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Cuthbert H, Riley M, Bhatt S, Au-Yeung CK, Arshad A, Eladawi S, Zisakis A, Tsermoulas G, Watts C, Wykes V. Utility of a prognostic assessment tool to predict survival following surgery for brain metastases. Neurooncol Pract 2023; 10:586-591. [PMID: 38026583 PMCID: PMC10666803 DOI: 10.1093/nop/npad047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Background Brain metastases account for more than 50% of all intracranial tumors and are associated with poor outcomes. Treatment decisions in this highly heterogenous cohort remain controversial due to the myriad of treatment options available, and there is no clearly defined standard of care. The prognosis in brain metastasis patients varies widely with tumor type, extracranial disease burden and patient performance status. Decision-making regarding treatment is, therefore, tailored to each patient and their disease. Methods This is a retrospective cohort study assessing survival outcomes following surgery for brain metastases over a 50-month period (April 1, 2014-June 30, 2018). We compared predicted survival using the diagnosis-specific Graded Prognostic Assessment (ds-GPA) with actual survival. Results A total of 186 patients were included in our cohort. Regression analysis demonstrated no significant correlation between actual and predicted outcome. The most common reason for exclusion was insufficient information being available to the neuro-oncology multidisciplinary team (MDT) meeting to allow GPA calculation. Conclusions In this study, we demonstrate that "predicted survival" using the ds-GPA does not correlate with "actual survival" in our operated patient cohort. We also identify a shortcoming in the amount of information available at MDT in order to implement the GPA appropriately. Patient selection for aggressive therapies is crucial, and this study emphasizes the need for treatment decisions to be individualized based on patient and cancer clinical characteristics.
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Affiliation(s)
- Hadleigh Cuthbert
- Department of Neurosurgery, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, UK
| | - Max Riley
- University of Birmingham Medical School, Birmingham, UK
| | - Shreya Bhatt
- University of Birmingham Medical School, Birmingham, UK
| | | | - Ayesha Arshad
- Department of Neurosurgery, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, UK
| | - Sondos Eladawi
- Department of Neurosurgery, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, UK
| | - Athanasios Zisakis
- Department of Neurosurgery, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, UK
| | - Georgios Tsermoulas
- Department of Neurosurgery, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, UK
| | - Colin Watts
- Department of Neurosurgery, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Victoria Wykes
- Department of Neurosurgery, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
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2
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Stambaugh C, Wang AY, Kim E, Mignano JE, Melhus CS, Rodrigues R, Huber K, Stambaugh N, Wu J. Survival and Radiation Dose Differences Between Single Versus Multi-Session Gamma Knife Stereotactic Radiosurgery in Patients Treated for Multiple (≥10) Brain Metastases. Cureus 2023; 15:e46901. [PMID: 37954747 PMCID: PMC10638890 DOI: 10.7759/cureus.46901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVE To explore whether treatment with multiple Gamma Knife sessions (mGK) resulted in different survival outcomes or cumulative radiation doses compared to single session Gamma Knife (sGK) in patients who have been treated for ≥10 brain metastases (BMs). METHODS Thirty-five patients with ≥10 BMs treated with Gamma Knife stereotactic radiosurgery (GK SRS) were identified and separated into sGK vs. mGK cohorts. Survival outcomes and dosimetry data were compared between the two groups. Recursive partitioning analysis (RPA) classes were used to further stratify patients. RESULTS mGK patients survived longer from the first GK treatment (p<0.009). By RPA class, patients with class 1 had a prolonged survival from BM diagnosis than those in classes 2 and 3 (p=0.004). However, survival was not significantly different between the classes from the first GK treatment (p=0.089). Stratified by mGK vs. sGK and RPA classes, sGK patients in RPA class 1 had the longest survival from BM diagnosis but the worst survival from GK treatment. mGK patients in any RPA class had the best survival from the first GK treatment. For patients with RPA class 2+3, mGK was associated with longer survival from both BM diagnosis and first treatment. Statistical but not clinical differences between the mGK vs. sGK groups were observed in the max dose to the targets and cochlea, and the V40Gy whole brain dose. CONCLUSIONS mGK may be beneficial if GK is initiated early at first BM diagnosis vs. sGK initiated late. Future research is required to confirm these findings and explore additional areas of interest, such as quality-of-life and economic considerations.
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Affiliation(s)
| | - Andy Y Wang
- Neurosurgery, Tufts University School of Medicine, Boston, USA
| | - Edward Kim
- Neurosurgery, Tufts University School of Medicine, Boston, USA
| | | | | | - Rahul Rodrigues
- Neurosurgery, Tufts University School of Medicine, Boston, USA
| | - Kathryn Huber
- Radiation Oncology, Tufts Medical Center, Boston, USA
| | | | - Julian Wu
- Neurosurgery, Tufts Medical Center, Boston, USA
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3
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Verhaak E, Schimmel WCM, Sitskoorn MM, Hanssens PEJ, Butterbrod E, Gehring K. The long-term course and relationship with survival of multidimensional fatigue in patients with brain metastases after Gamma Knife radiosurgery. J Cancer Res Clin Oncol 2023; 149:9891-9901. [PMID: 37249646 PMCID: PMC10423137 DOI: 10.1007/s00432-023-04857-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/13/2023] [Indexed: 05/31/2023]
Abstract
PURPOSE The aims of this study were to evaluate long-term multidimensional fatigue in patients with brain metastases (BM) up to 21 months after Gamma Knife radiosurgery (GKRS) and (change in) fatigue as predictor of survival. METHODS Patients with 1 to 10 BM, expected survival > 3 months, and Karnofsky Performance Status ≥ 70, and Dutch non-cancer controls were included. Fatigue was measured with the Multidimensional Fatigue Inventory. Levels of fatigue between patients and controls were compared using independent-samples t-tests. Linear mixed models were used to evaluate fatigue within the patient group up to 21 months after GKRS. Pre-GKRS fatigue and minimal clinically important (MCI) changes in fatigue in the first three months (defined as a 2-point difference) after GKRS were evaluated as predictors of survival time. RESULTS Prior to GKRS, patients with BM (n = 92) experienced significantly higher fatigue on all subscales than controls (n = 104). Over 21 months, physical fatigue increased, and mental fatigue decreased significantly. More specifically, general, and physical fatigue increased significantly between pre-GKRS and 3 months, followed by stable scores between 3 (n = 67) and 6 (n = 53), 6 and 12 (n = 34) and 12 and 21 (n = 21) months. An MCI increase in general or physical fatigue over the first 3 months after GKRS was a significant predictor of shorter survival time. CONCLUSION Except for mental fatigue, all aspects of fatigue remained elevated or further increased up to 21 months after treatment. Furthermore, an increase in general or physical fatigue within three months after GKRS may be a prognostic indicator for poorer survival. CLINICALTRIALS GOV IDENTIFIER NCT02953756, November 3, 2016.
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Affiliation(s)
- Eline Verhaak
- Department of Neurosurgery-Gamma Knife Center, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands.
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands.
| | - Wietske C M Schimmel
- Department of Neurosurgery-Gamma Knife Center, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
| | - Margriet M Sitskoorn
- Department of Neurosurgery-Gamma Knife Center, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
| | - Patrick E J Hanssens
- Department of Neurosurgery-Gamma Knife Center, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
| | - Elke Butterbrod
- Department of Neurosurgery-Gamma Knife Center, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
- Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Karin Gehring
- Department of Neurosurgery-Gamma Knife Center, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
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Hong S, Atkinson JL, Erickson D, Kizilbash SH, Little JT, Routman DM, Van Gompel JJ. Contemporary Treatment Outcome of Metastases to the Pituitary Gland. World Neurosurg 2023; 172:e684-e694. [PMID: 36764447 DOI: 10.1016/j.wneu.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVE Metastasis to the pituitary gland is uncommon. With life expectancy after cancer diagnosis improving, we sought to understand the effects of treating pituitary metastasis in the modern era of advanced cancer treatment. METHODS Patients who had been diagnosed with, and treated for, pituitary metastasis from 2000 to 2021 were retrospectively analyzed. RESULTS A total of 48 patients were identified, of whom 23 (48%) were women. The most common primary cancer was the lung (n = 23; 48%), followed by the breast (n = 9; 19%). Of the 48 patients, 29 (60%) had had hypopituitarism and 12 (25%), visual field deficits. Twenty-seven patients (56%) had had solitary pituitary metastasis, with no evidence of other intracranial metastatic lesions. Of the 48 patients, 14 (29%) had undergone surgery and 20 (42%) had undergone standalone radiation therapy (preceded by biopsy for 3). After surgery and/or radiation therapy, the visual field deficits had improved in 6 patients, hypopituitarism had improved in 4 patients, and hypopituitarism had occurred in 3 patients. The median overall survival (OS) was 12 months (interquartile range, 3.0-28 months). Multivariate analysis showed nonsolitary pituitary metastasis (hazard ratio, 2.8; 95% confidence interval, 1.5-5.5; P = 0.0021) and no surgery or radiation therapy (hazard ratio, 2.08; 95% confidence interval, 1.04-4.15; P = 0.038) were associated with OS. For those with solitary pituitary metastasis, the patients who had undergone surgery and/or radiation therapy had had better 1-year OS than patients who had not received either (P = 0.03). In contrast, for patients with nonsolitary pituitary metastasis, those who had undergone standalone radiation therapy had had better 1-year OS than the patients who had not received either (P = 0.03). CONCLUSIONS In the selected population, metastasis-directed therapy was associated with improved OS. Either correct patient selection for additional therapy or surgery and/or radiation therapy directly benefited patients' OS.
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Affiliation(s)
- Sukwoo Hong
- Departments of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John L Atkinson
- Departments of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Dana Erickson
- Departments of Otolaryngology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sani H Kizilbash
- Departments of Endocrinology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason T Little
- Departments of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - David M Routman
- Departments of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jamie J Van Gompel
- Departments of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA; Departments of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA.
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Wolfert C, Rohde V, Hussein A, Fiss I, Hernández-Durán S, Malzahn D, Bleckmann A, Mielke D, Schatlo B. Surgery for brain metastases: radiooncology scores predict survival-score index for radiosurgery, graded prognostic assessment, recursive partitioning analysis. Acta Neurochir (Wien) 2023; 165:231-238. [PMID: 36152217 PMCID: PMC9840567 DOI: 10.1007/s00701-022-05356-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 08/25/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Radiooncological scores are used to stratify patients for radiation therapy. We assessed their ability to predict overall survival (OS) in patients undergoing surgery for metastatic brain disease. METHODS We performed a post-hoc single-center analysis of 175 patients, prospectively enrolled in the MetastaSys study data. Score index of radiosurgery (SIR), graded prognostic assessment (GPA), and recursive partitioning analysis (RPA) were assessed. All scores consider age, systemic disease, and performance status prior to surgery. Furthermore, GPA and SIR include the number of intracranial lesions while SIR additionally requires metastatic lesion volume. Predictive values for case fatality at 1 year after surgery were compared among scoring systems. RESULTS All scores produced accurate reflections on OS after surgery (p ≤ 0.003). Median survival was 21-24 weeks in patients scored in the unfavorable cohorts, respectively. In cohorts with favorable scores, median survival ranged from 42 to 60 weeks. Favorable SIR was associated with a hazard ratio (HR) of 0.44 [0.29, 0.66] for death within 1 year. For GPA, the HR amounted to 0.44 [0.25, 0.75], while RPA had a HR of 0.30 [0.14, 0.63]. Overall test performance was highest for the SIR. CONCLUSIONS All scores proved useful in predicting OS. Considering our data, we recommend using the SIR for preoperative prognostic evaluation and counseling.
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Affiliation(s)
- Christina Wolfert
- Department of Neurosurgery, University Hospital Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Hospital Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Abdelhalim Hussein
- Department of Neurosurgery, University Hospital Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Ingo Fiss
- Department of Neurosurgery, University Hospital Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Silvia Hernández-Durán
- Department of Neurosurgery, University Hospital Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Dörthe Malzahn
- mzBiostatistics, Statistical Consultancy, 37075, Göttingen, Germany
| | - Annalen Bleckmann
- Clinic for Hematology/ Medical Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
- Medical Clinic A, Haematology, Haemostasiology, Oncology and Pulmonology, University Hospital Münster, 48149, Münster, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University Hospital Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Bawarjan Schatlo
- Department of Neurosurgery, University Hospital Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
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6
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Otto-Vollaard L, Quint S, de Pree IMN, Steinvoort IN, Tims OJL, Nuyttens JJ. Brain Metastases: Patient-Reported Outcome and Quality of Life After Whole-Brain Radiotherapy. J Palliat Med 2022; 25:1533-1539. [PMID: 35482284 DOI: 10.1089/jpm.2021.0533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: The aim of this prospective cohort study was to determine the outcome and quality of life (QoL) for patients with brain metastases treated with whole-brain radiotherapy (WBRT). Materials and Methods: WBRT was given to 162 patients. Treatment outcome was reported through telephone consultation at four and eight weeks after the last fraction of the treatment. Treatment outcome was scored as a benefit when patients reported positively on the question whether radiotherapy of the whole brain did relieve their complaints. Patients who scored the treatment as beneficial were categorized as responders. The European Organization for Research and Treatment of Cancer (EORTC) questionnaire QLQ-C15-PAL was scored at day 0 and eight weeks after the last fraction of WBRT. Results: Patients who were alive after 2 months and reported benefit from treatment had a median survival of 8.1 months compared with 2.9 months for patients who reported no benefit. Forty-three patients died within two months (27%). Median overall survival was 3.5 months. Improvement of neurological symptoms was the most commonly reported benefit of the treatment. The responders had significantly better sleep (p = 0.032) and were less tense (p = 0.014). The nonresponders were also less tense (p = 0.042), but had less appetite (p = 0.023), felt weaker (p = 0.011), and experienced more fatigue (p = 0.001). Conclusions: WBRT is effective in a selected group of patients. Forty-nine percent of the patients surviving two months reported benefit from the treatment, resulting in a significantly increased survival rate for this group. However, 27% of patients died within two months. QoL increased in responders, but decreased in nonresponders.
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Affiliation(s)
| | - Sandra Quint
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ilse M N de Pree
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Illona N Steinvoort
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Olijn J L Tims
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Joost J Nuyttens
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Yang K, Gutierrez E, Landry AP, Kalyvas A, Millesi M, Leite M, Jablonska PA, Weiss J, Millar BA, Conrad T, Laperriere N, Bernstein M, Zadeh G, Shultz D, Kongkham PN. Multiplicity does not significantly affect outcomes in brain metastasis patients treated with surgery. Neurooncol Adv 2022; 4:vdac022. [PMID: 35386569 PMCID: PMC8982197 DOI: 10.1093/noajnl/vdac022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Brain metastasis quantity may be a negative prognostic factor for patients requiring resection of at least one lesion.
Methods
We retrospectively reviewed patients who underwent surgical resection of brain metastases from July 2018 to June 2019 at our institution, and examined outcomes including overall survival (OS), progression free survival (PFS) and rates of local failure (LF). Patients were grouped according to the number of metastases at the time of surgery (single vs multiple).
Results
We identified 130 patients who underwent surgical resection as the initial treatment modality. At the time of surgery, 87 patients had only one lesion (control) and 43 had multiple (>1). Two-year OS for the entire cohort was 46%, with equal rates in both the multiple metastases group and the control group (p=0.335). 2-year PFS was 27%; 21% in the multiple metastases group and 31% in the control group (p=0.766). The rate of LF at 2-years was 32%, with equal rates in both the multiple lesion group and control group (p=0.889). On univariate analysis, multiplicity was not significantly correlated to OS (HR=0.80, 95% CI: 0.51-1.26, p=0.336), PFS (HR=1.06, 95% CI: 0.71-1.59, p=0.766) or LF (HR=1.06, 95% CI: 0.57-1.97, p=0.840). Multivariate analysis revealed preoperative tumor volume of the resected lesion to be the single correlate for OS (p=0.0032) and PFS (p=0.0081).
Conclusions
Having more than one metastasis does not negatively impact outcomes in patients treated with surgery. In carefully selected patients, especially those with large tumors, surgery should be considered regardless of the total number of lesions.
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Affiliation(s)
- Kaiyun Yang
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Enrique Gutierrez
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Alexander P Landry
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Matthias Millesi
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Matheuss Leite
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Jessica Weiss
- Department of Biostatistics, Princess Margaret Cancer Centre
| | - Barbara-Ann Millar
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Tatiana Conrad
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Normand Laperriere
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Mark Bernstein
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - David Shultz
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Paul N Kongkham
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
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8
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Kotecha R, Ahluwalia MS, Siomin V, McDermott MW. Surgery, Stereotactic Radiosurgery, and Systemic Therapy in the Management of Operable Brain Metastasis. Neurol Clin 2022; 40:421-436. [DOI: 10.1016/j.ncl.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Medikonda R, Jackson CM, Feghali J, Lim M. The Effects of Postoperative Neurological Deficits on Survival in Patients With Single Brain Metastasis. Oper Neurosurg (Hagerstown) 2021; 19:628-634. [PMID: 32717025 DOI: 10.1093/ons/opaa224] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 05/20/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The prognosis for brain metastasis is poor, and surgical resection is part of the standard of care for these patients as it has been shown to improve median overall survival. Development of neurological deficits after surgical resection has been associated with worsened outcomes in patients with glioblastoma. The effect of postoperative neurological deficits on survival in patients with single brain metastasis has not been studied to date. OBJECTIVE To evaluate the association between postoperative neurological deficits and median overall survival. METHODS A single-institution retrospective cohort study was performed on all patients with single brain metastasis undergoing surgical resection by a single neurosurgeon. RESULTS A total of 121 patients met the inclusion criteria for this study. Among them 61% of patients presented with a preoperative deficit, and 26% of patients had a new postoperative deficit. However, most postoperative deficits resolved and only 3.3% of patients developed a new permanent postoperative deficit. Median overall survival in patients with a new postoperative deficit was 2.4 mo, whereas mOS in patients without a postoperative deficit was 12.6 mo (P < .0001). CONCLUSION This study suggests that a new neurological deficit is associated with worsened outcomes after surgical resection of a single brain metastasis. This finding has potential implications for patient selection and counseling as the patients most likely to benefit from surgical resection are the patients who are most likely to have resolution of a preoperative deficit.
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Affiliation(s)
- Ravi Medikonda
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher M Jackson
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James Feghali
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael Lim
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Proescholdt MA, Schödel P, Doenitz C, Pukrop T, Höhne J, Schmidt NO, Schebesch KM. The Management of Brain Metastases-Systematic Review of Neurosurgical Aspects. Cancers (Basel) 2021; 13:1616. [PMID: 33807384 PMCID: PMC8036330 DOI: 10.3390/cancers13071616] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 02/07/2023] Open
Abstract
The multidisciplinary management of patients with brain metastases (BM) consists of surgical resection, different radiation treatment modalities, cytotoxic chemotherapy, and targeted molecular treatment. This review presents the current state of neurosurgical technology applied to achieve maximal resection with minimal morbidity as a treatment paradigm in patients with BM. In addition, we discuss the contribution of neurosurgical resection on functional outcome, advanced systemic treatment strategies, and enhanced understanding of the tumor biology.
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Affiliation(s)
- Martin A. Proescholdt
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Petra Schödel
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Christian Doenitz
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Tobias Pukrop
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
- Department of Medical Oncology, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Julius Höhne
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Nils Ole Schmidt
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Karl-Michael Schebesch
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
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11
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Marchand-Crety C, Riverain J, Drouet Y, Felici F, Jeandidier CL, Thariat J, Servagi-Vernat S. A new model outperforming RPA and DS-GPA scores for individualized survival prediction of patients following whole brain irradiation for brain metastasis. Cancer Radiother 2021; 25:447-456. [PMID: 33678525 DOI: 10.1016/j.canrad.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Survival after whole brain radiation therapy (WBRT) in patients with multiple brain metastases (BM) is currently predicted by group-based scoring systems with limited usability for decision. We aimed to develop a more relevant individualized predictive model than Radiation Therapy Oncology Group - Recursive Partitioning Analysis (RTOG-RPA) and Diagnosis - Specific Graded Prognostic Assessment (DS-GPA) for patients with limited life-expectancy. METHODS Based on a Discovery cohort of patients undergoing WBRT, multivariable piecewise Cox regression models with time cut-offs at 1 and 3 months were developed to predict overall survival (OS). A final parsimonious model was defined, and an external validation cohort was used to assess its discrimination and calibration at one, six, and 12 months. RESULTS In the 173-patient Discovery cohort, the majority of patients had primary lung cancer (56%), presence of extracranial disease (ECD) (75%), Eastern Cooperative Oncolgy Group - Performance Status (ECOG-PS) score 1 (41%) and no intracranial hypertension (ICH) (74%). Most patients were classified as the RPA class II (48%). The final piecewise Cox model was based on primary site, age, ECD, ECOG-PS and ICH. An external validation of the model was carried out using a cohort of 79 patients. Individualized survival estimates obtained with this model outperformed the RPA and DS-GPA scores for overall survival prediction at 1-month, 6-months and 12- months in both Discovery and Validation cohorts. A R/Shiny web application was developed to obtain individualized predictions for new patients, providing an easy-to-use tool for clinicians and researchers. CONCLUSION Our model provides individualized estimates of survival for poor prognosis patients undergoing WBRT, outperforming actual scoring systems.
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Affiliation(s)
- C Marchand-Crety
- Department of Radiation Oncology, Institut Godinot, Reims, France.
| | - J Riverain
- Department of Radiation Oncology, Centre François Baclesse, ARCHADE, Caen, France; Laboratoire de physique corpusculaire IN2P3/ENSICAEN, France
| | - Y Drouet
- Centre Léon Bérard, Département Prévention et Santé Publique, Lyon, France; Université de Lyon, CNRS UMR 5558 LBBE, Villeurbanne, France
| | - F Felici
- Department of Radiation Oncology, Institut Godinot, Reims, France
| | - C L Jeandidier
- Department of Radiation Oncology, Centre Paul Strauss, Unicancer, Strasbourg, France
| | - J Thariat
- Department of Radiation Oncology, Centre François Baclesse, ARCHADE, Caen, France; Laboratoire de physique corpusculaire IN2P3/ENSICAEN, France; UMR6534 Unicaen - Normandie Université, France
| | - S Servagi-Vernat
- Department of Radiation Oncology, Institut Godinot, Reims, France
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12
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Holub K, Louvel G. Poor performance status and brain metastases treatment: who may benefit from the stereotactic radiotherapy? J Neurooncol 2021; 152:383-393. [PMID: 33590401 DOI: 10.1007/s11060-021-03712-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 01/29/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Poor Performance Status (PS) of cancer patients, defined as PS score 2-3, is an impediment for many drug- and irradiation-based treatments, supported by the trials that exclude subjects with PS < 1. Reports on the benefits of stereotactic radiotherapy (SRT) for brain metastases (BMs) in poor PS patients are scarce. We sought to review the characteristics and survival outcomes of this cohort, to assess who may benefit most from SRT. METHODS We retrospectively evaluated 73 patients with PS 2 or 3 (63 and 10 cases) treated with SRT for 150 BMs from 2012 to 2018. Patients' characteristics and post-SRT survival, stratified by concomitant systemic treatment (CST) were assessed using the Kaplan-Meier method (p-value < 0.05). RESULTS Non-small cell lung cancer was the most frequent primary tumor. Extracranial metastases were present in 86.3% of patients. The median overall survival (mOS) after SRT was estimated as 6.0 months (range 0.2-37.7), with 6- and 12-month survival rates of 51.0% and 21.0%, respectively. CST was administrated to 59.7% of patients (immunotherapy, target therapy or chemotherapy). Patients treated with CST presented larger mOS (6.7 vs. 4.4 months for patients treated with SRT alone, p = 0.3), and better 6- and 12-month survival rates (59% and 24% vs. 37% and 18% in patients not treated with CST). CONCLUSIONS Survival rate after SRT for BMs in poor performance patients, especially with PS 2, can justify SRT, in particular if an effective systemic treatment is available. Both SRT and CST should be more accessible for these patients in clinical practice.
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Affiliation(s)
- Katarzyna Holub
- Radiotherapy Department, Gustave Roussy Cancer Campus, Villejuif, France. .,Universitat de Barcelona, Barcelona, Spain.
| | - Guillaume Louvel
- Radiotherapy Department, Gustave Roussy Cancer Campus, Villejuif, France
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13
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Patil R, Pandit P, Palwe V, Kate S, Gandhe S, Patil R, Ramesh YV, Nagarkar R. Evaluation of Prognostic Factors that Affect Survival Outcomes of Breast Cancer Patients with Brain Metastases: A Single Institutional Experience. Eur J Breast Health 2020; 17:62-67. [PMID: 33796832 DOI: 10.4274/ejbh.2020.5969] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/12/2020] [Indexed: 12/14/2022]
Abstract
Objective This study aimed to evaluate various prognostic factors that play a vital role in stratifying and guiding tailored treatment strategies and survival outcome in breast cancer patients with brain metastases (BM). Materials and Methods Data regarding demography, clinical presentation, molecular subtypes, risk-stratification, treatment details, and outcomes were retrieved from medical records. All time-to-event (survival) outcomes were analyzed by Kaplan-Meir method and compared using log-rank test. Univariate and multivariate analysis of relevant prognostic factors were performed and p-values ≤0.05 were considered statistically significant. Results A total of 88 patients (median age: 50 years) were included for this study. The median follow-up time of all surviving patients was ~20 months. During the follow-up, 82 (93.1%) patients died. The median survival of all patients was 12 months, with 1-year and 2-year overall survival (OS) rate of 51% and 22%, respectively. Based on univariate analysis, statistically significant prognostic factors for OS were molecular subtypes, number of BM, and Karnofsky Performance Status (KPS); however, number of BM and KPS emerged as independent predictors of survival based on multivariate analysis. Conclusion We conclude that, there are other important prognostic factor, such as number of BM, which may affect the OS of these patients, in addition to variables included in the diagnosis-specific graded prognostic assessment score. Prospective studies evaluating these factors are necessary to further refine the stratification of patients, which will aid the initiation of appropriate treatment to improve the OS of patients.
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Affiliation(s)
- Roshankumar Patil
- Department of Radiation Oncology, HCG Manavata Cancer Centre, Maharashtra, India
| | - Prakash Pandit
- Department of Radiation Oncology, HCG Manavata Cancer Centre, Maharashtra, India
| | - Vijay Palwe
- Department of Radiation Oncology, HCG Manavata Cancer Centre, Maharashtra, India
| | - Shruti Kate
- Department of Medical Oncology, HCG Manavata Cancer Centre, Maharashtra, India
| | - Sucheta Gandhe
- Department of Pathology, HCG Manavata Cancer Centre, Maharashtra, India
| | - Rahul Patil
- Department of Pathology, HCG Manavata Cancer Centre, Maharashtra, India
| | | | - Raj Nagarkar
- Department of Surgical Oncology, HCG Manavata Cancer Centre, Maharashtra, India
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Ampil FL, Richards TA. Necessary treatment of brain metastases in poor‐performance status patients: for all, for no one, or for whom? PRECISION RADIATION ONCOLOGY 2020. [DOI: 10.1002/pro6.1102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Federico L. Ampil
- Department of Radiology Division of Radiation Oncology Louisiana State University Health Sciences Center Shreveport Louisiana USA
| | - Troy A. Richards
- Department of Radiology Division of Radiation Oncology Louisiana State University Health Sciences Center Shreveport Louisiana USA
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15
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Sankey EW, Tsvankin V, Grabowski MM, Nayar G, Batich KA, Risman A, Champion CD, Salama AKS, Goodwin CR, Fecci PE. Operative and peri-operative considerations in the management of brain metastasis. Cancer Med 2019; 8:6809-6831. [PMID: 31568689 PMCID: PMC6853809 DOI: 10.1002/cam4.2577] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 09/07/2019] [Accepted: 09/09/2019] [Indexed: 12/24/2022] Open
Abstract
The number of patients who develop metastatic brain lesions is increasing as the diagnosis and treatment of systemic cancers continues to improve, resulting in longer patient survival. The role of surgery in the management of brain metastasis (BM), particularly multiple and recurrent metastases, remains controversial and continues to evolve. However, with appropriate patient selection, outcomes after surgery are typically favorable. In addition, surgery is the only means to obtain a tissue diagnosis and is the only effective treatment modality to quickly relieve neurological complications or life-threatening symptoms related to significant mass effect, CSF obstruction, and peritumoral edema. As such, a thorough understanding of the role of surgery in patients with metastatic brain lesions, as well as the factors associated with surgical outcomes, is essential for the effective management of this unique and growing patient population.
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Affiliation(s)
- Eric W. Sankey
- Department of NeurosurgeryDuke University Medical CenterDurhamNCUSA
| | - Vadim Tsvankin
- Department of NeurosurgeryDuke University Medical CenterDurhamNCUSA
| | | | - Gautam Nayar
- Department of NeurosurgeryUniversity of Pittsburgh Medical CenterPittsburghPAUSA
| | | | - Aida Risman
- School of MedicineMedical College of GeorgiaAugustaGAUSA
| | | | | | - C. Rory Goodwin
- Department of NeurosurgeryDuke University Medical CenterDurhamNCUSA
| | - Peter E. Fecci
- Department of NeurosurgeryDuke University Medical CenterDurhamNCUSA
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Ha IB, Song JH, Jeong BK, Jeong H, Lee YH, Choi HS, Kang KM. The usefulness of stereotactic radiosurgery for recursive partitioning analysis class II/III lung cancer patients with brain metastases in the modern treatment era. Medicine (Baltimore) 2019; 98:e17390. [PMID: 31577744 PMCID: PMC6783249 DOI: 10.1097/md.0000000000017390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Stereotactic radiosurgery (SRS) is considered the initial treatment for lung cancer patients with small-sized and limited number of brain metastases. The objective of this study was to assess clinical outcomes of SRS treatment using CyberKnife (CK) for recursive partitioning analysis (RPA) class II/III patients with 1 to 3 brain metastases from lung cancer and identify which patients in the high RPA class could benefit from SRS.A total of 48 lung cancer patients who received CK-based SRS for their metastatic brain lesions from 2010 to 2017 were retrospectively analyzed. Radiographic response was evaluated during follow-up period. Overall survival (OS) and intracranial progression-free survival (IPFS) were calculated and prognostic variables associated with OS and IPFS were evaluated.Median follow-up time was 6.6 months. Local control rates at 6 months and 1-year following SRS were 98% and 92%, respectively. The median OS of all patients was 8 months. One-year and 2-year OS rates were 40.8% and 20.9%, respectively. In multivariate analysis, uncontrolled primary disease (P = .01) and Eastern Cooperative Oncology Group performance status of 2 or 3 (P = .001) were independent prognostic factors for inferior OS. These 2 factors were also significantly associated with inferior IPFS. In subgroup analysis according to RPA class, primary disease status was the only prognostic factor, showing statistically significant OS differences in both RPA class II and III (controlled vs uncontrolled: 41.1 vs 12.3 months in RPA class II, P = .03; 26.9 vs 4.1 months in RPA class III, P = .01).Our results indicated that SRS could be an effective treatment option for RPA class II/III patients with brain metastases from lung cancer in the modern treatment era. SRS might be particularly considered for patients with controlled primary disease.
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Affiliation(s)
- In Bong Ha
- Department of Radiation Oncology, Gyeongsang National University School of Medicine, and Gyeongsang National University Hospital, Jinju
| | - Jin Ho Song
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul
| | - Bae Kwon Jeong
- Department of Radiation Oncology, Gyeongsang National University School of Medicine, and Gyeongsang National University Hospital, Jinju
- Institute of Health Science, Gyeongsang National University, Jinju
| | - Hojin Jeong
- Department of Radiation Oncology, Gyeongsang National University School of Medicine, and Gyeongsang National University Hospital, Jinju
- Institute of Health Science, Gyeongsang National University, Jinju
| | - Yun Hee Lee
- Department of Radiation Oncology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul
| | - Hoon Sik Choi
- Department of Radiation Oncology, Gyeongsang National University School of Medicine, and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Ki Mun Kang
- Institute of Health Science, Gyeongsang National University, Jinju
- Department of Radiation Oncology, Gyeongsang National University School of Medicine, and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
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Abstract
PURPOSE OF REVIEW Treatment of brain metastases represent a critical issue and different options have to be considered according to patients and tumour characteristics; in recent years, new therapeutic strategies have been proposed. In this review, we discuss the role of surgical resection on the basis of patient selection, new surgical techniques and the use of intraoperative adjuncts. The integration with postoperative whole brain radiotherapy will be also outlined because alternative treatment options are currently available. RECENT FINDINGS Surgical removal has been considered the mainstay in the treatment of brain metastases, in selected patients, with limited number of intracranial lesions and controlled primary disease, mainly in combination with whole brain radiotherapy. In the last few years, the increasing role of stereotactic focal radiotherapy has deeply modified the indications to open surgical procedures and whole brain radiotherapy. SUMMARY The appearance of brain metastases is considered a sign of bad prognosis. Treatment of these lesions is important for quality of life, providing local tumour control, preventing death from neurological causes and improving survival, although potentially only in a minority of patients. Careful patient selection, with adequate evaluation of clinical prognostic score, the use of appropriate surgical techniques and surgical adjuncts are major determinants of favourable outcome in patients undergoing resection of brain metastases.
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18
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She C, Wang R, Lu C, Sun Z, Li P, Yin Q, Liu Q, Wang P, Li W. Prognostic factors and outcome of surgically treated patients with brain metastases of non-small cell lung cancer. Thorac Cancer 2018; 10:137-142. [PMID: 30485664 PMCID: PMC6360214 DOI: 10.1111/1759-7714.12913] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/13/2018] [Accepted: 10/13/2018] [Indexed: 02/06/2023] Open
Abstract
Background Brain metastases (BM) are a common consequence of lung cancer and surgery is effective; however, the factors affecting survival after surgery are unclear. The aim of this study was to identify the outcomes and prognoses of post‐metastasectomy patients with BM from non‐small cell lung cancer (NSCLC) at a single institution over a 15‐year period. Methods NSCLC patients who had undergone BM surgery were retrospectively identified. Survival was analyzed using the Kaplan–Meier curve, and univariate and multivariate factors associated with survival were identified using the Cox proportional hazards model. Results The median overall survival was 9.8 months, 18 (14.8%) patients survived > 24 months, and 6 (4.9%) > 36 months. The one and two‐year survival rates were 41% and 18.6%, respectively. Univariate analysis revealed that recursive partitioning analysis (RPA) classification, Karnofsky Performance Scale (KPS) scores, BM number, extracranial metastasis status, different lesion locations, resection extent, postoperative treatment, and salvage therapy after recurrence significantly influenced patient survival. The different treatment modalities for primary lesions also affected postoperative survival. KPS ≥ 70, RPA class I/II, and postoperative chemotherapy were independent factors that decreased the risk of death from BM. Interestingly, the initial onset of intracranial lesions could increase the risk of death from BM. Conclusion A KPS score ≥ 70, RPA class I/II, and postoperative chemotherapy could benefit post‐metastasectomy patients with BM from NSCLC. Conversely, the initial onset of intracranial lesions is an unfavorable factor that increases the risk of death. These findings support the use of personalized therapy for patients with BM from NSCLC.
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Affiliation(s)
- Chunhua She
- Department of Neurosurgery and Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Ruixia Wang
- Department of Neurology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Changhong Lu
- Ultrasound Department, Binzhou People's Hospital, Binzhou, China
| | - Zengfeng Sun
- Department of Neurosurgery and Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Peng Li
- Department of Neurosurgery and Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Qiang Yin
- Department of Neurosurgery and Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Qun Liu
- Department of Neurosurgery and Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Peng Wang
- Department of Neurosurgery and Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Wenliang Li
- Department of Neurosurgery and Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
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19
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Gao HX, Huang SG, Du JF, Zhang XC, Jiang N, Kang WX, Mao J, Zhao Q. Comparison of Prognostic Indices in NSCLC Patients with Brain Metastases after Radiosurgery. Int J Biol Sci 2018; 14:2065-2072. [PMID: 30585269 PMCID: PMC6299364 DOI: 10.7150/ijbs.28608] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 10/05/2018] [Indexed: 11/05/2022] Open
Abstract
Prognostic indices are commonly used in the context of brain metastases radiotherapy to guide patient decision-making and clinical trial stratification. This study is to choose an appropriate prognostic index (PI) for non-small cell lung cancer (NSCLC) patients with brain metastases (BM) who underwent radiosurgery. A total of 103 patients with BM from NSCLC receiving radiosurgery were analyzed retrospectively. There are six prognostic factors were analyzed, including age, primary tumor control, extracranial metastasis, KPS score, number of lesions, max lesion volume; and four prognostic indices were compared, include Recursive Partitioning Analysis (RPA),Graded Prognostic Assessment (GPA), Score Index for Radiosurgery (SIR), Basic Score for Brain Metastases (BSBM). Survival curves were estimated with the Kaplan-Meier method and compared with a log-rank test stratified according to the PIs. Univariate and multivariate analysis was performed using the Cox regression analysis. The PI's predictive capacity was compared in terms of Akaike information criterion (AIC), Log-rank × 2, Concordance index (C-index) and calibration curve. The median survival time was 8 months, and the 6-months and 12-months survival rate were 61% and 26% respectively. All four prognostic indices were correlated with prognosis (P<0.005).The AIC for BSBM (686.317) was the minimum in the four PIs(range,686.317-739.113).The Log-rank × 2 value for BSBM (77.62) was the maximum in the four PIs (range,23.32-77.62).The C-index for BSBM (0.758)was superior than the other PIs predictive capacity (range,0.611-0.758). The calibration curve showed that the BSBM was able to predict 6-months and 12-months overall survival accurately. In conclusion, the BSBM may be the most accurate prognostic index for patients with BM from NSCLC who underwent radiosurgery.
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Affiliation(s)
- Hong Xiang Gao
- Department of Radiotherapy Oncology, Chang An Hospital, Xi'an, Shaan Xi, China.,Radiotherapy Department, 323 Hospital of People's Liberation Army, Xi'an, Shaan Xi, China
| | - Shi Gao Huang
- Faculty of Health Sciences, University of Macau, Taipa, Macao SAR, China
| | - Jian Fei Du
- Department of Radiotherapy Oncology, Chang An Hospital, Xi'an, Shaan Xi, China
| | - Xue Cheng Zhang
- Department of Radiotherapy Oncology, Chang An Hospital, Xi'an, Shaan Xi, China
| | - Nan Jiang
- Faculty of Health Sciences, University of Macau, Taipa, Macao SAR, China
| | - Wen Xing Kang
- Radiotherapy Department, 323 Hospital of People's Liberation Army, Xi'an, Shaan Xi, China
| | - Jian Mao
- Department of Radiotherapy Oncology, Chang An Hospital, Xi'an, Shaan Xi, China
| | - Qi Zhao
- Faculty of Health Sciences, University of Macau, Taipa, Macao SAR, China
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20
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Sinclair G, Benmakhlouf H, Brigui M, Maeurer M, Dodoo E. The concept of rapid rescue radiosurgery in the acute management of critically located brain metastases: A retrospective short-term outcome analysis. Surg Neurol Int 2018; 9:218. [PMID: 30505620 PMCID: PMC6219289 DOI: 10.4103/sni.sni_480_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 05/10/2018] [Indexed: 01/13/2023] Open
Abstract
Background: Adaptive hypofractionated gamma knife radiosurgery has been used to treat brain metastases in the eloquent regions while limiting the risk of adverse radiation effect (ARE). Ablative responses might be achieved within days to weeks with the goal to preserve the neurological function. The application of this treatment modality in selected acute/subacute settings has been termed Rapid Rescue Radiosurgery (RRR) in our department. We report the expeditious effects of RRR during treatment and 4 weeks after treatment completion. Methods: In all, 34 patients with 40 brain metastases, each treated over a period of 7 days in three separate gamma knife radiosurgery sessions (GKRS 1-3) between November 2013 and August 2017, were retrospectively analyzed in terms of tumor volume reduction, salvage of organs at risk (OAR), and radiation induced toxicity under the period of treatment (GKRS 1-3 = one week) and at first follow-up magnetic resonance imaging (MRI) (4 weeks after GKRS 3). Results: Mean tumor volume at GKRS 1 was 12.8 cm3. Mean peripheral doses at GKRS 1, GKRS 2, and GKRS 3 were 7.7 Gy, 8.1 Gy, and 8.4 Gy (range: 6.0-9.5 Gy) at the 35% to 50% isodose lines. In the surviving group at first follow-up (n = 28), mean tumor volume reduction was − 10% at GKRS 3 (1 week) and − 48% four weeks after GKRS 3. There was no further clinical deterioration between GKRS 3 and first follow-up in 21 patients. Six patients died prior to first follow-up due to extracranial disease. No ARE was noticed/reported. Conclusions: In this study, RRR proved effective in terms of rapid tumor volume reduction, debulking, and preservation/rescue of neurological function.
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Affiliation(s)
- Georges Sinclair
- Department of Neurosurgery, Karolinska Institute, Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Hamza Benmakhlouf
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska Institute, Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Marina Brigui
- Department of Neurosurgery, Karolinska Institute, Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Markus Maeurer
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institute, Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Ernest Dodoo
- Department of Neurosurgery, Karolinska Institute, Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
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Dincoglan F, Sager O, Gamsiz H, Uysal B, Demiral S, Oysul K, Sirin S, Caglan A, Beyzadeoglu M. Management of Patients with ≥4 Brain Metastases Using Stereotactic Radiosurgery Boost after Whole Brain Irradiation. TUMORI JOURNAL 2018. [DOI: 10.1177/1578.17210] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Ferrat Dincoglan
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Omer Sager
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Hakan Gamsiz
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Bora Uysal
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Selcuk Demiral
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Kaan Oysul
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Sait Sirin
- Department of Neurosurgery, Gulhane Military Medical Academy, Ankara, Turkey
| | - Ayca Caglan
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Murat Beyzadeoglu
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
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Salvati M, Tropeano MP, Maiola V, Lavalle L, Brogna C, Colonnese C, Frati A, D'Elia A. Multiple brain metastases: a surgical series and neurosurgical perspective. Neurol Sci 2018; 39:671-677. [PMID: 29383618 DOI: 10.1007/s10072-017-3220-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
Abstract
Despite review papers claim for radical treatment of oligometastatic patients, only few surgical series have been published. In this study, we analyze results and actual role of surgical resection for the management of patients with multiple brain metastases. This retrospective study compares surgical results of two groups of patients consecutively treated in our Institute from January 2004 to June 2015. The first group comprises all 32 patients with multiple brain metastases with only 2-3 lesions who underwent surgical resection of all lesions; the second group comprises 30 patients with a single surgically treated brain mestastasis compatible with the first group (match-paired control series). Median survival was 14.6 months for patients with multiple brain metastases (range 1-28 months) and 17.4 months for patients with a single brain metastasis (range 4-38 months); the difference was not statistically significant (P = 0.2). Neurological condition improved in 59.4% of patients with multiple metastases, it remained unchanged in 37.5% and worsened in 3.1%. In our series, selected patients with only 2-3 lesions with well-controlled systemic disease, life expectancy of more than 3 months, Karnofsky's performance status > 60, and surgically accessible lesions, benefited from surgical treatment in terms of survival and quality of life, with reduction or disappearance of significant neurological deficits. The prognosis for these patients is similar to that of patients with a single metastasis. It seems that patients with breast cancer included in our series had the worst prognosis if compared to other histotypes.
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Affiliation(s)
- Maurizio Salvati
- DAI Neurology and Psychiatry, Department of Neurosurgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Maria Pia Tropeano
- DAI Neurology and Psychiatry, Department of Neurosurgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Vincenza Maiola
- DAI Neurology and Psychiatry, Department of Neurosurgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Laura Lavalle
- Neuroscience Department, University of Siena, Siena, Italy
| | - Christian Brogna
- Clinical Fellow Neurosurgery, King's College Hospital, Greater London, London, UK
| | - Claudio Colonnese
- DAI Neurology and Psichiatry, Department of Neuroradiology, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Alessandro Frati
- Neurosurgery Department, IRCCS NEUROMED INM, Neurochirurgia, Via Atinense, 18, 86077, Pozzilli, IS, Italy
| | - Alessandro D'Elia
- Neurosurgery Department, IRCCS NEUROMED INM, Neurochirurgia, Via Atinense, 18, 86077, Pozzilli, IS, Italy.
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Abstract
Prevalence of cancer and its various related complications continues to rise. Increasingly these life-threatening complications are initially managed in the emergency department, making a prompt and accurate diagnosis crucial to effectively institute the proper treatment and establish goals of care. The following oncologic emergencies are reviewed in this article: pericardial tamponade, superior vena cava syndrome, brain metastasis, malignant spinal cord compression, and hyperviscosity syndrome.
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Affiliation(s)
- Umar A Khan
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 South Paca Street, 2nd Floor, Baltimore, MD 21201, USA
| | - Carl B Shanholtz
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 South Paca Street, 2nd Floor, Baltimore, MD 21201, USA
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 South Paca Street, 2nd Floor, Baltimore, MD 21201, USA.
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Vargas A, Conill C. In Regard to Kubicek et al. Int J Radiat Oncol Biol Phys 2017; 96:921-922. [PMID: 27788966 DOI: 10.1016/j.ijrobp.2016.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 07/19/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Andrés Vargas
- Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - Carlos Conill
- Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, Spain
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Aliabadi H, Nikpour AM, Yoo DS, Herndon JE, Sampson JH, Kirkpatrick JP. Pre-operative stereotactic radiosurgery treatment is preferred to post-operative treatment for smaller solitary brain metastases. Chin Neurosurg J 2017. [DOI: 10.1186/s41016-017-0092-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Yang J, Zhan W, Zhang H, Song T, Jia Y, Xu H, Lin B, Lv S, Liang X. Intensity-modulated radiation therapy for patients with 1 to 3 brain metastases in recursive partitioning analysis class 3. Medicine (Baltimore) 2017; 96:e7715. [PMID: 28984752 PMCID: PMC5737988 DOI: 10.1097/md.0000000000007715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The prognosis is extremely poor for patients with brain metastases in recursive partitioning analysis (RPA) class 3. It is not clear whether dose elevation for brain lesions in addition to whole-brain radiotherapy could improve survival for those patients. This study aimed to assess the efficacy and safety of dose elevation with intensity-modulated radiation therapy (IMRT) for patients with 1 to 3 brain metastases in RPA class 3.From January 2013 to December 2015, 24 patients with 1 to 3 brain metastases in RPA class 3 were included in this study. The median age was 60 (range 41-85) years and the mean graded prognostic assessment (GPA) score was 1.25 (range 0.5-2). Whole-brain radiotherapy (30 Gy) with a simultaneous integrated boost (SIB) to the brain metastases (totaling 40 Gy) was delivered in 10 fractions using IMRT technique. Survival times and overall safety were assessed. The significance of prognostic variables on survival was assessed by both univariate and multivariate analyses.All of the patients completed the planned SIB schedule. The overall response rate was 66.7%. The median survival time (MST) was 8 months for the entire group of patients. The MST was 5 months for patients with a GPA score of 0.5 to 1 (n = 11 patients) and 12 months with a GPA score of 1.5 to 2 (n = 13 patients). No acute or late toxicities greater than grade 2 were detected. Age and subsequent chemotherapy were significantly associated with MST on univariate and multivariate analyses.It is feasible to elevate radiation doses to 40 Gy using the IMRT technique in RPA class 3 patients with 1 to 3 brain metastases without serious toxicities. The preliminary results are encouraging and further studies with larger cohorts are warranted.
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27
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Bennett EE, Angelov L, Vogelbaum MA, Barnett GH, Chao ST, Murphy ES, Yu JS, Suh JH, Jia X, Stevens GH, Ahluwalia MS, Mohammadi AM. The Prognostic Role of Tumor Volume in the Outcome of Patients with Single Brain Metastasis After Stereotactic Radiosurgery. World Neurosurg 2017; 104:229-238. [DOI: 10.1016/j.wneu.2017.04.156] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 04/24/2017] [Indexed: 11/27/2022]
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Li H, Wang W, Jia H, Lian J, Cao J, Zhang X, Song X, Jia S, Li Z, Cao X, Zhou W, Han S, Yang W, Xi Y, Lian S. Prognostic model for brain metastases from lung adenocarcinoma identified with epidermal growth factor receptor mutation status. Thorac Cancer 2017; 8:436-442. [PMID: 28597503 PMCID: PMC5582515 DOI: 10.1111/1759-7714.12460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 05/03/2017] [Accepted: 05/08/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Several indices have been developed to predict survival of brain metastases (BM) based on prognostic factors. However, such models were designed for general brain metastases from different kinds of cancers, and prognostic factors vary between cancers and histological subtypes. Recently, studies have indicated that epidermal growth factor receptor (EGFR) mutation status may be a potential prognostic biological factor in BM from lung adenocarcinoma. Thus, we sought to define the role of EGFR mutation in prognoses and introduce a prognostic model specific for BM from lung adenocarcinoma. METHODS Data of 256 patients with BM from lung adenocarcinoma identified with EGFR mutations were collected. Independent prognostic factors were confirmed using a Cox regression model. The new prognostic model was developed based on the results of multivariable analyses. The score of each factor was calculated by six-month survival. Prognostic groups were divided into low, medium, and high risk based on the total scores. The prediction ability of the new model was compared to the three existing models. RESULTS EGFR mutation and Karnofsky performance status were independent prognostic factors and were thus integrated into the new prognostic model. The new model was superior to the three other scoring systems regarding the prediction of three, six, and 12-month survival by pairwise comparison of the area under the curve. CONCLUSION Our proposed prognostic model specific for BM from lung adenocarcinoma incorporating EGFR mutation status was valid in predicting patient survival. Further verification is warranted, with prospective testing using large sample sizes.
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Affiliation(s)
- Hongwei Li
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Weili Wang
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Haixia Jia
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Jianhong Lian
- Department of Surgery, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Jianzhong Cao
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Xiaqin Zhang
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Xing Song
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Sufang Jia
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Zhengran Li
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Xing Cao
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Wei Zhou
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Songye Han
- Department of Chemotherapy, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Weihua Yang
- Department of Chemotherapy, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Yanfen Xi
- Department of Pathology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Shenming Lian
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
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29
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Sinha R, Sage W, Watts C. The evolving clinical management of cerebral metastases. Eur J Surg Oncol 2016; 43:1173-1185. [PMID: 27986364 DOI: 10.1016/j.ejso.2016.10.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 10/05/2016] [Indexed: 11/26/2022] Open
Abstract
Concepts in the management of brain metastases are evolving. Until recently, brain metastases have been considered as a homogenous condition, managed with whole brain radiotherapy, surgical resection for large lesions and stereotactic radiosurgery for smaller lesions. Increasingly, specific systemic medical therapies are being used to treat brain metastases based on the primary site of disease. This disease specific management is causing a change in perspective about brain metastases and has led to improved survival for patients with primary disease subtypes amenable to tailored medical therapies. We review the recent literature to present evidence for the use of subtype specific medical therapies, advances in surgical resection techniques and stereotactic radiosurgery as the primary treatment modalities. The decline in use of whole brain radiotherapy as first line treatment is also discussed. Based on the recent literature, we propose a new management algorithm to reflect the progress in available options for tailoring disease specific treatments and support the change in paradigm to consider brain metastases as separate disease states based on the primary site of cancer rather than as a homogenous entity.
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Affiliation(s)
- R Sinha
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - W Sage
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - C Watts
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK.
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30
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Mulvenna P, Nankivell M, Barton R, Faivre-Finn C, Wilson P, McColl E, Moore B, Brisbane I, Ardron D, Holt T, Morgan S, Lee C, Waite K, Bayman N, Pugh C, Sydes B, Stephens R, Parmar MK, Langley RE. Dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ): results from a phase 3, non-inferiority, randomised trial. Lancet 2016; 388:2004-2014. [PMID: 27604504 PMCID: PMC5082599 DOI: 10.1016/s0140-6736(16)30825-x] [Citation(s) in RCA: 455] [Impact Index Per Article: 50.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Whole brain radiotherapy (WBRT) and dexamethasone are widely used to treat brain metastases from non-small cell lung cancer (NSCLC), although there have been no randomised clinical trials showing that WBRT improves either quality of life or overall survival. Even after treatment with WBRT, the prognosis of this patient group is poor. We aimed to establish whether WBRT could be omitted without a significant effect on survival or quality of life. METHODS The Quality of Life after Treatment for Brain Metastases (QUARTZ) study is a non-inferiority, phase 3 randomised trial done at 69 UK and three Australian centres. NSCLC patients with brain metastases unsuitable for surgical resection or stereotactic radiotherapy were randomly assigned (1:1) to optimal supportive care (OSC) including dexamethasone plus WBRT (20 Gy in five daily fractions) or OSC alone (including dexamethasone). The dose of dexamethasone was determined by the patients' symptoms and titrated downwards if symptoms improved. Allocation to treatment group was done by a phone call from the hospital to the Medical Research Council Clinical Trials Unit at University College London using a minimisation programme with a random element and stratification by centre, Karnofsky Performance Status (KPS), gender, status of brain metastases, and the status of primary lung cancer. The primary outcome measure was quality-adjusted life-years (QALYs). QALYs were generated from overall survival and patients' weekly completion of the EQ-5D questionnaire. Treatment with OSC alone was considered non-inferior if it was no more than 7 QALY days worse than treatment with WBRT plus OSC, which required 534 patients (80% power, 5% [one-sided] significance level). Analysis was done by intention to treat for all randomly assigned patients. The trial is registered with ISRCTN, number ISRCTN3826061. FINDINGS Between March 2, 2007, and Aug 29, 2014, 538 patients were recruited from 69 UK and three Australian centres, and were randomly assigned to receive either OSC plus WBRT (269) or OSC alone (269). Baseline characteristics were balanced between groups, and the median age of participants was 66 years (range 38-85). Significantly more episodes of drowsiness, hair loss, nausea, and dry or itchy scalp were reported while patients were receiving WBRT, although there was no evidence of a difference in the rate of serious adverse events between the two groups. There was no evidence of a difference in overall survival (hazard ratio 1·06, 95% CI 0·90-1·26), overall quality of life, or dexamethasone use between the two groups. The difference between the mean QALYs was 4·7 days (46·4 QALY days for the OSC plus WBRT group vs 41·7 QALY days for the OSC group), with two-sided 90% CI of -12·7 to 3·3. INTERPRETATION Although the primary outcome measure result includes the prespecified non-inferiority margin, the combination of the small difference in QALYs and the absence of a difference in survival and quality of life between the two groups suggests that WBRT provides little additional clinically significant benefit for this patient group. FUNDING Cancer Research UK, Medical Research Council Clinical Trials Unit at University College London, and the National Health and Medical Research Council in Australia.
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Affiliation(s)
- Paula Mulvenna
- Northern Centre for Cancer Care, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Matthew Nankivell
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Rachael Barton
- Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Hull, UK
| | - Corinne Faivre-Finn
- Institute of Cancer Sciences, The University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - Paula Wilson
- Bristol Haematology and Oncology Centre, Bristol, UK
| | - Elaine McColl
- Newcastle Clinical Trials Unit and Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Iona Brisbane
- The Beatson West of Scotland Cancer Centre, Greater Glasgow Health Board and Clyde, Glasgow, UK
| | | | - Tanya Holt
- Trans Tasman Radiation Oncology Group, Waratah, NSW, Australia; University of Queensland, QLD, Australia
| | | | | | | | - Neil Bayman
- Institute of Cancer Sciences, The University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - Cheryl Pugh
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Benjamin Sydes
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Richard Stephens
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Mahesh K Parmar
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Ruth E Langley
- Medical Research Council Clinical Trials Unit at University College London, London, UK.
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Kothari N, Mellon E, Hoffe SE, Frakes J, Shridhar R, Pimiento J, Meredith K, Tran ND, Saeed N, Almhanna K. Outcomes in patients with brain metastasis from esophageal carcinoma. J Gastrointest Oncol 2016; 7:562-9. [PMID: 27563446 DOI: 10.21037/jgo.2016.03.12] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Brain metastases from esophageal carcinoma have historically been rare and associated with poor prognosis. With improvements in systemic disease control, the incidence of brain metastases is expected to rise. To better inform management decisions, we sought to identify factors associated with survival in patients with brain metastasis from esophageal cancer. METHODS We retrospectively identified 49 patients with brain metastasis from stage I-IV primary esophageal cancer treated with surgery, radiation, or a combination of modalities at our tertiary referral center between 1998 and 2015. Medical records were reviewed to collect demographic and clinical information. RESULTS Median age at diagnosis of the primary esophageal cancer was 60 years. Forty-one (84%) patients were male and forty patients (82%) had adenocarcinoma. Median overall survival (MS) following esophageal cancer diagnosis was 24 months (range, 3-71 months), and median survival after the identification of brain metastases was 5 months (range, 1-52 months). On univariate analysis, only patients with poor Karnofsky performance status (KPS <70), recursive partitioning analysis (RPA) classification (III), or 3 or more brain metastases were found to have worsened survival after the diagnosis of brain metastases (all P<0.01). Factors not associated with survival were age, gender, histology (adenocarcinoma vs. other), palliative-intent treatment of the primary tumor, time to diagnosis of brain metastases from initial diagnosis, uncontrolled primary tumor at time of brain metastasis diagnosis, or extracranial metastases. On multivariate analysis (MVA, KPS excluded), patients with RPA class I (MS, 14.6 months) or II (MS, 5.0 months) disease had significantly improved overall survival compared to class III disease (MS, 1.6 months, P<0.01). Also on MVA, patients with 1 (MS, 10.7 months) or 2 (MS, 4.7 months) brain metastases had significantly improved overall survival compared to patients with 3 or more brain metastases (MS, 0.3 months, P<0.01). For the 36 patients with 1-2 brain metastases and KPS ≥70, MS was 11.1 months. CONCLUSIONS While the prognosis for esophageal cancer metastatic to brain remains poor overall, we found that patients with good performance status and limited number of brain lesions have superior survival. Aggressive management may further improve outcomes in these patients.
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Affiliation(s)
- Nishi Kothari
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Eric Mellon
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Sarah E Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Jessica Frakes
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Ravi Shridhar
- Department of Radiation Oncology, Florida Hospital Cancer Institute, Orlando, FL, USA
| | - Jose Pimiento
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Ken Meredith
- Department of Gastrointestinal Oncology, First Physicians Group, Sarasota, FL, USA
| | - Nam D Tran
- Department of Neuro-oncology. H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Nadia Saeed
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Khaldoun Almhanna
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
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Sinclair G, Bartek J, Martin H, Barsoum P, Dodoo E. Adaptive hypofractionated gamma knife radiosurgery for a large brainstem metastasis. Surg Neurol Int 2016; 7:S130-8. [PMID: 26958430 PMCID: PMC4765246 DOI: 10.4103/2152-7806.176138] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 12/28/2015] [Indexed: 11/24/2022] Open
Abstract
Background: To demonstrate how adaptive hypofractionated radiosurgery by gamma knife (GK) can be successfully utilized to treat a large brainstem metastasis - a novel approach to a challenging clinical situation. Case Description: A 42-year-old woman, diagnosed with metastatic nonsmall cell lung cancer in July 2011, initially treated with chemotherapy and tyrosine kinase inhibitors, developed multiple brain metastases March 2013, with subsequent whole brain radiotherapy, after which a magnetic resonance imaging (MRI) showed a significant volume regression of all brain metastases. A follow-up MRI in October 2013 revealed a growing brainstem lesion of 26 mm. Linear accelerator-based radiotherapy and microsurgery were judged contraindicated, why the decision was made to treat the patient with three separate radiosurgical sessions during the course of 1 week, with an 18% tumor volume reduction demonstrated after the last treatment. Follow-up MRI 2.5 months after her radiosurgical treatment showed a tumor volume reduction of 67% compared to the 1st day of treatment. Later on, the patient developed a radiation-induced perilesional edema although without major clinical implications. An MRI at 12 months and 18-fluoro-deoxyglucose positron emission tomography of the brain at 13 months showed decreased edema with no signs of tumor recurrence. Despite disease progression during the last months of her life, the patient's condition remained overall acceptable. Conclusion: GK-based stereotactic adaptive hypofractionation proved to be effective to achieve tumor control while limiting local adverse reactions. This surgical modality should be considered when managing larger brain lesions in critical areas.
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Affiliation(s)
- Georges Sinclair
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden; Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Heather Martin
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Pierre Barsoum
- Department of Medical Physics, Karolinska University Hospital, Stockholm, Sweden
| | - Ernest Dodoo
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
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Lucas JT, Colmer HG, White L, Fitzgerald N, Isom S, Bourland JD, Laxton AW, Tatter SB, Chan MD. Competing Risk Analysis of Neurologic versus Nonneurologic Death in Patients Undergoing Radiosurgical Salvage After Whole-Brain Radiation Therapy Failure: Who Actually Dies of Their Brain Metastases? Int J Radiat Oncol Biol Phys 2015; 92:1008-1015. [PMID: 26050609 PMCID: PMC4544707 DOI: 10.1016/j.ijrobp.2015.04.032] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 04/14/2015] [Accepted: 04/17/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE To estimate the hazard for neurologic (central nervous system, CNS) and nonneurologic (non-CNS) death associated with patient, treatment, and systemic disease status in patients receiving stereotactic radiosurgery after whole-brain radiation therapy (WBRT) failure, using a competing risk model. PATIENTS AND METHODS Of 757 patients, 293 experienced recurrence or new metastasis following WBRT. Univariate Cox proportional hazards regression identified covariates for consideration in the multivariate model. Competing risks multivariable regression was performed to estimate the adjusted hazard ratio (aHR) and 95% confidence interval (CI) for both CNS and non-CNS death after adjusting for patient, disease, and treatment factors. The resultant model was converted into an online calculator for ease of clinical use. RESULTS The cumulative incidence of CNS and non-CNS death at 6 and 12 months was 20.6% and 21.6%, and 34.4% and 35%, respectively. Patients with melanoma histology (relative to breast) (aHR 2.7, 95% CI 1.5-5.0), brainstem location (aHR 2.1, 95% CI 1.3-3.5), and number of metastases (aHR 1.09, 95% CI 1.04-1.2) had increased aHR for CNS death. Progressive systemic disease (aHR 0.55, 95% CI 0.4-0.8) and increasing lowest margin dose (aHR 0.97, 95% CI 0.9-0.99) were protective against CNS death. Patients with lung histology (aHR 1.3, 95% CI 1.1-1.9) and progressive systemic disease (aHR 2.14, 95% CI 1.5-3.0) had increased aHR for non-CNS death. CONCLUSION Our nomogram provides individual estimates of neurologic death after salvage stereotactic radiosurgery for patients who have failed prior WBRT, based on histology, neuroanatomical location, age, lowest margin dose, and number of metastases after adjusting for their competing risk of death from other causes.
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Affiliation(s)
- John T Lucas
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| | - Hentry G Colmer
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lance White
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nora Fitzgerald
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Scott Isom
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - John D Bourland
- Department of Radiation Oncology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Wong E, Tsao M, Zhang L, Danjoux C, Barnes E, Pulenzas N, Vuong S, Chow E. Survival of patients with multiple brain metastases treated with whole-brain radiotherapy. CNS Oncol 2015; 4:213-24. [PMID: 26118428 DOI: 10.2217/cns.15.17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To report the survival outcomes of patients with multiple brain metastases treated with whole-brain radiotherapy. PATIENTS & METHODS From 2004 to 2012, patients with brain metastases treated with whole-brain radiotherapy were included. Overall survival (OS) was calculated from the start of radiation treatment. Univariate and multivariate proportional hazard model of OS was conducted. Generalized R(2) statistic (ranged from 0 to 1) was calculated to determine the association with the outcome. RESULTS Nine-hundred-ninety-one patients were included. The actuarial median OS time was 2.7 months (95% CI: 2.5-2.9). Patients of older age (>65 years), lower Karnofsky performance status, not postoperative and patients with gastrointestinal, genitourinary or lung as opposed to breast cancer were more likely to have a shorter survival. CONCLUSION Short median survival of 2.7 months may reflect poorer prognosis of patients referred due to large amount of referrals for radiosurgery. Prognostic factors for survival should be considered at consultation.
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Affiliation(s)
- Erin Wong
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - May Tsao
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Liying Zhang
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Cyril Danjoux
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Elizabeth Barnes
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Natalie Pulenzas
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Sherlyn Vuong
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Edward Chow
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
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Putora PM, Ess S, Panje C, Hundsberger T, van Leyen K, Plasswilm L, Früh M. Prognostic significance of histology after resection of brain metastases and whole brain radiotherapy in non-small cell lung cancer (NSCLC). Clin Exp Metastasis 2015; 32:143-9. [PMID: 25628027 DOI: 10.1007/s10585-015-9699-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 01/20/2015] [Indexed: 01/15/2023]
Abstract
Brain metastases from non-small cell lung cancer (NSCLC) are associated with a poor prognosis. In selected cases, surgical resection of brain metastases may be indicated, but the identification of patients suitable for surgery remains difficult. We collected data on patient and tumour characteristics known or suspected to be associated with survival by chart review. Data was merged with available data from the local cancer registry. We identified 64 NSCLC patients with resected brain metastases. Median overall survival after resection was 9.1 months with only two patients (3%) surviving more than 71 and 80 months. One and 2-year survival were 42 and 12.5%. Median survival for males and patients with more comorbidities was shorter (8 vs. 10 months [p = 0.11] and 6 vs. 9 months [p = 0.06]). Patients with squamous cell carcinomas (33% of the patients) had a significantly worse survival than patients with other histologies (7 vs. 10 months [p = 0.02]) with no patient living longer than 2 years. Squamous cell histology was associated with worse prognosis after resection of brain metastases in patients with non-small cell lung cancer. Histology, among other parameters, may also be taken into account when choosing the appropriate patients for resection of brain metastases.
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Affiliation(s)
- Paul Martin Putora
- Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland,
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Besse B, Le Moulec S, Mazières J, Senellart H, Barlesi F, Chouaid C, Dansin E, Bérard H, Falchero L, Gervais R, Robinet G, Ruppert AM, Schott R, Léna H, Clément-Duchêne C, Quantin X, Souquet PJ, Trédaniel J, Moro-Sibilot D, Pérol M, Madroszyk AC, Soria JC. Bevacizumab in Patients with Nonsquamous Non–Small Cell Lung Cancer and Asymptomatic, Untreated Brain Metastases (BRAIN): A Nonrandomized, Phase II Study. Clin Cancer Res 2015; 21:1896-903. [DOI: 10.1158/1078-0432.ccr-14-2082] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 01/12/2015] [Indexed: 11/16/2022]
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White matter changes in breast cancer brain metastases patients who undergo radiosurgery alone compared to whole brain radiation therapy plus radiosurgery. J Neurooncol 2014; 121:583-90. [PMID: 25445836 DOI: 10.1007/s11060-014-1670-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 11/23/2014] [Indexed: 12/21/2022]
Abstract
Delayed toxicity after whole brain radiation therapy (WBRT) is of increasing concern in patients who survive more than one year with brain metastases from breast cancer. Radiation-related white matter toxicity is detected by magnetic resonance imaging (MRI) and has been correlated with neurocognitive dysfunction. This study assessed the risk of developing white matter changes (WMC) in breast cancer patients who underwent either WBRT plus stereotactic radiosurgery (SRS) or SRS alone. We retrospectively compared 35 patients with breast cancer brain metastases who received WBRT and SRS to 30 patients who only received SRS. All patients had evaluable imaging at a median of one year after their initial management. The development of white matter T2 prolongation as detected by T2 or FLAIR imaging was graded: grade 1 = little or no white matter T2 hyperintensity; grade 2 = limited periventricular hyperintensity; and grade 3 = diffuse white matter hyperintensity. After WBRT plus SRS, patients demonstrated a significantly higher incidence of WMC (p < 0.0001). After one year, 71.5 % of patients whose treatment included WBRT demonstrated WMC (42.9 % grade 2; 28.6 % grade 3). Only one patient receiving only SRS developed WMC. In long-term survivors of breast cancer, the risk of WMC was significantly reduced when SRS alone was used for management. Further prospective studies are necessary to determine how these findings correlate with neurocognitive toxicity. WBRT usage as initial management of limited brain disease should be replaced by SRS alone to reduce the risk of delayed white matter toxicity.
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Tanriverdi O, Kaytan-Saglam E, Ulger S, Bayoglu IV, Turker I, Ozturk-Topcu T, Cokmert S, Turhal S, Oktay E, Karabulut B, Kilic D, Kucukzeybek Y, Oksuzoglu B, Meydan N, Kaya V, Akman T, Ibis K, Saynak M, Sen CA, Uysal-Sonmez O, Pilancı KN, Demir G, Saglam S, Kocar M, Menekse S, Goksel G, Yapar-Taskoylu B, Yaren A, Uyeturk U, Avci N, Denizli B, Ilis-Temiz E. The clinical and pathological features of 133 colorectal cancer patients with brain metastasis: a multicenter retrospective analysis of the Gastrointestinal Tumors Working Committee of the Turkish Oncology Group (TOG). Med Oncol 2014; 31:152. [PMID: 25108599 DOI: 10.1007/s12032-014-0152-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 07/28/2014] [Indexed: 02/01/2023]
Abstract
Brain metastasis in colorectal cancer is highly rare. In the present study, we aimed to determine the frequency of brain metastasis in colorectal cancer patients and to establish prognostic characteristics of colorectal cancer patients with brain metastasis. In this cross-sectional study, the medical files of colorectal cancer patients with brain metastases who were definitely diagnosed by histopathologically were retrospectively reviewed. Brain metastasis was detected in 2.7 % (n = 133) of 4,864 colorectal cancer patients. The majority of cases were male (53 %), older than 65 years (59 %), with rectum cancer (56 %), a poorly differentiated tumor (70 %); had adenocarcinoma histology (97 %), and metachronous metastasis (86 %); received chemotherapy at least once for metastatic disease before brain metastasis developed (72 %), had progression with lung metastasis before (51 %), and 26 % (n = 31) of patients with extracranial disease at time the diagnosis of brain metastasis had both lung and bone metastases. The mean follow-up duration was 51 months (range 5-92), and the mean survival was 25.8 months (95 % CI 20.4-29.3). Overall survival rates were 81 % in the first year, 42.3 % in the third year, and 15.7 % in the fifth year. In multiple variable analysis, the most important independent risk factor for overall survival was determined as the presence of lung metastasis (HR 1.43, 95 % CI 1.27-4.14; P = 0.012). Brain metastasis develops late in the period of colorectal cancer and prognosis in these patients is poor. However, early screening of brain metastases in patients with lung metastasis may improve survival outcomes with new treatment modalities.
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Affiliation(s)
- Ozgur Tanriverdi
- Department of Medical Oncology, Faculty of Medicine, Medical School of Sitki Kocman University, Mugla, 48000, Turkey,
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Gazzeri R, Nalavenkata S, Teo C. Minimally invasive key-hole approach for the surgical treatment of single and multiple brain metastases. Clin Neurol Neurosurg 2014; 123:117-26. [DOI: 10.1016/j.clineuro.2014.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 05/13/2014] [Accepted: 05/18/2014] [Indexed: 10/25/2022]
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Rogne SG, Helseth E, Brandal P, Scheie D, Meling TR. Are melanomas averse to cerebellum? Cerebellar metastases in a surgical series. Acta Neurol Scand 2014; 130:1-10. [PMID: 24313862 DOI: 10.1111/ane.12206] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To study the propensity of different cancers to metastasize to the cerebrum and cerebellum, and to study overall survival (OS) and prognostic factors for patients after surgical resection for cerebellar metastases. MATERIALS AND METHODS From a prospectively collected tumor database, all patients that underwent a craniotomy for intracranial metastases between 2003 and 2011 at Oslo University Hospital were included. RESULTS One hundred and forty patients underwent resection for cerebellar metastases. Most common primary tumor sites were lung, colon/rectum, and breast in 45%, 19%, and 14%, respectively. None were prostate cancers. Melanoma metastases were significantly underrepresented, and colorectal cancer metastases significantly overrepresented in cerebellum, compared to the overall proportion of cerebellar/supratentorial metastases surgically resected (P < 0.05). Thirty-day post-operative mortality rate was 4.3%. Median OS was 7.7 months (95% CI 6.0-9.5 months) irrespective of post-operative adjuvant therapy. Median OS was 51.8, 8.4, and 3.4 months, respectively, for recursive partitioning analysis class 1(n = 11), 2 (n = 78) and 3 (n = 34). Significant negative prognostic factors were age ≥65 years, Karnofsky performance score (KPS) <70, extracranial metastases and uncontrolled systemic disease. CONCLUSIONS Melanoma metastases were significantly underrepresented in cerebellum, whereas colorectal cancer metastases were significantly overrepresented. Surgical mortality and OS after surgical treatment of cerebellar metastases were similar to the results of supratentorial metastases.
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Affiliation(s)
- S. G. Rogne
- Department of Neurosurgery; Oslo University Hospital; Oslo Norway
| | - E. Helseth
- Department of Neurosurgery; Oslo University Hospital; Oslo Norway
- Faculty of Medicine; University of Oslo; Oslo Norway
| | - P. Brandal
- Department of Oncology; Oslo University Hospital; The Norwegian Radium Hospital; Oslo Norway
| | - D. Scheie
- Department of Pathology; Oslo University Hospital - Rikshospitalet; Oslo Norway
| | - T. R. Meling
- Department of Neurosurgery; Oslo University Hospital; Oslo Norway
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Abstract
Prevalence of cancer and its various related complications continues to rise. Increasingly these life-threatening complications are initially managed in the emergency department, making a prompt and accurate diagnosis crucial to effectively institute the proper treatment and establish goals of care. The following oncologic emergencies are reviewed in this article: pericardial tamponade, superior vena cava syndrome, brain metastasis, malignant spinal cord compression, and hyperviscosity syndrome.
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Affiliation(s)
- Umar A Khan
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 South Paca Street, 2nd Floor, Baltimore, MD 21201, USA
| | - Carl B Shanholtz
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 South Paca Street, 2nd Floor, Baltimore, MD 21201, USA
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 South Paca Street, 2nd Floor, Baltimore, MD 21201, USA.
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Stavas M, Arneson K, Friedman J, Misra S. From Whole Brain to Hospice: Patterns of Care in Radiation Oncology. J Palliat Med 2014; 17:662-6. [DOI: 10.1089/jpm.2013.0549] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Mark Stavas
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kyle Arneson
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey Friedman
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sumathi Misra
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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McDuff SGR, Taich ZJ, Lawson JD, Sanghvi P, Wong ET, Barker FG, Hochberg FH, Loeffler JS, Warnke PC, Murphy KT, Mundt AJ, Carter BS, McDonald CR, Chen CC. Neurocognitive assessment following whole brain radiation therapy and radiosurgery for patients with cerebral metastases. J Neurol Neurosurg Psychiatry 2013; 84:1384-91. [PMID: 23715918 DOI: 10.1136/jnnp-2013-305166] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The treatment of metastatic brain lesions remains a central challenge in oncology. Because most chemotherapeutic agents do not effectively cross the blood-brain barrier, it is widely accepted that radiation remains the primary modality of treatment. The mode by which radiation should be delivered has, however, become a source of intense controversy in recent years. The controversy involves whether patients with a limited number of brain metastases should undergo whole brain radiation therapy (WBRT) or stereotactic radiosurgery (SRS) delivered only to the radiographically visible tumours. Survival is comparable for patients treated with either modality. Instead, the controversy involves the neurocognitive function (NCF) of radiating cerebrum that appeared radiographically normal relative to effects of the growth from micro-metastatic foci. A fundamental question in this debate involves quantifying the effect of WBRT in patients with cerebral metastasis. To disentangle the effects of WBRT on neurocognition from the effects inherent to the underlying disease, we analysed the results from randomised controlled studies of prophylactic cranial irradiation in oncology patients as well as studies where patients with limited cerebral metastasis were randomised to SRS versus SRS+WBRT. In aggregate, these results suggest deleterious effects of WBRT in select neurocognitive domains. However, there are insufficient data to resolve the controversy of upfront WBRT versus SRS in the management of patients with limited cerebral metastases.
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Affiliation(s)
- Susan G R McDuff
- Center for Theoretical and Applied Neuro-Oncology, University of California, , La Jolla, California, USA
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A comparison between cyberknife and neurosurgery in solitary brain metastases from non-small cell lung cancer. Clin Neurol Neurosurg 2013; 115:2009-14. [PMID: 23850045 DOI: 10.1016/j.clineuro.2013.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 06/04/2013] [Accepted: 06/10/2013] [Indexed: 11/22/2022]
Abstract
PURPOSE To evaluate the efficacy of cyberknife (CK) and neurosurgery (NS) in patients newly diagnosed as solitary brain metastasis (SBM) from non-small cell lung cancer (NSCLC). METHODS AND MATERIALS We retrospectively analyzed 76 patients between 1990 and 2012 from our institution, including 38 patients performing CK and the other half performing NS. The observation end point was overall survival time (OS), local control of treated metastasis (LC) and intracranial control (IC). Kaplan-Meier OS curves were compared with the log-rank test. Cox regression analysis was used to determine prognosticators for OS, LC and IC. RESULTS The baseline characteristic between the two groups was not significantly different. The 1-year OS rates were 53.5% and 30.5% in the CK group and NS group, respectively, (p=0.121). The 1-year LC rates were 50.8% and 31.3%, respectively, (p=0.078). The 1-year IC rates were 50.8% and 27.7%, respectively, (p=0.066). In multivariate analysis, improved OS was significantly associated with younger age (p=0.016), better ECOG performance status (p=0.000) and graded prognostic assessment (GPA, 3.5-4.0, p=0.006). The LC was also associated with better ECOG performance status (p=0.000). The IC was associated with both better ECOG performance status (p=0.000) and GPA (3.5-4.0, p=0.005). CONCLUSIONS There was no statistical difference between CK and NS for SBM from NSCLC in OS, LC and IC. However, CK is less invasive and may be more acceptable for patients. The result needs randomized trials to confirm and further study.
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45
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Best supportive care in patients with brain metastases and adverse prognostic factors: development of improved decision aids. Support Care Cancer 2013; 21:2671-8. [DOI: 10.1007/s00520-013-1840-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 04/25/2013] [Indexed: 10/26/2022]
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Stelzer KJ. Epidemiology and prognosis of brain metastases. Surg Neurol Int 2013; 4:S192-202. [PMID: 23717790 PMCID: PMC3656565 DOI: 10.4103/2152-7806.111296] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 02/01/2013] [Indexed: 01/23/2023] Open
Abstract
A substantial, but uncertain, number of patients with cancer develop brain metastases. Risk of brain metastasis is recognized to vary with type of primary cancer. Within specific types of primary cancer, prognostic factors for development of brain metastases are being recognized. Recent data suggest that molecular biomarkers that relate to cellular function can predict risk of developing brain metastases. Such information could optimize surveillance standards and/or be used to select patients for preventive interventions. Though average survival for patients with brain metastases is typically less than 6 months, it is well-recognized that subgroups of patients have significant probability of longer survival. Multiple prognostic models have been proposed, validated, and compared without clearly demonstrating superiority of one model over another. However, some factors show consistency as predictive variables across models, and performance status is almost universally significant. Application of predictive models to specific treatments has been difficult. Tumor-specific prognostic models are evolving, and combinations of biological and clinical factors may be used to optimize models for particular primary tumor types.
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Affiliation(s)
- Keith J Stelzer
- Department of Radiation Oncology, Celilo Cancer Center, Mid-Columbia Medical Center, The Dalles, Oregon, USA
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Hatiboglu MA, Wildrick DM, Sawaya R. The role of surgical resection in patients with brain metastases. Ecancermedicalscience 2013; 7:308. [PMID: 23634178 PMCID: PMC3628720 DOI: 10.3332/ecancer.2013.308] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Indexed: 11/09/2022] Open
Abstract
Brain metastasis is a devastating complication of systemic malignancy that affects a considerable number of cancer patients. The appearance of brain metastases is often considered to be a sign of poor prognosis; in patients with brain metastases poor survival time has been reported in the literature. Therefore, treatment of these brain lesions in cancer patients is important for quality of life, providing local tumour control, preventing death from neurological causes, and improving survival, although potentially only in a minority of patients. Surgical resection of brain metastases has been the cornerstone treatment in select patients. Careful patient selection, the use of appropriate surgical techniques, and surgical adjuncts are the major determinants of favourable outcome in patients undergoing resection of brain metastases. In this review, we explain the role of surgical resection in the treatment of patients with brain metastases with consideration of patient selection, surgical techniques and the use of intraoperative adjuncts.
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Affiliation(s)
- Mustafa Aziz Hatiboglu
- Department of Neurosurgery, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
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A Statistical Comparison of Prognostic Index Systems for Brain Metastases after Stereotactic Radiosurgery or Fractionated Stereotactic Radiation Therapy. Clin Oncol (R Coll Radiol) 2013; 25:227-35. [DOI: 10.1016/j.clon.2012.11.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 10/11/2012] [Accepted: 10/11/2012] [Indexed: 11/21/2022]
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Rodrigues G, Bauman G, Palma D, Louie AV, Mocanu J, Senan S, Lagerwaard F. Systematic review of brain metastases prognostic indices. Pract Radiat Oncol 2013; 3:101-6. [DOI: 10.1016/j.prro.2012.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 04/02/2012] [Indexed: 10/28/2022]
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Nieder C, Grosu AL, Mehta MP. Brain metastases research 1990-2010: pattern of citation and systematic review of highly cited articles. ScientificWorldJournal 2012; 2012:721598. [PMID: 23028253 PMCID: PMC3458272 DOI: 10.1100/2012/721598] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 08/26/2012] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND High and continuously increasing research activity related to different aspects of prevention, prediction, diagnosis and treatment of brain metastases has been performed between 1990 and 2010. One of the major databases contains 2695 scientific articles that were published during this time period. Different measures of impact, visibility, and quality of published research are available, each with its own pros and cons. For this overview, article citation rate was chosen. RESULTS Among the 10 most cited articles, 7 reported on randomized clinical trials. Nine covered surgical or radiosurgical approaches and the remaining one a widely adopted prognostic score. Overall, 30 randomized clinical trials were published between 1990 and 2010, including those with phase II design and excluding duplicate publications, for example, after longer followup or with focus on secondary endpoints. Twenty of these randomized clinical trials were published before 2008. Their median number of citations was 110, range 13-1013, compared to 5-6 citations for all types of publications. Annual citation rate appeared to gradually increase during the first 2-3 years after publication before reaching high levels. CONCLUSIONS A large variety of preclinical and clinical topics achieved high numbers of citations. However, areas such as quality of life, side effects, and end-of-life care were underrepresented. Efforts to increase their visibility might be warranted.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodø, Norway.
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