trial of Innovative Glioblastoma Therapy (INSIGhT) is a phase II platform trial that uses response adaptive randomization and genomic profiling to efficiently identify novel therapies for phase III testing. Three initial experimental arms (abemaciclib [a cyclin-dependent kinase [CDK]4/6 inhibitor], neratinib [an epidermal growth factor receptor [EGFR]/human epidermal growth factor receptor 2 inhibitor], and CC-115 [a deoxyribonucleic acid-dependent protein kinase/mammalian target of rapamycin inhibitor]) were simultaneously evaluated against a common control arm. We report the results for each arm and examine the feasibility and conduct of the adaptive platform design. PATIENTS AND METHODS Patients with newly diagnosed O6-methylguanine-DNA methyltransferase-unmethylated glioblastoma were eligible if they had tumor genotyping to identify prespecified biomarker subpopulations of dominant glioblastoma signaling pathways (EGFR, phosphatidylinositol 3-kinase, and CDK). Initial random assignment was 1:1:1:1 between control (radiation therapy and temozolomide) and the experimental arms. Subsequent Bayesian adaptive randomization was incorporated on the basis of biomarker-specific progression-free survival (PFS) data. The primary end point was overall survival (OS), and one-sided P values are reported. The trial is registered with ClinicalTrials.gov (identifier: NCT02977780). RESULTS Two hundred thirty-seven patients were treated (71 control; 73 abemaciclib; 81 neratinib; 12 CC-115) in years 2017-2021. Abemaciclib and neratinib were well tolerated, but CC-115 was associated with ≥ grade 3 treatment-related toxicity in 58% of patients. PFS was significantly longer with abemaciclib (hazard ratio [HR], 0.72; 95% CI, 0.49 to 1.06; one-sided P = .046) and neratinib (HR, 0.72; 95% CI, 0.50 to 1.02; one-sided P = .033) relative to the control arm but there was no PFS benefit with CC-115 (one-sided P = .523). None of the experimental therapies demonstrated a significant OS benefit (P > .05). CONCLUSION The INSIGhT design enabled efficient simultaneous testing of three experimental agents using a shared control arm and adaptive randomization. Two investigational arms had superior PFS compared with the control arm, but none demonstrated an OS benefit. The INSIGhT design may promote improved and more efficient therapeutic discovery in glioblastoma. New arms have been added to the trial.
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Affiliation(s)
- Rifaquat Rahman
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | - Eudocia Q Lee
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | | | - Mehdi Touat
- Brigham and Women's Hospital, Boston, MA
- Sorbonne Universite, Hôpitaux Universitaires La Pitié Salpêtrière, Paris, France
| | | | | | | | | | - Mary R Welch
- Division of Neuro-Oncology, Department of Neurology and Herbert Irving Comprehensive Cancer Center, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian, New York, NY
| | | | | | - Howard Colman
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | | | | | | | | | - Ugonma N Chukwueke
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Rameen Beroukhim
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Lakshmi Nayak
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | - Tracy T Batchelor
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | | | | | | | - Wenya Linda Bi
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | | | - Daphne Haas-Kogan
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Shyam Tanguturi
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | - Ayal Aizer
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | | | | | - David A Reardon
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Brian M Alexander
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Keith L Ligon
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Patrick Y Wen
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
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12
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Bellur S, Khosla AA, Ozair A, Kotecha R, McDermott MW, Ahluwalia MS. Management of Brain Metastases: A Review of Novel Therapies. Semin Neurol 2023; 43:845-858. [PMID: 38011864 DOI: 10.1055/s-0043-1776782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Brain metastases (BMs) represent the most common intracranial tumors in adults, and most commonly originate from lung, followed by breast, melanoma, kidney, and colorectal cancer. Management of BM is individualized based on the size and number of brain metastases, the extent of extracranial disease, the primary tumor subtype, neurological symptoms, and prior lines of therapy. Until recently, treatment strategies were limited to local therapies, like surgical resection and radiotherapy, the latter in the form of whole-brain radiotherapy or stereotactic radiosurgery. The next generation of local strategies includes laser interstitial thermal therapy, magnetic hyperthermic therapy, post-resection brachytherapy, and focused ultrasound. New targeted therapies and immunotherapies with documented intracranial activity have transformed clinical outcomes. Novel systemic therapies with intracranial utility include new anaplastic lymphoma kinase inhibitors like brigatinib and ensartinib; selective "rearranged during transfection" inhibitors like selpercatinib and pralsetinib; B-raf proto-oncogene inhibitors like encorafenib and vemurafenib; Kirsten rat sarcoma viral oncogene inhibitors like sotorasib and adagrasib; ROS1 gene rearrangement (ROS1) inhibitors, anti-neurotrophic tyrosine receptor kinase agents like larotrectinib and entrectinib; anti-human epidermal growth factor receptor 2/epidermal growth factor receptor exon 20 agent like poziotinib; and antibody-drug conjugates like trastuzumab-emtansine and trastuzumab-deruxtecan. This review highlights the modern multidisciplinary management of BM, emphasizing the integration of systemic and local therapies.
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Affiliation(s)
- Shreyas Bellur
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | | | - Ahmad Ozair
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Rupesh Kotecha
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Michael W McDermott
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida
| | - Manmeet S Ahluwalia
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
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13
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Lehrer EJ, Khosla AA, Ozair A, Gurewitz J, Bernstein K, Kondziolka D, Niranjan A, Wei Z, Lunsford LD, Mathieu D, Trudel C, Deibert CP, Malouff TD, Ruiz-Garcia H, Peterson JL, Patel S, Bonney P, Hwang L, Yu C, Zada G, Picozzi P, Franzini A, Attuati L, Prasad RN, Raval RR, Palmer JD, Lee CC, Yang HC, Fakhoury KR, Rusthoven CG, Dickstein DR, Sheehan JP, Trifiletti DM, Ahluwalia MS. Immune checkpoint inhibition and single fraction stereotactic radiosurgery in brain metastases from non-small cell lung cancer: an international multicenter study of 395 patients. J Neurooncol 2023; 165:63-77. [PMID: 37889444 DOI: 10.1007/s11060-023-04413-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/02/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE Approximately 80% of brain metastases originate from non-small cell lung cancer (NSCLC). Immune checkpoint inhibitors (ICI) and stereotactic radiosurgery (SRS) are frequently utilized in this setting. However, concerns remain regarding the risk of radiation necrosis (RN) when SRS and ICI are administered concurrently. METHODS A retrospective study was conducted through the International Radiosurgery Research Foundation. Logistic regression models and competing risks analyses were utilized to identify predictors of any grade RN and symptomatic RN (SRN). RESULTS The study included 395 patients with 2,540 brain metastases treated with single fraction SRS and ICI across 11 institutions in four countries with a median follow-up of 14.2 months. The median age was 67 years. The median margin SRS dose was 19 Gy; 36.5% of patients had a V12 Gy ≥ 10 cm3. On multivariable analysis, V12 Gy ≥ 10 cm3 was a significant predictor of developing any grade RN (OR: 2.18) and SRN (OR: 3.95). At 1-year, the cumulative incidence of any grade and SRN for all patients was 4.8% and 3.8%, respectively. For concurrent and non-concurrent groups, the cumulative incidence of any grade RN was 3.8% versus 5.3%, respectively (p = 0.35); and for SRN was 3.8% vs. 3.6%, respectively (p = 0.95). CONCLUSION The risk of any grade RN and symptomatic RN following single fraction SRS and ICI for NSCLC brain metastases increases as V12 Gy exceeds 10 cm3. Concurrent ICI and SRS do not appear to increase this risk. Radiosurgical planning techniques should aim to minimize V12 Gy.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA.
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Atulya A Khosla
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Ahmad Ozair
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Jason Gurewitz
- Department of Radiation Oncology, NYU Langone Medical Center, New York, NY, USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Medical Center, New York, NY, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - Claire Trudel
- Department of Medicine, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | | | - Timothy D Malouff
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Phillip Bonney
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Lindsay Hwang
- Department of Radiation Oncology, University of Southern California, Los Angeles, CA, USA
| | - Cheng Yu
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Piero Picozzi
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano (Mi), Italy
| | - Andrea Franzini
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano (Mi), Italy
| | - Luca Attuati
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano (Mi), Italy
| | - Rahul N Prasad
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Raju R Raval
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Kareem R Fakhoury
- Department of Radiation Oncology, University of Colorado, Denver, CO, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Denver, CO, USA
| | - Daniel R Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
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Ahluwalia MS, Rogers LR, Chaudhary R, Newton H, Ozair A, Khosla AA, Nixon AB, Adams BJ, Seon BK, Peereboom DM, Theuer CP. Endoglin inhibitor TRC105 with or without bevacizumab for bevacizumab-refractory glioblastoma (ENDOT): a multicenter phase II trial. Commun Med (Lond) 2023; 3:120. [PMID: 37684373 PMCID: PMC10491825 DOI: 10.1038/s43856-023-00347-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 08/04/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Glioblastoma (GBM), the most lethal primary brain tumor, has limited treatment options upon recurrence after chemoradiation and bevacizumab. TRC105 (carotuximab), a chimeric anti-endoglin (CD105) antibody, inhibits angiogenesis and potentiates activity of VEGF inhibitor bevacizumab in preclinical models. This study sought to assess safety, pharmacokinetics, and efficacy of TRC105 for bevacizumab-refractory GBM. METHODS We conducted a pre-registered (NCT01564914), multicenter, open-label phase II clinical trial (ENDOT). We administered 10 mg/kg TRC105 monotherapy (first cohort) in adults with GBM and radiographic progression following radiation, temozolomide and bevacizumab therapy. Primary outcome was median time-to-progression (TTP), amended after first cohort's enrollment to median overall survival (mOS). Secondary outcomes were objective response rate, safety and tolerability, and progression-free survival (PFS). RESULTS 6 patients were enrolled in TRC105 monotherapy cohort. Median TTP and PFS of 5 evaluable patients receiving monotherapy was 1.4 months, in whom plasma VEGF-A levels were elevated post-therapy. Lack of response led to protocol amendment, and second cohort's addition of bevacizumab+TRC105 with primary endpoint of mOS. 16 patients were enrolled in bevacizumab+TRC105 cohort. mOS of 15 evaluable patients was 5.7 (95%CI: 4.2-9.8) months. All 22 patients had measurable disease at baseline. Median PFS of 14 evaluable patients receiving bevacizumab+TRC105 was 1.8 months (95%CI 1.2-2.1). Serum TRC105 was measurable above target concentration of 25 ug/mL in all evaluable patients. Study medications were well-tolerated in both cohorts. Combined administration did not potentiate known toxicities of either medication, with cerebral hemorrhage not observed. CONCLUSIONS Single-agent TRC105 lacks activity in bevacizumab-refractory GBM, possibly secondary to upregulated VEGF-A expression. Meaningful mOS in bevacizumab+TRC105 cohort warrants further trials to investigate efficacy of combination therapy.
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Affiliation(s)
- Manmeet S Ahluwalia
- Rose and Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA.
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA.
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
| | - Lisa R Rogers
- Department of Neurosurgery, Henry Ford Health, Detroit, MI, USA
| | - Rekha Chaudhary
- Division of Hematology & Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Herbert Newton
- Department of Neurology, Ohio State University, Columbus, OH, USA
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Ahmad Ozair
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Atulya A Khosla
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Department of Internal Medicine, William Beaumont University Hospital, Royal Oak, MI, USA
| | | | | | - Ben K Seon
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - David M Peereboom
- Rose and Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
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15
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Lee J, Nicosia M, Hong ES, Silver DJ, Li C, Bayik D, Watson DC, Lauko A, Kay KE, Wang SZ, Johnson S, McGraw M, Grabowski MM, Kish DD, Desai AB, Goodman WA, Cameron SJ, Okada H, Valujskikh A, Fairchild RL, Ahluwalia MS, Lathia JD. Sex-Biased T-cell Exhaustion Drives Differential Immune Responses in Glioblastoma. Cancer Discov 2023; 13:2090-2105. [PMID: 37378557 PMCID: PMC10481130 DOI: 10.1158/2159-8290.cd-22-0869] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 05/14/2023] [Accepted: 06/23/2023] [Indexed: 06/29/2023]
Abstract
Sex differences in glioblastoma (GBM) incidence and outcome are well recognized, and emerging evidence suggests that these extend to genetic/epigenetic and cellular differences, including immune responses. However, the mechanisms driving immunologic sex differences are not fully understood. Here, we demonstrate that T cells play a critical role in driving GBM sex differences. Male mice exhibited accelerated tumor growth, with decreased frequency and increased exhaustion of CD8+ T cells in the tumor. Furthermore, a higher frequency of progenitor exhausted T cells was found in males, with improved responsiveness to anti-PD-1 treatment. Moreover, increased T-cell exhaustion was observed in male GBM patients. Bone marrow chimera and adoptive transfer models indicated that T cell-mediated tumor control was predominantly regulated in a cell-intrinsic manner, partially mediated by the X chromosome inactivation escape gene Kdm6a. These findings demonstrate that sex-biased predetermined behavior of T cells is critical for inducing sex differences in GBM progression and immunotherapy response. SIGNIFICANCE Immunotherapies in patients with GBM have been unsuccessful due to a variety of factors, including the highly immunosuppressive tumor microenvironment in GBM. This study demonstrates that sex-biased T-cell behaviors are predominantly intrinsically regulated, further suggesting sex-specific approaches can be leveraged to potentially improve the therapeutic efficacy of immunotherapy in GBM. See related commentary by Alspach, p. 1966. This article is featured in Selected Articles from This Issue, p. 1949.
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Affiliation(s)
- Juyeun Lee
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Nicosia
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ellen S. Hong
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Medical Scientist Training Program, Department of Medicine, Case Western Reserve University, Cleveland Ohio
| | - Daniel J. Silver
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Case Comprehensive Cancer Center, Cleveland, Ohio
| | - Cathy Li
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Defne Bayik
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Case Comprehensive Cancer Center, Cleveland, Ohio
| | - Dionysios C. Watson
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Hematology/Oncology Division, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Adam Lauko
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Medical Scientist Training Program, Department of Medicine, Case Western Reserve University, Cleveland Ohio
| | - Kristen E. Kay
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Sabrina Z. Wang
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Medical Scientist Training Program, Department of Medicine, Case Western Reserve University, Cleveland Ohio
| | - Sadie Johnson
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mary McGraw
- Rose Ella Burkhardt Brain Tumor Center, Cleveland Clinic, Cleveland, Ohio
| | | | - Danielle D. Kish
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amar B. Desai
- Case Comprehensive Cancer Center, Cleveland, Ohio
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Wendy A. Goodman
- Department of Pathology, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Scott J. Cameron
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hideho Okada
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Parker Institute for Cancer Immunotherapy, San Francisco, California
| | - Anna Valujskikh
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robert L. Fairchild
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Justin D. Lathia
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Case Comprehensive Cancer Center, Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor Center, Cleveland Clinic, Cleveland, Ohio
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16
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Kim MM, Mehta MP, Smart DK, Steeg PS, Hong JA, Espey MG, Prasanna PG, Crandon L, Hodgdon C, Kozak N, Armstrong TS, Morikawa A, Willmarth N, Tanner K, Boire A, Gephart MH, Margolin KA, Hattangadi-Gluth J, Tawbi H, Trifiletti DM, Chung C, Basu-Roy U, Burns R, Oliva ICG, Aizer AA, Anders CK, Davis J, Ahluwalia MS, Chiang V, Li J, Kotecha R, Formenti SC, Ellingson BM, Gondi V, Sperduto PW, Barnholtz-Sloan JS, Rodon J, Lee EQ, Khasraw M, Yeboa DN, Brastianos PK, Galanis E, Coleman CN, Ahmed MM. National Cancer Institute Collaborative Workshop on Shaping the Landscape of Brain Metastases Research: challenges and recommended priorities. Lancet Oncol 2023; 24:e344-e354. [PMID: 37541280 PMCID: PMC10681121 DOI: 10.1016/s1470-2045(23)00297-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/13/2023] [Accepted: 06/21/2023] [Indexed: 08/06/2023]
Abstract
Brain metastases are an increasing global public health concern, even as survival rates improve for patients with metastatic disease. Both metastases and the sequelae of their treatment are key determinants of the inter-related priorities of patient survival, function, and quality of life, mandating a multidimensional approach to clinical care and research. At a virtual National Cancer Institute Workshop in September, 2022, key stakeholders convened to define research priorities to address the crucial areas of unmet need for patients with brain metastases to achieve meaningful advances in patient outcomes. This Policy Review outlines existing knowledge gaps, collaborative opportunities, and specific recommendations regarding consensus priorities and future directions in brain metastases research. Achieving major advances in research will require enhanced coordination between the ongoing efforts of individual organisations and consortia. Importantly, the continual and active engagement of patients and patient advocates will be necessary to ensure that the directionality of all efforts reflects what is most meaningful in the context of patient care.
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Affiliation(s)
- Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - DeeDee K Smart
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Patricia S Steeg
- Women's Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Julie A Hong
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD, USA
| | - Michael G Espey
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD, USA
| | - Pataje G Prasanna
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD, USA
| | | | | | | | - Terri S Armstrong
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Aki Morikawa
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Kirk Tanner
- National Brain Tumor Society, Newton, MA, USA
| | - Adrienne Boire
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Jona Hattangadi-Gluth
- Department of Radiation Oncology, University of California San Diego Health, La Jolla, CA, USA
| | - Hussein Tawbi
- Department of Melanoma Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Caroline Chung
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Robyn Burns
- Melanoma Research Foundation, Washington, DC, USA
| | - Isabella C Glitza Oliva
- Department of Melanoma Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ayal A Aizer
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA
| | - Carey K Anders
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | | | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Veronica Chiang
- Department of Neurosurgery and Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Silvia C Formenti
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Benjamin M Ellingson
- UCLA Brain Tumor Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center Warrenville and Proton Center, Warrenville, IL, USA
| | - Paul W Sperduto
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Jill S Barnholtz-Sloan
- Informatics and Data Science Program, Center for Biomedical Informatics and Information Technology, Trans-Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Jordi Rodon
- Department of Investigational Cancer Therapeutics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eudocia Q Lee
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mustafa Khasraw
- Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA
| | - Debra Nana Yeboa
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Priscilla K Brastianos
- Division of Hematology/Oncology and Division of Neuro-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Evanthia Galanis
- Department of Oncology, Mayo Clinic Comprehensive Cancer Center, Mayo Clinic, Rochester, MN, USA
| | - C Norman Coleman
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD, USA
| | - Mansoor M Ahmed
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD, USA.
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17
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Alban TJ, Grabowski MM, Otvos B, Bayik D, Wang W, Zalavadia A, Makarov V, Troike K, McGraw M, Rabljenovic A, Lauko A, Neumann C, Roversi G, Waite KA, Cioffi G, Patil N, Tran TT, McCortney K, Steffens A, Diaz CM, Brown JM, Egan KM, Horbinski CM, Barnholtz-Sloan JS, Rajappa P, Vogelbaum MA, Bucala R, Chan TA, Ahluwalia MS, Lathia JD. The MIF promoter SNP rs755622 is associated with immune activation in glioblastoma. JCI Insight 2023; 8:e160024. [PMID: 37252795 PMCID: PMC10371339 DOI: 10.1172/jci.insight.160024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/25/2023] [Indexed: 06/01/2023] Open
Abstract
Intratumoral heterogeneity is a defining hallmark of glioblastoma, driving drug resistance and ultimately recurrence. Many somatic drivers of microenvironmental change have been shown to affect this heterogeneity and, ultimately, the treatment response. However, little is known about how germline mutations affect the tumoral microenvironment. Here, we find that the single-nucleotide polymorphism (SNP) rs755622 in the promoter of the cytokine macrophage migration inhibitory factor (MIF) is associated with increased leukocyte infiltration in glioblastoma. Furthermore, we identified an association between rs755622 and lactotransferrin expression, which could also be used as a biomarker for immune-infiltrated tumors. These findings demonstrate that a germline SNP in the promoter region of MIF may affect the immune microenvironment and further reveal a link between lactotransferrin and immune activation.
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Affiliation(s)
- Tyler J. Alban
- Department of Cardiovascular & Metabolic Sciences and Imaging Core, Lerner Research Institute
- Center for Immunotherapy and Precision Oncology, and
| | - Matthew M. Grabowski
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Balint Otvos
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Defne Bayik
- Department of Cardiovascular & Metabolic Sciences and Imaging Core, Lerner Research Institute
| | - Wesley Wang
- Nationwide Children’s Hospital, Institute for Genomic Medicine, Departments of Pediatrics and Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ajay Zalavadia
- Department of Cardiovascular & Metabolic Sciences and Imaging Core, Lerner Research Institute
| | - Vlad Makarov
- Center for Immunotherapy and Precision Oncology, and
| | - Katie Troike
- Department of Cardiovascular & Metabolic Sciences and Imaging Core, Lerner Research Institute
| | - Mary McGraw
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anja Rabljenovic
- Department of Cardiovascular & Metabolic Sciences and Imaging Core, Lerner Research Institute
| | - Adam Lauko
- Department of Cardiovascular & Metabolic Sciences and Imaging Core, Lerner Research Institute
| | - Chase Neumann
- Department of Cardiovascular & Metabolic Sciences and Imaging Core, Lerner Research Institute
| | - Gustavo Roversi
- Department of Cardiovascular & Metabolic Sciences and Imaging Core, Lerner Research Institute
| | - Kristin A. Waite
- Division of Cancer Epidemiology and Genetics, Trans-Divisional Research Program, Center for Biomedical Informatics and Information Technology, National Cancer Institute, Bethesda, Maryland, USA
| | - Gino Cioffi
- Division of Cancer Epidemiology and Genetics, Trans-Divisional Research Program, Center for Biomedical Informatics and Information Technology, National Cancer Institute, Bethesda, Maryland, USA
| | - Nirav Patil
- University Hospitals Research and Education Institute, Cleveland, Ohio, USA
| | - Thuy T. Tran
- Yale School of Medicine and Yale Cancer Center, New Haven, Connecticut, USA
| | - Kathleen McCortney
- Departments of Pathology and Neurosurgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alicia Steffens
- Departments of Pathology and Neurosurgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - J. Mark Brown
- Department of Cardiovascular & Metabolic Sciences and Imaging Core, Lerner Research Institute
- Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio, USA
- Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Kathleen M. Egan
- Departments of Pathology and Neurosurgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Craig M. Horbinski
- Departments of Pathology and Neurosurgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jill S. Barnholtz-Sloan
- Division of Cancer Epidemiology and Genetics, Trans-Divisional Research Program, Center for Biomedical Informatics and Information Technology, National Cancer Institute, Bethesda, Maryland, USA
| | - Prajwal Rajappa
- Nationwide Children’s Hospital, Institute for Genomic Medicine, Departments of Pediatrics and Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Michael A. Vogelbaum
- Departments of Cancer Epidemiology and Neuro-Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida, USA
| | - Richard Bucala
- Yale School of Medicine and Yale Cancer Center, New Haven, Connecticut, USA
| | - Timothy A. Chan
- Center for Immunotherapy and Precision Oncology, and
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio, USA
- Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | | | - Justin D. Lathia
- Department of Cardiovascular & Metabolic Sciences and Imaging Core, Lerner Research Institute
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio, USA
- Case Comprehensive Cancer Center, Cleveland, Ohio, USA
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18
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Tom MC, DiFilippo FP, Jones SE, Suh JH, Obuchowski NA, Smile TD, Murphy ES, Yu JS, Barnett GH, Angelov L, Mohammadi AM, Huang SS, Wu G, Johnson S, Peereboom DM, Stevens GHJ, Ahluwalia MS, Chao ST. 18F-fluciclovine PET/CT to distinguish radiation necrosis from tumor progression for brain metastases treated with radiosurgery: results of a prospective pilot study. J Neurooncol 2023; 163:647-655. [PMID: 37341842 DOI: 10.1007/s11060-023-04377-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 06/16/2023] [Indexed: 06/22/2023]
Abstract
PURPOSE Distinguishing radiation necrosis from tumor progression among patients with brain metastases previously treated with stereotactic radiosurgery represents a common diagnostic challenge. We performed a prospective pilot study to determine whether PET/CT with 18F-fluciclovine, a widely available amino acid PET radiotracer, repurposed intracranially, can accurately diagnose equivocal lesions. METHODS Adults with brain metastases previously treated with radiosurgery presenting with a follow-up tumor-protocol MRI brain equivocal for radiation necrosis versus tumor progression underwent an 18F-fluciclovine PET/CT of the brain within 30 days. The reference standard for final diagnosis consisted of clinical follow-up until multidisciplinary consensus or tissue confirmation. RESULTS Of 16 patients imaged from 7/2019 to 11/2020, 15 subjects were evaluable with 20 lesions (radiation necrosis, n = 16; tumor progression, n = 4). Higher SUVmax statistically significantly predicted tumor progression (AUC = 0.875; p = 0.011). Lesion SUVmean (AUC = 0.875; p = 0.018), SUVpeak (AUC = 0.813; p = 0.007), and SUVpeak-to-normal-brain (AUC = 0.859; p = 0.002) also predicted tumor progression, whereas SUVmax-to-normal-brain (p = 0.1) and SUVmean-to-normal-brain (p = 0.5) did not. Qualitative visual scores were significant predictors for readers 1 (AUC = 0.750; p < 0.001) and 3 (AUC = 0.781; p = 0.045), but not for reader 2 (p = 0.3). Visual interpretations were significant predictors for reader 1 (AUC = 0.898; p = 0.012) but not for reader 2 (p = 0.3) or 3 (p = 0.2). CONCLUSIONS In this prospective pilot study of patients with brain metastases previously treated with radiosurgery presenting with a contemporary MRI brain with a lesion equivocal for radiation necrosis versus tumor progression, 18F-fluciclovine PET/CT repurposed intracranially demonstrated encouraging diagnostic accuracy, supporting the pursuit of larger clinical trials which will be necessary to establish diagnostic criteria and performance.
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Affiliation(s)
- Martin C Tom
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Frank P DiFilippo
- Department of Nuclear Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Stephen E Jones
- Department of Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - John H Suh
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Nancy A Obuchowski
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Timothy D Smile
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Erin S Murphy
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Jennifer S Yu
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Gene H Barnett
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
- Department of Neurological Surgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lilyana Angelov
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
- Department of Neurological Surgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alireza M Mohammadi
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
- Department of Neurological Surgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Steve S Huang
- Department of Nuclear Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Guiyun Wu
- Department of Nuclear Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Scott Johnson
- Department of Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - David M Peereboom
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
- Taussig Cancer Institute, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Glen H J Stevens
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
- Department of Neurology, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Manmeet S Ahluwalia
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
- Taussig Cancer Institute, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samuel T Chao
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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19
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Lehrer EJ, Sheehan JP, Trifiletti DM, Ahluwalia MS. Imaging-defined radionecrosis following stereotactic radiosurgery in the setting of immune checkpoint inhibitors - a cause for alarm or a harbinger of enhanced anti-tumor immunity? World Neurosurg 2023:S1878-8750(23)00822-7. [PMID: 37343673 DOI: 10.1016/j.wneu.2023.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University
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20
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Tatineni V, O'Shea PJ, Saxena S, Khosla AA, Ozair A, Kotecha RR, Jia X, Rauf Y, Murphy ES, Chao ST, Suh JH, Peereboom DM, Ahluwalia MS. Combination of EGFR-Directed Tyrosine Kinase Inhibitors (EGFR-TKI) with Radiotherapy in Brain Metastases from Non-Small Cell Lung Cancer: A 2010-2019 Retrospective Cohort Study. Cancers (Basel) 2023; 15:cancers15113015. [PMID: 37296975 DOI: 10.3390/cancers15113015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/17/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023] Open
Abstract
INTRODUCTION Traditionally, brain metastases have been treated with stereotactic radiosurgery (SRS), whole-brain radiation (WBRT), and/or surgical resection. Non-small cell lung cancers (NSCLC), over half of which carry EGFR mutations, are the leading cause of brain metastases. EGFR-directed tyrosine kinase inhibitors (TKI) have shown promise in NSCLC; but their utility in NSCLC brain metastases (NSCLCBM) remains unclear. This work sought to investigate whether combining EGFR-TKI with WBRT and/or SRS improves overall survival (OS) in NSCLCBM. METHODS A retrospective review of NSCLCBM patients diagnosed during 2010-2019 at a tertiary-care US center was performed and reported following the 'strengthening the reporting of observational studies in epidemiology' (STROBE) guidelines. Data regarding socio-demographic and histopathological characteristics, molecular attributes, treatment strategies, and clinical outcomes were collected. Concurrent therapy was defined as the combination of EGFR-TKI and radiotherapy given within 28 days of each other. RESULTS A total of 239 patients with EGFR mutations were included. Of these, 32 patients had been treated with WBRT only, 51 patients received SRS only, 36 patients received SRS and WBRT only, 18 were given EGFR-TKI and SRS, and 29 were given EGFR-TKI and WBRT. Median OS for the WBRT-only group was 3.23 months, for SRS + WBRT it was 3.17 months, for EGFR-TKI + WBRT 15.50 months, for SRS only 21.73 months, and for EGFR-TKI + SRS 23.63 months. Multivariable analysis demonstrated significantly higher OS in the SRS-only group (HR = 0.38, 95% CI 0.17-0.84, p = 0.017) compared to the WBRT reference group. There were no significant differences in overall survival for the SRS + WBRT combination cohort (HR = 1.30, 95% CI = 0.60, 2.82, p = 0.50), EGFR-TKIs and WBRT combination cohort (HR = 0.93, 95% CI = 0.41, 2.08, p = 0.85), or the EGFR-TKI + SRS cohort (HR = 0.46, 95% CI = 0.20, 1.09, p = 0.07). CONCLUSIONS NSCLCBM patients treated with SRS had a significantly higher OS compared to patients treated with WBRT-only. While sample-size limitations and investigator-associated selection bias may limit the generalizability of these results, phase II/III clinicals trials are warranted to investigate synergistic efficacy of EGFR-TKI and SRS.
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Affiliation(s)
- Vineeth Tatineni
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - Patrick J O'Shea
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Shreya Saxena
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Atulya A Khosla
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Ahmad Ozair
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Rupesh R Kotecha
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Xuefei Jia
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - Yasmeen Rauf
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
- Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
- Division of Neuro-Oncology, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Erin S Murphy
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - Samuel T Chao
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - John H Suh
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - David M Peereboom
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
- Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - Manmeet S Ahluwalia
- 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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21
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Tatineni V, O'Shea PJ, Ozair A, Khosla AA, Saxena S, Rauf Y, Jia X, Murphy ES, Chao ST, Suh JH, Peereboom DM, Ahluwalia MS. First- versus Third-Generation EGFR Tyrosine Kinase Inhibitors in EGFR-Mutated Non-Small Cell Lung Cancer Patients with Brain Metastases. Cancers (Basel) 2023; 15:cancers15082382. [PMID: 37190312 DOI: 10.3390/cancers15082382] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023] Open
Abstract
Introduction: Up to 50% of non-small cell lung cancer (NSCLC) harbor EGFR alterations, the most common etiology behind brain metastases (BMs). First-generation EGFR-directed tyrosine kinase inhibitors (EGFR-TKI) are limited by blood-brain barrier penetration and T790M tumor mutations, wherein third-generation EGFR-TKIs, like Osimertinib, have shown greater activity. However, their efficacy has not been well-studied in later therapy lines in NSCLC patients with BMs (NSCLC-BM). We sought to compare outcomes of NSCLC-BM treated with either first- or third-generation EGFR-TKIs in first-line and 2nd-to-5th-line settings. Methods: A retrospective review of NSCLC-BM patients diagnosed during 2010-2019 at Cleveland Clinic, Ohio, US, a quaternary-care center, was performed and reported following 'strengthening the reporting of observational studies in epidemiology' (STROBE) guidelines. Data regarding socio-demographic, histopathological, molecular characteristics, and clinical outcomes were collected. Primary outcomes were median overall survival (mOS) and progression-free survival (mPFS). Multivariable Cox proportional hazards modeling and propensity score matching were utilized to adjust for confounders. Results: 239 NSCLC-BM patients with EGFR alterations were identified, of which 107 received EGFR-TKIs after diagnosis of BMs. 77.6% (83/107) received it as first-line treatment, and 30.8% (33/107) received it in later (2nd-5th) lines of therapy, with nine patients receiving it in both settings. 64 of 107 patients received first-generation (erlotinib/gefitinib) TKIs, with 53 receiving them in the first line setting and 13 receiving it in the 2nd-5th lines of therapy. 50 patients received Osimertinib as third-generation EGFR-TKI, 30 in first-line, and 20 in the 2nd-5th lines of therapy. Univariable analysis in first-line therapy demonstrated mOS of first- and third-generation EGFR-TKIs as 18.2 and 19.4 months, respectively (p = 0.57), while unadjusted mPFS of first- and third-generation EGFR-TKIs was 9.3 and 13.8 months, respectively (p = 0.14). In 2nd-5th line therapy, for first- and third-generation EGFR-TKIs, mOS was 17.3 and 11.9 months, (p = 0.19), while mPFS was 10.4 and 6.08 months, respectively (p = 0.41). After adjusting for age, performance status, presence of extracranial metastases, whole-brain radiotherapy, and presence of leptomeningeal metastases, hazard ratio (HR) for OS was 1.25 (95% CI 0.63-2.49, p = 0.52) for first-line therapy. Adjusted HR for mOS in 2nd-to-5th line therapy was 1.60 (95% CI 0.55-4.69, p = 0.39). Conclusions: No difference in survival was detected between first- and third-generation EGFR-TKIs in either first or 2nd-to-5th lines of therapy. Larger prospective studies are warranted reporting intracranial lesion size, EGFR alteration and expression levels in primary tumor and brain metastases, and response rates.
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Affiliation(s)
- Vineeth Tatineni
- Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Patrick J O'Shea
- Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44195, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Ahmad Ozair
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Atulya A Khosla
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Shreya Saxena
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Yasmeen Rauf
- Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44195, USA
- Division of Neuro-Oncology, University of North Carolina, Chapel Hill, NC 27514, USA
- Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - Xuefei Jia
- Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Erin S Murphy
- Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44195, USA
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - Samuel T Chao
- Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44195, USA
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - John H Suh
- Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44195, USA
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - David M Peereboom
- Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44195, USA
- Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - Manmeet S Ahluwalia
- Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44195, USA
- 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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22
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Chamorro Y, Ahluwalia MS, Rubens MB, Venkatappa SA, Belli AJ, Ritter N, Wang CK, Mahtani RL, Leon AS. BPI23-011: Real-World Study of First-Line Treatment Patterns in HR+/HER2– Metastatic Breast Cancer (MBC) at a Tertiary Care Cancer Institute. J Natl Compr Canc Netw 2023. [DOI: 10.6004/jnccn.2022.7212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
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23
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La Rosa A, Mittauer KE, Rzepczynski AE, Chuong MD, Kutuk T, Bassiri N, McAllister NC, Hall MD, McCulloch J, Alvarez D, Herrera R, Gutierrez AN, Tolakanahalli R, Odia Y, Ahluwalia MS, Mehta MP, Kotecha R. Treatment of glioblastoma using MRIdian® A3i BrainTx™: Imaging and treatment workflow demonstration. Med Dosim 2023:S0958-3947(23)00019-5. [PMID: 36966049 DOI: 10.1016/j.meddos.2023.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/09/2023] [Accepted: 02/17/2023] [Indexed: 03/27/2023]
Abstract
For patients with newly diagnosed glioblastoma, the current standard-of-care includes maximal safe resection, followed by concurrent chemoradiotherapy and adjuvant temozolomide, with tumor treating fields. Traditionally, diagnostic imaging is performed pre- and post-resection, without additional dedicated longitudinal imaging to evaluate tumor volumes or other treatment-related changes. However, the recent introduction of MR-guided radiotherapy using the ViewRay MRIdian A3i system includes a dedicated BrainTx package to facilitate the treatment of intracranial tumors and provides daily MR images. We present the first reported case of a glioblastoma imaged and treated using this workflow. In this case, a 67-year-old woman underwent adjuvant chemoradiotherapy after gross total resection of a left frontal glioblastoma. The radiotherapy treatment plan consisted of a traditional two-phase design (46 Gy followed by a sequential boost to a total dose of 60 Gy at 2 Gy/fraction). The treatment planning process, institutional workflow, treatment imaging, treatment timelines, and target volume changes visualized during treatment are presented. This case example using our institutional A3i system workflow successfully allows for imaging and treatment of primary brain tumors and has the potential for margin reduction, detection of early disease progression, or to detect the need for dose adaptation due to interfraction tumor volume changes.
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Affiliation(s)
- Alonso La Rosa
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Kathryn E Mittauer
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Amy E Rzepczynski
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Tugce Kutuk
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Nema Bassiri
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Nicole C McAllister
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - James McCulloch
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Diane Alvarez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Roberto Herrera
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Alonso N Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Ranjini Tolakanahalli
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Yazmin Odia
- Department of Neuro-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
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24
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Grabowski MM, Watson DC, Chung K, Lee J, Bayik D, Lauko A, Alban T, Melenhorst JJ, Chan T, Lathia JD, Ahluwalia MS, Mohammadi AM. Spatial immunosampling of MRI-defined glioblastoma regions reveals immunologic fingerprint of non-contrast enhancing, infiltrative tumor margins. medRxiv 2023:2023.03.09.23285970. [PMID: 36945620 PMCID: PMC10029063 DOI: 10.1101/2023.03.09.23285970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Glioblastoma (GBM) treatment includes maximal safe resection of the core and MRI contrast-enhancing (CE) tumor. Complete resection of the infiltrative non-contrast-enhancing (NCE) tumor rim is rarely achieved. We established a safe, semi-automated workflow for spatially-registered sampling of MRI-defined GBM regions in 19 patients with downstream analysis and biobanking, enabling studies of NCE, wherefrom recurrence/progression typically occurs. Immunophenotyping revealed underrepresentation of myeloid cell subsets and CD8+ T cells in the NCE. While NCE T cells phenotypically and functionally resembled those in matching CE tumor, subsets of activated (CD69hi) effector memory CD8+ T cells were overrepresented. Contrarily, CD25hi Tregs and other subsets were underrepresented. Overall, our study demonstrated that MRI-guided, spatially-registered, intraoperative immunosampling is feasible as part of routine GBM surgery. Further elucidation of the shared and spatially distinct microenvironmental biology of GBM will enable development of therapeutic approaches targeting the NCE infiltrative tumor to decrease GBM recurrence.
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Affiliation(s)
- Matthew M. Grabowski
- Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
- Case Comprehensive Cancer Center, Cleveland, OH, USA
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Dionysios C. Watson
- Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
- Case Comprehensive Cancer Center, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Kunho Chung
- Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
| | - Juyeun Lee
- Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
| | - Defne Bayik
- Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
| | - Adam Lauko
- Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
- Medical Scientist Training Program, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Tyler Alban
- Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
| | | | - Timothy Chan
- Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
- Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Justin D. Lathia
- Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
- Case Comprehensive Cancer Center, Cleveland, OH, USA
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
| | | | - Alireza M. Mohammadi
- Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
- Case Comprehensive Cancer Center, Cleveland, OH, USA
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
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25
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Ahluwalia MS, Reardon DA, Abad AP, Curry WT, Wong ET, Figel SA, Mechtler LL, Peereboom DM, Hutson AD, Withers HG, Liu S, Belal AN, Qiu J, Mogensen KM, Dharma SS, Dhawan A, Birkemeier MT, Casucci DM, Ciesielski MJ, Fenstermaker RA. Phase IIa Study of SurVaxM Plus Adjuvant Temozolomide for Newly Diagnosed Glioblastoma. J Clin Oncol 2023; 41:1453-1465. [PMID: 36521103 PMCID: PMC9995096 DOI: 10.1200/jco.22.00996] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 09/16/2022] [Accepted: 11/02/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Despite intensive treatment with surgery, radiation therapy, temozolomide (TMZ) chemotherapy, and tumor-treating fields, mortality of newly diagnosed glioblastoma (nGBM) remains very high. SurVaxM is a peptide vaccine conjugate that has been shown to activate the immune system against its target molecule survivin, which is highly expressed by glioblastoma cells. We conducted a phase IIa, open-label, multicenter trial evaluating the safety, immunologic effects, and survival of patients with nGBM receiving SurVaxM plus adjuvant TMZ following surgery and chemoradiation (ClinicalTrials.gov identifier: NCT02455557). METHODS Sixty-four patients with resected nGBM were enrolled including 38 men and 26 women, in the age range of 20-82 years. Following craniotomy and fractionated radiation therapy with concurrent TMZ, patients received four doses of SurVaxM (500 μg once every 2 weeks) in Montanide ISA-51 plus sargramostim (granulocyte macrophage colony-stimulating factor) subcutaneously. Patients subsequently received adjuvant TMZ and maintenance SurVaxM concurrently until progression. Progression-free survival (PFS) and overall survival (OS) were reported. Immunologic responses to SurVaxM were assessed. RESULTS SurVaxM plus TMZ was well tolerated with no serious adverse events attributable to SurVaxM. Of the 63 patients who were evaluable for outcome, 60 (95.2%) remained progression-free 6 months after diagnosis (prespecified primary end point). Median PFS was 11.4 months and median OS was 25.9 months measured from first dose of SurVaxM. SurVaxM produced survivin-specific CD8+ T cells and antibody/immunoglobulin G titers. Apparent clinical benefit of SurVaxM was observed in both methylated and unmethylated patients. CONCLUSION SurVaxM appeared to be safe and well tolerated. The combination represents a promising therapy for nGBM. For patients with nGBM treated in this manner, PFS may be an acceptable surrogate for OS. A large randomized clinical trial of SurVaxM for nGBM is in progress.
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Affiliation(s)
| | - David A. Reardon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ajay P. Abad
- Department of Neuro-oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - William T. Curry
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Eric T. Wong
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sheila A. Figel
- Department of Neurosurgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY
- MimiVax LLC, Buffalo, NY
| | - Laszlo L. Mechtler
- Department of Neuro-oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | - Alan D. Hutson
- Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Henry G. Withers
- Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Song Liu
- Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Ahmed N. Belal
- Department of Radiology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Jingxin Qiu
- Department of Pathology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Kathleen M. Mogensen
- Department of Neuro-oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Sanam S. Dharma
- Department of Neurosurgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Andrew Dhawan
- Neurological Institute, Cleveland Clinic, Cleveland, OH
| | | | - Danielle M. Casucci
- Department of Neurosurgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY
- MimiVax LLC, Buffalo, NY
| | - Michael J. Ciesielski
- Department of Neurosurgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY
- MimiVax LLC, Buffalo, NY
| | - Robert A. Fenstermaker
- Department of Neurosurgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY
- MimiVax LLC, Buffalo, NY
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26
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Ozair A, Bhat V, Alisch RS, Khosla AA, Kotecha RR, Odia Y, McDermott MW, Ahluwalia MS. DNA Methylation and Histone Modification in Low-Grade Gliomas: Current Understanding and Potential Clinical Targets. Cancers (Basel) 2023; 15:cancers15041342. [PMID: 36831683 PMCID: PMC9954183 DOI: 10.3390/cancers15041342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/02/2023] [Accepted: 02/14/2023] [Indexed: 02/22/2023] Open
Abstract
Gliomas, the most common type of malignant primary brain tumor, were conventionally classified through WHO Grades I-IV (now 1-4), with low-grade gliomas being entities belonging to Grades 1 or 2. While the focus of the WHO Classification for Central Nervous System (CNS) tumors had historically been on histopathological attributes, the recently released fifth edition of the classification (WHO CNS5) characterizes brain tumors, including gliomas, using an integration of histological and molecular features, including their epigenetic changes such as histone methylation, DNA methylation, and histone acetylation, which are increasingly being used for the classification of low-grade gliomas. This review describes the current understanding of the role of DNA methylation, demethylation, and histone modification in pathogenesis, clinical behavior, and outcomes of brain tumors, in particular of low-grade gliomas. The review also highlights potential diagnostic and/or therapeutic targets in associated cellular biomolecules, structures, and processes. Targeting of MGMT promoter methylation, TET-hTDG-BER pathway, association of G-CIMP with key gene mutations, PARP inhibition, IDH and 2-HG-associated processes, TERT mutation and ARL9-associated pathways, DNA Methyltransferase (DNMT) inhibition, Histone Deacetylase (HDAC) inhibition, BET inhibition, CpG site DNA methylation signatures, along with others, present exciting avenues for translational research. This review also summarizes the current clinical trial landscape associated with the therapeutic utility of epigenetics in low-grade gliomas. Much of the evidence currently remains restricted to preclinical studies, warranting further investigation to demonstrate true clinical utility.
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Affiliation(s)
- Ahmad Ozair
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
- Faculty of Medicine, King George’s Medical University, Lucknow 226003, India
| | - Vivek Bhat
- St. John’s Medical College, Bangalore 560034, India
| | - Reid S. Alisch
- Department of Neurosurgery, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Atulya A. Khosla
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Rupesh R. Kotecha
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Yazmin Odia
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Michael W. McDermott
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL 33176, USA
- Correspondence: (M.W.M.); (M.S.A.)
| | - Manmeet S. Ahluwalia
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL 33176, USA
- Correspondence: (M.W.M.); (M.S.A.)
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27
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Lehrer EJ, Kowalchuk RO, Gurewitz J, Bernstein K, Kondziolka D, Niranjan A, Wei Z, Lunsford LD, Fakhoury KR, Rusthoven CG, Mathieu D, Trudel C, Malouff TD, Ruiz-Garcia H, Bonney P, Hwang L, Yu C, Zada G, Patel S, Deibert CP, Picozzi P, Franzini A, Attuati L, Prasad RN, Raval RR, Palmer JD, Lee CC, Yang HC, Harmsen WS, Jones BM, Sharma S, Ahluwalia MS, Sheehan JP, Trifiletti DM. Concurrent Administration of Immune Checkpoint Inhibitors and Single Fraction Stereotactic Radiosurgery in Patients With Non-Small Cell Lung Cancer, Melanoma, and Renal Cell Carcinoma Brain Metastases is Not Associated With an Increased Risk of Radiation Necrosis Over Nonconcurrent Treatment: An International Multicenter Study of 657 Patients. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)00057-3. [PMID: 36690161 DOI: 10.1016/j.ijrobp.2023.01.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 01/04/2023] [Accepted: 01/09/2023] [Indexed: 01/22/2023]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) and immune checkpoint inhibitors (ICI) are highly effective treatments for brain metastases, particularly when these therapies are administered concurrently. However, there are limited data reporting the risk of radiation necrosis (RN) in this setting. METHODS AND MATERIALS Patients with brain metastases from primary non-small cell lung cancer, renal cell carcinoma, or melanoma treated with SRS and ICI were considered. Time-to-event analyses were conducted for any grade RN and symptomatic RN (SRN) with death incorporated as a competing risk. As a secondary analysis, recursive partitioning analysis (RPA) was used for model development, and a loop of potential models was analyzed, with the highest-fidelity model selected. Brain V12 Gy thresholds identified on RPA were then incorporated into the competing risks analysis. Concurrent SRS and ICI administration. RESULTS Six hundred fifty-seven patients with 4182 brain metastases across 11 international institutions were analyzed. The median follow-up for all patients was 13.4 months. The median follow-up was 12.8 months and 14.1 months for the concurrent and nonconcurrent groups, respectively (P = .03). The median patient age was 66 years, and the median Karnofsky Performance Status was 90. In patients with any grade RN, 1- and 2-year rates were 6.4% and 9.9%, respectively. In patients with SRN, 1- and 2-year rates were 4.8% and 7.2%, respectively. On RPA, the highest-fidelity models consistently identified V12 Gy as the dominant variable predictive of RN. Three risk groups were identified by V12 Gy: (1) < 12 cm3; (2) 20 cm3 ≥ V12 Gy ≥ 12 cm3; (3) V12 Gy > 20 cm3. In patients with any grade RN, 1-year rates were 3.7% (V12 Gy < 12 cm3), 10.3% (20 cm3 ≥ V12 Gy ≥ 12 cm3), and 12.6% (V12 Gy > 20 cm3); the 2-year rates were 7.5% (V12 Gy < 12 cm3), 13.8% (20 cm3 ≥ V12 Gy ≥ 12 cm3), and 15.4% (V12 Gy > 20 cm3) (P < 0.001). In patients with any SRN, 1-year rates were 2.4% (V12 Gy < 12 cm3), 8.9% (20 cm3 ≥ V12 Gy ≥ 12 cm3), and 10.3% (V12 Gy > 20 cm3); the 2-year rates were 4.4% (V12 Gy < 12 cm3), 12.4% (20 cm3 ≥ V12 Gy ≥ 12 cm3), and 13.1% (V12 Gy > 20 cm3; P < 0.001). There were no statistically significant differences in rates of any grade RN or SRN when accounting for therapy timing for all patients and by V12 risk group identified on RPA. CONCLUSIONS The use of SRS and ICI results in a low risk of any grade RN and SRN. This risk is not increased with concurrent administration. Therefore, ICI can safely be administered within 4-weeks of SRS. Three risk groups based on V12 Gy were identified, which clinicians may consider to further reduce rates of RN.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Roman O Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minneapolis
| | - Jason Gurewitz
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kareem R Fakhoury
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Quebec, Canada
| | - Claire Trudel
- Department of Medicine, Université de Sherbrooke, Centre de recherche du CHUS, Quebec, Canada
| | - Timothy D Malouff
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Phillip Bonney
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Lindsay Hwang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Cheng Yu
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | | | - Piero Picozzi
- Department of Neurosurgery, Humanitas Research Hospital-IRCCS, Rozzano (Mi), Italy
| | - Andrea Franzini
- Department of Neurosurgery, Humanitas Research Hospital-IRCCS, Rozzano (Mi), Italy
| | - Luca Attuati
- Department of Neurosurgery, Humanitas Research Hospital-IRCCS, Rozzano (Mi), Italy
| | - Rahul N Prasad
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Raju R Raval
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taiwan
| | | | - Brianna M Jones
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sonam Sharma
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Abstract
Glioblastoma is the most common and aggressive primary brain tumor in the adult population and leads to considerable morbidity and mortality. It has a dismal prognosis with average survival of 15-18 months, and the current standard-of-care treatment paradigm includes maximal surgical resection and postoperative concurrent chemoradiotherapy and maintenance chemotherapy, with consideration of Tumor Treating Fields. There is a major emphasis to enroll patients onto ongoing clinical trials to further improve treatment outcomes, given the aggressive nature of the disease course and poor patient survival. Recent research efforts have focused on radiotherapy dose intensification, regulation of the tumor microenvironment, and exploration of immunotherapeutic approaches to overcome the barriers to treatment. This review article outlines the current evidence-based management principles as well as reviews recent clinical trial data and ongoing clinical studies evaluating novel therapeutic options.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL.,Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Yazmin Odia
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL.,Division of Neuro-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Atulya A Khosla
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Manmeet S Ahluwalia
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL.,Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
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Kotecha R, La Rosa A, Kutuk T, Ahluwalia MS, Mehta MP. Evaluating the intracranial activity of adagrasib. Transl Lung Cancer Res 2023; 12:669-675. [PMID: 37197630 PMCID: PMC10183405 DOI: 10.21037/tlcr-23-74] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/23/2023] [Indexed: 04/09/2023]
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30
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Rosa AL, Gutierrez AN, Odia Y, McDermott MW, Ahluwalia MS, Mehta MP, Kotecha R. Temporally modulated pulsed proton re-irradiation (TMPPR) for recurrent high-grade gliomas. Neurooncol Adv 2023; 5:vdad074. [PMID: 37358937 PMCID: PMC10290511 DOI: 10.1093/noajnl/vdad074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Affiliation(s)
- Alonso La Rosa
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Alonso N Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Yazmin Odia
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
- Department of Neuro-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Michael W McDermott
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
- Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Manmeet S Ahluwalia
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Rupesh Kotecha
- Corresponding Author: Rupesh Kotecha, MD, Miami Cancer Institute, Baptist Health South Florida, 1R203, 8900 N Kendall Drive, Miami, FL 33176, USA ()
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31
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Lehrer EJ, Gurewitz J, Bernstein K, Kondziolka D, Fakhoury KR, Rusthoven CG, Niranjan A, Wei Z, Lunsford LD, Malouff TD, Ruiz-Garcia H, Peterson JL, Bonney P, Hwang L, Yu C, Zada G, Deibert CP, Prasad RN, Raval RR, Palmer JD, Patel S, Picozzi P, Franzini A, Attuati L, Mathieu D, Trudel C, Lee CC, Yang HC, Jones BM, Green S, Ahluwalia MS, Sheehan JP, Trifiletti DM. Concurrent Administration of Immune Checkpoint Inhibitors and Stereotactic Radiosurgery Is Well-Tolerated in Patients With Melanoma Brain Metastases: An International Multicenter Study of 203 Patients. Neurosurgery 2022; 91:872-882. [PMID: 36255215 DOI: 10.1227/neu.0000000000002127] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/20/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Melanoma brain metastases are commonly treated with stereotactic radiosurgery (SRS) and immune checkpoint inhibitors (ICIs). However, the toxicity of these 2 treatments is largely unknown when administered concurrently. OBJECTIVE To evaluate the risk of radiation necrosis (RN) with concurrent and nonconcurrent SRS and ICIs. METHODS The guidelines from the Strengthening the Reporting of Observational Studies in Epidemiology checklist were used. Inverse probability of treatment weighting, univariable and multivariable logistic regression, and the Kaplan-Meier method was utilized. RESULTS There were 203 patients with 1388 brain metastases across 11 international institutions in 4 countries with a median follow-up of 15.6 months. The rates of symptomatic RN were 9.4% and 8.2% in the concurrent and nonconcurrent groups, respectively ( P =.766). On multivariable logistic regression, V12 ≥ 10 cm 3 (odds ratio [OR]: 2.76; P =.006) and presence of BRAF mutation (OR: 2.20; P =.040) were associated with an increased risk of developing symptomatic RN; the use of concurrent over nonconcurrent therapy was not associated with an increased risk (OR: 1.06; P =.877). There were 20 grade 3 toxic events reported, and no grade 4 events reported. One patient experienced a grade 5 intracranial hemorrhage. The median overall survival was 36.1 and 19.8 months for the concurrent and nonconcurrent groups (log-rank P =.051), respectively. CONCLUSION Concurrent administration of ICIs and SRS are not associated with an increased risk of RN. Tumors harboring BRAF mutation, or perhaps prior exposure to targeted agents, may increase this risk. Radiosurgical optimization to maintain V12 < 10 cm 3 is a potential strategy to reduce the risk of RN.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jason Gurewitz
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York, USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA
| | - Kareem R Fakhoury
- Department of Radiation Oncology, University of Colorado, Denver, Colorado, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Denver, Colorado, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Timothy D Malouff
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Phillip Bonney
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | - Lindsay Hwang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Cheng Yu
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | | | - Rahul N Prasad
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Raju R Raval
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Piero Picozzi
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Andrea Franzini
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Luca Attuati
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Quebec, Canada
| | - Claire Trudel
- Department of Medicine, Université de Sherbrooke, Centre de recherche du CHUS, Quebec, Canada
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taiwan
| | - Brianna M Jones
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sheryl Green
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
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Aizer AA, Lamba N, Ahluwalia MS, Aldape K, Boire A, Brastianos PK, Brown PD, Camidge DR, Chiang VL, Davies MA, Hu LS, Huang RY, Kaufmann T, Kumthekar P, Lam K, Lee EQ, Lin NU, Mehta M, Parsons M, Reardon DA, Sheehan J, Soffietti R, Tawbi H, Weller M, Wen PY. Brain metastases: A Society for Neuro-Oncology (SNO) consensus review on current management and future directions. Neuro Oncol 2022; 24:1613-1646. [PMID: 35762249 PMCID: PMC9527527 DOI: 10.1093/neuonc/noac118] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Brain metastases occur commonly in patients with advanced solid malignancies. Yet, less is known about brain metastases than cancer-related entities of similar incidence. Advances in oncologic care have heightened the importance of intracranial management. Here, in this consensus review supported by the Society for Neuro-Oncology (SNO), we review the landscape of brain metastases with particular attention to management approaches and ongoing efforts with potential to shape future paradigms of care. Each coauthor carried an area of expertise within the field of brain metastases and initially composed, edited, or reviewed their specific subsection of interest. After each subsection was accordingly written, multiple drafts of the manuscript were circulated to the entire list of authors for group discussion and feedback. The hope is that the these consensus guidelines will accelerate progress in the understanding and management of patients with brain metastases, and highlight key areas in need of further exploration that will lead to dedicated trials and other research investigations designed to advance the field.
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Affiliation(s)
- Ayal A Aizer
- Corresponding Author: Dr. Ayal A. Aizer, MD/MHS, Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA ()
| | | | | | - Kenneth Aldape
- Laboratory of Pathology, National Cancer Institute, Bethesda, Maryland, USA
| | - Adrienne Boire
- Department of Neurology, Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Priscilla K Brastianos
- Departments of Neuro-Oncology and Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - D Ross Camidge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Veronica L Chiang
- Departments of Neurosurgery and Radiation Oncology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael A Davies
- Department of Melanoma Medical Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Leland S Hu
- Department of Radiology, Neuroradiology Division, Mayo Clinic, Phoenix, Arizona, USA
| | - Raymond Y Huang
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | | | - Priya Kumthekar
- Department of Neurology at The Feinberg School of Medicine at Northwestern University and The Malnati Brain Tumor Institute at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois, USA
| | - Keng Lam
- Department of Neurology, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, California, USA
| | - Eudocia Q Lee
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Minesh Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida, USA
| | - Michael Parsons
- Departments of Oncology and Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David A Reardon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Riccardo Soffietti
- Division of Neuro-Oncology, Department of Neuroscience Rita Levi Montalcini, University of Turin, Turin, Italy
| | - Hussein Tawbi
- Department of Melanoma Medical Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Patrick Y Wen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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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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34
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Lehrer EJ, Ahluwalia MS, Gurewitz J, Bernstein K, Kondziolka D, Niranjan A, Wei Z, Lunsford LD, Fakhoury KR, Rusthoven CG, Mathieu D, Trudel C, Malouff TD, Ruiz-Garcia H, Bonney P, Hwang L, Yu C, Zada G, Patel S, Deibert CP, Picozzi P, Franzini A, Attuati L, Prasad RN, Raval RR, Palmer JD, Lee CC, Yang HC, Jones BM, Green S, Sheehan JP, Trifiletti DM. Imaging-defined necrosis after treatment with single-fraction stereotactic radiosurgery and immune checkpoint inhibitors and its potential association with improved outcomes in patients with brain metastases: an international multicenter study of 697 patients. J Neurosurg 2022; 138:1178-1187. [PMID: 36115055 DOI: 10.3171/2022.7.jns22752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/15/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Immune checkpoint inhibitors (ICIs) and stereotactic radiosurgery (SRS) are commonly utilized in the management of brain metastases. Treatment-related imaging changes (TRICs) are a frequently observed clinical manifestation and are commonly classified as imaging-defined radiation necrosis. However, these findings are not well characterized and may predict a response to SRS and ICIs. The objective of this study was to investigate predictors of TRICs and their impact on patient survival. METHODS This retrospective multicenter cohort study was conducted through the International Radiosurgery Research Foundation. Member institutions submitted de-identified clinical and dosimetric data for patients with non-small cell lung cancer (NSCLC), melanoma, and renal cell carcinoma (RCC) brain metastases that had been treated with SRS and ICIs. Data were collected from March 2020 to February 2021. Univariable and multivariable Cox and logistic regression analyses were performed. The Kaplan-Meier method was used to evaluate overall survival (OS). The diagnosis-specific graded prognostic assessment was used to guide variable selection. TRICs were determined on the basis of MRI, PET/CT, or MR spectroscopy, and consensus by local clinical providers was required. RESULTS The analysis included 697 patients with 4536 brain metastases across 11 international institutions in 4 countries. The median follow-up after SRS was 13.6 months. The median age was 66 years (IQR 58-73 years), 54.1% of patients were male, and 57.3%, 36.3%, and 6.4% of tumors were NSCLC, melanoma, and RCC, respectively. All patients had undergone single-fraction radiosurgery to a median margin dose of 20 Gy (IQR 18-20 Gy). TRICs were observed in 9.8% of patients. The median OS for all patients was 24.5 months. On univariable analysis, Karnofsky Performance Status (KPS; HR 0.98, p < 0.001), TRICs (HR 0.67, p = 0.03), female sex (HR 0.67, p < 0.001), and prior resection (HR 0.60, p = 0.03) were associated with improved OS. On multivariable analysis, KPS (HR 0.98, p < 0.001) and TRICs (HR 0.66, p = 0.03) were associated with improved OS. A brain volume receiving ≥ 12 Gy of radiation (V12Gy) ≥ 10 cm3 (OR 2.78, p < 0.001), prior whole-brain radiation therapy (OR 3.46, p = 0.006), and RCC histology (OR 3.10, p = 0.01) were associated with an increased probability of developing TRICs. The median OS rates in patients with and without TRICs were 29.0 and 23.1 months, respectively (p = 0.03, log-rank test). CONCLUSIONS TRICs following ICI and SRS were associated with a median OS benefit of approximately 6 months in this retrospective multicenter study. Further prospective study and additional stratification are needed to validate these findings and further elucidate the role and etiology of this common clinical scenario.
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Affiliation(s)
- Eric J Lehrer
- 1Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | | | | | - Ajay Niranjan
- 5Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Zhishuo Wei
- 5Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- 5Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kareem R Fakhoury
- 6Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Chad G Rusthoven
- 6Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | | | - Claire Trudel
- 8Medicine, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec, Canada
| | - Timothy D Malouff
- 9Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Henry Ruiz-Garcia
- 9Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | | | - Lindsay Hwang
- 11Radiation Oncology, University of Southern California, Los Angeles, California
| | - Cheng Yu
- Departments of10Neurosurgery and
| | | | - Samir Patel
- 12Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Piero Picozzi
- 14Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Andrea Franzini
- 14Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Luca Attuati
- 14Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Rahul N Prasad
- 15Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Raju R Raval
- 15Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joshua D Palmer
- 15Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Cheng-Chia Lee
- 16Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; and
| | - Huai-Che Yang
- 16Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; and
| | - Brianna M Jones
- 1Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sheryl Green
- 1Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jason P Sheehan
- 17Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Matsui JK, Perlow HK, Raj RK, Nalin AP, Lehrer EJ, Kotecha R, Trifiletti DM, McClelland S, Kendra K, Williams N, Owen DH, Presley CJ, Thomas EM, Beyer SJ, Blakaj DM, Ahluwalia MS, Raval RR, Palmer JD. Treatment of Brain Metastases: The Synergy of Radiotherapy and Immune Checkpoint Inhibitors. Biomedicines 2022; 10:2211. [PMID: 36140312 PMCID: PMC9496359 DOI: 10.3390/biomedicines10092211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/31/2022] [Accepted: 09/02/2022] [Indexed: 11/27/2022] Open
Abstract
Brain metastases are a devastating sequela of common primary cancers (e.g., lung, breast, and skin) and have limited effective therapeutic options. Previously, systemic chemotherapy failed to demonstrate significant benefit in patients with brain metastases, but in recent decades, targeted therapies and more recently immune checkpoint inhibitors (ICIs) have yielded promising results in preclinical and clinical studies. Furthermore, there is significant interest in harnessing the immunomodulatory effects of radiotherapy (RT) to synergize with ICIs. Herein, we discuss studies evaluating the impact of RT dose and fractionation on the immune response, early studies supporting the synergistic interaction between RT and ICIs, and ongoing clinical trials assessing the benefit of combination therapy in patients with brain metastases.
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Affiliation(s)
| | - Haley K. Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Rohit K. Raj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Ansel P. Nalin
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | | | - Shearwood McClelland
- Departments of Radiation Oncology and Neurological Surgery, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Kari Kendra
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Nicole Williams
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Dwight H. Owen
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Carolyn J. Presley
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Evan M. Thomas
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Sasha J. Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Manmeet S. Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Raju R. Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Joshua D. Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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Sperduto PW, De B, Li J, Carpenter D, Kirkpatrick J, Milligan M, Shih HA, Kutuk T, Kotecha R, Higaki H, Otsuka M, Aoyama H, Bourgoin M, Roberge D, Dajani S, Sachdev S, Gainey J, Buatti JM, Breen W, Brown PD, Ni L, Braunstein S, Gallitto M, Wang TJC, Shanley R, Lou E, Shiao J, Gaspar LE, Tanabe S, Nakano T, An Y, Chiang V, Zeng L, Soliman H, Elhalawani H, Cagney D, Thomas E, Boggs DH, Ahluwalia MS, Mehta MP. Graded Prognostic Assessment (GPA) for Patients With Lung Cancer and Brain Metastases: Initial Report of the Small Cell Lung Cancer GPA and Update of the Non-Small Cell Lung Cancer GPA Including the Effect of Programmed Death Ligand 1 and Other Prognostic Factors. Int J Radiat Oncol Biol Phys 2022; 114:60-74. [PMID: 35331827 PMCID: PMC9378572 DOI: 10.1016/j.ijrobp.2022.03.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/02/2022] [Accepted: 03/14/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE Patients with lung cancer and brain metastases represent a markedly heterogeneous population. Accurate prognosis is essential to optimally individualize care. In prior publications, we described the graded prognostic assessment (GPA), but a GPA for patients with small cell lung cancer (SCLC) has never been reported, and in non-small cell lung cancer (NSCLC), the effect of programmed death ligand 1 (PD-L1) was unknown. The 3-fold purpose of this work is to provide the initial report of an SCLC GPA, to evaluate the effect of PD-L1 on survival in patients with NSCLC, and to update the Lung GPA accordingly. METHODS AND MATERIALS A multivariable analysis of prognostic factors and treatments associated with survival was performed on 4183 patients with lung cancer (3002 adenocarcinoma, 611 nonadenocarcinoma, 570 SCLC) with newly diagnosed brain metastases between January 1, 2015, and December 31, 2020, using a multi-institutional retrospective database. Significant variables were used to update the Lung GPA. RESULTS Overall median survival for lung adenocarcinoma, SCLC, and nonadenocarcinoma was 17, 10, and 8 months, respectively, but varied widely by GPA from 2 to 52 months. In SCLC, the significant prognostic factors were age, performance status, extracranial metastases, and number of brain metastases. In NSCLC, the distribution of molecular markers among patients with lung adenocarcinoma and known primary tumor molecular status revealed alterations/expression in PD-L1 50% to 100%, PD-L1 1% to 49%, epidermal growth factor receptor, and anaplastic lymphoma kinase in 32%, 31%, 30%, and 7%, respectively. Median survival of patients with lung adenocarcinoma and brain metastases with 0, 1% to 49%, and ≥50% PD-L1 expression was 17, 19, and 24 months, respectively (P < .01), confirming PD-L1 is a prognostic factor. Previously identified prognostic factors for NSCLC (epidermal growth factor receptor and anaplastic lymphoma kinase status, performance status, age, number of brain metastases, and extracranial metastases) were reaffirmed. These factors were incorporated into the updated Lung GPA with robust separation between subgroups for all histologies. CONCLUSIONS Survival for patients with lung cancer and brain metastases has improved but varies widely. The initial report of a GPA for SCLC is presented. For patients with NSCLC-adenocarcinoma and brain metastases, PD-L1 is a newly identified significant prognostic factor, and the previously identified factors were reaffirmed. The updated indices establish unique criteria for SCLC, NSCLC-nonadenocarcinoma, and NSCLC-adenocarcinoma (incorporating PD-L1). The updated Lung GPA, available for free at brainmetgpa.com, provides an accurate tool to estimate survival, individualize treatment, and stratify clinical trials.
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Affiliation(s)
| | - Brian De
- MD Anderson Cancer Center, Houston, Texas
| | - Jing Li
- MD Anderson Cancer Center, Houston, Texas
| | | | | | | | - Helen A Shih
- Massachusetts General Hospital, Boston, Massachusetts
| | - Tugce Kutuk
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Rupesh Kotecha
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | | | | | - Hidefumi Aoyama
- Hokkaido Cancer Center, Hokkaido, Japan; Hokkaido University, Sapporo, Japan
| | - Malie Bourgoin
- Centre Hospitalier de l' Université de Montreal, Montreal, Quebec, Canada
| | - David Roberge
- Centre Hospitalier de l' Université de Montreal, Montreal, Quebec, Canada
| | | | | | | | | | | | | | - Lisa Ni
- University of California, San Francisco, California
| | | | | | | | | | - Emil Lou
- University of Minnesota, Minneapolis, Minnesota
| | - Jay Shiao
- University of Colorado Denver, Denver, Colorado
| | - Laurie E Gaspar
- University of Colorado Denver, Denver, Colorado; Banner MD Anderson Cancer Center, Loveland, Colorado
| | | | | | - Yi An
- Yale University, New Haven, Connecticut
| | | | - Liang Zeng
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Evan Thomas
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Minesh P Mehta
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
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Ellingson BM, Gerstner ER, Lassman AB, Chung C, Colman H, Cole PE, Leung D, Allen JE, Ahluwalia MS, Boxerman J, Brown M, Goldin J, Nduom E, Hassan I, Gilbert MR, Mellinghoff IK, Weller M, Chang S, Arons D, Meehan C, Selig W, Tanner K, Alfred Yung WK, van den Bent M, Wen PY, Cloughesy TF. Hypothetical generalized framework for a new imaging endpoint of therapeutic activity in early phase clinical trials in brain tumors. Neuro Oncol 2022; 24:1219-1229. [PMID: 35380705 PMCID: PMC9340639 DOI: 10.1093/neuonc/noac086] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Imaging response assessment is a cornerstone of patient care and drug development in oncology. Clinicians/clinical researchers rely on tumor imaging to estimate the impact of new treatments and guide decision making for patients and candidate therapies. This is important in brain cancer, where associations between tumor size/growth and emerging neurological deficits are strong. Accurately measuring the impact of a new therapy on tumor growth early in clinical development, where patient numbers are small, would be valuable for decision making regarding late-stage development activation. Current attempts to measure the impact of a new therapy have limited influence on clinical development, as determination of progression, stability or response does not currently account for individual tumor growth kinetics prior to the initiation of experimental therapies. Therefore, we posit that imaging-based response assessment, often used as a tool for estimating clinical effect, is incomplete as it does not adequately account for growth trajectories or biological characteristics of tumors prior to the introduction of an investigational agent. Here, we propose modifications to the existing framework for evaluating imaging assessment in primary brain tumors that will provide a more reliable understanding of treatment effects. Measuring tumor growth trajectories prior to a given intervention may allow us to more confidently conclude whether there is an anti-tumor effect. This updated approach to imaging-based tumor response assessment is intended to improve our ability to select candidate therapies for later-stage development, including those that may not meet currently sought thresholds for "response" and ultimately lead to identification of effective treatments.
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Affiliation(s)
- Benjamin M Ellingson
- UCLA Brain Tumor Imaging Laboratory, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Elizabeth R Gerstner
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew B Lassman
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, Herbert Irving Comprehensive Cancer Center, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Caroline Chung
- University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Howard Colman
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | | | - David Leung
- Bristol Myers Squibb, Princeton, New Jersey, USA
| | | | | | - Jerrold Boxerman
- Rhode Island Hospital and Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Matthew Brown
- UCLA Brain Tumor Imaging Laboratory, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Jonathan Goldin
- UCLA Brain Tumor Imaging Laboratory, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Edjah Nduom
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Islam Hassan
- Servier Pharmaceuticals, Boston, Massachusetts, USA
| | - Mark R Gilbert
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ingo K Mellinghoff
- Department of Neurology and Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Switzerland
| | - Susan Chang
- Division of Neuro-Oncology, University of California San Francisco, San Francisco, California, USA
| | - David Arons
- National Brain Tumor Society, Newton, Massachusetts, USA
| | - Clair Meehan
- National Brain Tumor Society, Newton, Massachusetts, USA
| | | | - Kirk Tanner
- National Brain Tumor Society, Newton, Massachusetts, USA
| | - W K Alfred Yung
- University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Martin van den Bent
- Brain Tumor Center at Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Patrick Y Wen
- Dana Farber Cancer Institute, Harvard University, Boston, Massachusetts, USA
| | - Timothy F Cloughesy
- UCLA Neuro Oncology Program, Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
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Abstract
Brain tumors remain one of the most difficult tumors to treat and, depending on the diagnosis, have a poor prognosis. Of brain tumors, glioblastoma (GBM) is the most common malignant glioma and has a dismal prognosis, with only about 5% of patients alive five years after diagnosis. While advances in targeted therapies and immunotherapies are rapidly improving outcomes in a variety of other cancers, the standard of care for GBM has largely remained unaltered since 2005. There are many well-studied challenges that are either unique to brain tumors (i.e., blood-brain barrier and immunosuppressive environment) or amplified within GBM (i.e., tumor heterogeneity at the cellular and molecular levels, plasticity, and cancer stem cells) that make this disease particularly difficult to treat. While we touch on all these concepts, the focus of this review is to discuss the immense inter- and intra-tumoral heterogeneity and advances in our understanding of tumor cell plasticity and epigenetics in GBM. With each improvement in technology, our understanding of the complexity of tumoral heterogeneity and plasticity improves and we gain more clarity on the causes underlying previous therapeutic failures. However, these advances are unlocking new therapeutic opportunities that scientists and physicians are currently exploiting and have the potential for new breakthroughs.
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Affiliation(s)
- Adam Lauko
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States; Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States; Medical Scientist Training Program, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Alice Lo
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Manmeet S Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, United States; Case Comprehensive Cancer Center, Cleveland, OH, United States
| | - Justin D Lathia
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States; Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States; Medical Scientist Training Program, Case Western Reserve University School of Medicine, Cleveland, OH, United States; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, United States; Case Comprehensive Cancer Center, Cleveland, OH, United States.
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39
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Tewari S, Tom MC, Park DYJ, Wei W, Chao ST, Yu JS, Suh JH, Kilic S, Peereboom DM, Stevens GHJ, Lathia JD, Prayson R, Barnett GH, Angelov L, Mohammadi AM, Ahluwalia MS, Murphy ES. Sex-Specific Differences in Low Grade Glioma Presentation and Outcome. Int J Radiat Oncol Biol Phys 2022; 114:283-292. [PMID: 35667529 DOI: 10.1016/j.ijrobp.2022.05.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 05/02/2022] [Accepted: 05/18/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE In addition to established prognostic factors in low-grade glioma (LGG), studies suggest a sexual dimorphism with male sex portending worse prognosis. Our objective was to identify the impact of sex on presentation and outcomes in LGG. METHODS We conducted a retrospective cohort study of adults (aged ≥ 18 years) diagnosed with LGG (WHO 2016 grade 2 glioma). Patients with IDH wildtype tumors were excluded. Patients were matched between male and female sex by age, treatment, and surgery via propensity score matching. Patient, tumor, and treatment characteristics were analyzed by sex. Endpoints included overall survival (OS), next intervention free survival (NIFS), progression free survival (PFS), and malignant transformation free survival (MTFS). Kaplan Meier analyses and Cox proportional hazards regression multivariable analysis (MVA) with backwards elimination was completed. RESULTS Of the 532 patients identified, 258 (48%) were male. Males were more likely to present with seizure (69.38% vs. 56.57%, p = 0.002), but no other statistically significant differences between sexes at presentation were identified. 5-year OS was higher in females at 87% (95% CI 83%-91%) versus 78% (95% CI 73-84%) in males (p=0.0045). NIFS was significantly higher in female patients at 68% (95% CI 62-74%) versus 57% (95% CI 51%-64%) in males (p = 0.009). On MVA, female sex was independently associated with improved OS (HR 1.54, 95% CI 1.16-2.05; p= 0.002), NIFS (HR 1.42, 95% CI 1.42; p= 0.004), and MTFS (HR 1.62, 95% CI 1.24-2.12; p= 0.0004). In patients with molecularly defined LGG (IDH and 1p19q status) (n = 291), female sex remained independently associated with improved OS (HR 1.79, 95% CI 1.16-2.77; p = 0.008) and NIFS (HR 1.45, 95% CI 1.07-1.96; p = 0.016). CONCLUSIONS In this study, female sex was independently associated with improved outcomes. These findings support intrinsic sex-specific differences in LGG behavior, justifying further studies to optimize management and therapeutics based on sex.
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Affiliation(s)
- Surabhi Tewari
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Martin C Tom
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Deborah Y J Park
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Wei Wei
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Samuel T Chao
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Jennifer S Yu
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner Research Institute, Cleveland, OH
| | - John H Suh
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Sarah Kilic
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - David M Peereboom
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Glen H J Stevens
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Justin D Lathia
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Cleveland Clinic Lerner Research Institute, Cleveland, OH
| | - Richard Prayson
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Cleveland Clinic Lerner Research Institute, Cleveland, OH
| | - Gene H Barnett
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Lilyana Angelov
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Alireza M Mohammadi
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Manmeet S Ahluwalia
- Department of Solid Tumor Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Erin S Murphy
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH.
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Kutuk T, Abrams KJ, Tom MC, Rubens M, Appel H, Sidani C, Hall MD, Tolakanahalli R, Wieczorek DJJ, Gutierrez AN, McDermott MW, Ahluwalia MS, Mehta MP, Kotecha R. Dedicated isotropic 3-D T1 SPACE sequence imaging for radiosurgery planning improves brain metastases detection and reduces the risk of intracranial relapse. Radiother Oncol 2022; 173:84-92. [PMID: 35662657 DOI: 10.1016/j.radonc.2022.05.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/11/2022] [Accepted: 05/27/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is increasingly used for brain metastases (BM) patients, but distant intracranial failure (DIF) remains the principal disadvantage of this focal therapeutic approach. The objective of this study was to determine if dedicated SRS imaging would improve lesion detection and reduce DIF. METHODS Between 02/2020 and 01/2021, SRS patients at a tertiary care institution underwent dedicated treatment planning MRIs of the brain including MPRAGE and SPACE post-contrast sequences. DIF was calculated using the Kaplan-Meier method; comparisons were made to a historical consecutive cohort treated using MPRAGE alone (02/2019-01/2020). RESULTS 134 patients underwent 171 SRS courses for 821 BM imaged with both MPRAGE and SPACE (primary cohort). MPRAGE sequence evaluation alone detected 679 lesions. With neuroradiologists evaluating SPACE and MPRAGE, an additional 108 lesions were identified (p<0.001). Upon multidisciplinary review, 34 additional lesions were identified. Compared to the historical cohort (103 patients, 135 SRS courses, 479 BM), the primary cohort had improved median time to DIF (13.5 vs. 5.1 months, p=0.004). The benefit was even more pronounced for patients treated for their first SRS course (18.4 vs. 6.3 months, p=0.001). SRS using MPRAGE and SPACE was associated with a 60% reduction in risk of DIF compared to the historical cohort (HR: 0.40; 95%CI: 0.28-0.57, p<0.001). CONCLUSIONS Among BM patients treated with SRS, a treatment planning SPACE sequence in addition to MPRAGE substantially improved lesion detection and was associated with a statistically significant and clinically meaningful prolongation in time to DIF, especially for patients undergoing their first SRS course.
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Affiliation(s)
- Tugce Kutuk
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, United States.
| | - Kevin J Abrams
- Department of Radiology, Baptist Health South Florida, Miami, FL, 33176, United States
| | - Martin C Tom
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, United States; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, United States
| | - Muni Rubens
- Department of Clinical Informatics, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, United States.
| | - Haley Appel
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, United States
| | - Charif Sidani
- Department of Radiology, Baptist Health South Florida, Miami, FL, 33176, United States
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, United States; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, United States
| | - Ranjini Tolakanahalli
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, United States; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, United States
| | - D Jay J Wieczorek
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, United States; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, United States
| | - Alonso N Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, United States; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, United States
| | - Michael W McDermott
- Department of Neurosurgery, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176 United States; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, United States
| | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, United States
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, United States; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, United States
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, United States; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, United States; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, United States.
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41
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Kotecha R, Tonse R, Menendez MAR, Williams A, Diaz Z, Tom MC, Hall MD, Mehta MP, Alvarez R, Siomin V, Odia Y, Ahluwalia MS, McDermott MW. Evaluation of the impact of pre-operative stereotactic radiotherapy on the acute changes in histopathologic and immune marker profiles of brain metastases. Sci Rep 2022; 12:4567. [PMID: 35296750 PMCID: PMC8927473 DOI: 10.1038/s41598-022-08507-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 02/23/2022] [Indexed: 12/04/2022] Open
Abstract
The unique acute effects of the large fractional doses that characterize stereotactic radiosurgery (SRS) or radiotherapy (SRT), specifically in terms of antitumor immune cellular processes, vascular damage, tumor necrosis, and apoptosis on brain metastasis have yet to be empirically demonstrated. The objective of this study is to provide the first in-human evaluation of the acute biological effects of SRS/SRT in resected brain metastasis. Tumor samples from patients who underwent dose-escalated preoperative SRT followed by resection with available non-irradiated primary tumor tissues were retrieved from our institutional biorepository. All primary tumors and irradiated metastases were evaluated for the following parameters: tumor necrosis, T-cells, natural killer cells, vessel density, vascular endothelial growth factor, and apoptotic factors. Twenty-two patients with irradiated and resected brain metastases and paired non-irradiated primary tumor samples met inclusion criteria. Patients underwent a median preoperative SRT dose of 18 Gy (Range: 15–20 Gy) in 1 fraction, with 3 patients receiving 27–30 Gy in 3–5 fractions, followed by resection within median interval of 67.8 h (R: 18.25–160.61 h). The rate of necrosis was significantly higher in irradiated brain metastases than non-irradiated primary tumors (p < 0.001). Decreases in all immunomodulatory cell populations were found in irradiated metastases compared to primary tumors: CD3 + (p = 0.003), CD4 + (p = 0.01), and CD8 + (p = 0.01). Pre-operative SRT is associated with acute effects such as increased tumor necrosis and differences in expression of immunomodulatory factors, an effect that does not appear to be time dependent, within the limited intervals explored within the context of this analysis.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Office 1R203, Miami, FL, 33176, USA. .,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
| | - Raees Tonse
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Office 1R203, Miami, FL, 33176, USA
| | | | - Andre Williams
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Zuanel Diaz
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Martin C Tom
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Office 1R203, Miami, FL, 33176, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Office 1R203, Miami, FL, 33176, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Office 1R203, Miami, FL, 33176, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Reinier Alvarez
- Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Vitaly Siomin
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.,Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Yazmin Odia
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.,Department of Neuro-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Manmeet S Ahluwalia
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.,Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Michael W McDermott
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.,Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
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Tom MC, Milano MT, Chao ST, Soltys SG, Knisely JP, Sahgal A, Nagpal S, Lo SS, Jabbari S, Wang TJ, Ahluwalia MS, Simonson M, Palmer JD, Gephart MH, Halasz LM, Garg AK, Chiang VL, Chang EL. Executive summary of american radium society’s appropriate use criteria for the postoperative management of lower grade gliomas. Radiother Oncol 2022; 170:79-88. [DOI: 10.1016/j.radonc.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
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43
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Kotecha R, Ahluwalia MS, Siomin V, McDermott MW. Surgery, Stereotactic Radiosurgery, and Systemic Therapy in the Management of Operable Brain Metastasis. Neurol Clin 2022; 40:421-436. [DOI: 10.1016/j.ncl.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Bagley SJ, Kothari S, Rahman R, Lee EQ, Dunn GP, Galanis E, Chang SM, Burt Nabors L, Ahluwalia MS, Stupp R, Mehta MP, Reardon DA, Grossman SA, Sulman EP, Sampson JH, Khagi S, Weller M, Cloughesy TF, Wen PY, Khasraw M. Glioblastoma Clinical Trials: Current Landscape and Opportunities for Improvement. Clin Cancer Res 2022; 28:594-602. [PMID: 34561269 PMCID: PMC9044253 DOI: 10.1158/1078-0432.ccr-21-2750] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/29/2021] [Accepted: 09/14/2021] [Indexed: 11/16/2022]
Abstract
Therapeutic advances for glioblastoma have been minimal over the past 2 decades. In light of the multitude of recent phase III trials that have failed to meet their primary endpoints following promising preclinical and early-phase programs, a Society for Neuro-Oncology Think Tank was held in November 2020 to prioritize areas for improvement in the conduct of glioblastoma clinical trials. Here, we review the literature, identify challenges related to clinical trial eligibility criteria and trial design in glioblastoma, and provide recommendations from the Think Tank. In addition, we provide a data-driven context with which to frame this discussion by analyzing key study design features of adult glioblastoma clinical trials listed on ClinicalTrials.gov as "recruiting" or "not yet recruiting" as of February 2021.
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Affiliation(s)
- Stephen J. Bagley
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Shawn Kothari
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rifaquat Rahman
- Department of Radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Eudocia Q. Lee
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gavin P. Dunn
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri
| | | | - Susan M. Chang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Louis Burt Nabors
- Division of Neuro-oncology, Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Manmeet S. Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Roger Stupp
- Department of Medicine, Northwestern University, Chicago, Illinois
| | - Minesh P. Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - David A. Reardon
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Stuart A. Grossman
- Department of Oncology, Johns Hopkins Kimmel Cancer Center, Baltimore, Maryland
| | - Erik P. Sulman
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, New York
| | - John H. Sampson
- Preston Robert Tisch Brain Tumor Center, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Simon Khagi
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Michael Weller
- Department of Neurology and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Timothy F. Cloughesy
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Patrick Y. Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mustafa Khasraw
- Preston Robert Tisch Brain Tumor Center, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
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45
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Anders NM, Romo CG, Hemingway A, Ahluwalia MS, Rudek MA. Quantitation of terameprocol in human plasma by liquid chromatography-tandem mass spectrometry. J Pharm Biomed Anal 2022; 209:114525. [PMID: 34906921 PMCID: PMC8742791 DOI: 10.1016/j.jpba.2021.114525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 02/07/2023]
Abstract
The global transcription inhibitor terameprocol is being evaluated clinically as an oral formulation to treat high-grade glioma. A sensitive, reliable method was developed to quantitate terameprocol using LC-MS/MS to perform detailed pharmacokinetic studies. Sample preparation involved protein precipitation using acetonitrile. Separation of terameprocol and the internal standard, Sorafenib-methyl-d3, was achieved with a Zorbax XDB C18 column (2.1 × 50 mm, 3.5 µm) and gradient elution over a 2-minute total analytical run time. A SCIEX 4500 or SCIEX 5500 triple quadrupole mass spectrometer operated in positive electrospray ionization mode was used for terameprocol detection. The assay range of 5-1000 ng/mL was demonstrated to be accurate (92.7-107.4%) and precise (CV ≤ 11.3%). A sample diluted 1:10 (v/v) was accurately quantitated. Terameprocol in plasma has been proven stable for at least 20 months when stored at -70 °C. The method was applied to the measurement of total plasma concentrations of terameprocol in a patient with a high-grade glioma receiving a 300 mg oral dose.
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Affiliation(s)
- Nicole M Anders
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA; Department of Oncology, School of Medicine, Johns Hopkins University, 1650 Orleans Street, Baltimore, MD 21231, USA
| | - Carlos G Romo
- Department of Neurology, School of Medicine, Johns Hopkins University, 1650 Orleans Street, Baltimore, MD 21231, USA; Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Johns Hopkins University, 1650 Orleans Street, Baltimore, MD 21231, USA
| | - Avelina Hemingway
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - Manmeet S Ahluwalia
- Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44195, USA; Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Michelle A Rudek
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA; Department of Oncology, School of Medicine, Johns Hopkins University, 1650 Orleans Street, Baltimore, MD 21231, USA; Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Johns Hopkins University, 1650 Orleans Street, Baltimore, MD 21231, USA.
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Lehrer EJ, Gurewitz J, Bernstein K, Patel D, Kondziolka D, Niranjan A, Wei Z, Lunsford LD, Malouff TD, Ruiz‐Garcia H, Patel S, Bonney PA, Hwang L, Yu C, Zada G, Mathieu D, Trudel C, Prasad RN, Palmer JD, Jones BM, Sharma S, Fakhoury KR, Rusthoven CG, Deibert CP, Picozzi P, Franzini A, Attuati L, Lee C, Yang H, Ahluwalia MS, Sheehan JP, Trifiletti DM. Radiation necrosis in renal cell carcinoma brain metastases treated with checkpoint inhibitors and radiosurgery: An international multicenter study. Cancer 2022; 128:1429-1438. [DOI: 10.1002/cncr.34087] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/08/2021] [Accepted: 11/22/2021] [Indexed: 12/18/2022]
Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology Icahn School of Medicine at Mount Sinai New York New York
| | - Jason Gurewitz
- Department of Radiation Oncology NYU Langone Medical Center New York New York
| | - Kenneth Bernstein
- Department of Radiation Oncology NYU Langone Medical Center New York New York
| | - Dev Patel
- Department of Neurosurgery NYU Langone Medical Center New York New York
| | | | - Ajay Niranjan
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Zhishuo Wei
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - L. Dade Lunsford
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | | | | | - Samir Patel
- Division of Radiation Oncology Department of Oncology University of Alberta Edmonton Alberta Canada
| | - Phillip A. Bonney
- Department of Neurosurgery University of Southern California Los Angeles California
| | - Lindsay Hwang
- Department of Radiation Oncology University of Southern California Los Angeles California
| | - Cheng Yu
- Department of Neurosurgery University of Southern California Los Angeles California
| | - Gabriel Zada
- Department of Neurosurgery University of Southern California Los Angeles California
| | - David Mathieu
- Department of Neurosurgery Université de Sherbrooke, Centre de Recherche du CHUS Quebec Quebec Canada
| | - Claire Trudel
- Department of Medicine Université de Sherbrooke, Centre de Recherche du CHUS Quebec Quebec Canada
| | - Rahul N. Prasad
- Department of Radiation Oncology Ohio State University Wexner Medical Center Columbus Ohio
| | - Joshua D. Palmer
- Department of Radiation Oncology Ohio State University Wexner Medical Center Columbus Ohio
| | - Brianna M. Jones
- Department of Radiation Oncology Icahn School of Medicine at Mount Sinai New York New York
| | - Sonam Sharma
- Department of Radiation Oncology Icahn School of Medicine at Mount Sinai New York New York
| | | | - Chad G. Rusthoven
- Department of Radiation Oncology University of Colorado Denver Colorado
| | | | - Piero Picozzi
- Department of Neurosurgery Humanitas Research Hospital–IRCCS Rozzano Italy
| | - Andrea Franzini
- Department of Neurosurgery Humanitas Research Hospital–IRCCS Rozzano Italy
| | - Luca Attuati
- Department of Neurosurgery Humanitas Research Hospital–IRCCS Rozzano Italy
| | - Cheng‐Chia Lee
- Department of Neurosurgery Neurological InstituteTaipei Veteran General Hospital Taipei Taiwan
| | - Huai‐Che Yang
- Department of Neurosurgery Neurological InstituteTaipei Veteran General Hospital Taipei Taiwan
| | | | - Jason P. Sheehan
- Department of Neurological Surgery University of Virginia Charlottesville Virginia
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47
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Park DY, Tom MC, Wei W, Tewari S, Ahluwalia MS, Yu JS, Chao ST, Suh JH, Peereboom D, Stevens GHJ, Barnett GH, Angelov L, Mohammadi AM, Hogan T, Kissel C, Lapin B, Schuermeyer I, Parsons MW, Naugle R, Murphy ES. Quality of life following concurrent temozolomide-based chemoradiation therapy or observation in low-grade glioma. J Neurooncol 2022; 156:499-507. [DOI: 10.1007/s11060-021-03920-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022]
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48
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Lauko A, Kotecha R, Barnett A, Li H, Tatineni V, Ali A, Patil P, Mohammadi AM, Chao ST, Murphy ES, Angelov L, Suh JH, Barnett GH, Pennell NA, Ahluwalia MS. Author Correction: Impact of KRAS mutation status on the efficacy of immunotherapy in lung cancer brain metastases. Sci Rep 2022; 12:1147. [PMID: 35039661 PMCID: PMC8763914 DOI: 10.1038/s41598-022-05489-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Adam Lauko
- Case Western Reserve University School of Medicine MSTP, Cleveland, OH, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Addison Barnett
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, OH, USA
| | - Hong Li
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Vineeth Tatineni
- Department of Internal Medicine, Summa Health, Akron City Hospital, Akron, OH, USA
| | - Assad Ali
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, OH, USA
| | - Pradnya Patil
- Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alireza M Mohammadi
- Case Western Reserve University School of Medicine MSTP, Cleveland, OH, USA.,Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, OH, USA.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samuel T Chao
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, OH, USA.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Erin S Murphy
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, OH, USA.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lilyana Angelov
- Case Western Reserve University School of Medicine MSTP, Cleveland, OH, USA.,Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, OH, USA.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John H Suh
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, OH, USA.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gene H Barnett
- Case Western Reserve University School of Medicine MSTP, Cleveland, OH, USA.,Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, OH, USA.,Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nathan A Pennell
- Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Manmeet S Ahluwalia
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA. .,Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, 8900 North Kendall Drive, Miami, FL, 33176, USA.
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Soffietti R, Bettegowda C, Mellinghoff IK, Warren KE, Ahluwalia MS, De Groot JF, Galanis E, Gilbert MR, Jaeckle KA, Le Rhun E, Rudà R, Seoane J, Thon N, Umemura Y, Weller M, van den Bent MJ, Vogelbaum MA, Chang SM, Wen PY. Liquid biopsy in gliomas: A RANO review and proposals for clinical applications. Neuro Oncol 2022; 24:855-871. [PMID: 34999836 PMCID: PMC9159432 DOI: 10.1093/neuonc/noac004] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND There is an extensive literature highlighting the utility of blood-based liquid biopsies in several extracranial tumors for diagnosis and monitoring. METHODS The RANO (Response Assessment in Neuro-Oncology) group developed a multidisciplinary international Task Force to review the English literature on liquid biopsy in gliomas focusing on the most frequently used techniques, that is circulating tumor DNA, circulating tumor cells, and extracellular vesicles in blood and CSF. RESULTS ctDNA has a higher sensitivity and capacity to represent the spatial and temporal heterogeneity in comparison to circulating tumor cells. Exosomes have the advantages to cross an intact blood-brain barrier and carry also RNA, miRNA, and proteins. Several clinical applications of liquid biopsies are suggested: to establish a diagnosis when tissue is not available, monitor the residual disease after surgery, distinguish progression from pseudoprogression, and predict the outcome. CONCLUSIONS There is a need for standardization of biofluid collection, choice of an analyte, and detection strategies along with rigorous testing in future clinical trials to validate findings and enable entry into clinical practice.
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Affiliation(s)
- Riccardo Soffietti
- Corresponding Author: Riccardo Soffietti, MD, Division of Neuro-Oncology, Department of Neuroscience, University and City of Health and Science Hospital, Via Cherasco 15, 10126 Turin, Italy ()
| | | | | | | | - Manmeet S Ahluwalia
- Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - John F De Groot
- Department of Neuro-Oncology, University of Texas, MD Anderson Cancer Center Houston, Houston, Texas, USA
| | - Evanthia Galanis
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark R Gilbert
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Kurt A Jaeckle
- Department of Neurology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Emilie Le Rhun
- Departments of Neurology & Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Roberta Rudà
- Department of Neurology, Castelfranco Veneto/Treviso Hospital and Division of Neuro-Oncology, Department of Neuroscience, University of Turin, Turin, Italy
| | - Joan Seoane
- Vall d’Hebron Institute of Oncology (VHIO) University Hospital, Universitat Autònoma de Barcelona, ICREA,CIBERONC, Barcelona, Spain
| | - Niklas Thon
- Division of Neuro-Oncology, Department of Neurosurgery, Ludwig Maximilians University School of Medicine, Munich, Germany
| | - Yoshie Umemura
- Division of Neuro-Oncology, Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Martin J van den Bent
- Department of Neurology, Brain Tumor Center at Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Susan M Chang
- Division of Neuro-Oncology, University of California San Francisco, San Francisco, California, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
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50
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Taslimi S, Brar K, Ellenbogen Y, Deng J, Hou W, Moraes FY, Glantz M, Zacharia BE, Tan A, Ahluwalia MS, Khasraw M, Zadeh G, Mansouri A. Comparative Efficacy of Systemic Agents for Brain Metastases From Non-Small-Cell Lung Cancer With an EGFR Mutation/ALK Rearrangement: A Systematic Review and Network Meta-Analysis. Front Oncol 2021; 11:739765. [PMID: 34950579 PMCID: PMC8691653 DOI: 10.3389/fonc.2021.739765] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 11/15/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Brain metastases (BM) from non-small-cell lung cancer (NSCLC) are frequent and carry significant morbidity, and current management options include varying local and systemic therapies. Here, we performed a systematic review and network meta-analysis to determine the ideal treatment regimen for NSCLC BMs with targetable EGFR-mutations/ALK-rearrangements. METHODS We searched MEDLINE, EMBASE, Web of Science, ClinicalTrials.gov, CENTRAL and references of key studies for randomized controlled trials (RCTs) published from inception until June 2020. Comparative RCTs including ≥10 patients were selected. We used a frequentist random-effects model for network meta-analysis (NMA) and assessed the certainty of evidence using the GRADE approach. Our primary outcome of interest was intracranial progression-free survival (iPFS). RESULTS We included 24 studies representing 19 trials with 1623 total patients. Targeted tyrosine kinase inhibitors (TKIs) significantly improved iPFS, with second-and third- generation TKIs showing the greatest benefit (HR=0.25, 95%CI 0.15-0.40). Overall PFS was also improved compared to conventional chemotherapy (HR=0.47, 95%CI 0.36-0.61). In EGFR-mutant patients, osimertinib showed the greatest benefit in iPFS (HR=0.32, 95%CI 0.15-0.69) compared to conventional chemotherapy, while gefitinib + chemotherapy showed the greatest overall PFS benefit (HR=0.26, 95%CI 0.10-0.70). All ALKi improved overall PFS compared to conventional chemotherapy, with alectinib having the greatest benefit (HR=0.13, 95%CI 0.07-0.24). CONCLUSIONS In patients with NSCLC BMs and EGFR/ALK mutations, targeted TKIs improve intracranial and overall PFS compared to conventional modalities such as chemotherapy, with greater efficacy seen using newer generations of TKIs. This data is important for treatment selection and patient counseling, and highlights areas for future RCT research. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=179060.
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Affiliation(s)
- Shervin Taslimi
- Division of Neurosurgery, Department of Surgery, Queen’s University, Kingston, ON, Canada
| | - Karanbir Brar
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Yosef Ellenbogen
- Division of Neurosurgery, Department of Surgery, Queen’s University, Kingston, ON, Canada
| | - Jiawen Deng
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Winston Hou
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Fabio Y. Moraes
- Department of Oncology, Queen’s University, Kingston, ON, Canada
| | - Michael Glantz
- Department of Neurosurgery, Penn State Health, Hershey, PA, United States
- Penn State Cancer Institute, Hershey, PA, United States
| | - Brad E. Zacharia
- Department of Neurosurgery, Penn State Health, Hershey, PA, United States
- Penn State Cancer Institute, Hershey, PA, United States
| | - Aaron Tan
- Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Manmeet S. Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Mustafa Khasraw
- The Preston Robert Tisch Brain Tumor Center, Duke University, Durham, NC, United States
| | - Gelareh Zadeh
- Division of Neurosurgery, Department of Surgery, Queen’s University, Kingston, ON, Canada
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State Health, Hershey, PA, United States
- Penn State Cancer Institute, Hershey, PA, United States
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