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Abstract
Brain metastases are the most common intracranial tumors and are increasing in incidence as overall cancer survival improves. Diagnosis of brain metastases involves both clinical examination and magnetic resonance imaging. Treatment may involve a combination of surgery, radiotherapy, and systemic medical therapy depending on the patient’s neurologic status, performance status, and overall oncologic burden. Advances in these domains have substantially impacted the management of brain metastases and improved performance status and survival for some patients. Indications for surgery have expanded with improved patient selection, imaging, and intraoperative monitoring. Robust evidence supports the use of whole brain radiotherapy and stereotactic radiosurgery, for both standalone and adjuvant indications, in almost all patients. Lastly, while systemic medical therapy has historically provided little benefit, modern immunotherapeutic agents have demonstrated promise. Current investigation seeks to determine the utility of neoadjuvant radiotherapy and laser interstitial thermal therapy, which have shown benefit in limited studies to date. This article provides a review of the epidemiology, pathology, diagnosis, and treatment of brain metastases and the corresponding supporting evidence.
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Affiliation(s)
- Alex W Brenner
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Akash J Patel
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
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Hou R, Li H, Cao J, Song X, Zhang X, Wang W. Validation of a novel prognostic index: BMS-Score for patients with brain metastases of small cell lung cancer. Ann Palliat Med 2021; 10:29-36. [PMID: 33440957 DOI: 10.21037/apm-20-1819] [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] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/14/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND A new disease-specific prognostic score (Disease-specific Prognostic Score for Patients With Brain Metastases From Small-cell Lung Cancer termed BMS-Score) was published to clarify the prognosis of patients with brain metastasis (BM) of small cell lung cancer (SCLC) treated with whole brain radiotherapy (WBRT). The purpose of the present study was to validate the prognostic value of the newly proposed BMS-Score through comparison with three other previously published prognostic indices. METHODS In total, 451 patients with BM of SCLC treated with WBRT at the Shanxi Province Cancer Hospital from January 2010 to December 2019 were included. The clinical characteristics of all patients were recorded and follow-up was through April 2020. Overall survival (OS) was calculated by Kaplan-Meier analysis, and univariate and multivariate analyses were used to calculate the prognostic cofactors. The concordance index (C-index) was used to assess the prognostic value of the following four prognostic systems: recursive partitioning analysis (RPA), diagnosis-specific graded prognostic assessment (DS-GPA), basic score for brain metastases (BSBM), and the newly proposed BMS-Score. RESULTS The independent factors affecting the prognosis of SCLC patients with BM included the Karnofsky performance score (KPS), number of brain metastases, extracranial metastases (ECM) state, and whether treatment had been received before BM. RPA, BSBM, DS-GPA, and BMS-Score log-rank test P values were all less than 0.001 among each group (P<0.001). The C-indices of the four groups were 0.554, 0.584, 0.588, and 0.643, respectively. CONCLUSIONS The four prognostic scoring systems exhibited medium predictive value for SCLC. The BMS-Score had the best applicability compared with the other three prognosis indices.
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Affiliation(s)
- Ru Hou
- Shanxi Medical University, Taiyuan, China
| | - Hongwei Li
- Department of Radiotherapy, Shanxi Province Cancer Hospital and Affiliated Cancer Hospital of Shanxi Medical University, Taiyuan, China.
| | - Jianzhong Cao
- Department of Radiotherapy, Shanxi Province Cancer Hospital and Affiliated Cancer Hospital of Shanxi Medical University, Taiyuan, China
| | - Xin Song
- Department of Radiotherapy, Shanxi Province Cancer Hospital and Affiliated Cancer Hospital of Shanxi Medical University, Taiyuan, China
| | - Xiaqin Zhang
- Department of Radiotherapy, Shanxi Province Cancer Hospital and Affiliated Cancer Hospital of Shanxi Medical University, Taiyuan, China
| | - Weili Wang
- Department of Radiotherapy, Shanxi Province Cancer Hospital and Affiliated Cancer Hospital of Shanxi Medical University, Taiyuan, China
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Khan M, Arooj S, Li R, Tian Y, Zhang J, Lin J, Liang Y, Xu A, Zheng R, Liu M, Yuan Y. Tumor Primary Site and Histology Subtypes Role in Radiotherapeutic Management of Brain Metastases. Front Oncol 2020; 10:781. [PMID: 32733787 PMCID: PMC7358601 DOI: 10.3389/fonc.2020.00781] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [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: 08/14/2019] [Accepted: 04/22/2020] [Indexed: 12/12/2022] Open
Abstract
Randomized controlled trials have failed to report any survival advantage for WBRT combined with SRS in the management of brain metastases, despite the enhanced local and distant control in comparison to each treatment alone. Literature review have revealed important role of primary histology of the tumor when dealing with brain metastases. NSCLC responds better to combined approach even when there was only single brain metastasis present while breast cancer has registered better survival with SRS alone probably due to better response of primary tumor to advancement in surgical and chemotherapeutic agents. Furthermore, mutation status (EGFR/ALK) in lung cancer and receptor status (ER/PR/HER2) in breast cancer also exhibit diversity in their response to radiotherapy. Radioresistant tumors like renal cell carcinoma and melanoma brain metastases have achieved better results when treated with SRS alone. Secondly, single brain metastasis may benefit from local and distant brain control achieved with combined treatment. These diverse outcomes suggest a primary histology-based analysis of the radiotherapy regimens (WBRT, SRS, or their combination) would more ideally establish the role of radiotherapy in the management of brain metastases. Molecularly targeted therapeutic and immunotherapeutic agents have revealed synergism with radiation therapy particularly SRS in treating cancer patients with brain metastases. Clinical updates in this regard have also been reviewed.
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Affiliation(s)
- Muhammad Khan
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China.,Department of Oncology, First affiliated Hospital of Anhui Medical University, Hefei, China
| | - Sumbal Arooj
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China.,Department of Oncology, First affiliated Hospital of Anhui Medical University, Hefei, China.,Department of Biochemistry, University of Sialkot, Sialkot, Pakistan
| | - Rong Li
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Yunhong Tian
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Jian Zhang
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Jie Lin
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Yingying Liang
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Anan Xu
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Ronghui Zheng
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Mengzhong Liu
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yawei Yuan
- Department of Radiation Oncology, State Key Laboratory of Respiratory Disease, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
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Khan M, Lin J, Liao G, Tian Y, Liang Y, Li R, Liu M, Yuan Y. Whole Brain Radiation Therapy Plus Stereotactic Radiosurgery in the Treatment of Brain Metastases Leading to Improved Survival in Patients With Favorable Prognostic Factors. Front Oncol 2019; 9:205. [PMID: 30984624 PMCID: PMC6449627 DOI: 10.3389/fonc.2019.00205] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 01/02/2019] [Accepted: 03/11/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Significantly better local control is achieved with combination of whole brain radiotherapy and stereotactic radiosurgery in the treatment of multiple brain metastases. However, no survival benefit was reported from this advantage in local control. Objective: The objective of this study was to review the available evidence whether better local control achieved with whole brain radiotherapy plus stereotactic radiosurgery leads to any benefit in survival in patients with favorable prognostic factors. Methods and Materials: Electronic databases (PubMed, MEDLINE, and Cochrane Library) were searched until Oct 2018 to identify studies published in English that compared efficacy of whole brain radiotherapy plus stereotactic radiosurgery vs. whole brain radiotherapy alone or stereotactic radiosurgery alone in patients with brain metastases stratified on prognostic indices (Recursive Partitioning Analysis and Diagnosis-Specific Graded Prognostic Assessment). Primary outcome was survival. Results: Five studies (n = 2728) were identified, 3 secondary analyses of the previously published RCTs and 2 retrospective studies, meeting the inclusion criteria. whole brain radiotherapy plus stereotactic radiosurgery showed improved survival in brain metastatic cancer patients with better prognostic factors particularly when compared to whole brain radiotherapy only. Its survival advantage over stereotactic radiosurgery only was limited to non-small cell lung cancer primary tumor histology. Conclusions: Whole brain radiotherapy in combination with stereotactic radiosurgery may improve survival and could be recommended selectively in patients with favorable prognostic factors particularly in comparison to whole brain radiotherapy only.
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Affiliation(s)
- Muhammad Khan
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China.,Department of Oncology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jie Lin
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China
| | - Guixiang Liao
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China
| | - Yunhong Tian
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China
| | - Yingying Liang
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China
| | - Rong Li
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China
| | - Mengzhong Liu
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Sun Yat-sen Medical University, Guangzhou, China
| | - Yawei Yuan
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China
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Crowe W, Wang L, Zhang Z, Varagic J, Bourland JD, Chan MD, Habib AA, Zhao D. MRI evaluation of the effects of whole brain radiotherapy on breast cancer brain metastasis. Int J Radiat Biol 2019; 95:338-346. [PMID: 30499763 DOI: 10.1080/09553002.2019.1554920] [Citation(s) in RCA: 20] [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: 01/01/2023]
Abstract
PURPOSE To assess early changes in brain metastasis in response to whole brain radiotherapy (WBRT) by longitudinal Magnetic Resonance Imaging (MRI). MATERIALS AND METHODS Using a 7T system, MRI examinations of brain metastases in a breast cancer MDA-MD231-Br mouse model were conducted before and 24 hours after 3 daily fractionations of 4 Gy WBRT. Besides anatomic MRI, diffusion-weighted (DW) MRI and dynamic contrast-enhanced (DCE) MRI were applied to study cytotoxic effect and blood-tumor-barrier (BTB) permeability change, respectively. RESULTS Before treatment, high-resolution T2-weighted images revealed hyperintense multifocal lesions, many of which (∼50%) were not enhanced on T1-weighted contrast images, indicating intact BTB in the brain metastases. While no difference in the number of new lesions was observed, WBRT-treated tumors were significantly smaller than sham controls (p < .05). DW MRI detected significant increase in apparent diffusion coefficient (ADC) in WBRT tumors (p < .05), which correlated with elevated caspase 3 staining of apoptotic cells. Many lesions remained non-enhanced post WBRT. However, quantitative DCE MRI analysis showed significantly higher permeability parameter, Ktrans, in WBRT than the sham group (p < .05), despite marked spatial heterogeneity. CONCLUSIONS MRI allowed non-invasive assessments of WBRT induced changes in BTB permeability, which may provide useful information for potential combination treatment.
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Affiliation(s)
- William Crowe
- a Department of Biomedical Engineering , Wake Forest School of Medicine , Winston-Salem , NC , USA
| | - Lulu Wang
- a Department of Biomedical Engineering , Wake Forest School of Medicine , Winston-Salem , NC , USA
| | - Zhongwei Zhang
- a Department of Biomedical Engineering , Wake Forest School of Medicine , Winston-Salem , NC , USA
| | - Jasmina Varagic
- b Department of Surgery , Wake Forest School of Medicine , Winston-Salem , NC , USA
| | - J Daniel Bourland
- a Department of Biomedical Engineering , Wake Forest School of Medicine , Winston-Salem , NC , USA.,c Department of Radiation Oncology , Wake Forest School of Medicine , Winston-Salem , NC , USA
| | - Michael D Chan
- c Department of Radiation Oncology , Wake Forest School of Medicine , Winston-Salem , NC , USA
| | - Amyn A Habib
- d Department of Neurology and Neurotherapeutics , University of Texas Southwestern Medical Center and VA North Texas Medical Center , Dallas , TX , USA
| | - Dawen Zhao
- a Department of Biomedical Engineering , Wake Forest School of Medicine , Winston-Salem , NC , USA.,e Department of Cancer Biology , Wake Forest School of Medicine , Winston-Salem , NC , USA
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O'Beirn M, Benghiat H, Meade S, Heyes G, Sawlani V, Kong A, Hartley A, Sanghera P. The Expanding Role of Radiosurgery for Brain Metastases. Medicines (Basel) 2018; 5:medicines5030090. [PMID: 30110927 PMCID: PMC6165316 DOI: 10.3390/medicines5030090] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/03/2018] [Accepted: 08/07/2018] [Indexed: 06/08/2023]
Abstract
Stereotactic radiosurgery (SRS) has become increasingly important in the management of brain metastases due to improving systemic disease control and rising incidence. Initial trials demonstrated SRS with whole-brain radiotherapy (WBRT) improved local control rates compared with WBRT alone. Concerns with WBRT associated neurocognitive toxicity have contributed to a greater use of SRS alone, including for patients with multiple metastases and following surgical resection. Molecular information, targeted agents, and immunotherapy have also altered the landscape for the management of brain metastases. This review summarises current and emerging data on the role of SRS in the management of brain metastases.
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Affiliation(s)
- Mark O'Beirn
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
| | - Helen Benghiat
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
| | - Sara Meade
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
| | - Geoff Heyes
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
| | - Vijay Sawlani
- Neuroradiology, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
| | - Anthony Kong
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
| | - Andrew Hartley
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
| | - Paul Sanghera
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
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Ulahannan D, Lee SM. Erlotinib plus concurrent whole-brain radiation therapy for non-small cell lung cancers patients with multiple brain metastases. Transl Lung Cancer Res 2016; 5:208-11. [PMID: 27186518 DOI: 10.21037/tlcr.2016.03.06] [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] [Indexed: 01/12/2023]
Abstract
Sequencing of the epidermal growth factor receptor (EGFR) gene to identify mutations in lung adenocarcinomas is routine in clinical practice. The use of tyrosine kinase inhibitors (TKIs) has transformed the management of patients with brain metastases harboring EGFR mutations, with improved response rates (RR) and survival. We evaluate the role of concurrent TKI therapy and radiotherapy in this group of patients, considering this data in the context of emerging concepts in this advancing field.
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Affiliation(s)
- Danny Ulahannan
- CRUK Lung Cancer of Excellence, UCL Cancer Institute, Paul O'Gorman Building, University College Hospital, London, UK
| | - Siow-Ming Lee
- CRUK Lung Cancer of Excellence, UCL Cancer Institute, Paul O'Gorman Building, University College Hospital, London, UK
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