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Bi Q, Lian X, Shen J, Zhang F, Xu T. Exploration of radiotherapy strategy for brain metastasis patients with driver gene positivity in lung cancer. J Cancer 2024; 15:1994-2002. [PMID: 38434971 PMCID: PMC10905398 DOI: 10.7150/jca.91875] [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: 11/04/2023] [Accepted: 01/26/2024] [Indexed: 03/05/2024] Open
Abstract
Objective: To assess the disparities in effectiveness and identify outcome predictors in the treatment of a targeted-first and radiotherapy-first regimen with driver gene-positive lung cancer brain metastases. Materials and Methods: This retrospective study analyzed patients with driver gene-positive lung cancer brain metastases who received first-targeted and first-radiotherapy regimens, respectively, with SIB-WBRT (whole brain tissue 40 Gy/20 fractions, tumor tissue boosted to 56-60 Gy/20 fractions) and local irradiation (prescription dose range of 20-60 Gy/2-25 fractions, most commonly delivered as 30 Gy/5 fractions, with a BED range of 28-100.8 Gy) at Peking Union Medical College Hospital from September 2015 to December 2021. The primary endpoint was intracranial progression free survival (iPFS). Secondary endpoints included overall survival (OS), intracranial new lesions, and tumor control. The Kaplan-Meier method was utilized to depict and estimate iPFS, OS, intracranial new lesions and tumor control. The Cox regression analysis was conducted to assess the association between relevant factors and outcomes. Results: 88 patients were enrolled in targeted-first and radiotherapy-first regimen, totally. And no difference was found in the comparison of iPFS between the two groups (HR=1.180, 95%CI: 0.622-2.237, P=0.613). No difference was found in the comparison of OS between the two groups (HR=1.208, 95%CI: 0.679-2.150, P=0.520). No difference was found in the comparison of intracranial new lesions between the two groups (HR=1.184, 95%CI: 0.569-2.463, P=0.652). There was a difference in the local control time between the two groups, with radiotherapy-first regimen being superior (HR=2.397, 95% CI:1.453-3.954, P<0.001). Patient age (HR=1.054, 95%CI: 1.026- 1.082, P<0.001), radiotherapy modality (HR=0.128, 95%CI: 0.041-0.401, P<0.001), metastasis volume (HR=1.426, 95%CI: 1.209-1.682, P<0.001), number of metastases(HR=14.960, 95%CI: 1.990-112.444, P=0.009), extracranial disease status (HR=0.387, 95%CI: 0.170-0.880, P=0.023) and therapy sequence (HR=13.800, 95%CI: 4.455-42.751, P<0.001) were associated with local control. Conclusion: Targeted-first regimen was not found to improve patients' iPFS relative to radiotherapy-first regimen in patients with brain metastases. Radiotherapy-first regimen for brain metastases demonstrated superior local control compared to targeted-first regimen. Patient's age, radiotherapy modality, metastasis volume, number of metastases, extracranial disease status and therapy sequence may be related to local control of metastases.
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Affiliation(s)
- Qian Bi
- Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xin Lian
- Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jing Shen
- Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Fuquan Zhang
- Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Tao Xu
- Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College
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Kiss T, Ungvari A, Gulej R, Nyúl-Tóth Á, Tarantini S, Benyo Z, Csik B, Yabluchanskiy A, Mukli P, Csiszar A, Ungvari Z. Whole brain irradiation-induced endothelial dysfunction in the mouse brain. GeroScience 2024; 46:531-541. [PMID: 37953375 PMCID: PMC10828224 DOI: 10.1007/s11357-023-00990-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 07/29/2023] [Accepted: 10/05/2023] [Indexed: 11/14/2023] Open
Abstract
Whole brain irradiation (WBI), also known as whole brain radiation therapy (WBRT), is a well-established treatment for multiple brain metastases and as a preventive measure to reduce the risk of recurrence after surgical removal of a cerebral metastasis. However, WBI has been found to lead to a gradual decline in neurocognitive function in approximately 50% of patients who survive the treatment, significantly impacting their overall quality of life. Recent preclinical investigations have shed light on the underlying mechanisms of this adverse effect, revealing a complex cerebrovascular injury that involves the induction of cellular senescence in various components of the neurovascular unit, including endothelial cells. The emergence of cellular senescence following WBI has been implicated in the disruption of the blood-brain barrier and impairment of neurovascular coupling responses following irradiation. Building upon these findings, the present study aims to test the hypothesis that WBI-induced endothelial injury promotes endothelial dysfunction, which mimics the aging phenotype. To investigate this hypothesis, we employed a clinically relevant fractionated WBI protocol (5 Gy twice weekly for 4 weeks) on young mice. Both the WBI-treated and control mice were fitted with a cranial window, enabling the assessment of microvascular endothelial function. In order to evaluate the endothelium-dependent, NO-mediated cerebral blood flow (CBF) responses, we topically administered acetylcholine and ATP, and measured the resulting changes using laser Doppler flowmetry. We found that the increases in regional CBF induced by acetylcholine and ATP were significantly diminished in mice subjected to WBI. These findings provide additional preclinical evidence supporting the notion that WBI induces dysfunction in cerebrovascular endothelial cells, which in turn likely contributes to the detrimental long-term effects of the treatment. This endothelial dysfunction resembles an accelerated aging phenotype in the cerebrovascular system and is likely causally linked to the development of cognitive impairment. By integrating these findings with our previous results, we have deepened our understanding of the lasting consequences of WBI. Moreover, our study underscores the critical role of cerebromicrovascular health in safeguarding cognitive function over the long term. This enhanced understanding highlights the importance of prioritizing cerebromicrovascular health in the context of preserving cognitive abilities.
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Affiliation(s)
- Tamas Kiss
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Translational Medicine, Semmelweis University, Budapest, Hungary
- Eötvös Loránd Research Network and Semmelweis University (ELKH-SE) Cerebrovascular and Neurocognitive Disorders Research Group, Budapest, Hungary
| | - Anna Ungvari
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary.
- Department of Public Health, Semmelweis University, Semmelweis University, Budapest, Hungary.
| | - Rafal Gulej
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ádám Nyúl-Tóth
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- Department of Public Health, Semmelweis University, Semmelweis University, Budapest, Hungary
| | - Stefano Tarantini
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Zoltan Benyo
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Translational Medicine, Semmelweis University, Budapest, Hungary
- Eötvös Loránd Research Network and Semmelweis University (ELKH-SE) Cerebrovascular and Neurocognitive Disorders Research Group, Budapest, Hungary
| | - Boglarka Csik
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Andriy Yabluchanskiy
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Peter Mukli
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Anna Csiszar
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Translational Medicine, Semmelweis University, Budapest, Hungary
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
| | - Zoltan Ungvari
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Zhang H, Hu B, Pang H. Dosimetric comparison of helical tomotherapy and volumetric modulated arc therapy in hippocampal avoidance whole-brain radiotherapy. J Appl Clin Med Phys 2024; 25:e14218. [PMID: 38013656 PMCID: PMC10795432 DOI: 10.1002/acm2.14218] [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: 07/27/2023] [Revised: 09/06/2023] [Accepted: 11/12/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVE This study aimed to discuss the dosimetric advantages of helical tomotherapy (HT) and volumetric modulated arc therapy (VMAT) technology in hippocampal avoidance whole-brain radiotherapy and provide references for clinical selection of ideal radiotherapy technology. METHODS A total of 20 patients with hippocampal avoidance whole-brain radiotherapy were chosen randomly. Computed tomography (CT) and MRI scanning images were input into the treatment planning system (TPS). After the CT and enhanced magnetic resonance T1 weighted images were fused and registered, the same radiation therapy physician was invited to outline the tumor target volume. PTV-HS refers to the whole brain subtracted by 5 mm outward expansion of the hippocampus (HP). The prescribed dose was 30 Gy/10 fractions. HT and VMAT plans were designed for each patient in accordance with PTV. Under the premise that the 95% isodose curve covers the PTV, dose-volume histogram was applied to evaluate the PTV, conformal index (CI), heterogeneity index (HI), maximum dose (Dmax), mean dose (Dmean), minimum dose (Dmin) and absorbed doses of organs at risk (OARs) in HT and VMAT plans. Paired t-test was performed to compare the differences between two radiation therapy plans, and p < 0.05 was considered statistically significant. RESULTS These two plans had no significant difference in PTV-HS (max, min, and mean). However, the HI and CI of the HT plan were significantly better than those of the VMAT plan, showing statistically significant difference (p < 0.05). The HT plan was significantly superior to the VMAT plan in terms of the Dmax, Dmin, and Dmean of HP, left and right eye lens, left and right eye, and spinal cord, showing statistically significant difference (p < 0.05). The HT plan was also better than the VMAT plan in terms of the Dmax of the left optic nerve. However, the two plans showed no obvious differences in terms of the absorbed doses of the right optic nerve and brainstem, without statistical significance. CONCLUSIONS Compared with the VMAT plan of hippocampal avoidance, HT technology has significant dosimetric advantages. HT plans significantly decreased the radiation dose and radiation volume of OARs surrounding the target area (e.g., surrounding eye lens and eye, especially hippocampal avoidance area) while increasing the CI and HI of PTV dose in whole brain radiotherapy (WBRT) greatly, thus enabling the decrease in the incidence rate of radioactive nerve function impairment.
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Affiliation(s)
- Huai‐wen Zhang
- Department of RadiotherapyJiangxi Cancer HospitalThe Second Affiliated Hospital of Nanchang Medical College NHCKey Laboratory of Personalized Diagnosis and Treatment of Nasopharyngeal CarcinomaNanchangChina
- Department of Oncology, The third people's hospital of JingdezhenThe third people's hospital of Jingdezhen affiliated to Nanchang Medical CollegeJingdezhenChina
| | - Bo Hu
- Key Laboratory of Nondestructive Testing of Ministry of EducationNanchang HangKong UniversityNanchangChina
| | - Hao‐wen Pang
- Department of OncologyThe Affiliated Hospital of Southwest Medical UniversitySichuanChina
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Lapadula L, Piombino M, Bianculli A, Caivano R, Capobianco A, Cacciatore A, Cozzolino M, Oliviero C, D'andrea B, Mileo A, Leone A, Carbone F, Fochi NP, Landriscina M, Colamaria A, Giordano G. Third whole-brain radiation therapy for multiple brain metastases. Should it be considered in selected patients? Cancer Radiother 2023; 27:725-730. [PMID: 37777371 DOI: 10.1016/j.canrad.2023.05.003] [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: 02/13/2023] [Revised: 04/25/2023] [Accepted: 05/08/2023] [Indexed: 10/02/2023]
Abstract
Whole brain reirradiation for the treatment of multiple brain metastases has shown promising results. However, concerns remain over the possible neurotoxic effects of the cumulative dose as well as the questionable radiosensitivity of recurrent metastases. A second reirradiation of the whole brain is ordinarily performed in our department for palliative purposes in patients presenting with multiple metastatic brain progression. For this study, an investigational third whole brain reirradiation has been administered to highly selected patients to obtain disease control and delay progression. Clinical outcomes and neurological toxicity were also evaluated.
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Affiliation(s)
- L Lapadula
- Radiation Oncology Department, IRCCS-CROB, Rionero in Vulture, Italy
| | - M Piombino
- Radiation Oncology Department AUOC, Policlinico Bari, Italy
| | - A Bianculli
- Radiation Oncology Department, IRCCS-CROB, Rionero in Vulture, Italy
| | - R Caivano
- Radiation Oncology Department, IRCCS-CROB, Rionero in Vulture, Italy
| | - A Capobianco
- Multidisciplinary Oncology, Health Directorate Department, IRCCS Referral Cancer Center of Basilicata (CROB), Rionero in Vulture, Italy
| | - A Cacciatore
- Radiation Oncology Department, IRCCS-CROB, Rionero in Vulture, Italy
| | - M Cozzolino
- Radiation Oncology Department, IRCCS-CROB, Rionero in Vulture, Italy
| | - C Oliviero
- Radiation Oncology Department, IRCCS-CROB, Rionero in Vulture, Italy
| | - B D'andrea
- Radiation Oncology Department, IRCCS-CROB, Rionero in Vulture, Italy
| | - A Mileo
- Oncology Unit, IRCCS Referral Cancer Center of Basilicata (CROB), Rionero in Vulture, Italy
| | - A Leone
- Department of Neurosurgery, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany; Faculty of Human Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - F Carbone
- Department of Neurosurgery, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany; Division of Neurosurgery, "Riuniti" Hospital, University of Foggia, FG 71121 Foggia, Italy
| | - N P Fochi
- Division of Neurosurgery, "Riuniti" Hospital, University of Foggia, FG 71121 Foggia, Italy.
| | - M Landriscina
- Unit of Medical Oncology, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy
| | - A Colamaria
- Division of Neurosurgery, Policlinico "Riuniti", Foggia, Italy
| | - G Giordano
- Unit of Medical Oncology, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy
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Giordano G, Griguolo G, Landriscina M, Meattini I, Carbone F, Leone A, Del Re M, Fogli S, Danesi R, Colamaria A, Dieci MV. Multidisciplinary management of HER2-positive breast cancer with brain metastases: An evidence-based pragmatic approach moving from pathophysiology to clinical data. Crit Rev Oncol Hematol 2023; 192:104185. [PMID: 37863404 DOI: 10.1016/j.critrevonc.2023.104185] [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: 04/20/2023] [Revised: 10/02/2023] [Accepted: 10/16/2023] [Indexed: 10/22/2023] Open
Abstract
INTRODUCTION About 30-50 % of stage IV HER2+ breast cancers (BC) will present brain metastases (BMs). Their management is based on both local treatment and systemic therapy. Despite therapeutic advances, BMs still impact on survival and quality of life and the development of more effective systemic therapies represents an unmet clinical need. MATERIALS AND METHODS A thorough analysis of the published literature including ongoing clinical trials has been performed, investigating concepts spanning from the pathophysiology of tumor microenvironment to clinical considerations with the aim to summarize the current and future locoregional and systemic strategies. RESULTS Different trials have investigated monotherapies and combination treatments, highlighting how the blood-brain barrier (BBB) represents a major problem hindering diffusion and consequently efficacy of such options. Trastuzumab has long been the mainstay of systemic therapy and over the last two decades other HER2-targeted agents including lapatinib, pertuzumab, and trastuzumab emtansine, as well as more recently neratinib, tucatinib, and trastuzumab deruxtecan, have been introduced in clinical practice after showing promising results in randomized controlled trials. CONCLUSIONS We ultimately propose an evidence-based treatment algorithm for clinicians treating HER2 + BCs patients with BMs.
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Affiliation(s)
- Guido Giordano
- Unit of Medical Oncology and Biomolecular Therapy, Department of Medical and Surgical Sciences - Policlinico Riuniti, University of Foggia, Foggia 71122, Italy.
| | - Gaia Griguolo
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova 35128, Italy; Division of Oncology 2, Veneto Institute of Oncology IOV - IRCCS, Padova 35128, Italy
| | - Matteo Landriscina
- Unit of Medical Oncology and Biomolecular Therapy, Department of Medical and Surgical Sciences - Policlinico Riuniti, University of Foggia, Foggia 71122, Italy
| | - Icro Meattini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy; Department of Experimental and Clinical Biomedical Sciences M Serio, University of Florence, Florence, Italy, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Francesco Carbone
- Department of Neurosurgery, Städtisches Klinikum Karlsruhe, Karlsruher Neurozentrum, Karlsruhe 76133, Germany
| | - Augusto Leone
- Department of Neurosurgery, Städtisches Klinikum Karlsruhe, Karlsruher Neurozentrum, Karlsruhe 76133, Germany; Faculty of Human Medicine, Charité Universitätsmedizin Berlin, Berlin 10117, Germany
| | - Marzia Del Re
- Clinical Pharmacology and Pharmacogenetics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Stefano Fogli
- Clinical Pharmacology and Pharmacogenetics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Romano Danesi
- Clinical Pharmacology and Pharmacogenetics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Antonio Colamaria
- Division of Neurosurgery, Policlinico Riuniti Foggia, Foggia 71122, Italy
| | - Maria Vittoria Dieci
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova 35128, Italy; Division of Oncology 2, Veneto Institute of Oncology IOV - IRCCS, Padova 35128, Italy
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Luciano A, Liguori L, Polcaro G, Sabbatino F, Pepe S. Evaluation of Potential Predictive Biomarkers for Defining Brain Radiotherapy Efficacy in Non-Small Cell Lung Cancer Patients with Brain Metastases: A Case Report and a Narrative Review. Clin Pract 2023; 13:1549-1560. [PMID: 38131685 PMCID: PMC10742049 DOI: 10.3390/clinpract13060136] [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: 09/24/2023] [Revised: 11/16/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023] Open
Abstract
Non-small cell lung cancer (NSCLC) is the second most common cancer worldwide, resulting in 1.8 million deaths per year. Most patients are diagnosed with a metastatic disease. Brain metastases are one of the most common metastatic sites and are associated with severe neurological symptoms, shorter survival, and the worst clinical outcomes. Brain radiotherapy and systemic oncological therapies are currently used for controlling both cancer progression and neurological symptoms. Brain radiotherapy includes stereotactic brain ablative radiotherapy (SBRT) or whole brain radiotherapy (WBRT). SBRT is applied for single or multiple (up to ten) small (diameter less than 4 cm) lesions, whereas WBRT is usually applied for multiple (more than ten) and large (diameter greater than 4 cm) brain metastases. In both cases, radiotherapy application may be viewed as an overtreatment which causes severe toxicities without achieving a significant clinical benefit. Thus far, a number of scoring systems to define the potential clinical benefits derived from brain radiotherapy have been proposed. However, most are not well established in clinical practice. In this article, we present a clinical case of a patient with advanced NSCLC carrying a BRAFV600E mutation and brain metastases. We review the variables in addition to applicable scoring systems considered to have potential for predicting clinical outcomes and benefits of brain radiotherapy in patients with advanced NSCLC and brain metastases. Lastly, we highlight the unmet need of specific scoring systems for advanced NSCLC patients with brain metastases carrying oncogene alterations including BRAFV600E mutations.
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Affiliation(s)
- Angelo Luciano
- Oncology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (A.L.); (L.L.); (G.P.); (S.P.)
- Oncology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
| | - Luigi Liguori
- Oncology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (A.L.); (L.L.); (G.P.); (S.P.)
- Oncology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
| | - Giovanna Polcaro
- Oncology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (A.L.); (L.L.); (G.P.); (S.P.)
| | - Francesco Sabbatino
- Oncology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (A.L.); (L.L.); (G.P.); (S.P.)
| | - Stefano Pepe
- Oncology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (A.L.); (L.L.); (G.P.); (S.P.)
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Yang B, Liang Y, He S, Liu Y, Zhang K, Qiu J. Dosimetric comparison of coplanar and noncoplanar volumetric modulated arc therapy for hippocampal-sparing whole-brain radiation therapy. Med Dosim 2023:S0958-3947(23)00073-0. [PMID: 38016886 DOI: 10.1016/j.meddos.2023.08.010] [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: 04/04/2023] [Revised: 06/21/2023] [Accepted: 08/24/2023] [Indexed: 11/30/2023]
Abstract
Whole brain radiation therapy with hippocampal-sparing (HS-WBRT) is a novel treatment of brain metastases, which can relieve symptoms reduce recurrence in the central nervous system, and spare the hippocampus without compromising target coverage. This study aims to find out the superior combination of the treatment planning system and linear accelerator between Eclipse (version 15.6) with TrueBeam and uRT-TPOIS (vision R001.4) with uRT-linac 506c in HS-WBRT. The coplanar and noncoplanar volumetric modulated arc therapy (VMAT) for HS-WBRT plans were evaluated and compared on both combinations, respectively. Twenty patients for HS-WBRT were retrospectively selected at Peking Union Medical College Hospital (PUMCH) from 2021 to 2022. The coplanar and noncoplanar HS-WBRT treatment plans were designed by Eclipse and uRT-TPOIS referring to RTOG 0933 dose criteria, and their dosimetry parameters were compared. In addition, the plan complexity, monitor units, and beam-on time were recorded for Eclipse plans delivered on TrueBeam and uRT-TPOIS plans delivered on uRT-linac 506c. The results demonstrated that the dosimetric criteria of 4 types of HS-WBRT plans could meet the requirements of RTOG 0933. In terms of target coverage, dosimetric indexes of Eclipse plans and uRT-TPOIS plans were comparable, and the former is slightly better. As for metrics of organs-at-risk protection, coplanar and noncoplanar plans conducted by uRT-TPOIS were greatly superior to those by Eclipse. For coplanar and noncoplanar plans designed by the same treatment planning system, most of the dosimetric indexes had no significant difference. The monitor units of uRT-TPOIS plans was higher than that of Eclipse plans, but the modulation complexity of them were close, and uRT-TPOIS with uRT-linac 506c significantly reduced beam-on-time consumption by 9% on average for coplanar plans and 26% for noncoplanar plans compared to Eclipse with TrueBeam. This study firstly compared the coplanar and noncoplanar HS-WBRT treatment plans between Eclipse with TrueBeam and uRT-TPOIS with uRT-linac 506c in terms of dosimetry indexes, modulation complexity, and time consumption. It is shown that the radiation treatment solution of uRT-TPOIS with uRT-linac 506c is comparable with Eclipse with TrueBeam in terms of planning design, and significantly reduced the delivery time, which can be applied in clinical practice and promoted as a treatment format.
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Affiliation(s)
- Bo Yang
- Department of Radiation Oncology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, China
| | - Yongguang Liang
- Department of Radiation Oncology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, China
| | - Shumeng He
- United Imaging Research Institute of Intelligent Imaging, Beijing, 100094, China
| | - Yinglong Liu
- United Imaging Research Institute of Innovative Medical Equipment, Shenzhen, 518045, China
| | - Kang Zhang
- Shanghai United Imaging Healthcare Co., Ltd., Shanghai, 201807, China
| | - Jie Qiu
- Department of Radiation Oncology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, China.
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Mazzarella C, Chiesa S, Toppi L, Hohaus S, Gaudino S, D'Alo F, Dinapoli N, Davide R, Zinicola T, Bracci S, Martino A, Beghella Bartoli F, Lepre E, Bertolini R, Mariani S, Colosimo C, Frascino V, Mattiucci GC, Gambacorta MA, Valentini V, Balducci M. May we routinely spare hippocampal region in primary central nervous system lymphoma during whole brain radiotherapy? Radiat Oncol 2023; 18:161. [PMID: 37784190 PMCID: PMC10546760 DOI: 10.1186/s13014-023-02251-2] [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: 01/12/2022] [Accepted: 03/27/2023] [Indexed: 10/04/2023] Open
Abstract
PURPOSE One of the main limiting factors of whole-brain radiation therapy (WBRT) for primary central nervous system lymphoma (PCNSL) is the impairment of neurocognitive functions (NCFs), which is mainly caused by radiation-induced injury to the hippocampus. With a view to preventing NCF impairment and personalizing treatment, we explored the feasibility of sparing the hippocampus during WBRT by correlating the sites of PCNSL lesions with the hippocampus. METHODS AND MATERIALS Pre-treatment MR images from patients who underwent WBRT between 2010 and January 2020-and post-radiotherapy images in cases of relapse-were imported into the Varian Eclipse treatment-planning system and registered with the simulation CT. We constructed three 3-dimensional envelopes around the hippocampus at distances of 5, 10 and 15 mm and also contoured primary lesions and recurrences. RESULTS We analyzed 43 patients with 66 primary lesions: 9/66 (13.6%) involved the hippocampus and 11/66 (16.7%) were located within 5 mm of it. Thirty-six lesions (54.5%) were situated more than 15 mm from the hippocampus, while 10/66 (15.2%) were between 5 and 15 mm from it. The most common location was in deep brain structures (31%). Thirty-five of the 66 lesions relapsed: in field in 14/35 (40%) and outfield in 21/35 (60%) in different sites. Globally, 16/35 recurrences (45.7%) were located in the hippocampus or within 5 mm of it. CONCLUSION These data show that routinely sparing the hippocampus is not feasible. This approach could be considered in selected patients, when the lesion is more than 15 mm from the hippocampus.
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Affiliation(s)
- Ciro Mazzarella
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, largo A. Gemelli, Rome, Italy.
| | - Silvia Chiesa
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, largo A. Gemelli, Rome, Italy
| | - Lucrezia Toppi
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, largo A. Gemelli, Rome, Italy
| | - Stefan Hohaus
- UOC di Ematologia, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
- Istituto di Ematologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simona Gaudino
- UOC di Neuroradiologia, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Francesco D'Alo
- UOC di Ematologia, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
- Istituto di Ematologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicola Dinapoli
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, largo A. Gemelli, Rome, Italy
| | - Resta Davide
- UOC di Ematologia, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Tiziano Zinicola
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, largo A. Gemelli, Rome, Italy
| | - Serena Bracci
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, largo A. Gemelli, Rome, Italy
| | - Antonella Martino
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, largo A. Gemelli, Rome, Italy
| | - Francesco Beghella Bartoli
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, largo A. Gemelli, Rome, Italy
| | - Elisabetta Lepre
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, largo A. Gemelli, Rome, Italy
| | - Roberta Bertolini
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, largo A. Gemelli, Rome, Italy
| | - Silvia Mariani
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, largo A. Gemelli, Rome, Italy
| | - Cesare Colosimo
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Frascino
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, largo A. Gemelli, Rome, Italy
| | - Gian Carlo Mattiucci
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, largo A. Gemelli, Rome, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Antonietta Gambacorta
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, largo A. Gemelli, Rome, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Valentini
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, largo A. Gemelli, Rome, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mario Balducci
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, largo A. Gemelli, Rome, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
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Gulej R, Nyúl-Tóth Á, Ahire C, DelFavero J, Balasubramanian P, Kiss T, Tarantini S, Benyo Z, Pacher P, Csik B, Yabluchanskiy A, Mukli P, Kuan-Celarier A, Krizbai IA, Campisi J, Sonntag WE, Csiszar A, Ungvari Z. Elimination of senescent cells by treatment with Navitoclax/ABT263 reverses whole brain irradiation-induced blood-brain barrier disruption in the mouse brain. GeroScience 2023; 45:2983-3002. [PMID: 37642933 PMCID: PMC10643778 DOI: 10.1007/s11357-023-00870-x] [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: 02/12/2023] [Accepted: 07/06/2023] [Indexed: 08/31/2023] Open
Abstract
Whole brain irradiation (WBI), a commonly employed therapy for multiple brain metastases and as a prophylactic measure after cerebral metastasis resection, is associated with a progressive decline in neurocognitive function, significantly impacting the quality of life for approximately half of the surviving patients. Recent preclinical investigations have shed light on the multifaceted cerebrovascular injury mechanisms underlying this side effect of WBI. In this study, we aimed to test the hypothesis that WBI induces endothelial senescence, contributing to chronic disruption of the blood-brain barrier (BBB) and microvascular rarefaction. To accomplish this, we utilized transgenic p16-3MR mice, which enable the identification and selective elimination of senescent cells. These mice were subjected to a clinically relevant fractionated WBI protocol (5 Gy twice weekly for 4 weeks), and cranial windows were applied to both WBI-treated and control mice. Quantitative assessment of BBB permeability and capillary density was performed using two-photon microscopy at the 6-month post-irradiation time point. The presence of senescent microvascular endothelial cells was assessed by imaging flow cytometry, immunolabeling, and single-cell RNA-sequencing (scRNA-seq). WBI induced endothelial senescence, which associated with chronic BBB disruption and a trend for decreased microvascular density in the mouse cortex. In order to investigate the cause-and-effect relationship between WBI-induced senescence and microvascular injury, senescent cells were selectively removed from animals subjected to WBI treatment using Navitoclax/ABT263, a well-known senolytic drug. This intervention was carried out at the 3-month post-WBI time point. In WBI-treated mice, Navitoclax/ABT263 effectively eliminated senescent endothelial cells, which was associated with decreased BBB permeability and a trend for increased cortical capillarization. Our findings provide additional preclinical evidence that senolytic treatment approaches may be developed for prevention of the side effects of WBI.
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Affiliation(s)
- Rafal Gulej
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Ádám Nyúl-Tóth
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- International Training Program in Geroscience, Institute of Biophysics, Biological Research Centre, Eötvös Loránd Research Network, Szeged, Hungary
| | - Chetan Ahire
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jordan DelFavero
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Priya Balasubramanian
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
| | - Tamas Kiss
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, First Department of Pediatrics, Semmelweis University, Budapest, Hungary
- Eötvös Loránd Research Network and Semmelweis University (ELKH-SE) Cerebrovascular and Neurocognitive Disorders Research Group, Budapest, Hungary
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Translational Medicine, Semmelweis University, Budapest, Hungary
- Graduate School, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Stefano Tarantini
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
| | - Zoltan Benyo
- Eötvös Loránd Research Network and Semmelweis University (ELKH-SE) Cerebrovascular and Neurocognitive Disorders Research Group, Budapest, Hungary
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Translational Medicine, Semmelweis University, Budapest, Hungary
- Graduate School, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Pal Pacher
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institute On Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA
| | - Boglarka Csik
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Andriy Yabluchanskiy
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Peter Mukli
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Anna Kuan-Celarier
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - István A Krizbai
- International Training Program in Geroscience, Institute of Biophysics, Biological Research Centre, Eötvös Loránd Research Network, Szeged, Hungary
- Institute of Life Sciences, Vasile Goldiş Western University of Arad, Arad, Romania
| | | | - William E Sonntag
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Anna Csiszar
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Zoltan Ungvari
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary.
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA.
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Popp I, Hartong NE, Nieder C, Grosu AL. PRO: Do We Still Need Whole-Brain Irradiation for Brain Metastases? Cancers (Basel) 2023; 15:3193. [PMID: 37370802 DOI: 10.3390/cancers15123193] [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: 04/23/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
(1) Background: In recent decades, the use of whole-brain radiation therapy (WBRT) in the treatment of brain metastases has significantly decreased, with clinicians fearing adverse neurocognitive events and data showing limited efficacy regarding local tumor control and overall survival. The present study thus aimed to reassess the role that WBRT holds in the treatment of brain metastases. (2) Methods: This review summarizes the available evidence from 1990 until today supporting the use of WBRT, as well as new developments in WBRT and their clinical implications. (3) Results: While one to four brain metastases should be exclusively treated with radiosurgery, WBRT does remain an option for patients with multiple metastases. In particular, hippocampus-avoidance WBRT, WBRT with dose escalation to the metastases, and their combination have shown promising results and offer valid alternatives to local stereotactic radiotherapy. Ongoing and published prospective trials on the efficacy and toxicity of these new methods are presented. (4) Conclusions: Unlike conventional WBRT, which has limited indications, modern WBRT techniques continue to have a significant role to play in the treatment of multiple brain metastases. In which situations radiosurgery or WBRT should be the first option should be investigated in further studies. Until then, the therapeutic decision must be made individually depending on the oncological context.
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Affiliation(s)
- Ilinca Popp
- Department of Radiation Oncology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Freiburg, 69120 Heidelberg, Germany
| | - Nanna E Hartong
- Department of Radiation Oncology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Freiburg, 69120 Heidelberg, Germany
| | - Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, 9037 Tromsø, Norway
| | - Anca-L Grosu
- Department of Radiation Oncology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Freiburg, 69120 Heidelberg, Germany
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11
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Epperla N, Reljic T, Chowdhury SM, Ferreri AJM, Kumar A, Hamadani M. Autologous hematopoietic cell transplantation versus whole-brain radiotherapy consolidation in primary central nervous system lymphoma: A systematic review and meta-analysis. Hematol Oncol 2023; 41:88-96. [PMID: 36192141 DOI: 10.1002/hon.3083] [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: 04/03/2022] [Revised: 08/18/2022] [Accepted: 09/17/2022] [Indexed: 02/03/2023]
Abstract
The management of newly diagnosed primary central nervous system lymphoma (PCNSL) includes administration of high-dose methotrexate based regimens followed by consolidation therapy to minimize the risk of relapse. However, the best consolidation strategy (autologous hematopoietic cell transplant [auto-HCT] vs. whole-brain radiotherapy [WBRT]) is controversial. Hence, we performed a systematic review and meta-analysis of all randomized controlled trials that compared auto-HCT versus WBRT consolidation for patients with PCNSL after first-line treatment.The primary outcome was overall survival (OS), while the secondary outcomes included progression-free survival (PFS), response rates (overall response rate [ORR] and complete remission [CR]), relapse rate, treatment-related mortality (TRM), and neuropsychological adverse events. We performed a pooled analysis of the single-arm studies that incorporated auto-HCT or WBRT consolidation and evaluated neurocognitive outcomes. Only two studies met the inclusion criteria (n = 240). There was no significant difference in OS (HR = 1.50; 95% CI = 0.95-2.36), PFS (HR = 0.99; 95% CI = 0.44-2.22), ORR (RR = 1.48; 95% CI = 0.90-2.44), CR rate (RR = 1.21; 95% CI = 0.90-1.63), relapse rate (RR = 0.46; 95% CI = 0.05-4.28), and TRM (RR = 5.67; 95% CI = 1.01-31.91). The neuropsychological tests to assess neurocognitive domains were different and inconsistently reported in the two studies and therefore we were unable to perform a meta-analysis but provide a descriptive assessment. Both the studies showed a significant decline in the attention/executive function (based on the trail making test A and trail making test B) in those receiving WBRT compared to auto-HCT. We found 9 single-arm phase II studies that reported data on outcomes associated with either auto-HCT (5 studies) or WBRT (4 studies) consolidation. Of these, two studies (n = 43) reported data on neurocognitive decline following auto-HCT consolidation. Pooled proportion of patients with neurocognitive decline in these studies was 6% (95% CI, 0%-17%) for those receiving auto-HCT and there was no heterogeneity between studies (I2 = 0%). Three studies (n = 122) reported data on neurocognitive decline following WBRT consolidation. Pooled proportion of patients with neurocognitive decline in these studies was 43% (95% CI, 11%-78%) for those receiving WBRT and there was high heterogeneity between studies (I2 = 94%). There was significant heterogeneity between subgroups (p = 0.035). The outcomes were not significantly different in patients with PCNSL receiving auto-HCT or WBRT consolidation therapies, however, there is a higher degree of neurocognitive decline associated with WBRT compared to auto-HCT consolidation. The decision to choose a consolidation strategy needs to be individualized based on age, frailty, and co-morbidities.
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Affiliation(s)
- Narendranath Epperla
- Division of Hematology, Department of Medicine, The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Tea Reljic
- Department of Internal Medicine, Research Methodology and Biostatistics Core, Office of Research, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | | | - Andrés J M Ferreri
- Department of Onco-hematology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Ambuj Kumar
- Department of Internal Medicine, Research Methodology and Biostatistics Core, Office of Research, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Mehdi Hamadani
- BMT & Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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12
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DE LA Pinta C. Radiotherapy in Prostate Brain Metastases: A Review of the Literature. Anticancer Res 2023; 43:311-315. [PMID: 36585188 DOI: 10.21873/anticanres.16165] [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: 10/30/2022] [Revised: 11/12/2022] [Accepted: 11/15/2022] [Indexed: 01/01/2023]
Abstract
Brain metastases in prostate cancer are infrequent. Treatment of brain metastases includes radiotherapy. The aim of this literature review was to study whole brain radiotherapy, radiosurgery, and fractionated stereotactic radiotherapy and its applications in the treatment of prostate brain metastasis. We searched MEDLINE and PUBMED for articles published in the last 5 years and identified 153 articles. After examining them, 31 articles met the selection criteria and were included. Most were retrospective studies. MeSH terms used in the search included: prostate cancer OR prostate brain metastases AND radiotherapy, brain metastases AND radiotherapy AND prostate cancer. English language articles with information on the type of radiotherapy, doses and fractionation, indications, local control, toxicities, and survival of radiotherapy in prostate brain metastasis were included in this review. All articles were assessed for validity and relevant content. The usual treatment of prostate brain metastasis involves whole brain radiotherapy; however, the current trend in the metastases of prostate cancer and of other origins is the use of radiosurgery techniques or stereotactic body radiotherapy.
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13
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Yao S, Zuo H, Li W, Cai Y, Zhang Q, Pang L, Jing Y, Yin X, Cheng H. The correlations between psychological distress, cognitive impairment and quality of life in patients with brain metastases after whole-brain radiotherapy. Clin Transl Oncol 2023; 25:207-17. [PMID: 36038750 DOI: 10.1007/s12094-022-02927-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/09/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Psychological distress and cognitive impairment are highly prevalent among patients with brain metastases after whole-brain radiotherapy (WBRT). Our purpose was to evaluate the correlations between psychological distress, cognitive impairment and quality of life in patients with brain metastases after WBRT. METHODS Seventy-one patients with brain metastasis treated with WBRT were enrolled in this study and were investigated with several scales, including the Montreal Cognitive Assessment Scale (MoCA), the Functional Assessment of Cancer Therapy-Cognitive Function version 3 (FACT-Cog, version 3), the Functional Assessment of Cancer Therapy-Brain Module version 4 (FACT-Br, version 4) and the Psychological Distress Thermometer (DT), before and after WBRT. RESULTS The MoCA, FACT-Cog and FACT-Br scores in patients with brain metastases were significantly decreased after WBRT compared with before WBRT (z = - 7.106, - 6.933 and - 6.250, respectively, P < 0.001), while the DT scores were significantly increased (z = 6.613, P < 0.001). There was an obvious negative correlation between the DT score and the FACT-Cog score (r = - 0.660, P < 0.001), a significant negative correlation between the DT score and the FACT-Br score (r = - 0.833, P < 0.001), and an obvious positive correlation between the FACT-Cog score and the FACT-Br score (r = 0.603, P < 0.001). These results suggest that WBRT can cause cognitive impairment in patients with brain metastases, increase their psychological distress and reduce their quality of life (QOL). CONCLUSION After receiving WBRT, the cognitive function and QOL of patients with brain metastases were decreased, while psychological distress increased. The cognitive impairment and the decline of QOL after WBRT are associated with increased psychological distress, and that the decline of QOL is associated with cognitive impairment of patients.
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14
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Hintelmann K, Petersen C, Borgmann K. Radiotherapeutic Strategies to Overcome Resistance of Breast Cancer Brain Metastases by Considering Immunogenic Aspects of Cancer Stem Cells. Cancers (Basel) 2022; 15:211. [PMID: 36612206 PMCID: PMC9818478 DOI: 10.3390/cancers15010211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022] Open
Abstract
Breast cancer is the most diagnosed cancer in women, and symptomatic brain metastases (BCBMs) occur in 15-20% of metastatic breast cancer cases. Despite technological advances in radiation therapy (RT), the prognosis of patients is limited. This has been attributed to radioresistant breast cancer stem cells (BCSCs), among other factors. The aim of this review article is to summarize the evidence of cancer-stem-cell-mediated radioresistance in brain metastases of breast cancer from radiobiologic and radiation oncologic perspectives to allow for the better interpretability of preclinical and clinical evidence and to facilitate its translation into new therapeutic strategies. To this end, the etiology of brain metastasis in breast cancer, its radiotherapeutic treatment options, resistance mechanisms in BCSCs, and effects of molecularly targeted therapies in combination with radiotherapy involving immune checkpoint inhibitors are described and classified. This is considered in the context of the central nervous system (CNS) as a particular metastatic niche involving the blood-brain barrier and the CNS immune system. The compilation of this existing knowledge serves to identify possible synergistic effects between systemic molecularly targeted therapies and ionizing radiation (IR) by considering both BCSCs' relevant resistance mechanisms and effects on normal tissue of the CNS.
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Affiliation(s)
- Katharina Hintelmann
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
- Laboratory of Radiobiology and Experimental Radiooncology, Center of Oncology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Cordula Petersen
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Kerstin Borgmann
- Laboratory of Radiobiology and Experimental Radiooncology, Center of Oncology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
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Samhouri Y, Mustafa Ali MK, Law J, Khan C, Wegner R, Lee ST, Lister J. Consolidative Autologous Stem Cell Transplantation Versus Whole Brain Radiation in PCNSL; a Nationwide Analysis. Clin Lymphoma Myeloma Leuk 2022; 22:735-743. [PMID: 35705438 DOI: 10.1016/j.clml.2022.05.007] [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] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 05/19/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The best consolidation strategy after induction chemotherapy in Primary CNS Lymphoma (PCNSL) remains controversial. Our objective is to estimate the overall survival (OS) for autologous stem cell transplantation (ASCT) versus whole brain radiation (WBRT) in the consolidation setting. We also sought to evaluate the factors affecting treatment selection METHODS: We identified 1620 patients with PCNSL who received chemotherapy followed by either ASCT or WBRT between 2004 and 2015 from the National Cancer Database. A propensity score weighting methodology was used to compare survival outcomes. Factors affecting treatment selection were investigated using a logistic regression model. Annual percentage change (APC) was calculated to assess the trend of ASCT use. RESULTS Only 12.2% of patients received ASCT, and this proportion rose steadily between 2004 and 2015, with APC of +23%. Treatment selection was affected by age, type of area, distance from the treating facility, and level of education. With a median follow-up of 68.4 months, adjusted-median OS was 91.4 months and not reached for WBRT and ASCT groups, respectively (P < .001). 5-year OS was 74.4% in the ASCT group versus 58.7% in the WBRT group (HR 0.40, 95% CI 0.27-0.60, P -value < .01). CONCLUSION Socioeconomic factors affect the selection of consolidative treatment in patients with PCNSL which can alter outcomes. Frequency of consolidative ASCT is increasing for patients with PCNSL. This is the first and largest cohort study, to our knowledge, to show an OS advantage in favor of ASCT. This OS benefit needs to be confirmed in a randomized controlled fashion.
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Affiliation(s)
- Yazan Samhouri
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh PA.
| | - Moaath K Mustafa Ali
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland Medical Center, Baltimore MD
| | - Jennie Law
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland Medical Center, Baltimore MD
| | - Cyrus Khan
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh PA
| | - Rodney Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh PA
| | - Seung Tae Lee
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland Medical Center, Baltimore MD
| | - John Lister
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh PA
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Kahl KH, Shiban E, Gutser S, Maurer CJ, Sommer B, Müller H, Konietzko I, Grossert U, Berlis A, Janzen T, Stüben G. Focal cavity radiotherapy after neurosurgical resection of brain metastases: sparing neurotoxicity without compromising locoregional control. Strahlenther Onkol 2022. [PMID: 36149437 DOI: 10.1007/s00066-022-02003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Does focal cavity radiotherapy after resection of brain metastasis "spare" whole-brain radiotherapy, which is associated with toxicity for patients, through the complete course of their disease without compromising long-term local control of the brain? METHODS We retrospectively analyzed outcomes of patients who underwent adjuvant focal cavity radiotherapy between 2014 and 2021 at our center. RESULTS A total of 83 patients with 86 resected brain metastases were analyzed. 64% had singular, 36% two to four brain metastases. In cases with multiple metastases, omitted lesions were treated with radiosurgery. Median follow-up was 7.3 months (range 0-71.2 months), 1‑year overall survival rate was 57.8% (95% CI 44.9-68.8%). Radiotherapy was administered with a median biologically effective dose (α/β 10) surrounding the planning target volume of 48 Gy (range 23.4-60 Gy). Estimated 1‑year local control rate was 82.7% (95% CI 67.7-91.2%), estimated 1‑year distant brain control rate was 55.7% (95% CI 40.5-68.4%), estimated 1‑year leptomeningeal disease rate was 16.0% (95% CI 7.3-32.9%). Eleven distant brain recurrences could be salvaged with radiosurgery. In the further course of disease, 14 patients (17%) developed disseminated metastatic disease in the brain. Estimated 1‑year free of whole-brain radiotherapy rate was 72.3% (95% CI 57.1-82.9%). All applied treatments led to an estimated 1‑year neuro-control rate of 79.1% (95% CI 65.0-88.0%), estimated 1‑year radionecrosis rate was 23% (95% CI 12.4-40.5%). CONCLUSION In our single-center study, focal cavity radiotherapy was associated with high local control. In three out of four patients, whole-brain radiotherapy could be avoided in the complete course of disease, using radiosurgery as salvage approach without compromising neuro-control.
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Xu Y, Xu Y, Men K, Xiao J, Dai J. Application of piecewise VMAT technique to whole-brain radiotherapy with simultaneous integrated boost for multiple metastases. Radiat Oncol 2022; 17:86. [PMID: 35526019 PMCID: PMC9077835 DOI: 10.1186/s13014-022-02059-6] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/25/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE This study implemented a piecewise volumetric modulated arc therapy (P-VMAT) for realizing whole-brain radiation therapy (WBRT) with simultaneous integrated boost (SIB) for multiple brain metastases (> 40 metastases) with a conventional C-arm linear accelerator. MATERIALS AND METHODS This study retrospectively analyzed 10 patients with multiple brain metastases (40-120 metastases, median 76), who underwent WBRT and SIB using helical tomotherapy (HT). The prescribed doses were 40 Gy/20 f and 60 Gy/20 f for WBRT and SIB, respectively. Corresponding new HT plans were designed with P-VMAT using 7 arcs. For each arc, the collimator was rotated to 45°, and the field width was limited to 2.5 cm with 0.5 cm overlap with adjacent arcs. Thus, each arc covered only one section of the brain target volume. A conventional dual arc VMAT (DA-VMAT) plan was also designed. HT, P-VMAT, and DA-VMAT plans were compared using dose distribution reviews and dosimetric parameters. ArcCHECK phantom measurements were performed for verification of P-VMAT plans. RESULTS No significant differences in the mean coverage of the whole-brain target and metastases were observed between HT and P-VMAT (p > 0.05). The conformity index for the whole-brain target improved with P-VMAT compared with HT (p < 0.05). Furthermore, the volume of 44 Gy V44 (110% of prescribed dose for WBRT) received for whole-brain significantly reduced with P-VMAT from 38.2 ± 12.9% to 23.3 ± 9.4% (p < 0.05), and the maximum dose for organs at risks such as the hippocampus, optical nerve, optical chiasm, and spinal cord declined with P-VMAT (p < 0.05). Unlike HT and P-VMAT, DA-VMAT was clinically unacceptable because V44 in the whole-brain was too high (54.7 ± 8.2%). The mean absolute dose gamma passing rate for P-VMAT plans was 97.6 ± 1.1% (3%/3 mm criterion, 10%). CONCLUSIONS P-VMAT is favorable for WBRT and SIB for multiple brain metastases. It provides comparable coverage of whole-brain target and SIB, with better conformity, lower V44, and better dose sparing of organs at risk compared with HT. Furthermore, results show that DA-VMAT fails clinical practice even for a relatively large number of brain metastases with a high degree of plan complexity. The patient specific verification demonstrates the feasibility of P-VMAT for clinical application.
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Affiliation(s)
- Yuan Xu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yingjie Xu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Kuo Men
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jianping Xiao
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jianrong Dai
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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Popp I, Grosu AL, Fennell JT, Fischer M, Baltas D, Wiehle R. Optimization of hippocampus sparing during whole brain radiation therapy with simultaneous integrated boost-tutorial and efficacy of complete directional hippocampal blocking. Strahlenther Onkol 2022. [PMID: 35357511 DOI: 10.1007/s00066-022-01916-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/20/2022] [Indexed: 11/25/2022]
Abstract
Purpose Hippocampus-avoidance whole brain radiotherapy with simultaneous integrated boost (HA-WBRT+SIB) is a complex treatment option for patients with multiple brain metastases, aiming to prevent neurocognitive decline and simultaneously increase tumor control. Achieving efficient hippocampal dose reduction in this context can be challenging. The aim of the current study is to present and analyze the efficacy of complete directional hippocampal blocking in reducing the hippocampal dose during HA-WBRT+SIB. Methods A total of 30 patients with multiple metastases having undergone HA-WBRT+SIB were identified. The prescribed dose was 30 Gy in 12 fractions to the whole brain, with 98% of the hippocampus receiving ≤ 9 Gy and 2% ≤ 17 Gy and with SIB to metastases/resection cavities of 36–51 Gy in 12 fractions. Alternative treatment plans were calculated using complete directional hippocampal blocking and compared to conventional plans regarding target coverage, homogeneity, conformity, dose to hippocampi and organs at risk. Results All alternative plans reached prescription doses. Hippocampal blocking enabled more successful sparing of the hippocampus, with a mean dose of 8.79 ± 0.99 Gy compared to 10.07 ± 0.96 Gy in 12 fractions with the conventional method (p < 0.0001). The mean dose to the whole brain (excluding metastases and hippocampal avoidance region) was 30.52 ± 0.80 Gy with conventional planning and 30.28 ± 0.11 Gy with hippocampal blocking (p = 0.11). Target coverage, conformity and homogeneity indices for whole brain and metastases, as well as doses to organs at risk were similar between planning methods (p > 0.003). Conclusion Complete directional hippocampal blocking is an efficient method for achieving improved hippocampal sparing during HA-WBRT+SIB.
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Chen J, Sinclair G, Rozati H, Hill L, Pakzad-Shahabi L, Wang J, Calvez KL, Paddick I, Williams M. Improving on whole-brain radiotherapy in patients with large brain metastases: A planning study to support the AROMA clinical trial. Radiother Oncol 2022:S0167-8140(22)00096-2. [PMID: 35182688 DOI: 10.1016/j.radonc.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE To develop a novel dose-escalated volumetric modulated arc therapy (VMAT) strategy for patients with single or multiple large brain metastases which can deliver a higher dose to individual lesions for better local control (LC), and to compare dosimetry between whole brain radiotherapy (WBRT), hippocampal-sparing whole brain radiotherapy (HS-WBRT) and different VMAT-based focal radiotherapy approaches. METHODS AND MATERIALS We identified 20 patients with one to ten brain metastases and at least one lesion larger than 15 cm3 who had received WBRT as part of routine care. For each patient, we designed and evaluated five radiotherapy treatment plans, including WBRT, HS-WBRT and three VMAT dosing models. A dose of 20 Gy in 5 fractions was prescribed to the whole brain or target volumes depending on the plan, with higher doses to smaller lesions and dose-escalated inner planning target volumes (DE-iPTV) in VMAT plans, respectively. Treatment plans were evaluated using the efficiency index, mean dose and D0.1cc to the target volumes and organs at risk. RESULTS Compared with WBRT, VMAT plans achieved a significantly more efficient dose distribution in brain lesions, especially with our DE-iPTV model, while minimising the dose to the normal brain and other organs at risks (OARs) (p < 0.05). CONCLUSIONS VMAT plans obtained higher doses to brain metastases and minimised doses to OARs. Dose-escalated VMAT for larger lesions allows higher radiotherapy doses to be delivered to larger lesions while maintaining safe doses to OARs.
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Abstract
OBJECTIVE Approximately 50-90% of brain metastatic patients who receive radiation therapy (RT) exhibit cognitive decline which may affects the quality of life of cancer survivors. Hence preservation of cognitive functions in brain metastatic patients becomes important. This review aims to evaluates the pathology or mechanism of cognitive function impairment after brain irradiation and strategies available to preserve cognitive function after radiation therapy. DATA SOURCES Published articles evaluating the pathology behind radiation induced cognitive impairment and strategies to resolve or preserve cognitive impairment were searched for in scientific databases (eg: PubMed, Scopus, Cochrane database, Google scholar) using keywords including memantine, brain metastases, radiation therapy, pathophysiology, pathogenesis, mechanism and prevention. DATA SUMMARY Several hypotheses have been offered to explain the mechanism of radiation induced cognitive decline. Among them, vascular hypotheses play a significant role. Some pharmacological agents have been also tested in patients receiving radiotherapy, memantine was found beneficial based with the reference to existing data. CONCLUSION Future studies are required to evaluate the impact of memantine in different types of radiation therapy procedures and its effects on quality of life of brain metastatic survivors.
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Affiliation(s)
| | - M P Narmadha
- Department of Pharmacy Practice, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Sruthi Kalavagunta
- Department of Radiation Oncology, 29286Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Ajay Sasidharan
- Department of Radiation Oncology, 29286Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Debnarayan Dutta
- Department of Radiation Oncology, 29286Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
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Matsuzaki T, Ikemura S, Shinozaki T, Iwami E, Nakajima T, Katayama M, Shimamoto Y, Sasaki A, Serizawa T, Terashima T. Non-small cell lung cancer with multiple brain metastases remains relapse-free for more than 13 years: A case report. Mol Clin Oncol 2021; 16:18. [PMID: 34881038 PMCID: PMC8637853 DOI: 10.3892/mco.2021.2448] [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: 11/15/2019] [Accepted: 09/13/2021] [Indexed: 11/06/2022] Open
Abstract
Brain metastasis (BM) in patients with non-small cell lung cancer (NSCLC) is usually associated with a poor prognosis. A 55-year-old Japanese man visited Tokyo Dental College Ichikawa General Hospital with complaints of motor aphasia and fatigue. Enhanced magnetic resonance imaging of the brain revealed multiple tumors. The patient's medical history included lung cancer surgery performed at another hospital 3 months prior to his visit to our hospital. Total resection of the left frontal tumor revealed BM from lung adenocarcinoma. Stereotactic radiosurgery (SRS) was performed for the remaining three BMs. At 9 months after SRS, another new BM was discovered, and SRS was again performed. More than 13 years have elapsed since the last SRS was performed, and the patient has remained relapse-free. To the best of our knowledge, this is the first case report describing a patient with NSCLC with multiple BMs who has remained relapse-free for >13 years with no neurological dysfunction, including cognitive deficit.
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Affiliation(s)
- Tatsu Matsuzaki
- Department of Respiratory Medicine, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Chiba 272-8513, Japan
| | - Shinnosuke Ikemura
- Department of Respiratory Medicine, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Chiba 272-8513, Japan
| | - Taro Shinozaki
- Department of Respiratory Medicine, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Chiba 272-8513, Japan
| | - Eri Iwami
- Department of Respiratory Medicine, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Chiba 272-8513, Japan
| | - Takahiro Nakajima
- Department of Respiratory Medicine, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Chiba 272-8513, Japan
| | - Masateru Katayama
- Department of Neurosurgery, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Chiba 272-8513, Japan
| | - Yoshinori Shimamoto
- Department of Neurosurgery, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Chiba 272-8513, Japan
| | - Aya Sasaki
- Department of Pathology and Laboratory Medicine, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Chiba 272-8513, Japan
| | - Toru Serizawa
- Tokyo Gamma Unit Center, Tsukiji Neurological Clinic, Tokyo 104-0045, Japan
| | - Takeshi Terashima
- Department of Respiratory Medicine, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Chiba 272-8513, Japan
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22
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Khan M, Zhao Z, Li X, Liao G. Anti-PD1 Therapy Plus Whole-Brain Radiation Therapy May Prolong PFS in Selected Non-Small Cell Lung Cancer Patients with Brain Metastases: A Retrospective Study. Int J Gen Med 2021; 14:8903-8918. [PMID: 34858054 PMCID: PMC8631977 DOI: 10.2147/ijgm.s333890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 08/12/2021] [Accepted: 10/06/2021] [Indexed: 12/17/2022] Open
Abstract
Background Whole-brain radiotherapy (WBRT) remains an essential modality of treatment for brain metastases (BMs) derived from non-small cell lung cancer (NSCLC) patients and anti-PD-1 therapy has demonstrated intracranial responses in these patients. We aimed to evaluate if the combination of the two treatments could yield additive efficacy. Methods A retrospective review of our institution’s database was carried out to identify NSCLC patients with BMs who had been treated with anti-PD1 therapy and/or WBRT between 2015 and 2020. Patient characteristics, main outcomes, including progression-free survival (PFS) and overall survival (OS), and factors affecting these outcomes were analyzed. SPSS 24 was used for statistical analysis. Appropriate statistical tests were employed according to the type of data. Results Overall, 21 NSCLC BM patients were identified that had received WBRT. Of these, ten had been additionally treated with anti-PD1 therapy within 30 days of WBRT initiation. Median PFS was 3 (95% CI 0.8–5.1) months with WBRT alone versus 11 (95% CI 6.3–15.6) months with combined treatment. Risk of disease progression was 71% lower with the combined approach (HR 0.29, 95% CI 0.11–0.80; p=0.016). A trend toward improved OS was also observed with the combined approach (HR 0.33, 95% CI 0.08–1.12; p=0.107). Concurrent treatment (p=0.028) and male sex (p=0.052) were associated with improved PFS, while OS was associated only with age (p=0.02). Conclusion Concurrent WBRT and anti-PD1 therapy may delay progression and improve survival in BM patients with confirmed EGFR- and ALK-negative NSCLC histology. Prospective studies are warranted to validate and elucidate on the additive effect of the two modalities.
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Affiliation(s)
- Muhammad Khan
- Department of Oncology, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, People's Republic of China.,Department of Oncology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People's Republic of China
| | - Zhihong Zhao
- Department of Nephrology, Shenzhen People's Hospital, Second Clinical Medicine Centre, Jinan University, Shenzhen, People's Republic of China
| | - Xianming Li
- Department of Oncology, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, People's Republic of China
| | - Guixiang Liao
- Department of Oncology, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, People's Republic of China
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Wu J, Gao F, Wang W, Zhang X, Dong M, Zhang L, Li X, Li L, Sun Z, Wang X, Fu X, Zhu L, Ding M, Niu S, Li Z, Chang Y, Nan F, Yan J, Yu H, Wu X, Zhou Z, Zhang J, Zhang M. Fotemustine-based therapy in combination with rituximab as a first-line induction chemotherapy followed by WBRT for newly diagnosed primary central nervous system lymphoma: a prospective phase II trial. Cancer Biol Med 2021; 19:j.issn.2095-3941.2021.0026. [PMID: 34633776 PMCID: PMC9334761 DOI: 10.20892/j.issn.2095-3941.2021.0026] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 05/24/2021] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the safety, efficacy, and feasibility of the rituximab, fotemustine, pemetrexed, and dexamethasone (R-FPD) regimen followed by whole-brain radiotherapy (WBRT) for patients with primary central nervous system lymphoma (PCNSL). METHODS A prospective, single-center phase II clinical trial was conducted. Patients with PCNSL newly diagnosed at the First Affiliated Hospital of Zhengzhou University between July 2018 and July 2020 were studied. The R-FPD regimen consisted of rituximab (375 mg/m2 i.v. on D0), fotemustine (100 mg/m2 i.v. on D1), pemetrexed (600 mg/m2 i.v. on D1), and dexamethasone (40 mg i.v. on D1-5). Patients 60 years or younger who showed a complete response (CR) were treated with 23.4 Gy of WBRT after the end of chemotherapy; those older than 60 years with CR were treated with a wait-and-see approach; and those who did not show CR after the 4th cycle of chemotherapy were given salvage WBRT 30 Gy + local tumor field irradiation up to 45 Gy, regardless of age. RESULTS A total of 30 patients were included. After 2 cycles, the objective response rate (ORR) was 96.5% (28/29, 1 CR, 27 PR, 0 SD, and 1 PD). After 4 cycles, the ORR was 73.1% (19/26, 11 CR, 8 PR, 4 SD, and 3 PD). After WBRT, the ORR was 90.9% (10/11, 7 CR, 3 PR, and 1 SD). The grade III and IV toxicity responses were mainly leukopenia (20.0%), thrombocytopenia (23.3%), and anemia (10.0%). CONCLUSIONS Fotemustine-based therapy in combination with rituximab chemotherapy followed by WBRT can improve outcomes, providing ORR benefits and favorable tolerability in patients newly diagnosed with PCNSL.
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Affiliation(s)
- Jingjing Wu
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Fenghua Gao
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Wenhua Wang
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Xudong Zhang
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Meng Dong
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Lei Zhang
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Xin Li
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Ling Li
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Zhenchang Sun
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Xinhua Wang
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Xiaorui Fu
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Linan Zhu
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Mengjie Ding
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Songtao Niu
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Zhaoming Li
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Yu Chang
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Feifei Nan
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Jiaqian Yan
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Hui Yu
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Xiaolong Wu
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Zhiyuan Zhou
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Jieming Zhang
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Mingzhi Zhang
- Cancer Research Institute, Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
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Institoris A, Murphy-Royal C, Tarantini S, Yabluchanskiy A, Haidey JN, Csiszar A, Ungvari Z, Gordon GR. Whole brain irradiation in mice causes long-term impairment in astrocytic calcium signaling but preserves astrocyte-astrocyte coupling. GeroScience 2021; 43:197-212. [PMID: 33094399 PMCID: PMC8050172 DOI: 10.1007/s11357-020-00289-8] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/14/2020] [Indexed: 11/29/2022] Open
Abstract
Whole brain irradiation (WBI) therapy is an important treatment for brain metastases and potential microscopic malignancies. WBI promotes progressive cognitive dysfunction in over half of surviving patients, yet, the underlying mechanisms remain obscure. Astrocytes play critical roles in the regulation of neuronal activity, brain metabolism, and cerebral blood flow, and while neurons are considered radioresistant, astrocytes are sensitive to γ-irradiation. Hallmarks of astrocyte function are the ability to generate stimulus-induced intercellular Ca2+ signals and to move metabolic substrates through the connected astrocyte network. We tested the hypothesis that WBI-induced cognitive impairment associates with persistent impairment of astrocytic Ca2+ signaling and/or gap junctional coupling. Mice were subjected to a clinically relevant protocol of fractionated WBI, and 12 to 15 months after irradiation, we confirmed persistent cognitive impairment compared to controls. To test the integrity of astrocyte-to-astrocyte gap junctional coupling postWBI, astrocytes were loaded with Alexa-488-hydrazide by patch-based dye infusion, and the increase of fluorescence signal in neighboring astrocyte cell bodies was assessed with 2-photon microscopy in acute slices of the sensory-motor cortex. We found that WBI did not affect astrocyte-to-astrocyte gap junctional coupling. Astrocytic Ca2+ responses induced by bath administration of phenylephrine (detected with Rhod-2/AM) were also unaltered by WBI. However, an electrical stimulation protocol used in long-term potentiation (theta burst), revealed attenuated astrocyte Ca2+ responses in the astrocyte arbor and soma in WBI. Our data show that WBI causes a long-lasting decrement in synaptic-evoked astrocyte Ca2+ signals 12-15 months postirradiation, which may be an important contributor to cognitive decline seen after WBI.
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Affiliation(s)
- Adam Institoris
- Department of Physiology and Pharmacology, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Ciaran Murphy-Royal
- Department of Physiology and Pharmacology, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Stefano Tarantini
- Department of Biochemistry and Molecular Biology, Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Andriy Yabluchanskiy
- Department of Biochemistry and Molecular Biology, Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jordan N Haidey
- Department of Physiology and Pharmacology, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Anna Csiszar
- Department of Biochemistry and Molecular Biology, Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Zoltan Ungvari
- Department of Biochemistry and Molecular Biology, Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Grant R Gordon
- Department of Physiology and Pharmacology, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.
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Glatzer M, Faivre-Finn C, De Ruysscher D, Widder J, Van Houtte P, Troost EGC, Slotman BJ, Ramella S, Pöttgen C, Peeters STH, Nestle U, McDonald F, Le Pechoux C, Dziadziuszko R, Belderbos J, Ricardi U, Manapov F, Lievens Y, Geets X, Dieckmann K, Guckenberger M, Andratschke N, Süveg K, Putora PM. Role of radiotherapy in the management of brain metastases of NSCLC - Decision criteria in clinical routine. Radiother Oncol 2020; 154:269-273. [PMID: 33186683 DOI: 10.1016/j.radonc.2020.10.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/27/2020] [Accepted: 10/31/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Whole brain radiotherapy (WBRT) is a common treatment option for brain metastases secondary to non-small cell lung cancer (NSCLC). Data from the QUARTZ trial suggest that WBRT can be omitted in selected patients and treated with optimal supportive care alone. Nevertheless, WBRT is still widely used to treat brain metastases secondary to NSCLC. We analysed decision criteria influencing the selection for WBRT among European radiation oncology experts. METHODS Twenty-two European radiation oncology experts in lung cancer as selected by the European Society for Therapeutic Radiation Oncology (ESTRO) for previous projects and by the Advisory Committee on Radiation Oncology Practice (ACROP) for lung cancer were asked to describe their strategies in the management of brain metastases of NSCLC. Treatment strategies were subsequently converted into decision trees and analysed for agreement and discrepancies. RESULTS Eight decision criteria (suitability for SRS, performance status, symptoms, eligibility for targeted therapy, extra-cranial tumour control, age, prognostic scores and "Zugzwang" (the compulsion to treat)) were identified. WBRT was recommended by a majority of the European experts for symptomatic patients not suitable for radiosurgery or fractionated stereotactic radiotherapy. There was also a tendency to use WBRT in the ALK/EGFR/ROS1 negative NSCLC setting. CONCLUSION Despite the results of the QUARTZ trial WBRT is still widely used among European radiation oncology experts.
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Affiliation(s)
- Markus Glatzer
- Department of Radiation Oncology, Kantonsspital St. Gallen, Switzerland.
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, University of Manchester & The Christie NHS Foundation Trust Manchester, United Kingdom
| | - Dirk De Ruysscher
- Maastricht University Medical Center, Department of Radiation Oncology (Maastro Clinic), School for Oncology and Developmental Biology (GROW), Maastricht, The Netherlands
| | - Joachim Widder
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | - Paul Van Houtte
- Department of Radiation Oncology, Institut Bordet, Université Libre Bruxelles, Belgium
| | - Esther G C Troost
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam University Medical Centers, VUMC, The Netherlands
| | - Sara Ramella
- Department of Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Christoph Pöttgen
- Department of Radiation Oncology, West German Tumor Centre, University of Duisburg-Essen Medical School, Germany
| | - Stephanie T H Peeters
- Maastricht University Medical Center, Department of Radiation Oncology (Maastro Clinic), School for Oncology and Developmental Biology (GROW), Maastricht, The Netherlands
| | - Ursula Nestle
- Department of Radiation Oncology, Kliniken Maria Hilf, Moenchengladbach, Germany; Department of Radiation Oncology, University Hospital Freiburg, Germany
| | - Fiona McDonald
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Cecile Le Pechoux
- Departement Oncologie Radiotherapie, Gustave Roussy, Villejuif, France
| | | | - José Belderbos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Farkhad Manapov
- Department of Radiation Oncology, LMU Klinikum, University of Munich, Germany
| | - Yolande Lievens
- Radiation Oncology Department, Ghent University Hospital and Ghent University, Belgium
| | - Xavier Geets
- Department of Radiation Oncology, Cliniques universitaires Saint-Luc, MIRO - IREC Lab, UCL, Belgium
| | - Karin Dieckmann
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Krisztian Süveg
- Department of Radiation Oncology, Kantonsspital St. Gallen, Switzerland
| | - Paul M Putora
- Department of Radiation Oncology, Kantonsspital St. Gallen, Switzerland; Department of Radiation Oncology, University of Bern, Switzerland
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Perlow HK, Dibs K, Liu K, Jiang W, Rajappa P, Blakaj DM, Palmer J, Raval RR. Whole-Brain Radiation Therapy Versus Stereotactic Radiosurgery for Cerebral Metastases. Neurosurg Clin N Am 2020; 31:565-573. [PMID: 32921352 DOI: 10.1016/j.nec.2020.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 10/23/2022]
Abstract
Whole-brain radiation therapy (WBRT) was frequently used to treat brain metastases in the past. Stereotactic radiosurgery (SRS) is now generally preferred to WBRT for patients with limited brain metastases. SRS can also be used to treat extensive brain metastases (>10-15 metastases), and clinical trials are currently comparing WBRT with SRS for extensive disease. SRS may allow for an increased risk of radiation necrosis or leptomeningeal disease dissemination after treatment. Preoperative SRS and multifraction radiotherapy decrease the risk of these side effects and may soon become standard of care. Combining SRS with immune checkpoint inhibitors may improve patient outcomes.
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Affiliation(s)
- Haley K Perlow
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - Khaled Dibs
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - Kevin Liu
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - William Jiang
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - Prajwal Rajappa
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA; Department of Neurological Surgery, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Dukagjin M Blakaj
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - Joshua Palmer
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - Raju R Raval
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA.
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Dhermain F, Noël G, Antoni D, Tallet A. Role of radiation therapy in brain metastases management. Cancer Radiother 2020; 24:463-469. [PMID: 32828669 DOI: 10.1016/j.canrad.2020.06.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 05/15/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 01/26/2023]
Abstract
The challenge of the management of brain metastases has not finished yet. Although new diagnosis-specific prognostic assessment classifications and guidelines for patients with brain metastases help to guide treatment more appropriately, and even if the development of modern technologies in imaging and radiation treatment, as well as improved new systemic therapies, allow to reduce cognitive side effects and make retreatment or multiple and combined treatment possible, several questions remain unanswered. However, tailoring the treatment to the patient and his expectations is still essential; in other words, patients with a poor prognosis should not be over-treated, and those with a favorable prognosis may not be subtracted to the best treatment option. Some ongoing trials with appropriate endpoints could better inform our choices. Finally, a case-by-case inter-disciplinary discussion remains essential.
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Affiliation(s)
- F Dhermain
- Département de radiothérapie-oncologique, hôpital universitaire Gustave-Roussy, université Paris Saclay, 114, rue Édouard-Vaillant, 94805 Villejuif, France.
| | - G Noël
- Département de radiothérapie-oncologique, centre Paul-Strauss, 3, rue de la-Porte-de-l'Hôpital, 67065 Strasbourg, France; Université de Strasbourg, CNRS, IHPC UMR 7178, centre Paul-Strauss, 67000 Strasbourg, France
| | - D Antoni
- Département de radiothérapie-oncologique, centre Paul-Strauss, 3, rue de la-Porte-de-l'Hôpital, 67065 Strasbourg, France; Université de Strasbourg, CNRS, IHPC UMR 7178, centre Paul-Strauss, 67000 Strasbourg, France
| | - A Tallet
- Département de radiothérapie-oncologique, institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13273 Marseille 09, France; CRCM, institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13273 Marseille 09, France
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28
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White RJ, Abel S, Horne ZD, Lee J, Edington H, Greenberg L, Younes H, Hilton C, Wegner RE. Melanoma brain metastases: is it time to eliminate radiotherapy? J Neurooncol 2020; 149:27-33. [PMID: 32556863 DOI: 10.1007/s11060-020-03485-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/03/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Immunotherapy has demonstrated efficacy in treatment of intracranial metastasis from melanoma, calling into question the role of intracranial radiotherapy (RT). Herein, we assessed the utilization patterns of intracranial RT in patients with melanoma brain metastasis and compared outcomes in patients treated with immunotherapy alone versus immunotherapy in addition to intracranial RT. METHODS We queried the National Cancer Database (NCDB) for patients with melanoma brain metastases treated with immunotherapy and intracranial RT or immunotherapy alone. Multivariable logistic regression identified variables associated with increased likelihood of receiving immunotherapy alone. Multivariable Cox regression was used to identify co-variates predictive of overall survival (OS). Propensity matching was used to account for indication bias. RESULTS We identified 528 and 142 patients that were treated with combination therapy and immunotherapy alone, respectively. Patients with lower comorbidity score were more likely to receive immunotherapy alone. Extracranial disease and treatment at a non-academic center were associated with worse OS. Median OS for all patients was 11.0 months. Treatment with stereotactic radiosurgery (SRS) in addition to immunotherapy was superior to immunotherapy alone, median OS of 19.0 versus 11.5 months (p = 0.006). Whole brain radiation therapy (WBRT) in combination with immunotherapy performed worse than immunotherapy alone, median OS of 7.7 versus 11.5 months (p = 0.0255). CONCLUSIONS For melanoma patients requiring WBRT, immunotherapy alone may be reasonable in asymptomatic patients. For those eligible for SRS, combination therapy may provide better outcomes. Results of ongoing prospective studies will help provide guidance regarding the use of radioimmunotherapy in this population.
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Abstract
Primary central nervous system (CNS) lymphoma (PCNSL) is a rare subtype of aggressive non-Hodgkin lymphoma originating within the CNS. Whole brain irradiation (WBRT) has been utilized in combination with high-dose methotrexate (HD-MTX), unfortunately with a high rate of late neurocognitive decline, particularly in the elderly. HD-MTX-based combination chemotherapy regimens have been developed as induction therapy for PCNSL and shown to improve response rates. Consolidation treatment, such as reduced-dose WBRT or high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (HDT-ASCT) is vital to controlling the disease. Two phase II trials randomizing PCNSL patients to WBRT or HDT-ASCT were recently published, showing comparable survival but better neurocognitive function in patients receiving HDT-ASCT. A key agent in HDT-ASCT for PCNSL is thiotepa, which, however, has been unavailable in Japan since 2011. Therefore, a clinical trial of HDT-ASCT with thiotepa was performed, and we are currently awaiting drug approval. Several targeted drugs are being trialed in patients with relapsed or refractory PCNSL. The treatment strategy of PCNSL is still developing to improve survival and reduce toxicity.
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Affiliation(s)
- Eisei Kondo
- Department of Hematology, Kawasaki Medical School
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30
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Yabluchanskiy A, Tarantini S, Balasubramanian P, Kiss T, Csipo T, Fülöp GA, Lipecz A, Ahire C, DelFavero J, Nyul-Toth A, Sonntag WE, Schwartzman ML, Campisi J, Csiszar A, Ungvari Z. Pharmacological or genetic depletion of senescent astrocytes prevents whole brain irradiation-induced impairment of neurovascular coupling responses protecting cognitive function in mice. GeroScience 2020; 42:409-428. [PMID: 31960269 PMCID: PMC7205933 DOI: 10.1007/s11357-020-00154-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [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] [Received: 11/02/2019] [Accepted: 01/08/2020] [Indexed: 12/11/2022] Open
Abstract
Whole brain irradiation (WBI, also known as whole brain radiation therapy or WBRT) is a mainstream therapy for patients with identifiable brain metastases and as a prophylaxis for microscopic malignancies. WBI accelerates brain aging, causing progressive cognitive dysfunction in ~ 50% of surviving patients, thus compromising quality of life. The mechanisms responsible for this WBI side effect remain obscure, and there are no effective treatments or prevention strategies. Here, we test the hypothesis that WBI induces astrocyte senescence, which contributes to impaired astrocytic neurovascular coupling (NVC) responses and the genesis of cognitive decline. To achieve this goal, we used transgenic p16-3MR mice, which allows the detection and selective elimination of senescent cells. We subjected these mice to a clinically relevant protocol of fractionated WBI (5 Gy twice weekly for 4 weeks). WBI-treated and control mice were tested for spatial memory performance (radial arm water maze), astrocyte-dependent NVC responses (whisker-stimulation-induced increases in cerebral blood flow, assessed by laser speckle contrast imaging), NVC-related gene expression, astrocytic release of eicosanoid gliotransmitters and the presence of senescent astrocytes (by flow cytometry, immunohistochemistry and gene expression profiling) at 6 months post-irradiation. WBI induced senescence in astrocytes, which associated with NVC dysfunction and impaired performance on cognitive tasks. To establish a causal relationship between WBI-induced senescence and NVC dysfunction, senescent cells were depleted from WBI-treated animals (at 3 months post-WBI) by genetic (ganciclovir treatment) or pharmacological (treatment with the BCL-2/BCL-xL inhibitor ABT263/Navitoclax, a known senolytic drug) means. In WBI-treated mice, both treatments effectively eliminated senescent astrocytes, rescued NVC responses, and improved cognitive performance. Our findings suggest that the use of senolytic drugs can be a promising strategy for preventing the cognitive impairment associated with WBI.
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Affiliation(s)
- Andriy Yabluchanskiy
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, 975 N. E. 10th Street - BRC 1303, Oklahoma City, OK, 731042, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Stefano Tarantini
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, 975 N. E. 10th Street - BRC 1303, Oklahoma City, OK, 731042, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Priya Balasubramanian
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, 975 N. E. 10th Street - BRC 1303, Oklahoma City, OK, 731042, USA
| | - Tamas Kiss
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, 975 N. E. 10th Street - BRC 1303, Oklahoma City, OK, 731042, USA
- International Training Program in Geroscience, Theoretical Medicine Doctoral School/Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Tamas Csipo
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, 975 N. E. 10th Street - BRC 1303, Oklahoma City, OK, 731042, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- International Training Program in Geroscience, Division of Clinical Physiology, Department of Cardiology/ Kalman Laki Doctoral School, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Gábor A Fülöp
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, 975 N. E. 10th Street - BRC 1303, Oklahoma City, OK, 731042, USA
- International Training Program in Geroscience, Division of Clinical Physiology, Department of Cardiology/ Kalman Laki Doctoral School, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Agnes Lipecz
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, 975 N. E. 10th Street - BRC 1303, Oklahoma City, OK, 731042, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Chetan Ahire
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, 975 N. E. 10th Street - BRC 1303, Oklahoma City, OK, 731042, USA
| | - Jordan DelFavero
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, 975 N. E. 10th Street - BRC 1303, Oklahoma City, OK, 731042, USA
| | - Adam Nyul-Toth
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, 975 N. E. 10th Street - BRC 1303, Oklahoma City, OK, 731042, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- Institute of Biophysics, Biological Research Centre, Szeged, Hungary
| | - William E Sonntag
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, 975 N. E. 10th Street - BRC 1303, Oklahoma City, OK, 731042, USA
| | - Michal L Schwartzman
- Department of Pharmacology, New York Medical College School of Medicine, Valhalla, NY, USA
| | | | - Anna Csiszar
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, 975 N. E. 10th Street - BRC 1303, Oklahoma City, OK, 731042, USA
- Buck Institute for Research on Aging, Novato, CA, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Institute of Clinical Experimental Research, Semmelweis University, Budapest, Hungary
| | - Zoltan Ungvari
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Oklahoma Center for Geroscience, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, 975 N. E. 10th Street - BRC 1303, Oklahoma City, OK, 731042, USA.
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary.
- International Training Program in Geroscience, Theoretical Medicine Doctoral School/Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary.
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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Ni M, Jiang A, Liu W, Sheng Y, Zeng H, Liu N, Gao Q, Wang Y, Yu J, Yuan S. Whole brain radiation therapy plus focal boost may be a suitable strategy for brain metastases in SCLC patients: a multi-center study. Radiat Oncol 2020; 15:70. [PMID: 32213185 DOI: 10.1186/s13014-020-01509-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 03/02/2020] [Indexed: 12/03/2022] Open
Abstract
Background The treatment for brain metastases in small cell lung cancer (SCLC) is still controversial. The purpose of this study was to compare different brain radiotherapy treatments on SCLC patients with brain metastases. Methods In this multi-center retrospective study, SCLC patients who had undergone whole brain radiation therapy (WBRT) or stereotactic radiosurgery (SRS) for brain metastases from January 2012 to December 2018 were retrospectively screened. Results A total of 263 eligible SCLC patients were included in this study, among whom, 73 were women and 190 were men. According to accepted brain radiotherapy, the remaining patients were divided into WBRT plus focal radiation boost (WBRT+boost), WBRT, and SRS groups. In pairwise comparisons of the overall survival (OS), WBRT+boost group led to longer survival than did WBRT both in all patients (17.9 vs 8.7 months; P < 0.001) and 140 matched patients (17.9 vs 11.7 months; P = 0.045). There were no significant differences in OS between WBRT+boost and SRS groups in all patients (17.9 vs 14.5 months; P = 0.432). Among 74 matched patients between WBRT+boost and SRS groups, however, patients who received WBRT+boost led to a longer survival than did SRS alone (21.8 vs 12.9 months; P = 0.040). In pairwise comparison of the intracranial progression-free survival time (iPFS), WBRT+boost group also showed survival advantages over WBRT (10.8 vs 6.5 months; P = 0.005) and SRS groups (10.8 vs 7.5 months; P = 0.032). Conclusion Due to the SCLC-derived multiple brain metastases and better survival time, focal radiation boost combined with adjuvant WBRT may be a preferred strategy for SCLC patients with brain metastases.
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Yan W, Liu Y, Li J, Han A, Kong L, Yu J, Zhu H. Whole brain radiation therapy does not improve the overall survival of EGFR-mutant NSCLC patients with leptomeningeal metastasis. Radiat Oncol 2019; 14:168. [PMID: 31521171 DOI: 10.1186/s13014-019-1376-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 09/09/2019] [Indexed: 12/25/2022] Open
Abstract
Background Leptomeningeal metastasis (LM) is a devastating and terminal complication of advanced non-small-cell lung cancer (NSCLC), especially in patients harboring epidermal growth factor receptor (EGFR) mutations. The role of whole brain radiation therapy (WBRT) in the treatment of EGFR-mutant NSCLC patients with LM is not conclusive. Therefore, we conducted a retrospective study to evaluate the therapeutic effect of WBRT in this setting. Methods EGFR-mutant NSCLC patients with LM, who had previously received treatment at the Shandong Cancer Hospital and Institute from July 2014 to March 2018 were reviewed retrospectively. LM was diagnosed by positive CSF cytology and/or leptomeningeal-enhanced magnetic resonance imaging (MRI). Survival was estimated using the Kaplan-Meier method. Results In total, 51 EGFR-mutated NSCLC patients with LM were eligible for analysis, subdivided into 26 in the WBRT group and 25 in the non-WBRT group. No significant differences were observed in intracranial ORR (15.4% vs. 16%, p = 0.952) and DCR (34.7% vs. 28%, p = 0.611) between the two groups. The median iPFSLM and OSLM for the entire cohort were 3.3 months (95% CI: 2.77–3.83) and 12.6 months (95% CI: 9.66–15.54), respectively. No difference in iPFSLM was observed between the WBRT and non-WBRT groups (median 3.9 vs. 2.8 months; HR = 0.506, p = 0.052). The median OSLM was 13.6 months in the WBRT group, compared with 5.7 months in the non-WBRT group (HR = 0.454, p = 0.022). Multivariate analyses of OSLM showed that KPS ≥ 80 at the time of LM diagnosis (HR = 0.428, 95% CI: 0.19–0.94; p = 0.034) and the administration of EGFR-TKIs (HR = 0.258, 95% CI: 0.11–0.58; p = 0.001) were independent predictors of survival, but WBRT (HR = 0.49, 95% CI: 0.24–1.01; p = 0.54) was not. Toxicities associated with WBRT or other treatment were rare. Conclusion For EGFR-mutated NSCLC patients with LM, WBRT did not improve intracranial treatment response and survival statistically.
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Yan W, Jing W, An N, Tian Y, Guo D, Kong L, Zhu H, Yu J. The clinical characteristic and prognostic factors of leptomeningeal metastasis in patients with non-small-cell lung cancer-a retrospective study from one single cancer institute. Cancer Med 2019; 8:2769-2776. [PMID: 30993909 PMCID: PMC6558588 DOI: 10.1002/cam4.2156] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 02/11/2019] [Revised: 03/27/2019] [Accepted: 03/27/2019] [Indexed: 12/19/2022] Open
Abstract
Background Leptomeningeal metastasis (LM) is a detrimental complication of advanced non‐small‐cell lung cancer (NSCLC), and the optimal therapeutic approach for LM patients is in shortage. This retrospective study aimed to investigate the clinical features and prognostic factors of NSCLC patients with LM. Methods We retrospectively reviewed the medical records of NSCLC patients with LM at the Shandong Cancer Hospital and Institute between July 2014 and March 2018. Identified cases had pathology‐proven NSCLC with either positive cerebrospinal fluid cytology or leptomeningeal enhancement by MRI. Results One hundred and thirty‐six NSCLC patients (58 men, 78 women) with LM were enrolled in the retrospective study; median age was 55 years (range, 29‐89 years). Fifty‐one patients harbored EGFR mutations, ALK rearrangement was detected in 6 patients. Treatment for LM consisted of EGFR‐TKIs alone in 11 patients, whole brain radiotherapy (WBRT) alone in 19 patients, Chemotherapy (ChT) alone in 12 patients, EGFR‐TKIs plus WBRT in 30 patients, WBRT plus ChT in 25 patients, and EGFR‐TKIs plus ChT in 24 patients. The median progression‐free survival was 3.9 months (95% confidence interval [CI]: 3.178‐4.622), and the median overall survival (OSLM) was 9.8 months (95% CI:7.5‐12.1). Thirty patients who received WBRT plus EGFR‐TKIs achieved longer survival than those who only received WBRT (median 13.6 vs 8.8 months; P = 0.027), but did not add any survival benefit than those only received EGFR‐TKIs (median 13.6 vs 13.9 months; P = 0.352). A multivariate analysis indicated that KPS ≥ 80 (hazard ratio [HR] = 0.592, 95% CI:0.369‐0.95; P = 0.03) and EGFR‐TKIs (HR = 0.507, 95% CI:0.283‐0.908; P = 0.022) after LM diagnosis were independent favourable predictors of survival, whereas smoking (HR = 1.181, 95% CI:1.009‐3.246; P = 0.047) was an independent predictor of poor survival. Conclusions Our results suggest that patients with good performance statuses, non‐smoking patients, and the administration of EGFR‐TKIs might improve clinical outcomes in NSCLC patients with LM.
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Affiliation(s)
- Weiwei Yan
- School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong, China.,Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
| | - Wang Jing
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
| | - Ning An
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
| | - Yaru Tian
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
| | - Dong Guo
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
| | - Li Kong
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
| | - Hui Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
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Chidambaram S, Pannullo SC, Schwartz TH, Wernicke AG. Reirradiation of Recurrent Brain Metastases: Where Do We Stand? World Neurosurg 2019; 125:156-163. [PMID: 30738931 DOI: 10.1016/j.wneu.2019.01.182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 11/09/2018] [Revised: 01/17/2019] [Accepted: 01/19/2019] [Indexed: 10/27/2022]
Abstract
Brain metastases occur in a large portion of patients with cancer. Although advances in radiotherapy have helped to improve survival, they have also raised questions regarding the best modality for retreatment in the context of recurrent disease. The spectrum of treatment options for recurrent intracranial metastatic disease after previous radiotherapy includes salvage stereotactic radiosurgery, whole brain radiotherapy, and brachytherapy. We have comprehensively reviewed the existing data on the efficacy and toxicity of the various reirradiation treatment modalities. We examined the key clinical considerations that guide patient selection, such as dose, tumor size, interval to retreatment, and local control and survival rates.
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Affiliation(s)
- Swathi Chidambaram
- Department of Neurosurgery, Weill Medical College of Cornell University, New York, New York, USA
| | - Susan C Pannullo
- Department of Neurosurgery, Weill Medical College of Cornell University, New York, New York, USA
| | - Theodore H Schwartz
- Department of Neurosurgery, Weill Medical College of Cornell University, New York, New York, USA
| | - A Gabriella Wernicke
- Department of Neurosurgery, Weill Medical College of Cornell University, New York, New York, USA; Department of Radiation Oncology, Weill Medical College of Cornell University, New York, New York, USA.
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Suzuki R, Wei X, Allen PK, Welsh JW, Cox JD, Komaki R, Lin SH. Outcomes of re-irradiation for brain recurrence after prophylactic or therapeutic whole-brain irradiation for small cell lung Cancer: a retrospective analysis. Radiat Oncol 2018; 13:258. [PMID: 30594213 PMCID: PMC6310962 DOI: 10.1186/s13014-018-1205-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 04/10/2018] [Accepted: 12/18/2018] [Indexed: 12/31/2022] Open
Abstract
Background Small cell lung cancer (SCLC) can recur in the brain after whole-brain irradiation (WBI). We documented outcomes after treatment of such recurrences and sought predictors of local control and overall survival (OS). Materials and methods Eighty-five patients with SCLC and brain recurrence after prophylactic or therapeutic WBI in 1998–2015 were identified and data were extracted from the medical records. Survival was estimated with the Kaplan-Meier method, and univariate and multivariate Cox proportional hazards modeling was used to identify factors associated with OS or further brain progression. Results Brain recurrence was treated by stereotactic radiosurgery (SRS) in 33 patients (39%), repeat WBI in 14 (16%), chemotherapy-only in 16 (19%), and observation in 22 (26%). Median OS time after brain recurrence (OSrec) was 4.3 months for all patients; 6-month OSrec rates were 58% after SRS, 21% after repeat WBI, 50% after chemotherapy-only, and 5% after observation (P < 0.001). Inferior OSrec was associated with poor performance status (ECOG score ≥ 3) and uncontrolled extracranial disease. Superior OSrec was associated with receipt of ≥4 chemotherapy cycles before brain recurrence and receipt of chemotherapy, SRS, or repeat WBI afterward. Receipt of chemotherapy after brain recurrence correlated with brain progression. Conclusions Some patients with brain recurrence after WBI for SCLC can survive for extended periods with appropriate intervention, especially those with adequate performance status or controlled extracranial disease.
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Affiliation(s)
- Ryoko Suzuki
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - Xiong Wei
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - Pamela K Allen
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - James W Welsh
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - James D Cox
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - Ritsuko Komaki
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - Steven H Lin
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA. .,Present address: Department of Radiation Oncology, Tokyo Medical and Dental University, 1 Chome-5-45 Yushima, Bunkyō, Tokyo, 113-8510, Japan.
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Abstract
The incidence of brain metastases is projected to rise because survival rates of lung cancer, breast cancer, and melanoma continue to improve (1). The brain is being identified as a sanctuary site for harboring metastases despite excellent control of extracranial disease. This is thought to occur because the drug therapies that control extracranial disease have limited central nervous system (CNS) penetration. The development of brain metastases is a devastating diagnosis affecting both quality of life (QOL) and survival. Symptoms after diagnosis can include headache, nausea, vomiting, seizure, neurocognitive decline, and focal neurologic deficit. Some of these symptoms can be irreversible even after successful treatment of intracranial disease. Treatment of brain metastases often necessitates surgery and radiation. There have been some reports of systemic therapies offering an intracranial response however long-term data is lacking. These treatments for CNS metastases can also lead to neurocognitive sequelae impacting quality of life. Therefore, preventing disease from spreading to the brain is a topic that has generated much interest in oncology. Prophylactic cranial Irradiation (PCI) has been used in leukemia, small cell lung cancer (SCLC), and non-small cell lung cancer (NSCLC). While showing effectiveness in preventing intracranial disease development, its carries with it side effects of neurocognitive decline that can affect QOL. There are Clinical trials exploring novel delivery of PCI and concurrent neuroprotective drug therapy to try to mitigate these neurocognitive sequelae. These will be important trials to complete, as PCI has shown promise in controlling disease and prolonging survival in select patient populations. There are also drug therapies that have shown efficacy in preventing CNS metastases development. This review will explore the current therapies available to prevent CNS metastases.
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Affiliation(s)
- Joseph A Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
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Wang Y, Liu S, Wei X, Yan B, Li J, Su Z, Liu A, Zhang Y. Non-small cell lung cancer leptomeningeal metastases treated with intrathecal therapy plus osimertinib and temozolomide and whole-brain radiation therapy: a case report. Onco Targets Ther 2018; 11:4733-4738. [PMID: 30127621 PMCID: PMC6091472 DOI: 10.2147/ott.s164968] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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] [Indexed: 01/16/2023] Open
Abstract
RATIONALE Leptomeningeal metastasis (LM) is an important cause of mortality in patients with non-small cell lung cancer (NSCLC). As the symptoms of LM and its early clinical manifestations are nonspecific, early diagnosis of LM is difficult. However, there are few treatment options for LM, which leads to a poor prognosis; thus, increased clinical attention is necessary. The effects of most systemic chemotherapies on metastatic brain tumors (brain metastases and LMs) are limited as they cannot pass the blood-brain barrier; therefore, whole-brain radiation therapy is a therapeutic option. Osimertinib is a potent and irreversible third-generation oral epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI). It binds to EGFR with high affinity when the EGFR T790M mutation is present together with sensitizing mutations. The clinical efficacy of osimertinib in NSCLC patients carrying the T790M mutation has been demonstrated in clinical trial NCT02468661. Intrathecal injection of chemotherapeutic drugs can be directed to a specific lesion. Temozolomide is one such drug, and its effect has been confirmed. PATIENT AND INTERVENTIONS We treated a 38-year-old patient with NSCLC who carried the EGFR L858R mutation. We administered a combination of oral osimertinib and oral temozolomide plus an intrathecal injection of cytarabine and whole-brain radiation therapy for symptomatic multiple brain metastases. OUTCOMES The patient showed a marked response to this combination therapy. To date (after ~18 months), no recurrence or new lesions have been observed and he is asymptomatic. His disease-free survival surpasses that achieved with any monotherapy for LM. LESSONS This is the first report to demonstrate the response to combination therapy in an NSCLC patient with LM. These findings indicate the potential utility of chemotherapy combined with radiotherapy combined with targeted therapy combined with local treatment, as each treatment acts via a different mechanism, enhancing their therapeutic effects.
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Affiliation(s)
- Yunmei Wang
- Department of Medical Oncology, Shaanxi Provincial Cancer Hospital Affiliated to Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, People's Republic of China,
| | - Shuguang Liu
- Department of orthopedics, Hong Hui Hospital, the Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi 710004, People's Republic of China
| | - Xiaohui Wei
- Department of Medical Oncology, Shaanxi Provincial Cancer Hospital Affiliated to Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, People's Republic of China,
| | - Bin Yan
- Department of Radiology, Shaanxi Provincial Cancer Hospital Affiliated to Medical School, Xi'an Jiao tong University, Xi'an, Shaanxi 710061, People's Republic of China
| | - Jun Li
- Department of Radiology, Shaanxi Provincial Cancer Hospital Affiliated to Medical School, Xi'an Jiao tong University, Xi'an, Shaanxi 710061, People's Republic of China
| | - Zhixiang Su
- Department of Medical Oncology, Shaanxi Provincial Cancer Hospital Affiliated to Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, People's Republic of China,
| | - Aiqin Liu
- Department of Medical Oncology, Shaanxi Provincial Cancer Hospital Affiliated to Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, People's Republic of China,
| | - Yanjun Zhang
- Department of Medical Oncology, Shaanxi Provincial Cancer Hospital Affiliated to Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, People's Republic of China,
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Churilla TM, Handorf E, Collette S, Collette L, Dong Y, Aizer AA, Kocher M, Soffietti R, Alexander BM, Weiss SE. Whole brain radiotherapy after stereotactic radiosurgery or surgical resection among patients with one to three brain metastases and favorable prognoses: a secondary analysis of EORTC 22952-26001. Ann Oncol 2018; 28:2588-2594. [PMID: 28961826 DOI: 10.1093/annonc/mdx332] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background The absence of a survival benefit for whole brain radiotherapy (WBRT) among randomized trials has been attributed to a competing risk of death from extracranial disease. We re-analyzed EORTC 22952 to assess the impact of WBRT on survival for patients with controlled extracranial disease or favorable prognoses. Patients and methods We utilized Cox regression, landmark analysis, and the Kaplan-Meier method to evaluate the impact of WBRT on survival accounting for (i) extracranial progression as a time-dependent covariate in all patients and (ii) diagnosis-specific graded prognostic assessment (GPA) score in patients with primary non-small-cell lung cancer (NSCLC). Results A total of 329 patients treated per-protocol were included for analysis with a median follow up of 26 months. One hundred and fifteen (35%) patients had no extracranial progression; 70 (21%) patients had progression <90 days, 65 (20%) between 90 and 180 days, and 79 (24%) patients >180 days from randomization. There was no difference in the model-based risk of death in the WBRT group before [hazard ratio (HR) (95% CI)=0.70 (0.45-1.11), P = 0.133), or after [HR (95% CI)=1.20 (0.89-1.61), P = 0.214] extracranial progression. Among 177 patients with NSCLC, 175 had data available for GPA calculation. There was no significant survival benefit to WBRT among NSCLC patients with favorable GPA scores [HR (95% CI)=1.10 (0.68-1.79)] or unfavorable GPA scores [HR (95% CI)=1.11 (0.71-1.76)]. Conclusions Among patients with limited extracranial disease and one to three brain metastases at enrollment, we found no significant survival benefit to WBRT among NSCLC patients with favorable GPA scores or patients with any histology and controlled extracranial disease status. This exploratory analysis of phase III data supports the practice of omitting WBRT for patients with limited brain metastases undergoing SRS and close surveillance. Clinical Trials Number NCT00002899.
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Affiliation(s)
- T M Churilla
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA
| | - E Handorf
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA
| | | | | | - Y Dong
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA
| | - A A Aizer
- Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, USA
| | - M Kocher
- Department of Radiation Oncology, University of Cologne, Cologne, Germany
| | - R Soffietti
- Department of Neuro-oncology, University of Turin and City of Health and Science Hospital, Torino, Italy
| | - B M Alexander
- Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, USA
| | - S E Weiss
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA;.
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Abstract
PURPOSE OF REVIEW To summarize current approaches in the management of brain metastases from non-small cell lung cancer (NSCLC). RECENT FINDINGS Local treatment has evolved from whole-brain radiotherapy (WBRT) to increasing use of stereotactic radiosurgery (SRS) alone for patients with limited (1-4) brain metastases. Trials have established post-operative SRS as an alternative to adjuvant WBRT following resection of brain metastases. Second-generation TKIs for ALK rearranged NSCLC have demonstrated improved CNS penetration and activity. Current brain metastasis trials are focused on reducing cognitive toxicity: hippocampal sparing WBRT, SRS for 5-15 metastases, pre-operative SRS, and use of systemic targeted agents or immunotherapy. The role for radiotherapy in the management of brain metastases is becoming better defined with local treatment shifting from WBRT to SRS alone for limited brain metastases and post-operative SRS for resected metastases. Further trials are warranted to define the optimal integration of newer systemic agents with local therapies.
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Affiliation(s)
- Thomas M Churilla
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, 19111, USA
| | - Stephanie E Weiss
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, 19111, USA.
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Thieme AH, Stromberger C, Ghadjar P, Piper SK, Budach V. A novel voxel based homogeneity index: Rationale and clinical implications for whole-brain radiation therapy. Radiother Oncol 2018; 128:229-35. [PMID: 29699833 DOI: 10.1016/j.radonc.2018.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 03/30/2018] [Accepted: 04/06/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE OR OBJECTIVE A homogeneity index (HI) measures the uniformity of a dose distribution within a given target volume. Traditional HIs only use a limited number of dose-volume histogram data-points for calculation. A voxel-based homogeneity index (VHI) is proposed which utilizes the entire information of the three-dimensional dose distribution. We compared the VHI with existing HIs and analyzed if VHI results were associated with treatment outcomes in patients who underwent therapeutic WBRT. MATERIAL AND METHODS The VHI analyzes deviations from the prescribed dose in each voxel of the target volume. We retrospectively analyzed WBRT treatment plans. Overall survival (OS), CNS progression-free-survival (CNS PFS) and hazard rates were compared for tertile-split levels of the VHI using the Kaplan-Meier methods and multivariable Cox-regression analysis. RESULTS WBRT treatment plans (n = 770) were used for HIs comparison. OS and CNS PFS were assessed for 430 patients. The VHI showed a higher sensitivity for dose inhomogeneities. Lower OS and CNS PFS were observed for higher levels of VHIUnderdosage, particularly in patients with good performance status (KPS >70%) (OS: Log-rank P = .007, HR = 1.37 95%CI [1.09, 1.72]). CONCLUSION Higher sensitivity and feasibility to assess treatment plan quality using the VHI were demonstrated. First clinical implications were found in terms of compromised OS/CNS PFS for WBRT with radiation underdosage.
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Bernhardt D, König L, Aufderstrasse S, Krisam J, Hoerner-Rieber J, Adeberg S, Bozorgmehr F, El Shafie R, Lang K, Kappes J, Thomas M, Herth F, Heußel CP, Warth A, Marcrom S, Debus J, Steins M, Rieken S. Generation of a New Disease-specific Prognostic Score for Patients With Brain Metastases From Small-cell Lung Cancer Treated With Whole Brain Radiotherapy (BMS-Score) and Validation of Two Other Indices. Clin Lung Cancer 2017; 19:340-345. [PMID: 29373273 DOI: 10.1016/j.cllc.2017.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 10/02/2017] [Revised: 11/22/2017] [Accepted: 12/08/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Patients with small-cell lung cancer (SCLC) demonstrate an exception in the treatment of brain metastases (BM), because in patients with SCLC whole brain radiotherapy (WBRT) only is the preferred treatment modality. The purpose of this study was to develop a prognostic score for patients with brain metastases from SCLC treated with WBRT. PATIENTS AND METHODS The present study was conducted utilizing a single-institution, previously described, retrospective database of patients with SCLC who were treated with WBRT (n = 221). Univariate and multivariate analyses were performed to generate the "brain metastases from SCLC score" (BMS score) based on favorable prognostic factors: Karnofsky performance status (KPS > 70), extracerebral disease status (stable disease/controlled), and time of appearance of BM (synchronous). Furthermore, the disease-specific graded prognostic assessment score as well as the recursive partitioning analysis (RPA) were performed and compared with the new BMS score by using the log-rank (Mantel-Cox) test. RESULTS BMS score and RPA showed the most significant differences between classes (P < .001). BMS score revealed a mean overall survival (OS) of 2.62 months in group I (0-1 points), 6.61 months in group II (2-3 points), and 12.31 months in group III (4 points). The BMS score also identified the group with the shortest survival (2.62 months in group I), and the numbers of patients in each group were most equally distributed with the BMS score. CONCLUSION The new BMS score was more prognostic than the RPA and disease-specific graded prognostic assessment scores. The BMS score is easy to use and reflects known prognostic factors in contemporary patients with SCLC treated with WBRT. Future studies are necessary to validate these findings.
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Affiliation(s)
- Denise Bernhardt
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany.
| | - Laila König
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Sophie Aufderstrasse
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Johannes Krisam
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Juliane Hoerner-Rieber
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Sebastian Adeberg
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Farastuk Bozorgmehr
- Department of Thoracic Oncology, Thoraxklinik, Heidelberg University, Translational Lung Research Centre Heidelberg (TLRC-H), Heidelberg, Germany; Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Rami El Shafie
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Kristin Lang
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Jutta Kappes
- Department of Pneumology, Thoraxklinik, Heidelberg University, Heidelberg, Germany; Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Michael Thomas
- Department of Thoracic Oncology, Thoraxklinik, Heidelberg University, Translational Lung Research Centre Heidelberg (TLRC-H), Heidelberg, Germany; Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Felix Herth
- Department of Pneumology, Thoraxklinik, Heidelberg University, Heidelberg, Germany; Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Claus Peter Heußel
- Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, Germany; Diagnostic and Interventional Radiology at University of Heidelberg, Heidelberg, Germany
| | - Arne Warth
- Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Institute of Pathology, Heidelberg University, Heidelberg, Germany
| | - Samuel Marcrom
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Jürgen Debus
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Martin Steins
- Department of Thoracic Oncology, Thoraxklinik, Heidelberg University, Translational Lung Research Centre Heidelberg (TLRC-H), Heidelberg, Germany
| | - Stefan Rieken
- University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
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Bernhardt D, Adeberg S, Bozorgmehr F, Opfermann N, Hörner-Rieber J, König L, Kappes J, Thomas M, Unterberg A, Herth F, Heußel CP, Warth A, Debus J, Steins M, Rieken S. Outcome and prognostic factors in single brain metastases from small-cell lung cancer. Strahlenther Onkol 2017; 194:98-106. [PMID: 29085978 DOI: 10.1007/s00066-017-1228-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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: 05/22/2017] [Accepted: 10/12/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE Whole brain radiation therapy (WBRT) is historically the standard of care for patients with brain metastases (BM) from small-cell lung cancer (SCLC), although locally ablative treatments are the standard of care for patients with 1-4 BM from other solid tumors. The objective of this analysis was to find prognostic factors influencing overall survival (OS) and intracranial progression-free survival (iPFS) in SCLC patients with single BM (SBM) treated with WBRT. METHODS A total of 52 patients were identified in the authors' cancer center database with histologically confirmed SCLC and contrast-enhanced magnet resonance imaging (MRI) or computed tomography (CT), which confirmed SBM between 2006 and 2015 and were therefore treated with WBRT. A Kaplan-Meier survival analysis was performed for OS analyses. The log-rank (Mantel-Cox) test was used to compare survival curves. Univariate Cox proportional-hazards ratios (HRs) were used to assess the influence of cofactors on OS and iPFS. RESULTS The median OS after WBRT was 5 months and the median iPFS after WBRT 16 months. Patients that received surgery prior to WBRT had a significantly longer median OS of 19 months compared to 5 months in the group receiving only WBRT (p = 0.03; HR 2.24; 95% confidence interval [CI] 1.06-4.73). Patients with synchronous disease had a significantly longer OS compared to patients with metachronous BM (6 months vs. 3 months, p = 0.005; HR 0.27; 95% CI 0.11-0.68). Univariate analysis for OS revealed a statistically significant effect for metachronous disease (HR 2.25; 95% CI 1.14-4.46; p = 0.019), initial response to first-line chemotherapy (HR 0.58; 95% CI 0.35-0.97; p = 0.04), and surgical resection (HR 0.36; 95% CI 0.15-0.88; p = 0.026). OS was significantly affected by metachronous disease in multivariate analysis (HR 2.20; 95% CI 1.09-4.45; p = 0.028). CONCLUSIONS Univariate analysis revealed that surgery followed by WBRT can improve OS in patients with SBM in SCLC. Furthermore, synchronous disease and response to initial chemotherapy appeared to be major prognostic factors. Multivariate analysis revealed metachronous disease as a significantly negative prognostic factor on OS. The value of WBRT, stereotactic radiosurgery (SRS), or surgery alone or in combination for patients with a limited number of BM in SCLC should be evaluated in further prospective clinical trials.
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Affiliation(s)
- Denise Bernhardt
- Department of Radiation Oncology, INF 400, University Hospital Heidelberg, 69120, Heidelberg, Germany. .,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany. .,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany.
| | - Sebastian Adeberg
- Department of Radiation Oncology, INF 400, University Hospital Heidelberg, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany
| | - Farastuk Bozorgmehr
- Department of Thoracic Oncology, Thoraxklinik, Translational Lung Research Centre Heidelberg (TLRC-H), Heidelberg University, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Nils Opfermann
- Department of Radiation Oncology, INF 400, University Hospital Heidelberg, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, INF 400, University Hospital Heidelberg, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, INF 400, University Hospital Heidelberg, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany
| | - Jutta Kappes
- Department of Pneumology, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Michael Thomas
- Department of Thoracic Oncology, Thoraxklinik, Translational Lung Research Centre Heidelberg (TLRC-H), Heidelberg University, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, INF 400, University Hospital Heidelberg, 69120, Heidelberg, Germany
| | - Felix Herth
- Department of Pneumology, Thoraxklinik, Heidelberg University, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Claus Peter Heußel
- Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany.,Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.,Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany
| | - Arne Warth
- Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany.,Institute of Pathology, Heidelberg University, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, INF 400, University Hospital Heidelberg, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany
| | - Martin Steins
- Department of Thoracic Oncology, Thoraxklinik, Translational Lung Research Centre Heidelberg (TLRC-H), Heidelberg University, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, INF 400, University Hospital Heidelberg, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
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He Q, Bi X, Ren C, Wang Y, Zou P, Zhang H, Chi N, Xiu C, Wang Y, Tao R. Phase II Study of the Efficacy and Safety of High-dose Pemetrexed in Combination with Cisplatin Versus Temozolomide for the Treatment of Non-small Cell Lung Cancer with Brain Metastases. Anticancer Res 2017; 37:4711-4716. [PMID: 28739776 DOI: 10.21873/anticanres.11877] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 05/19/2017] [Revised: 07/07/2017] [Accepted: 07/07/2017] [Indexed: 11/10/2022]
Abstract
The aim of this study was to explore the efficacy and safety of high-dose pemetrexed with cisplatin versus combination with temozolomide in patients with brain metastases (BM) of lung adenocarcinoma. After standard whole-brain radiotherapy (WBRT, 30 Gy/10 fractions), patients with BM of non-small cell lung cancer (NSCLC) were given high-dose pemetrexed (900 mg/m2) on day 1 of each cycle (3 weeks), and cisplatin was administered on days 1-3 in the cisplatin-treated group. The temozolomide-treated group was treated as follows: 75 mg/m2 temozolomide orally with concurrent WBRT followed by 150 mg/m2 temozolomide on days 1-5 with high-dose pemetrexed (900 mg/m2) on day 1 of each cycle (3 weeks). Six cycles later, high-dose pemetrexed (900 mg/m2) monotherapy or the best available supportive therapy was administered to both groups. An evaluation was carried out every 2-3 cycles. The primary end-points were objective response rate (ORR), progression-free survival (PFS), and overall survival (OS). Secondary end-points included safety and tolerability. Thirty-two patients in the pemetrexed plus cisplatin (PC) group and 28 patients in the pemetrexed plus temozolomide (PT) group were enrolled from November 2013 to October 2015. The ORR was 68.8% and 75%, in the PC and PT groups, respectively, and there was no statistically significant difference between the two groups (p=0.711). The median PFS rates of the PC and PT groups were 13.6 months and 16.9 months, respectively, and the median OS rates of the PC and PT groups were 18.9 months and 19.3 months, respectively. There were no differences in PFS and OS between the two groups. There were no grade 4 or higher side-effects in either group, but grade 3 side-effects such as leucopenia (2/32, 6.3%), nausea/vomiting (2/32, 6.3%), alopecia (1/32, 3.1%), rash (3/32, 9.4%) and renal insufficiency (1/32, 3.1%) were observed in the PC group, whereas the PT-group-only showed the following grade 3 side-effects: leucopenia (1/28, 3.6%) and nausea/vomiting (2/28, 7.1%). The data showed that the PT group achieved the same efficacy in PFS and OS as the PC group but with fewer toxicities. Therefore, high-dose pemetrexed plus temozolomide may be a better regimen for treating NSCLC with BM due to its better safety.
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Affiliation(s)
- Qiaowei He
- Department of Neurosurgery, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, P.R. China
| | - Xizhuang Bi
- Department of Neurology, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, P.R. China
| | - Chao Ren
- Department of Neurology, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, P.R. China
| | - Yong Wang
- Department of Neurosurgery, Shandong Cancer Hospital, Jinan, P.R. China
| | - Peng Zou
- Department of Neurosurgery, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, P.R. China
| | - Hongtao Zhang
- Department of Neurosurgery, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, P.R. China
| | - Nan Chi
- Department of Neurosurgery, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, P.R. China
| | - Chunming Xiu
- Department of Neurosurgery, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, P.R. China
| | - Yunbo Wang
- Department of Neurosurgery, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, P.R. China
| | - Rongjie Tao
- Department of Neurosurgery, Shandong Cancer Hospital, Jinan, P.R. China
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Zheng H, Liu QX, Hou B, Zhou D, Li JM, Lu X, Wu QP, Dai JG. Clinical outcomes of WBRT plus EGFR-TKIs versus WBRT or TKIs alone for the treatment of cerebral metastatic NSCLC patients: a meta-analysis. Oncotarget 2017; 8:57356-57364. [PMID: 28915676 PMCID: PMC5593647 DOI: 10.18632/oncotarget.19054] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 04/19/2017] [Accepted: 06/24/2017] [Indexed: 02/05/2023] Open
Abstract
Whether WBRT plus EGFR-TKIs has a greater survival benefit than EGFR-TKIs alone or WBRT alone remains controversial in NSCLC patients with multiple brain metastases. To rectify this, we conducted a systematic meta-analysis based on 9 retrospective studies and 1 randomized controlled study published between 2012 and 2016, comprising 1041 patients. Five studies were included in the comparison of WBRT plus EGFR-TKIs and EGFR-TKIs alone. The combined HR for OS of patients with EGFR mutation was 1.25 [95% CI 0.98–2.15; P = 0.08] and for intracranial PFS was 1.30 [95% CI 1.03–1.65; P = 0.03], which revealed that EGFR-TKIs alone produced a superior intracranial PFS than WBRT plus EGFR-TKIs. Five studies were included in the comparison of WBRT plus EGFR-TKIs and WBRT alone. The combined HR for OS, intracranial PFS and extracranial PFS were 0.52 [95% CI 0.37–0.75; P = 0.0004], 0.36 [95% CI 0.24–0.53; P < 0.001] and 0.52 [95% CI 0.38–0.71; P < 0.001], respectively, which revealed a significant benefit of WBRT plus EGFR-TKIs compared with WBRT alone. The results indicated that EGFR-TKIs alone should be the first option for the treatment of NSCLC patients with multiple BM, especially with EGFR mutation, since it provides similar OS and extracranial PFS but superior intracranial PFS compared with WBRT plus EGFR-TKIs.
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Affiliation(s)
- Hong Zheng
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Quan-Xing Liu
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Bin Hou
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Dong Zhou
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Jing-Meng Li
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Xiao Lu
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Qiu-Ping Wu
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Ji-Gang Dai
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
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Bernhardt D, Adeberg S, Bozorgmehr F, Opfermann N, Hoerner-Rieber J, König L, Kappes J, Thomas M, Herth F, Heußel CP, Warth A, Debus J, Steins M, Rieken S. Outcome and prognostic factors in patients with brain metastases from small-cell lung cancer treated with whole brain radiotherapy. J Neurooncol 2017; 134:205-12. [PMID: 28560661 DOI: 10.1007/s11060-017-2510-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/20/2017] [Indexed: 12/20/2022]
Abstract
The purpose of this study was to evaluate prognostic factors associated with overall survival (OS) and neurological progression free survival (nPFS) in small-cell lung cancer (SCLC) patients with brain metastases who received whole-brain radiotherapy (WBRT). From 2003 to 2015, 229 SCLC patients diagnosed with brain metastases who received WBRT were analyzed retrospectively. In this cohort 219 patients (95%) received a total photon dose of 30 Gy in 10 fractions. The prognostic factors evaluated for OS and nPFS were: age, Karnofsky Performance Status (KPS), number of brain metastases, synchronous versus metachronous disease, initial response to chemotherapy, the Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class and thoracic radiation. Median OS after WBRT was 6 months and the median nPFS after WBRT was 11 months. Patients with synchronous cerebral metastases had a significantly better median OS with 8 months compared to patients with metachronous metastases with a median survival of 3 months (p < 0.0001; HR 0.46; 95% CI 0.31-0.67). Based on RPA classification median survival after WBRT was 17 months in RPA class I, 7 months in class II and 3 months in class III (p < 0.0001). Karnofsky performance status scale (KPS < 70%) was significantly associated with OS in both univariate (HR 2.84; p < 0.001) and multivariate analyses (HR 2.56; p = 0.011). Further, metachronous brain metastases (HR 1.8; p < 0.001), initial response to first-line chemotherapy (HR 0.51, p < 0.001) and RPA class III (HR 2.74; p < 0.001) were significantly associated with OS in univariate analysis. In multivariate analysis metachronous disease (HR 1.89; p < 0.001) and initial response to chemotherapy (HR 0.61; p < 0.001) were further identified as significant prognostic factors. NPFS was negatively significantly influenced by poor KPS (HR 2.56; p = 0.011), higher number of brain metastases (HR 1.97; p = 0.02), and higher RPA class (HR 2.26; p = 0.03) in univariate analysis. In this series, the main prognostic factors associated with OS were performance status, time of appearance of intracranial disease (synchronous vs. metachronous), initial response to chemotherapy and higher RPA class. NPFS was negatively influenced by poor KPS, multiplicity of brain metastases, and higher RPA class in univariate analysis. For patients with low performance status, metachronous disease or RPA class III, WBRT should be weighed against supportive therapy with steroids alone or palliative chemotherapy.
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46
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Wu CC, Wuu YR, Jani A, Saraf A, Tai CH, Lapa ME, Andrew JIS, Tiwari A, Saadatmand HJ, Isaacson SR, Cheng SK, Wang TJC. Whole-brain Irradiation Field Design: A Comparison of Parotid Dose. Med Dosim 2017; 42:145-149. [PMID: 28479012 DOI: 10.1016/j.meddos.2017.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 11/10/2016] [Accepted: 02/27/2017] [Indexed: 10/19/2022]
Abstract
Whole-brain radiation therapy (WBRT) plays an important role in patients with diffusely metastatic intracranial disease. Whether the extent of the radiation field design to C1 or C2 affects parotid dose and risk for developing xerostomia is unknown. The goal of this study is to examine the parotid dose based off of the inferior extent of WBRT field to either C1 or C2. Patients treated with WBRT with either 30 Gy or 37.5 Gy from 2011 to 2014 at a single institution were examined. Parotid dose constraints were compared with Radiation Therapy Oncology Group (RTOG) 0615 nasopharyngeal carcinoma for a 33-fraction treatment: mean <26 Gy, volume constraint at 20 Gy (V20) < 20 cc, and dose at 50% of the parotid volume (D50) < 30 Gy. Biologically effective dose (BED) conversions with an α/β of 3 for normal parotid were performed to compare with 10-fraction and 15-fraction treatments of WBRT. The constraints are as follows: mean < BED 32.83 Gy, V15.76 (for 10-fraction WBRT) or V17.35 (for 15-fraction WBRT) < 20 cc, and D50 < BED 39.09 Gy. Nineteen patients treated to C1 and 26 patients treated to C2 were analyzed. Comparing WBRT to C1 with WBRT to C2, the mean left, right, and both parotids' doses were lower when treated to C1. Converting mean dose to BED3, the parotid doses were lower than BED3 constraint of 32.83 Gy: left (30.12 Gy), right (30.69 Gy), and both parotids (30.32 Gy). V20 to combined parotids was lower in patients treated to C1. When accounting for fractionation of WBRT received, the mean corrected V20 volume was less than 20 cc when treating to C1. D50 for C1 was lower than C2 for the left parotid, right parotid, and both parotids. BED3 conversion for the mean D50 of the left, right, and both parotids was less than 39.09 Gy. In conclusion, WBRT to C1 limits parotid dose, and parotid dose constraints are achievable compared with inferior border at C2. A possible mean parotid dose constraint with BED3 should be less than 32.83 Gy.
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Affiliation(s)
- Cheng-Chia Wu
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Yen-Ruh Wuu
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Ashish Jani
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Anurag Saraf
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Cheng-Hung Tai
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Matthew E Lapa
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Jacquelyn I S Andrew
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Akhil Tiwari
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Heva J Saadatmand
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Steven R Isaacson
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032; Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032
| | - Simon K Cheng
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032; Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY 10032.
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032; Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY 10032.
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Kępka L, Tyc-Szczepaniak D, Bujko K, Olszyna-Serementa M, Michalski W, Sprawka A, Trąbska-Kluch B, Komosińska K, Wasilewska-Teśluk E, Czeremszyńska B. Stereotactic radiotherapy of the tumor bed compared to whole brain radiotherapy after surgery of single brain metastasis: Results from a randomized trial. Radiother Oncol 2016; 121:217-24. [PMID: 27793446 DOI: 10.1016/j.radonc.2016.10.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 09/27/2016] [Accepted: 10/03/2016] [Indexed: 01/07/2023]
Abstract
PURPOSE To evaluate if neurological/cognitive function outcomes in patients with resected single brain metastasis (BM) after stereotactic radiotherapy of the tumor bed (SRT-TB) are not inferior compared to those achieved with whole-brain radiotherapy (WBRT). METHODS Patients with total/subtotal resection of single BM were randomly assigned either to SRT-TB (n=29) or WBRT (n=30). SRT-TB arm consisted of 15Gy/1 fraction, or 5×5Gy. WBRT consisted of 30Gy/10 fractions. Neurological/cognitive failure was defined as a decrease of neurological score by one point or more, or a worsening of the MiniMental test by at least 3 points, or neurological death. Cumulative incidence of neurological/cognitive failure (CINCF), neurological death (CIND), and overall survival (OS) were compared. RESULTS Median follow-up was 29months (range: 8-45) for 15 patients still alive. The difference in the probability of CINCF at 6months (primary endpoint) was -8% in favor of WBRT (95% confidence interval: +17% -35%; non-inferiority margin: -20%). In the intention-to-treat analysis, two-year CIND rates were 66% vs. 31%, for SRT-TB and WBRT arm, respectively, p=.015. The corresponding figures for OS were 10% vs. 37%, p=.046. CONCLUSIONS Non-inferiority of SRT-TB was not demonstrated in our underpowered study. More data from randomized studies are needed for confirmation of the value of this method.
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He Q, Wang Y, Zou P, Wang Y, Xiu C, Zhang H, Chi N, Zou H, Xu J, Zhou S, Tao R. Phase II Study of High-Dose Pemetrexed Plus Cisplatin as First-Line Chemotherapy In the Treatment of Patients with Brain Metastases from Lung Adenocarcinoma. World Neurosurg 2016; 99:758-762. [PMID: 27060518 DOI: 10.1016/j.wneu.2016.03.098] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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: 12/08/2015] [Revised: 03/29/2016] [Accepted: 03/30/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Brain metastases (BMs) occur in up to 40% of patients with nonsmall-cell lung cancer (NSCLC). When surgery or radiosurgery is not possible, whole-brain radiotherapy (WBRT) is the standard treatment, with a cerebral response rate of approximately 30%. Pemetrexed-based chemotherapy presents an approximately 40% response rate on brain lesions of NSCLC with brain metastases. METHODS This trial assessed the efficacy and safety of high-dose pemetrexed plus cisplatin in NSCLC with BMs after WBRT. Thirty-two patients with Karnofsky Performance Status ≥70 were enrolled. Patients of NSCLC with brain metastases were eligible for WBRT, which was administered at 30 Gy/10f. Thereafter, high-dose pemetrexed plus cisplatin was given up to 6 cycles. Primary end point was objective response rate (RR) and progression-free survival on BM. Secondary end points included extracerebral and overall RR, safety profile, and survival. RESULTS The objective cerebral RR (complete and partial response) was 68.8 % (22 of 32 patients). Extracerebral and globe RR was 37.5% and 31.3%, respectively. The median progression-free survival of BM was 13.6 months, and median overall survival was 19.1 months. CONCLUSIONS This modality of treatment appears to a better efficacy and a good safety of BM, as well as extracerebral. Further clinical studies are warranted.
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Affiliation(s)
- Qiaowei He
- Department of Neurosurgery, Qingdao University affiliated Yantai Yuhuangding Hospital, Shandong Province, P. R. China
| | - Yong Wang
- Department of Neurosurgery, Shandong Cancer Hospital, Shandong Province, P. R. China
| | - Peng Zou
- Department of Neurosurgery, Qingdao University affiliated Yantai Yuhuangding Hospital, Shandong Province, P. R. China
| | - Yunbo Wang
- Department of Neurosurgery, Qingdao University affiliated Yantai Yuhuangding Hospital, Shandong Province, P. R. China
| | - Chunming Xiu
- Department of Neurosurgery, Qingdao University affiliated Yantai Yuhuangding Hospital, Shandong Province, P. R. China
| | - Hongtao Zhang
- Department of Neurosurgery, Qingdao University affiliated Yantai Yuhuangding Hospital, Shandong Province, P. R. China
| | - Nan Chi
- Department of Neurosurgery, Qingdao University affiliated Yantai Yuhuangding Hospital, Shandong Province, P. R. China
| | - Haining Zou
- Department of Neurosurgery, Qingdao University affiliated Yantai Yuhuangding Hospital, Shandong Province, P. R. China
| | - Jun Xu
- Department of Neurosurgery, Shandong Cancer Hospital, Shandong Province, P. R. China
| | - Shizhen Zhou
- Department of Neurosurgery, Shandong Cancer Hospital, Shandong Province, P. R. China
| | - Rongjie Tao
- Department of Neurosurgery, Shandong Cancer Hospital, Shandong Province, P. R. China.
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Abstract
AIMS To describe results of melanoma brain metastases (BM) treated with whole-brain radiation (WBRT). METHODS Retrospective review of patients with melanoma BM treated with WBRT divided into two groups based on the timing of WBRT (at BM diagnosis or recurrence). RESULTS We identified 61 patients with melanoma BM who received WBRT. For the group treated at diagnosis (n = 39): median overall survival was 3 months; best radiographic response included one partial response, ten stable disease, 18 progressive disease, and ten no follow-up imaging. For the group treated at recurrence (n = 22): median overall survival was 3 months; best radiographic response was three partial response, four stable disease, eight progressive disease, and seven no follow-up imaging. CONCLUSION WBRT activity was limited; however, its role in symptom palliation is unclear.
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Xu Q, Chen X, Qian D, Wang Y, Meng S, Liu H, Zhou C. Treatment and prognostic analysis of patients with leptomeningeal metastases from non-small cell lung cancer. Thorac Cancer 2015; 6:407-12. [PMID: 26273394 PMCID: PMC4511317 DOI: 10.1111/1759-7714.12188] [Citation(s) in RCA: 18] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 10/04/2014] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Leptomeningeal metastases (LM) from non-small cell lung cancer (NSCLC) are associated with poor prognosis and optimal treatment for this subgroup of NSCLC patients is controversial. The purpose of this study is to evaluate treatment options and prognostic factors of NSCLC patients with LM. METHODS We retrospectively analyzed data of 108 patients who had been diagnosed with LM from NSCLC between May 2006 and August 2013. RESULTS The median survival time (MST) of the 108 patients was 5.3 months, and the one-year survival rate was 23.7%. Forty-nine patients received whole brain radiotherapy (WBRT) and the MST of patients who received WBRT and those who did not were 6.4 and 4.3 months, respectively. Forty-two patients were treated with epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) after being diagnosed with LM. These patients had prolonged survival (11.1 vs. 4.4 months). Patients who received concomitant WBRT and EGFR-TKIs had the longest MST (12.3 months). Eastern Cooperative Oncology Group performance status, whether patients received WBRT, and/or EGFR-TKIs were independent prognostic factors for patients with LM from NSCLC. CONCLUSION WBRT, EGFR-TKIs or combined therapy, could lead to better clinical outcomes for NSCLC patients with LM. EGFR-TKIs plus WBRT has the potential to be the standard strategy for LM in NSCLC patients.
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Affiliation(s)
- Qinghua Xu
- Department of Radiation Oncology, Shanghai Pulmonary Hospital, School of Medicine, Soochow University Suzhou, China ; Department of Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University Shanghai, China
| | - Xiu Chen
- Department of Respiratory, Zaozhuang Municipal Hospital Zaozhuang, China
| | - Danwen Qian
- Department of Respiratory, Nanjing Red Cross Hospital Nanjing, China
| | - Yongsheng Wang
- Department of Respiratory Medicine, Drum Tower Hospital, Medical School of Nanjing University Nanjing, China
| | - Shuyan Meng
- Department of Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University Shanghai, China
| | - Hui Liu
- Department of Radiation Oncology, Shanghai Pulmonary Hospital, School of Medicine, Soochow University Suzhou, China
| | - Caicun Zhou
- Department of Oncology, Shanghai Pulmonary Hospital, School of Medicine, Soochow University Suzhou, China ; Department of Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University Shanghai, China
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