Management Of Brain Metastases Research Articles

RBIO-06. STEREOTACTIC RADIOSURGERY ENHANCES T-CELL RECEPTOR REPERTOIRES AND INDUCES IMMUNOGENICITY IN BRAIN METASTASIS

Abstract BACKGROUND Brain metastasis is a frequent and deadly complication of systemic malignancy. The incidence rate is increasing and the prognosis remains poor, in contrast to recent advances in the management of systemic malignancy. Our previous work revealed an immunosuppressive microenvironment in brain metastasis and correlation between T-cell status and patient outcomes, shared across the primary tumor histologies. Therefore, we hypothesize that induction of immunogenicity has potential to improve brain metastasis patient outcome. METHODS Pre-operative stereotactic radiosurgery (SRS) (n = 44) and post-operative SRS (n = 47) brain metastasis specimens were collected from an ongoing clinical trial (MDACC protocol 2018-0552) designed to determine optimal timing of SRS for the treatment of brain metastasis. The patient materials were extracted DNA and RNA, and subjected to T-cell receptor (TCR) repertoire sequencing and mRNA-seq to interrogate radiation-induced immunogenicity. RESULTS In a preliminary analysis of the first 21 specimens, Gene Set Enrichment Analysis revealed that SRS significantly enhanced multiple immune-related signaling pathways including interferon response, along with apoptotic pathways, in brain metastasis. We also found that TCR signaling and PD-1 signaling was upregulated by radiotherapy. TCR repertoire analysis further identified increased density and diversity of TCRs induced by SRS treatment. Profiling of the remaining sample set is currently ongoing. CONCLUSIONS In light of our previous finding regarding the correlation between immune status and outcomes of patients with brain metastases, reversing immunosuppression in brain metastasis could be a key factor on patient prognosis and treatment. Our TCR repertoire and mRNA sequencing analyses with pre-operative and post-operative SRS brain metastasis cohorts support a role for radiation-induced immunogenicity, pointing to a prospective therapeutic approach for brain metastasis management.

Multidisciplinary management strategies for recurrent brain metastasis after prior radiotherapy: An overview.

As cancer patients with intracranial metastatic disease experience increasingly prolonged survival, the diagnosis and management of recurrent brain metastasis pose significant challenges in clinical practice. Prior to deciding upon a management strategy, it is necessary to ascertain whether patients have recurrent/progressive disease vs adverse radiation effect, classify the recurrence as local or distant in the brain, evaluate the extent of intracranial disease (size, number and location of lesions, and brain metastasis velocity), the status of extracranial disease, and enumerate the interval from the last intracranially directed intervention to disease recurrence. A spectrum of salvage local treatment options includes surgery (resection and laser interstitial thermal therapy [LITT]) with or without adjuvant radiotherapy in the forms of external beam radiotherapy, intraoperative radiotherapy, or brachytherapy. Nonoperative salvage local treatments also range from single fraction and fractionated stereotactic radiosurgery (SRS/FSRS) to whole brain radiation therapy (WBRT). Optimal integration of systemic therapies, preferably with central nervous system (CNS) activity, may also require reinterrogation of brain metastasis tissue to identify actionable molecular alterations specific to intracranial progressive disease. Ultimately, the selection of the appropriate management approach necessitates a sophisticated understanding of patient, tumor, and prior treatment-related factors and is often multimodal; hence, interdisciplinary evaluation for such patients is indispensable.

Immune Checkpoint Inhibitors in the Management of Brain Metastases from Non-Small Cell Lung Cancer: A Comprehensive Review of Current Trials, Guidelines and Future Directions

Background: Brain metastases (BM) are a common, severe complication in patients with non-small cell lung cancer (NSCLC) and are difficult to treat due to their complex tumor biology and the intricate microenvironment of the brain. Objectives: This review examines the current role of immune checkpoint inhibitors (ICIs) in treating NSCLC with BM, focusing on the latest clinical trials, emerging strategies, current guidelines, and future directions. We highlight the efficacy of ICIs as monotherapy and in combination with other treatments such as radiotherapy, stereotactic radiosurgery, chemotherapy, and anti-VEGF agents. Results: While no single treatment sequence is universally accepted, combining ICIs with traditional therapies forms the core of the current treatment protocols. ICIs targeting the PD-1/PD-L1 pathway have significantly advanced NSCLC treatment, demonstrated by improved overall and progression-free survival in various settings. However, optimizing these benefits requires careful consideration of potential side effects, including cognitive decline and radiation necrosis, and the impact of steroid use on ICI efficacy. Conclusion: The review underscores the necessity for a personalized, integrated multidisciplinary treatment approach. Future research should focus on refining combination therapies and understanding the optimal sequence and timing of treatment.

Modeling the management of patients with human epidermal growth factor receptor 2-positive breast cancer with liquid biopsy: the future of precision medicine.

In the evolving landscape of human epidermal growth factor receptor 2 (HER2)-positive breast cancer (BC) management, liquid biopsy offers unprecedented opportunities for guiding clinical decisions. Here, we review the most recent findings on liquid biopsy applications in HER2-positive BC and its potential role in addressing challenges specific to this BC subtype. Recent studies have highlighted the significance of liquid biopsy analytes, primarily circulating tumor DNA (ctDNA) and circulating tumor cells (CTCs), in stratifying patients' prognosis, predicting treatment response, and monitoring tumor evolution in both early and advanced stages of BC. Liquid biopsy holds promise in studying minimal residual disease to detect and potentially treat disease recurrence before it manifests clinically. Additionally, liquid biopsy may have significant implication in the management of brain metastasis, a major challenge in HER2-positive BC, and could redefine parameters for determining HER2 positivity. Combining ctDNA and CTCs is crucial for a comprehensive understanding of HER2-positive tumors, as they provide complementary insights. Research efforts are needed to address analytical challenges, validate, and broaden the application of liquid biopsy in HER2-positive BC. This effort will ultimately facilitate its integration into clinical practice, optimizing the care of patients with HER2-positive tumors.

Thymic Squamous Cell Carcinoma and Brain Metastases: Case Report and Literature Review

Thymic squamous cell carcinoma (TSCC) is a rare cancer that is typically characterized by low rates of brain metastases. However, when it does occur, brain metastases of TSCC can have significant clinical implications due to its rarity and lack of established management guidelines. In this literature review and case report, we explore the clinical presentation, management, and outcomes of patients with brain metastases of TSCC.Our literature review found that brain metastases of TSCC are relatively rare, with an estimated incidence of 5-10 % among patients with advanced-stage disease. Management of brain metastases of TSCC often involves a combination of surgical resection, radiation therapy, and chemotherapy. However, due to the rarity of this condition, there is currently limited evidence to guide optimal treatment strategies.We also present a case report of a patient with TSCC who was presented with a brain metastasis. This case highlights the importance of early diagnosis and prompt management of brain metastasis of TSCC to improve patient outcomes. Our review and case report underscore the need for further research to improve our understanding of the clinical characteristics, optimal management, and prognosis of patients with brain metastasis of TSCC.

Evolutionary Trend Analysis of Research on Immunotherapy for Brain Metastasis Based on Machine-Learning Scientometrics.

Brain metastases challenge cancer treatments with poor prognoses, despite ongoing advancements. Immunotherapy effectively alleviates advanced cancer, exhibiting immense potential to revolutionize brain metastasis management. To identify research priorities that optimize immunotherapies for brain metastases, 2164 related publications were analyzed. Scientometric visualization via R software, VOSviewer, and CiteSpace showed the interrelationships among literature, institutions, authors, and topic areas of focus. The publication rate and citations have grown exponentially over the past decade, with the US, China, and Germany as the major contributors. The University of Texas MD Anderson Cancer Center ranked highest in publications, while Memorial Sloan Kettering Cancer Center was most cited. Clusters of keywords revealed six hotspots: 'Immunology', 'Check Point Inhibitors', 'Lung Cancer', 'Immunotherapy', 'Melanoma', 'Breast Cancer', and 'Microenvironment'. Melanoma, the most studied primary tumor with brain metastases offers promising immunotherapy advancements with generalizability and adaptability to other cancers. Our results outline the holistic overview of immunotherapy research for brain metastases, which pinpoints the forefront in the field, and directs researchers toward critical inquiries for enhanced mechanistic insight and improved clinical outcomes. Moreover, governmental and funding agencies will benefit from assigning financial resources to entities and regions with the greatest potential for combating brain metastases through immunotherapy.

Utility of ultra‐high‐field magnetic resonance imaging in the detection and management of brain metastases

Utility of ultra‐high‐field magnetic resonance imaging in the detection and management of brain metastases

Navigating the Complexities of Brain Metastases Management.

The management of brain metastases, a potentially devastating complication of advanced cancers, has become increasingly complex with advancements in local and systemic therapies. Improved outcomes and extended survival for patients with metastatic solid tumors have led to a surge in the prevalence and possibly incidence of brain metastases, affecting up to 40% of individuals with solid tumors. Enhanced imaging technologies contribute to more accurate and early detection, shaping the understanding of the intricate landscape of this condition. Traditionally, surgery and radiation stood as the mainstays of treatment because of the limited efficacy of systemic therapies within the brain. However, emerging clinical data, particularly in melanoma, lung, and breast cancers, reveal promising results with novel systemic treatments such as immunotherapy and targeted therapies. Despite the historical exclusion of patients with active brain metastases from clinical trials, a shift is occurring toward a more inclusive approach. This chapter delves into the multifaceted challenges associated with managing brain metastases, with a focus on the evolving landscape of systemic approaches as well as the intricacies of shared decision making, providing a comprehensive overview of the current state and future directions in navigating the complexities of brain metastases management.

Surgical Management of Brain Metastasis from Esophageal Cancer: A Systematic Review and Single-Center Experience

Brain metastases from esophageal cancer (BMEC) are rare and aggressive, with limited literature on optimal treatment modalities and a standard of care yet to be established. The objective of this study was to systematically review existing literature and perform a retrospective analysis of our institution's patients to evaluate the influence of different treatment modalities on patient outcomes. A systematic review of the literature following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines and a retrospective review of our institutional experience with BMEC were both conducted. Data based on mean survival,histology, metastasis location, and treatment modality were abstracted. A total of 48 studies representing 136 patients with BMEC were identified, in addition to the 11 patients treated at our institution. There were a total of 100 males (12 unreported), with a median age of 62.2 at diagnosis in our systematic review, along with 8 males with a median age of 62 in our institutional review. Collectively, survival rates observed based on histology were not similar (squamous cell carcinoma: 9.2months, adenocarcinoma: 13.4months), however, based on treatment modalities (surgery: 11.6months, radiation: 10.4months, chemotherapy: 12.3months), and metastasis location (supratentorial: 10.5months, infratentorial: 9.9months), the survival times were comparable. Our review suggests that causes of death were often independent of brain metastases highlighting the need for further studies on early detection and prevention of primary esophageal cancer, as well as improved treatment modalities for BMECs.

Abstract PO1-05-01: Cyclin-dependent Kinase 4/6 Inhibitors Combined with Radiotherapy in the Management of Brain Metastases in HR-positive/HER2-negative Breast Cancer Patients

Abstract Purpose: Cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) plus endocrine therapy demonstrated overall survival benefits in advanced breast cancer patients (ABC), hormone receptor-positive, HER2-negative (HR+/HER2-) and remains the mainstay in the first and second-line treatment. Brain metastases are rare at the beginning of treatment in this group of patients and are found more often during subsequent lines of treatment and other subtypes of breast cancer. However, there is a paucity of data on the safety and efficacy of multimodality CDK4/6i and radiotherapy treatment in the management of brain metastases. Thus, we performed a retrospective analysis of ABC patients (pts) treated at our institution with radiation therapy to the brain and CDK4/6i. Pts who received radiotherapy before CDK4/6i initiation or concurrently with CDK4/6i (group 1) were compared to the patients who progressed in the brain during CDK4/6i treatment and then received radiotherapy (group 2). The primary endpoint was progression-free survival (PFS) in group 1 vs. group 2; the secondary endpoints were local control (LC) within the brain in group 1 vs. group 2 and severe toxicity. Materials/Methods: Among 379 pts who received CDK4/6i, 26 pts (6.9%) received radiotherapy to the brain. 17 pts received radiotherapy before or concurrent with CDK4/6i and were included in group 1. Nine pts received radiotherapy after CDK4/6i discontinuation due to disease progression and comprised group 2. Results: The median age was 51.5 years (IQR range 41-62). Six pts had de novo metastatic disease. The majority of patients were treated in the first-line setting (15 pts, 58%). 17 pts received ribociclib, 7 palbociclib, and 2 abemaciclib. 15 pts received letrozole as an endocrine compound and 11 pts fulvestrant. 19 pts (73%) received previous chemotherapy. Six pts had an ECOG performance status of 0, 15 pts ECOG 1, and 5 pts ECOG 2. The most common local treatment was whole-brain radiotherapy with a total dose of 20 Gy delivered in 5 fractions (fr) (11 pts: 4 pts VMAT, 2 pts IMRT, 3 pts 3D, and 2 pts 2D). Eight pts received stereotactic radiation therapy (6 pts with Linac: 2 pts 24 Gy/2 fr, 2 pts 24 Gy/3 fr, 2 pts 25 Gy/5 fr; 1 pt GammKnife 20 Gy/1 fr, 1 pt Cyberknife 15 Gy/3 fr). Six- and 12-month PFS in group 1 was 88.2% (95% CI74.1-100) and 58.8% (95% CI: 37.7- 91.8), respectively, whereas in group 2, six- and 12-month PFS was 55.6% (95%CI: 31- 99.7) and 44.4% (95% CI: 21- 92.2), respectively. Six- and 12-month LC in group 1 was 92.3% (95%CI: 78.9-100) and 83.9% (65.7-100), respectively. LC in group 2 was poor: 3-month LC was only 66.7 (30-100). At a median follow-up of 8.8 months, no unanticipated toxicity was reported. Conclusion: Multimodality treatment with CDK4/6i and radiotherapy to the brain is safe and effective. Patients who developed metastases during CDK4/6i treatment tend to have a worse prognosis in comparison to those who received prior radiotherapy. CDK4/6i following radiotherapy seems to be an effective and valuable treatment option in this particular metastatic breast cancer population. Citation Format: Marcin Kubeczko, Dorota Gabryś, Anna Polakiewicz-Gilowska, Aleksandra Krzywon, Donata Gräupner, Barbara Łanoszka, Marta Mianowska-Malec, Aleksandra Leśniak, Katarzyna Świderska, Konstanty Chomik, Barbara Grandys, Michał Jarząb. Cyclin-dependent Kinase 4/6 Inhibitors Combined with Radiotherapy in the Management of Brain Metastases in HR-positive/HER2-negative Breast Cancer Patients [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-05-01.

Efficacy and Safety of Stereotactic Radiosurgery Versus Whole Brain Radiotherapy for the Management of Brain Metastasis: A Systematic Review and Meta-analysis (P4-5.011)

Efficacy and Safety of Stereotactic Radiosurgery Versus Whole Brain Radiotherapy for the Management of Brain Metastasis: A Systematic Review and Meta-analysis (P4-5.011)

Hypofractionated Stereotactic Radiosurgery in the Management of Brain Metastases.

Stereotactic radiosurgery (SRS) is an important weapon in the management of brain metastases. Single-fraction SRS is associated with local control rates ranging from approximately 70% to 100%, which are largely dependent on lesion and postoperative cavity size. The rates of local control and improved neurocognitive outcomes compared with conventional whole-brain radiation therapy have led to increased adoption of SRS in these settings. However, when treating larger targets and/or targets located in eloquent locations, the risk of normal tissue toxicity and adverse radiation effects within healthy brain tissue becomes significantly higher. Thus, hypofractionated SRS has become a widely adopted approach, which allows for the delivery of ablative doses of radiation while also minimizing the risk of toxicity. This approach has been studied in multiple retrospective reports in both the postoperative and intact settings. While there are no reported randomized data to date, there are trials underway evaluating this paradigm. In this article, we review the role of hypofractionated SRS in the management of brain metastases and emerging data that will serve to validate this treatment approach. Pertinent articles and references were obtained from a comprehensive search of PubMed/MEDLINE and clinicaltrials.gov .

Stereotactic Radiosurgery and Stereotactic Fractionated Radiotherapy in the Management of Brain Metastases.

The management of brain metastases (BM) remains an important and complex issue in the treatment of cancer-related neurological complications. BM are particularly common in patients diagnosed with lung, melanoma, or breast cancer. Over the past decade, therapeutic approaches for the majority of BM patients have changed. Considering and addressing the fact that patients with BM are living longer, the need to provide effective local control while preserving quality of life and neurocognition is fundamental. Over the past decade, SRS and SRT have become a more commonly chosen treatment option for BM. Despite significant advances in the treatment of BM, numerous questions remain regarding patient selection and optimal treatment sequencing. Clinical trials are critical to advancing our understanding of BM, especially as more therapeutic alternatives become available. Therefore, it is imperative for interdisciplinary teams to improve their understanding of the latest advances in SRS-SRT. This review aims to comprehensively explore SRS and SRT as treatments for BM, covering clinical considerations in their application (e.g., patient selection and eligibility), managing limited and multiple intact BM, addressing brainstem metastases, exploring combination therapies with systemic treatments, and considering the health economic perspective.

From pre-clinical to translational brain metastasis research: current challenges and emerging opportunities.

Brain metastasis, characterized by poor clinical outcomes, is a devastating disease. Despite significant mechanistic and therapeutic advances in recent years, pivotal improvements in clinical interventions have remained elusive. The heterogeneous nature of the primary tumor of origin, complications in drug delivery across the blood-brain barrier, and the distinct microenvironment collectively pose formidable clinical challenges in developing new treatments for patients with brain metastasis. Although current preclinical models have deepened our basic understanding of the disease, much of the existing research on brain metastasis has employed a reductionist approach. This approach, which often relies on either in vitro systems or in vivo injection models in young and treatment-naive mouse models, does not give sufficient consideration to the clinical context. Given the translational importance of brain metastasis research, we advocate for the design of preclinical experimental models that take into account these unique clinical challenges and align more closely with current clinical practices. We anticipate that aligning and simulating real-world patient conditions will facilitate the development of more translatable treatment regimens. This brief review outlines the most pressing clinical challenges, the current state of research in addressing them, and offers perspectives on innovative metastasis models and tools aimed at identifying novel strategies for more effective management of clinical brain metastasis.

Consensus guidelines for the management of intracranial metastases for low- and middle-income countries.

Metastatic tumours are among the most common types of brain tumours. However, in low- and middle-income countries (LMICs), the numbers are considerably lower. This does not necessarily indicate a decreased incidence but rather points to decreased survival rates or limited access to healthcare. The challenge of achieving better outcomes, along with associated costs and resource constraints, often hinders the effective management of brain metastasis. Even in cases where localised disease can potentially be managed to improve survival, these challenges persist. The purpose of these guidelines is to address these challenges and outline a management strategy within the context of LMICs.

Is two-staged gamma knife surgery a reasonable management option for very large cerebellar metastases? A case series of three patients.

Two-staged gamma knife surgery (GKS) is a method that may extend the upper tumor volume limit for using GKS in the management of brain metastases. However, the safety of treating very large posterior fossa lesions with this technique has not been well demonstrated. Therefore, we analyzed our experience in treating cerebellar metastases larger than 12 cm3 with two-staged GKS. Four consecutive patients harboring 12 to 30 cm3 cerebellar metastases scheduled two-staged GKS were included in the study, and all but one patient completed the treatment. The treatment doses were 10-13Gy. All patients were followed with regular MR imaging and clinical assessments, and the tumor volumes were measured on all treatment and follow-up images. Tumor progression was not demonstrated in any of the patients. Tumor volumes decreased by, on average, more than half between the two stages. The median survival was 22months, and no patient died due to intracranial tumor progression. Peritumoral edema at the first GKS resolved in all patients, replaced by asymptomatic mild T2 changes in two of them not requiring any treatment. No radiation-induced complication has developed thus far. Staged GKS seems to be a feasible management option for very large cerebellar metastases.

Coordination of anti-CTLA-4 with whole-brain radiation therapy decreases tumor burden during treatment in a novel syngeneic model of lung cancer brain metastasis

Lung cancer is the most common primary tumor to metastasize to the brain. Although advances in lung cancer therapy have increased rates of survival over the past few decades, control and treatment of lung cancer brain metastasis remains an urgent clinical need. Herein, we examine the temporal coordination of α-CTLA-4 administration in combination with whole-brain radiation therapy in a syngeneic preclinical model of lung cancer brain metastasis in both C57Bl/6 and athymic nude mice. Brain tumor burden, survival, and weight loss were monitored. Immunotherapy administration 24 h prior to irradiation resulted in increased brain tumor burden, while administration of immunotherapy 12 h after radiation decreased tumor burden. Neither of the treatments affected survival outcomes or weight loss due to brain tumor recurrence. These findings suggest that the coordination of α-CTLA-4 administration in addition to whole-brain radiation therapy may be a viable strategy for reduction of tumor burden for the management of lung cancer brain metastasis.

Evolution of the Management of Brain Metastases: A Bibliometric Analysis

A systematic review of the published literature was conducted to analyze the management evolution of brain metastases from different cancers. Using the keywords “brain metastasis”, “brain metastases”, “CNS metastasis”, “CNS metastases”, “phase III” AND/OR “Randomized Controlled Trial” (RCT), relevant articles were searched for on the SCOPUS database. A total of 1986 articles were retrieved, published over a 45-year period (1977–2022). Relevant articles were defined as clinical studies describing the treatment or prevention of brain metastases from any cancer. Articles on imaging, quality of life, cognitive impairment after treatment, or primary brain tumors were excluded. After a secondary analysis, reviewing the abstracts and/or full texts, 724 articles were found to be relevant. Publications significantly increased in the last 10 years. A total of 252 articles (34.8%) were published in 12 core journals, receiving 50% of the citations. The number of publications in Frontiers in Oncology, BMC Cancer, and Radiotherapy and Oncology have increased considerably over the last few years. There were 111 randomized controlled trials, 128 review articles, and 63 meta-analyses. Most randomized trials reported on brain metastases management from unselected tumors (49), lung cancer (47), or breast cancer (11). In the last 5 years (2017 to 2022), management of brain metastasis has moved on from WBRT, the use of chemotherapy, and radio-sensitization to three directions. First, Radiosurgery or Radiotherapy (SRS/SRT), or hippocampal-sparing WBRT is employed to reduce radiation toxicity. Second, it has moved to the use of novel agents, such as tyrosine kinase inhibitors (TKI) and immune checkpoint inhibitors (ICI) and third, to the use of molecularly directed therapy such as TKIs, in asymptomatic low volume metastasis, obviating the need for WBRT.

Immunotherapy as a promising treatment strategy for dmmr colorectal cancer with brain metastasis: a case report

Brain metastasis in colorectal cancer is a rare occurrence with poor prognosis and limited treatment options. This case report presents a unique and previously unreported case of brain metastasis in a patient with dMMR (DNA mismatch repair-deficient) colorectal cancer. The patient, a 70-year-old male, initially presented with abdominal pain and was diagnosed with moderately differentiated adenocarcinoma of the right colon. Following surgical resection and adjuvant chemotherapy, the patient developed cognitive decline and was found to have a metastatic lesion in the left temporal lobe. Immunohistochemical analysis revealed MSH2 positivity and MSH6, MLH1, and PMS2 negativity, indicating dMMR status. Further genetic testing showed wild-type Kras, Nras, and Braf, and high tumor mutational burden (TMB). The patient was subsequently treated with pembrolizumab immunotherapy, resulting in a significant improvement of symptoms and a reduction in the size of brain metastasis. This case highlights the rarity and challenging management of brain metastasis in colorectal cancer, particularly in the context of dMMR tumors. The successful use of immunotherapy in this case provides valuable insights into the potential efficacy of immune-based treatments for dMMR colorectal cancer with brain metastasis, underscoring the need for further research in this field.

Advancements without consensus: differing practice patterns highlight unanswered questions in the management of brain metastases from EGFR- and ALK-positive non-small cell lung cancer

Advancements without consensus: differing practice patterns highlight unanswered questions in the management of brain metastases from EGFR- and ALK-positive non-small cell lung cancer