International Journal of Radiation Oncology*Biology*Physics
A randomized phase III study of accelerated hyperfractionation versus standard in patients with unresected brain metastases: A report of the radiation therapy oncology group (RTOG) 9104
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Cited by (286)
Métastases du système nerveux central
2023, Revue des Maladies Respiratoires ActualitesLe cancer bronchique est le premier pourvoyeur de métastases cérébrales(MC). La prévalence des MC peut atteindre 50 % des cancers bronchiques non à petites cellules (CBNPC) et 80 % des cancers bronchique à petites cellules (CPC) au cours du suivi. La prévalence est également plus importante en présence de certaines addictions oncogéniques tels que les mutations de l’EGFR ou les translocations d’ALK. De plus, les MC entraînent une importante morbi-mortalité. Elles sont directement responsables du décès dans 50 % des cas.
L’évolution des MC sous traitement est variable, et peut être différente de la tumeur primitive. Ceci est probablement dû à une hétérogénéité moléculaire entre la MC et la tumeur primitive, liée à la fois à la barrière hémato encéphalique (BHE) et à un microenvironnement tumoral très différent.
Selon l’histologie, la présence d’une addiction oncogénique et le profil d’expression de PDL1, les traitements systémiques pourront reposer sur de l’immunothérapie seule, une combinaison chimiothérapie-immunothérapie ou une thérapie ciblée. De plus en plus de données sont disponibles sur l’efficacité intracérébrale des traitements systémiques, y compris pour les nouvelles classes thérapeutiques en développement. Outre les traitements systémiques, les traitements locaux reposeront sur : la chirurgie, la radiothérapie pan-cérébrale ou la radiothérapie stéréotaxique (RTS). Le choix du traitement local et sa place par rapport au traitement systémique dépend entre autres du nombre et du volume des lésions cérébrales. Du fait d’effets indésirables moindres, la RTS a une place grandissante dans la prise en charge. L’irradiation encéphalique prophylactique est limitée aux CPC qui répondent au traitement systémique.
1877-1203/© 2023 SPLF. Publié par Elsevier Masson SAS. Tous droits réservés.
Lung cancer is the leading provider of brain metastases (BMs). The prevalence of BMs varies depending on pathology and can occur in up to 50% of non-small cell lung cancers (NSCLC) and 80% of small cell lung cancers (SCLC) during follow-up. BMs prevalence is also higher in case of oncogenic addictions such as EGFR mutations or ALK rearrangements. Furthermore, BMs result in significant morbidity and mortality. They are directly responsible for death in 50% of cases.
BMs evolution and response to treatments is heterogeneous, and can be different from the primary tumor. This is due to molecular differences between BMs and primary tumors related to the blood-brain barrier (BBB) but also to a very different tumor microenvironment.
Depending on pathology, tumor mutation profile and PDL1 expression, systemic treatments may be based on immunotherapy alone, a combination of chemotherapy and immunotherapy, or targeted therapies. More and more data are available on intracranial response of systemic treatments, including data for new treatments in development. In addition to systemic treatments, local treatments such as surgery, whole brain radio therapy (WBRT) or stereotactic radiotherapy (SBRT) should be considered. Local treatment choice mainly depends on the number and volume of brain lesions. Because of fewer side effects, SBRT is becoming an increasingly important part of treatment. On the contrary, prophylactic cranial irradiation is limited to SCLCs with good response to chemotherapy.
1877-1203/© 2023 SPLF. Published by Elsevier Masson SAS. All rights reserved.
Efficacy of stereotactic radiosurgery as single or combined therapy for brain metastasis: A systematic review and meta-analysis
2023, Critical Reviews in Oncology/HematologyTo determine the efficacy of stereotactic radiosurgery (SRS) in treating patients with brain metastases (BMs), a network meta-analysis (NMA) of randomized controlled trials (RCTs) and a direct comparison of cohort studies were performed. Relevant literature regarding the effectiveness of SRS alone and in combination with whole-brain radiotherapy (WBRT) and surgery was retrieved using systematic database searches up to April 2019. The patterns of overall survival (OS), one-year OS, progression-free survival (PFS), one-year local brain control (LBC), one-year distant brain control (DBC), neurological death (ND), and complication rate were analyzed. A total of 18 RCTs and 37 cohorts were included in the meta-analysis. Our data revealed that SRS carried a better OS than SRS+WBRT (p = 0.048) and WBRT (p = 0.041). Also, SRS+WBRT demonstrated a significantly improved PFS, LBC, and DBC compared to WBRT alone and SRS alone. Finally, SRS achieved the same LBC as high as surgery, but intracranial relapse occurred considerably more frequently in the absence of WBRT. However, there were not any significant differences in ND and toxicities between SRS and other groups. Therefore, SRS alone may be a better alternative since increased patient survival may outweigh the increased risk of brain tumor recurrence associated with it.
Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline
2022, Practical Radiation OncologyThis guideline provides updated evidence-based recommendations addressing recent developments in the management of patients with brain metastases, including advanced radiation therapy techniques such as stereotactic radiosurgery (SRS) and hippocampal avoidance whole brain radiation therapy and the emergence of systemic therapies with central nervous system activity.
The American Society for Radiation Oncology convened a task force to address 4 key questions focused on the radiotherapeutic management of intact and resected brain metastases from nonhematologic solid tumors. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength.
Strong recommendations are made for SRS for patients with limited brain metastases and Eastern Cooperative Oncology Group performance status 0 to 2. Multidisciplinary discussion with neurosurgery is conditionally recommended to consider surgical resection for all tumors causing mass effect and/or that are greater than 4 cm. For patients with symptomatic brain metastases, upfront local therapy is strongly recommended. For patients with asymptomatic brain metastases eligible for central nervous system–active systemic therapy, multidisciplinary and patient-centered decision-making to determine whether local therapy may be safely deferred is conditionally recommended. For patients with resected brain metastases, SRS is strongly recommended to improve local control. For patients with favorable prognosis and brain metastases receiving whole brain radiation therapy, hippocampal avoidance and memantine are strongly recommended. For patients with poor prognosis, early introduction of palliative care for symptom management and caregiver support are strongly recommended.
The task force has proposed recommendations to inform best clinical practices on the use of radiation therapy for brain metastases with strong emphasis on multidisciplinary care.
Intracranial metastases
2022, Handbook of Neuro-Oncology NeuroimagingApproximately 30% of patients with solid tumours develop brain metastases, which have historically been approached as a single entity with poor prognosis. The advancement in our understanding of the biologic and molecular underpinnings of different diseases, as well as the advancement in technologies and surgical approaches, has led to numerous treatment options for most patients with brain metastases, allowing for personalisation of management. The development of prognostic indices that take into account clinical, anatomical, histological and molecular factors has allowed physicians to tailor individualised treatment plans. Advancements in imaging modalities enable more accurate methods to diagnose brain metastases and determine the efficacy of treatments. This chapter discusses the epidemiology, clinical presentations, prognostic systems, imaging modalities and management options for patients with brain metastases.
Brain metastases: An update on the multi-disciplinary approach of clinical management
2022, NeurochirurgieBrain metastasis (BM) is the most common malignant intracranial neoplasm in adults with over 100,000 new cases annually in the United States and outnumbering primary brain tumors 10:1.
The incidence of BM in adult cancer patients ranges from 10-40%, and is increasing with improved surveillance, effective systemic therapy, and an aging population. The overall prognosis of cancer patients is largely dependent on the presence or absence of brain metastasis, and therefore, a timely and accurate diagnosis is crucial for improving long-term outcomes, especially in the current era of significantly improved systemic therapy for many common cancers. BM should be suspected in any cancer patient who develops new neurological deficits or behavioral abnormalities. Gadolinium enhanced MRI is the preferred imaging technique and BM must be distinguished from other pathologies. Large, symptomatic lesion(s) in patients with good functional status are best treated with surgery and stereotactic radiosurgery (SRS). Due to neurocognitive side effects and improved overall survival of cancer patients, whole brain radiotherapy (WBRT) is reserved as salvage therapy for patients with multiple lesions or as palliation. Newer approaches including multi-lesion stereotactic surgery, targeted therapy, and immunotherapy are also being investigated to improve outcomes while preserving quality of life.
With the significant advancements in the systemic treatment for cancer patients, addressing BM effectively is critical for overall survival. In addition to patient's performance status, therapeutic approach should be based on the type of primary tumor and associated molecular profile as well as the size, number, and location of metastatic lesion(s).
Radiation Therapy for Brain Metastases: A Systematic Review
2021, Practical Radiation OncologyThis evidence report synthesizes the available evidence on radiation therapy for brain metastases.
The literature search included PubMed, EMBASE, Web of Science, Scopus, CINAHL, clinicaltrials.gov, and published guidelines in July 2020; independently submitted data, expert consultation, and contacting authors. Included studies were randomized controlled trials (RCTs) and large observational studies (for safety assessments), evaluating whole brain radiation therapy (WBRT) and stereotactic radiosurgery (SRS) alone or in combination, as initial or postoperative treatment, with or without systemic therapy for adults with brain metastases due to lung cancer, breast cancer, or melanoma.
Ninety-seven studies reported in 189 publications were identified, but the number of analyses was limited owing to different intervention and comparator combinations as well as insufficient reporting of outcome data. Risk of bias varied, and 25 trials were terminated early, predominantly owing to poor accrual. The combination of SRS plus WBRT compared with SRS alone or WBRT alone showed no statistically significant difference in overall survival (hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.69%-1.73%; 4 RCTs) or death owing to brain metastases (relative risk [RR], 0.93; 95% CI, 0.48%-1.81%; 3 RCTs). Radiation therapy after surgery did not improve overall survival compared with surgery alone (HR, 0.98; 95% CI, 0.76%-1.26%; 5 RCTs). Data for quality of life, functional status, and cognitive effects were insufficient to determine effects of WBRT, SRS, or postsurgery interventions.
We did not find systematic differences across interventions in serious adverse events, number of adverse events, radiation necrosis, fatigue, or seizures. WBRT plus systemic therapy (RR 1.44; 95% CI, 1.03%-2.00%; 14 studies) was associated with increased risks for vomiting compared with WBRT alone.
Despite the substantial research literature on radiation therapy, comparative effectiveness information is limited. There is a need for more data on patient-relevant outcomes such as quality of life, functional status, and cognitive effects.