Treatment Of Brain Metastases Research Articles

The incidence of brain metastases in breast cancer according to molecular subtype and stage: a 10-year single institution analysis.

Breast cancer (BC) is the second most common etiology of brain metastases (BrM). We aimed to examine the incidence of BrM among all BC patients presenting to a large tertiary cancer centre over one decade. We included all BC patients presenting consecutively between 2009 and 2019 and cross referenced that cohort to a radiotherapy database, identifying patients treated for BrM at any time following their initial presentation. Cumulative incidences (CI) of BrM diagnoses were calculated using death as a competing risk and compared using the Fine-Gray method. Overall survival was estimated using the Kaplan Meier method. We identified 12,995 unique patients. The CI of BrM in patients who initially presented with Stage 0-4 disease was 2.1%, 3.7%, 9.4%, 10.6%, and 28.7%, respectively at 10years. For 8,951 patients with available molecular subtype data, 6,470 (72%), 961 (11%), 1,023 (11%), and 497 (6%) had hormone-receptor (HR)-positive/ERBB2-, HR-negative/ERBB2-, HR-positive/ERBB2 + , and HR-negative/ERBB2 + disease, respectively; the CI of BrM in each was 7.6%, 25.3%, 24.1%, and 26.6%, at 10years following BC diagnosis, respectively. Median overall survival (OS) following BC diagnosis and BrM diagnosis was 28years 95% CI [25, 32] and 10months 95% CI [9, 12], respectively. From a large, registry-based study, we observed that patients with ERBB2 + and triple negative BC have the highest incidence of BrM. Our data supports prospective surveillance brain MRI studies. Given advancements in BrM treatment, clinicians should have a low threshold for brain imaging in BC patients with high risk subtypes.

Advances in determining the gross tumor target volume for radiotherapy of brain metastases

Brain metastases (BMs) are the most prevalent intracranial malignant tumors in adults and are the leading cause of mortality attributed to malignant brain diseases. Radiotherapy (RT) plays a critical role in the treatment of BMs, with local RT techniques such as stereotactic radiosurgery (SRS)/stereotactic body radiotherapy (SBRT) showing remarkable therapeutic effectiveness. The precise determination of gross tumor target volume (GTV) is crucial for ensuring the effectiveness of SRS/SBRT. Multimodal imaging techniques such as CT, MRI, and PET are extensively used for the diagnosis of BMs and GTV determination. With the development of functional imaging and artificial intelligence (AI) technology, there are more innovative ways to determine GTV for BMs, which significantly improve the accuracy and efficiency of the determination. This article provides an overview of the progress in GTV determination for RT in BMs.

Response of treatment-naive brain metastases to stereotactic radiosurgery

With improvements in survival for patients with metastatic cancer, long-term local control of brain metastases has become an increasingly important clinical priority. While consensus guidelines recommend surgery followed by stereotactic radiosurgery (SRS) for lesions >3 cm, smaller lesions (≤3 cm) treated with SRS alone elicit variable responses. To determine factors influencing this variable response to SRS, we analyzed outcomes of brain metastases ≤3 cm diameter in patients with no prior systemic therapy treated with frame-based single-fraction SRS. Following SRS, 259 out of 1733 (15%) treated lesions demonstrated MRI findings concerning for local treatment failure (LTF), of which 202 /1733 (12%) demonstrated LTF and 54/1733 (3%) had an adverse radiation effect. Multivariate analysis demonstrated tumor size (>1.5 cm) and melanoma histology were associated with higher LTF rates. Our results demonstrate that brain metastases ≤3 cm are not uniformly responsive to SRS and suggest that prospective studies to evaluate the effect of SRS alone or in combination with surgery on brain metastases ≤3 cm matched by tumor size and histology are warranted. These studies will help establish multi-disciplinary treatment guidelines that improve local control while minimizing radiation necrosis during treatment of brain metastasis ≤3 cm.

Abstract PO5-16-10: The efficacy of novel antibody-drug-conjugates on brain metastases in metastatic breast cancer patients – a multicenter real-world analysis

Abstract 15 – 30% of all patients with metastatic breast cancer (MBC) develop brain metastases (BMs). Treatment of BMs include radiation therapy and surgical resection while systemic treatment is challenging and prospective evidence for the treatment of active brain metastases is restricted to the small molecule Tucatinib. Recently, the antibody-drug-conjugates (ADCs) Sacituzumab-Govitecan (SG) and Trastuzumab-Deruxtecan (T-DXd) have shown to be highly effective in the treatment of triple-negative (SG), HER2-positive (T-DXd) and HR+/HER2- (SG and, in case of HER2-low-expression, T-DxD) MBC. However, there is only limited data, whether these macromolecules are also effective in patients with BMs. We therefore aimed to examine the efficacy of SG and T-DXd in patients with stable and active BMs in a multicenter real-world analysis. Female patients with stable or active BMs who were treated with either SG or T-DXd at the breast centers of Tuebingen University, Ulm University or Freiburg University in Germany before June 30, 2023 were included into this analysis. Data cut-off for this analysis was July 10, 2023. BMs were classified as active if they were newly diagnosed and did not require local treatment or if they were progressing and did not require local treatment. Preexisting BMs without intracranial disease progression or preexisting/newly diagnosed BMs that had been treated by surgery and/or radiotherapy directly prior to SG/T-DXd therapy were considered as stable. All patients underwent baseline magnetic resonance imaging (MRI) of the brain and received follow-up MRIs at least every three months. Growth dynamics of BMs were assessed by board certified neuroradiologists. Intracranial disease control rate (icDCR) was defined as the percentage of patients with at least intracranial stable disease at the first follow-up MRI. Intracranial progression-free survival (icPFS) was determined as the period between the first application of SG or T-DXd and intracranial disease progression or treatment cessation due to the patients’ will or the onset of intolerable toxicity. If ADC treatment was discontinued due to extracranial disease progression albeit at least stable intracranial disease patients were censored. Overall survival (OS) was defined as the period between the first application of SG or T-DXd and death. In total, 26 patients were included with a median of two prior therapy lines in the metastatic setting (range 2 – 15). 10 (38%) and 14 (54%) patients received SG and T-DXd, respectively. 2/26 (8%) patients receiving SG were consecutively subjected to T-DXd treatment. SG was applied to 12/12 patients (100%) due to triple-negative MBC and 12/16 patients (75%) treated with T-DXd were HER2-positive. The remaining 4/16 patients (25%) treated with T-DXd showed HER2 low tumor biology. 5/12 (42%) and 8/16 (50%) patients treated with SG or T-DXd had active BMs at treatment initiation. The icDCR was 33% (95% CI: 5% - 61%)/81% (95% CI: 62% - 100%) for all patients treated with SG/T-DXd and 40% (95% CI: 0% - 88%)/75% (95% CI: 43% - 100%) in case of active BMs. After a median follow-up of 7.2 months, 10/12 (83.3%) patients treated with SG and 4/16 (25%) patients subjected to T-DXd had discontinued treatment. Median icPFS was 3.1 months (95% CI: 0.4 – 5.8 months) for SG and not reached for T-DXd. 7/12 (58%) patients treated with SG and 4/16 patients (25%) treated with T-DXd died until data cut-off. Median OS was 7.2 months (95% CI: 3.0 – 11.4 months) for patients treated with SG and not reached for patients treated with T-DXd. SG and T-DXd showed promising clinical activity in both, stable and active cerebral breast cancer metastasis. Updated PFS and OS data will be reported at the meeting. Citation Format: Dominik Dannehl, Henning Schäffler, Tobias Engler, Lea Volmer, Arne Estler, Ilinca Popp, Stefanie Lorenz, Eva-Maria Grischke, Markus Hahn, Ghazaleh Tabatabai, Ingolf Juhasz-Böss, Wolfgang Janni, Sara Brucker, Florin-Andrei Taran, Andreas Hartkopf. The efficacy of novel antibody-drug-conjugates on brain metastases in metastatic breast cancer patients – a multicenter real-world analysis [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 PO5-16-10.

Abstract ED07-03: Novel Systemic Therapy Strategies for HER2+ Brain Metastases

Abstract More than 1/3 of patients with HER2+ metastatic breast cancer will develop brain metastases. Local therapies such as resection or radiation therapy continue to play a pivotal role in brain metastases treatment. However, receipt of HER2-directed systemic therapies lead to significant survival advances for both stable and active brain metastases and are integral to optimal outcomes. We will review clinical goals for stable and active brain metastases. In the last few years, novel early line systemic therapy regimens have improved outcomes for HER2+ brain metastases which will be reviewed. We will review evolving evidence that Antibody Drug Conjugates targeting HER2 have robust intracranial activity. We will review exciting HER2 directed tyrosine kinase inhibitors and combinations. Citation Format: S. Sammons. Novel Systemic Therapy Strategies for HER2+ Brain Metastases [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 ED07-03.

Abstract PO5-20-03: Phase I/II study of stereotactic radiosurgery with concurrent olaparib followed by adjuvant durvalumab and physician’s choice systemic therapy in subjects with breast cancer brain metastases

Abstract BACKGROUND: Despite progress in the treatment of brain metastasis for HER2+ breast cancer, outcomes for patients with HER2-negative breast cancer brain metastases remain poor. Current standard of care consists of local therapies, including surgery and radiotherapy, followed by systemic therapy. Preclinical studies show inhibitors of poly(ADP-ribose) polymerase (PARP) are effective in combination with radiation therapy as a DNA damage response inhibitor. Triple-negative breast cancer (TNBC) has higher rates of homologous recombination deficiency compared to other breast cancer subtypes, and together with HER2-negative, BRCA-mutated breast cancer would be particularly sensitive to PARP inhibition. PARP inhibition has also demonstrated promising efficacy combined with immunotherapy in patients with germline BRCA-mutant and metastatic TNBC in clinical trials (MEDIOLA, TOPACIO). In addition, immunotherapy with stereotactic radiosurgery (SRS) is associated with favorable intracranial control and survival in patients with brain metastases. We hypothesize that this biologically-driven combination will enhance local control of SRS-treated brain metastases through synergy with PARP inhibition, while controlling micrometastatic disease in the brain and extracranial sites via potentiation of the immune response. METHODS: We are conducting a multi-institution, Phase I/II trial of SRS plus olaparib, followed by durvalumab (with physician’s choice systemic therapy), for patients with TNBC (any BRCA status) or HER2-negative with BRCA-mutated (germline or somatic) breast cancer brain metastases [NCT04711824]. A total of 41 patients are planned for enrollment at 8 sites. The primary objectives are to evaluate safety and tolerability (Phase I) and determine intracranial disease control at 6 months (Phase II) of this treatment combination. Secondary objectives include determining clinical activity via intracranial and global progression-free survival, overall survival, and intracranial and extracranial response rate. Exploratory objectives will assess potential biomarkers of treatment response, including changes in circulating tumor cells and DNA in blood and cerebrospinal fluid, germline and tumor mutations in DNA repair pathway genes, and PD-L1 expression, as well as quality of life and patient-reported outcomes. A surgical sub-study (n=5) will evaluate olaparib concentration/distribution in resected brain metastases. As of June 2023, cohort 2 of phase I has been completed without dose-limiting toxicity. Citation Format: Colette Shen, Yara Abdou, Linda Chen, Xianming Tan, Gaorav Gupta, Mina Lobbous, Filipa Lynce, Erica Stringer-Reasor, Carey Anders. Phase I/II study of stereotactic radiosurgery with concurrent olaparib followed by adjuvant durvalumab and physician’s choice systemic therapy in subjects with breast cancer brain metastases [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 PO5-20-03.

Abstract PO2-27-09: Clinical impact of routine MRI screening for brain metastases in patients with HER2 positive or triple negative metastatic breast cancer

Abstract Background: Routine screening for brain metastases (BMs) is currently not recommended in patients with metastatic breast cancer (BC). There is a growing consensus on the need for the screening of BMs in HER2 positive and triple negative breast cancer (TNBC) because 40% of patients experience BMs throughout the disease course and systemic treatment options with intracranial efficacy are now available. However, there is a lack of prospective study data on this matter. We conducted a prospective cohort study to evaluate the role of brain MRI screening for the patient with metastatic BC. Methods: Patients who newly diagnosed metastatic HER2+ or TNBC were eligible. Screening brain MRI was planned at diagnosis and failure from first line and second line of systemic therapy. All patients underwent complete physical examination and comprehensive neurologic assessment at baseline and thereafter. Patients who diagnosed symptomatic BMs were dropped from the study and subsequent treatment including local therapies and survival data were collected. Primary endpoint was the percentage of patients diagnosed with asymptomatic BMs. Results: A total of 147 patients were enrolled between Sep 2018 and Aug 2023 at Yonsei Cancer Center. The median age was 51 years (range, 29-80) and most patients (92.5%, n=136) had good performance status (ECOG 0-1). The tumor subtypes were as follows: TNBC, 51.0%; HER2 (ER-, HER2+), 29.3%; luminal-HER2 (ER+, HER2+), 19.7%. The cumulative incidence of asymptomatic BMs was 20.4% for overall patients; 24.0% for TNBC (18/75), 14.0% for HER2 (6/43), and 20.7% for luminal HER2 (6/29). Symptomatic detection of BMs during study period was 14.7% for TNBC, 18.6% for HER2, and 6.9% for luminal-HER2. Initial local treatment was stereotactic radiosurgery in 30 patients (58.8%), whole-brain radiation therapy in 14 patients (27.5%), surgical resection in 2 patients (3.9%) and 6 patients (11.8%) did not receive any treatment for BMs. After a median follow-up of 20.1 months, the median overall survival following a diagnosis of BMs was 23.7 vs 7.3 months (hazard ratio 0.41; 95% CI, 0.17 to 0.95; P = .04) in patients with asymptomatic and symptomatic BMs, respectively. Conclusions: We identified approximately 20% of patients with HER2+ or TNBC as asymptomatic BMs. Emerging systemic therapies showed promising intracranial response would warrant the detection of asymptomatic BMs through routine MRI screening. Incidence of brain metastases by subtypes Citation Format: Gun Min Kim, Joo Hyuk Sohn, Min Hwan Kim, Seul-Gi Kim, Hyung Soon Park, Jong Hee Jang, Yong Bae Kim, Seung-koo Lee. Clinical impact of routine MRI screening for brain metastases in patients with HER2 positive or triple negative metastatic breast cancer [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 PO2-27-09.

Stereotactic radiosurgery for brain metastasis from cholangiocarcinoma.

Accounting for approximately 15% of primary liver cancers and 3% of gastrointestinal malignancies, cholangiocarcinoma (CCA) poses a serious health concern given its high mortality rate. Managing brain metastases (BMs) from CCA is challenging because of their rarity and poor prognosis, with little guidance on treatment from the literature. In this study, the authors aimed to evaluate the safety and efficacy of stereotactic radiosurgery (SRS) in managing BMs from CCA. This multicenter retrospective study included 13 CCA patients with 41 BMs treated with SRS from October 2006 to April 2022 at eight institutions affiliated with the International Radiosurgery Research Foundation. Inclusion criteria were a CCA diagnosis, an age over 18 years, no other malignancies, single-fraction SRS treatment for BMs, and at least one follow-up image. Data on demographics, tumor characteristics, treatment details, and outcomes were collected. The primary endpoints were local control (LC), intracranial progression-free survival (PFS), and overall survival (OS). The secondary endpoint was the development of adverse radiation effects (AREs). The median radiological follow-up was 5 months (range 1-18 months). At the last follow-up, LC was achieved in 39 (95.1%) of 41 BMs. New distant metastases were observed in 3 patients (23.1%), and the mean intracranial PFS was 9.4 months (95% CI 6.5-12.3 months). Six-month and 1-year OS rates were 38.5% and 11.5%, respectively, and the median OS was 6 months (95% CI 4.9-7.2 months). Concurrent immunotherapy was associated with a high risk of local failure (HR 29.665, 95% CI 1.799-489.206, p = 0.018), and the absence of systemic chemotherapy before SRS was linked to reduced OS (HR 6.658, 95% CI 1.173-37.776, p = 0.032). Regarding AREs, only 1 patient (7.7%) experienced right hemiparesis and was treated with corticosteroid therapy. SRS is an effective option for managing BMs in CCA patients, showing promise in LC and a high safety profile.

Gamma Knife Versus Volumetric Arc Modulated Therapy in a Linear Accelerator in Treatment of Multiple Brain Metastasis: Literature Review

This literature review introduces the treatment results of Gamma Knife radiosurgery (GKRS) and volumetric arc therapy (VMAT) administered by linear accelerators for patients diagnosed with multiple brain metastases. The present study aimed to compare Gamma Knife radiosurgery with Volumetric Arc Modulated Therapy (VMAT) administered using a linear accelerator for brain metastases and their respective safety profiles and therapeutic results. The review assesses research on treatment precision, local control rates, survival outcomes, radiation necrosis incidence, and post-treatment quality of life. It evaluates technical progress, treatment plans, and physiological effects on brain tissue. Both modalities have the potential for managing brain metastases, with GKRS being beneficial for well-defined lesions and VMAT being a flexible and efficient option for larger or irregular-shaped metastases. The study highlights the unique benefits of each therapy for different types of brain metastases. GKRS and VMAT are effective treatments for brain metastases, using concentrated radiation for localised lesions and advanced imaging techniques for intricate or expanded regions. GKRS offers precise interventions with minimal invasiveness, suitable for patients with lower metastatic burdens or suboptimal surgical tolerance. Both therapies show similar effectiveness in local control and survival but may be better suited for specific patient needs and lesion characteristics

Genetic and Immunological Characterization of Brain Metastases from Solid Cancers.

Brain metastasis, a leading cause of cancer death, is a clinical challenge. Recently, genetic characterization of brain metastatic lesions based on next generation sequencing-based advanced technologies, such as single-cell RNA sequencing, has been performed to develop novel efficient therapies. The present study aimed to investigate brain-metastasis-specific biomarkers as well as relevant prognostic factors. The genetic profiles and expression levels of immune response-associated genes and 820 cancer-associated genes were compared between primary cancer lesions and metastatic cancer lesions obtained from nine cancer patients at the Shizuoka Cancer Center. Cytokine and chemokine marker genes were analyzed via quantitative PCR. T-cell receptor (TCR) repertoire profiling was performed for the same patients. For survival analysis, survival data of 52 cancer patients with brain metastases were utilized. Comparison of driver mutation profiling between primary and metastatic lesions revealed shared core mutations in both lesions and a few new mutations in metastatic lesions. A high tumor mutation burden (TMB) was detected in metastatic lesions. Volcano plot analysis revealed specific features of the metastatic tumor microenvironment, such as cancer signaling promotion and immune suppression due to decreased immune cell infiltration. Survival analysis revealed that three genes, the TREML2 gene, the BTLA gene on activated microglia and the CERS2 gene on metastatic tumor, were potent prognostic factors. High TMB in metastatic lesions indicates potential benefit from immune checkpoint inhibitor usage for brain metastasis and TREML2 and BTLA are factors associated with poor prognosis. Activated microglia may be novel targets for the treatment of brain metastasis.

Neuroprotection in radiotherapy of brain metastases: A pattern-of-care analysis in Germany, Austria and Switzerland by the German Society for radiation Oncology − working group Neuro-Radio-Oncology (DEGRO AG-NRO)

Background and purposeMany patients with solid tumors develop brain metastases (BM). With more patients surviving long-term, preservation of neurocognitive function gains importance. In recent years, several methods to delay cognitive deterioration have been tested in clinical trials. However, knowledge on the extent to which these neuroprotective strategies have been implemented in clinical practice is missing. Materials and methodsWe performed an online survey regarding treatment patterns of BM in German-speaking countries, focused on the use of neuroprotective approaches. The survey was distributed among radiation oncologists (ROs) registered within the database of the German Society for Radiation Oncology (DEGRO). ResultsPhysicians of 78 centers participated in the survey. Whole brain radiotherapy (WBRT) is still preferred by 70 % of ROs over stereotactic radiotherapy (SRT) in patients with 6–10 BM. For 4–5 BM WBRT is preferred by 23 % of ROs. The fraction of ROs using hippocampal sparing (HS) in WBRT has increased to 89 %, although the technique is used on a regular basis only by a minority (26 %). The drug memantine is not widely prescribed (14% of ROs). A trend was observed for university hospitals to implement neuroprotective approaches more frequently. ConclusionThere is considerable heterogeneity regarding the treatment of BM in German-speaking countries and a general standard of care is lacking. Neuroprotective strategies are not yet standard approaches in daily clinical routine, although usage is increasing. Further clinical trials, as well as improvement of technical opportunities and reimbursement, might further shift the treatment landscape towards neuroprotective radiation treatments in the future.

Development and validation of an MRI-Based nomogram to predict the effectiveness of immunotherapy for brain metastasis in patients with non-small cell lung cancer.

The variability and unpredictability of immune checkpoint inhibitors (ICIs) in treating brain metastases (BMs) in patients with advanced non-small cell lung cancer (NSCLC) is the main concern. We assessed the utility of novel imaging biomarkers (radiomics) for discerning patients with NSCLC and BMs who would derive advantages from ICIs treatment. Data clinical outcomes and pretreatment magnetic resonance images (MRI) were collected on patients with NSCLC with BMs treated with ICIs between June 2019 and June 2022 and divided into training and test sets. Metastatic brain lesions were contoured using ITK-SNAP software, and 3748 radiomic features capturing both intra- and peritumoral texture patterns were extracted. A clinical radiomic nomogram (CRN) was built to evaluate intracranial progression-free survival, progression-free survival, and overall survival. The prognostic value of the CRN was assessed by Kaplan-Meier survival analysis and log-rank tests. In the study, a total of 174 patients were included, and 122 and 52 were allocated to the training and validation sets correspondingly. The intratumoral radiomic signature, peritumoral radiomic signature, clinical signature, and CRN predicted intracranial objective response rate. Kaplan-Meier analyses showed a significantly longer intracranial progression-free survival in the low-CRN group than in the high-CRN group (p < 0.001). The CRN was also significantly associated with progression-free survival (p < 0.001) but not overall survival. Radiomics biomarkers from pretreatment MRI images were predictive of intracranial response. Pretreatment radiomics may allow the early prediction of benefits.

Brain metastasis from the perspective of molecular mechanisms and treatment, presenting a new approach for targeting ion channels by nano drugs

Brain metastasis is the most prevalent neurologic problem of systemic cancer and it can increase the mortality rate in patients with cancer. It occurs more in patients with lung cancer, breast cancer, and melanoma. There are several molecular mechanisms in cancer cell progression, invasion, and location in new places during brain metastasis. Significant interactions between cancer cells, the brain microenvironment, and the blood-brain barrier (BBB) play a major role in brain metastasis. This study will focus on molecular mechanisms that contribute to cancer metastasis into the brain and finding new treatments with molecular research. Treatment strategies in patients with brain metastasis include surgical resection, radiotherapy, and chemotherapy; however, the penetration of chemotherapy drugs beyond the BBB is limited. Studying molecular, cellular, and physical mechanisms in brain metastasis helps to improve new strategies in drug delivery across the BBB. There are significant impacts of ion channels in brain metastasis and cancer treatment failure. Targeting molecular mechanisms and ion channels in brain metastasis led to increasing the better response in these patients. In this way, nano-drugs have caused a revolution in effective targeting and drug delivery in cancer treatment. This review describes the advances to facilitate the penetration of drugs in the BBB by using nano-drugs especially those that are targeting ion channels.

B7-H3 Expression in Breast Cancer and Brain Metastasis.

Brain metastasis is a significant challenge for some breast cancer patients, marked by its aggressive nature, limited treatment options, and poor clinical outcomes. Immunotherapies have emerged as a promising avenue for brain metastasis treatment. B7-H3 (CD276) is an immune checkpoint molecule involved in T cell suppression, which is associated with poor survival in cancer patients. Given the increasing number of clinical trials using B7-H3 targeting CAR T cell therapies, we examined B7-H3 expression across breast cancer subtypes and in breast cancer brain metastases to assess its potential as an interventional target. B7-H3 expression was investigated using immunohistochemistry on tissue microarrays of three clinical cohorts: (i) unselected primary breast cancers (n = 347); (ii) brain metastatic breast cancers (n = 61) and breast cancer brain metastases (n = 80, including a subset of 53 patient-matched breast and brain metastasis cases); and (iii) mixed brain metastases from a range of primary tumours (n = 137). In primary breast cancers, B7-H3 expression significantly correlated with higher tumour grades and aggressive breast cancer subtypes, as well as poorer 5-year survival outcomes. Subcellular localisation of B7-H3 impacted breast cancer-specific survival, with cytoplasmic staining also correlating with a poorer outcome. Its expression was frequently detected in brain metastases from breast cancers, with up to 90% expressing B7-H3. However, not all brain metastases showed high levels of expression, with those from colorectal and renal tumours showing a low frequency of B7-H3 expression (0/14 and 2/16, respectively). The prevalence of B7-H3 expression in breast cancers and breast cancer brain metastases indicates potential opportunities for B7-H3 targeted therapies in breast cancer management.

154 Elucidating the Immune Landscape of Radiation Necrosis Through Single Cell Analysis of Recurrent Brain Lesions in Patients After Stereotactic Radio Surgery

INTRODUCTION: Radiation necrosis (RN), a common and morbid side effect of radiosurgical treatment of brain metastasis, is becoming more prevalent as immunotherapy options and patient survival improve. Thought to be immunologically driven, the pathophysiology of RN remains poorly defined. Further, RN is often indistinguishable from regrowing metastases after stereotactic radiosurgery (SRS), requiring invasive brain biopsy for diagnosis. METHODS: We collected 20 intraoperative samples from patients undergoing craniotomy for RN and/or metastatic tumor, as well as time-matched blood and CSF. We created a tissue bank, processed samples, and using fluorescence-activated cell sorting (FACS) and 10x Genomics single cell RNA sequencing, analyzed the cellular immune profile of lesional tissue, blood, and CSF. RESULTS: RN tissue demonstrates a robust, detectable expression of immune cells, including CD8+ and CD4+ T cells, natural killer (NK) and myeloid cells. Importantly, clustering of RN-derived immune cells (including T cells, myeloid cells, and NK cells) is reflected in the blood and CSF, with similar immune profiles. We demonstrate a subpopulation of myeloid cells with a microglia signature (CD14+, LYZ-, MS4A7+), and a separate population expressing interferon-stimulated gene (ISG). Supporting these findings, pathway analysis of top blood markers reveals pathways involved in innate and inflammatory immune responses in the blood of RN patients. CONCLUSIONS: These findings demonstrate the feasibility of extracting live cells from RN tissue for scRNAseq analysis and suggest that there are unique signatures of RN that can be detected in the blood and CSF of patients. This work has the potential to open new avenues for improved diagnostic and therapeutic approaches to allow earlier detection and more effective treatment of RN in patients with metastatic brain tumors.

A new updated prognostic index for patients with brain metastases (BMs) treated with palliative whole brain radiotherapy (WBRT) in the era of precision oncology. METASNCore project.

Palliative WBRT is the main treatment for multiple BMs. Recent studies report no benefit in survival after WBRT compared to palliative supportive care in patients (pts) with poor prognosis. A new era of systemic treatment strategies based on targeted therapies are improving the prognosis of patients with BMs. The purpose of this study is to develop a prognostic score in palliative pts with BMs who undergo WBRT in this new setting. 239 pts with BMs who received palliative WBRT between 2013-2022 in our center were analyzed retrospectively. The score was designed according to the value of the β coefficient of each variable with statistical significance in the multivariate model using Cox regression. Once the score was established, a comparison was performed according to Kaplan-Meier and was analyzed by log-rank test. 149 pts (62.3%) were male and median (m) age was 60 years. 139 (58,2%) were lung cancer and 35 (14,6%) breast cancer. All patients received 30Gys in 10 sessions. m overall survival (OS) was 3,74 months (ms). 37 pts (15,5%) had a specific target mutation. We found that 62 pts were in group < 4 points with mOS 6,89ms (CI 95% 3,18-10,62), 84 in group 4-7 points with mOS 4,01ms (CI 95% 3,40-4,62) and 92 pts in group > 7 points with mOS 2,72ms (CI 95% 1,93-3,52) (p < 0,001). METASNCore items are associated with OS and they could be useful to select palliative pts to receive WBRT. More studies are necessary to corroborate our findings.

Abstract 5703: Development of RVL-101, a CDK4/6-selective, small molecule inhibitor with superior CNS penetration and combinability potential for the effective treatment of primary and metastatic brain tumors

Abstract Cyclin-dependent kinases 4 and 6 (CDK4/6) are key regulators of the cell cycle that are frequently dysregulated in cancer, leading to unchecked cell growth. CDK4/6 inhibitors have emerged as a promising class of anticancer agents that selectively target this pathway. The primary mode of action of CDK4/6 inhibitors relies on the disruption of retinoblastoma (Rb) protein phosphorylation, which thereby blocks cell cycle progression from G1 to S phase and reduces proliferation of cancer cells by a cytostatic mechanism. However, despite their efficacy, approved and clinical-stage CDK4/6 inhibitors have modest penetration of unbound drug into the brain, limiting their utility in the treatment of brain metastases and primary brain tumors. Additionally, despite the potential benefits of CDK4/6 inhibitors as combination therapies with cytotoxic agents, adjunctive treatment options remain underexplored due to the poor safety profiles of existing therapies. RVL-101 is a preclinical, investigational drug with a novel pharmacophore that has a low nanomolar activity against CDK4, is CDK2,6,7,9-sparing, and maintains &amp;gt;500-fold selectivity over CDK1. To maximize the potential of RVL-101 as a preferred combination partner, this novel agent has been engineered to have exquisite kinome- and safety-panel selectivity with no measured CYP inhibition or induction liabilities. RVL-101 is differentiated from approved and clinical stage CDK4/6 inhibitors having both high partitioning into the brain (Kp) and high free-brain (Kpu,u = 0.7) levels resulting in equal levels of unbound drug in all relevant compartments at steady state. Like other CDK4/6 agents, RVL-101 is broadly efficacious in vivo in ER+/HER2- xenograft models at well-tolerated doses. However, RVL-101 has also demonstrated robust activity in HR-/HER2+ xenograft models as a single-agent and has uniquely shown improved tumor inhibition effect in combination with approved HER2 cytotoxic therapeutics tucatinib and fam-trastuzumab-deruxtecan. RVL-101 was also tested in a GBM model as a monotherapy and in conjunction with the cytotoxic agent temozolomide (TMZ). Remarkably, QD dosing of the cytostatic agent, RVL-101, after pulsatile pretreatment with TMZ led to dramatic synergistic efficacy compared to either agent alone, leading to 100% survival of all animals on the dual therapy arm for more than 3 weeks post discontinuation of dosing. RVL-101 offers the combination of substantial therapeutic benefit and consistent free-drug levels in plasma and CNS that could lead to safe and effective treatment for a broader patient population. Citation Format: John E. Campbell, Bo-Sheng Pan, Michael Bower, Peter Bertinato, Nisha Perez, Victoria Gras Andreu, Neha Rana, Sophia Tabchouri, Ankit Gupta, Jonah Kallenbach. Development of RVL-101, a CDK4/6-selective, small molecule inhibitor with superior CNS penetration and combinability potential for the effective treatment of primary and metastatic brain tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 5703.

Abstract 1979: Preclinical characterization of NVL-330, a selective and brain penetrant HER2 tyrosine kinase inhibitor with broad activity on HER2 oncogenic alterations

Abstract Background: Oncogenic mutations and gene amplifications in the HER2 receptor tyrosine kinase are detected in approximately 2 - 4% and 1 - 5%, respectively, of non-small cell lung cancers (NSCLC) in the US. Exon 20 insertion mutations (exon20ins) are the predominant HER2 mutations in NSCLC, and ~50% of HER2-mutant metastatic NSCLC patients develop brain metastases. The antibody drug conjugate trastuzumab deruxtecan (T-DXd) has received FDA accelerated approval for HER2-mutant NSCLC, but currently there are no approved tyrosine kinase inhibitors (TKIs) for this indication. NVL-330 is a novel, brain-penetrant, HER2-selective TKI, designed to address the combined medical need of treating HER2-mutant tumors, avoiding treatment related adverse events due to off-target inhibition of wild-type EGFR, and treating brain metastases. Here we characterized the preclinical pharmacological profile of NVL-330 in comparison to other investigational HER2-targeting TKIs and T-DXd. Methods: TKIs were profiled in cellular phospho-HER2, phospho-EGFR, and viability assays. In vivo antitumor studies were performed in nude mice with HER2-altered subcutaneous or intracranial tumors. T-DXd concentration was measured in an ELISA assay. The unbound brain-to-plasma partitioning ratio (Κp,uu) was determined at one hour after oral 10 mg/kg dosing in Wistar Han rats. Results: NVL-330 broadly inhibited HER2 oncogenic alterations, including amplified wild-type HER2, HER2 exon20ins and non-exon20ins mutants, with potency and selectivity over wild-type EGFR comparable to investigational HER2-selective TKI zongertinib. By contrast, NVL-330 had a higher Kp,uu than zongertinib in rats. In a patient-derived xenograft model harboring HER2 exon20ins, treatment with NVL-330 suppressed phospho-HER2 and downstream signaling, increased total HER2 and caused dose-dependent tumor regression at well tolerated doses. In the HER2amp NCI-N87 subcutaneous xenograft model, oral administration of 30 mg/kg NVL-330 twice per day induced tumor regression, similar to that achieved by intravenous administration of 10 mg/kg T-DXd once every three weeks, a human-relevant dose in mice. By comparison, in the intracranial setting with the same tumor model and dosing regimens, NVL-330 induced tumor regression, whereas T-DXd provided tumor stasis. Pharmacokinetic analysis in these intracranial tumor bearing mice indicated that NVL-330 had significantly higher brain penetrance than T-DXd. Conclusions: NVL-330 was broadly and selectively active against HER2 oncogenic alterations in vitro and in vivo, and demonstrated brain penetrance in rodents exceeding that of HER2 investigational TKI zongertinib and T-DXd. This preclinical profile supports the potential for NVL-330 to address a medical need for patients with HER2-driven cancers, including those with brain metastases. Citation Format: Yuting Sun, Kristin L. Andrews, Anupong Tangpeerachaikul, Tuan M. Nguyen, Baudouin Gerard, Nancy E. Kohl, Joshua C. Horan, Henry E. Pelish. Preclinical characterization of NVL-330, a selective and brain penetrant HER2 tyrosine kinase inhibitor with broad activity on HER2 oncogenic alterations [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1979.

Abstract 4139: Prolyl 4-hydroxylase subunit alpha 1 acts as a novel target for lung adenocarcinoma brain metastasis

Abstract Lung cancer is the most lethal cancer worldwide, with a high incidence of distant metastasis. Many lung adenocarcinoma (LUAD) patients experience brain metastasis during the disease process with unfavorable prognosis. Our previous study has discovered that P4HA1 was exclusively upregulated in brain metastatic cells. Through the analysis of single-cell RNA sequencing of LUAD samples, we found that the expression of P4HA1 in brain metastatic tumor cells is higher than that in primary tumor cells. This finding was further confirmed by immunohistochemical staining. Significantly, a strong presence of P4HA1 in primary tumors is associated with a reduced duration of disease-free survival in individuals with LUAD. Overexpression of P4HA1 in A549 and PC9 cell lines significantly increased the incidence of brain metastasis in BALB/c nude mice, whereas knockdown of P4HA1 in high brain metastatic cells significantly decreased the incidence of brain metastasis and reduced the tumor foci in brain with improved survival. Utilization of DHB, a P4HA1 inhibitor, exerts both therapeutic and preventive effects in relieving brain metastases in nude mice. Furthermore, remarkable inhibition of tumor growth by DHB was observed in patient derived xenograft (PDX) models. RNA sequencing analysis demonstrated that the reduction of P4HA1 expression had a substantial impact on cell adhesion and extracellular matrix (ECM)-receptors interactions. Western blotting analysis verified that the decrease in P4HA1 expression led to a drop in the expression of adhesion molecules ICAM1, VCAM1, NCAM1, as well as integrin molecules ITGA2 and ITGA3. Furthermore, when endothelial cells were co-cultured with conditioned medium from tumor cells, it was observed that the expression of the tight junction molecule ZO1 was reduced after co-culturing with conditioned medium from P4HA1 knockdown A549 cells. The results from the in vitro blood-brain barrier (BBB) model and in vivo biofluorescence imaging indicate that P4HA1 promoted brain metastasis of LUAD via modulating the ability of tumor cells to cross the blood-brain barrier. In conclusion, our study reveals that overexpression of P4HA1 promotes metastatic spread to the brain, and targeting P4HA1 could be a promising therapeutic strategy for the treatment of lung adenocarcinoma brain metastasis. Citation Format: Yan He, Zhenyu Luo, Yucheng Dong, Rui Wan, Xue Zhang, Hua Bai, Jie Wang. Prolyl 4-hydroxylase subunit alpha 1 acts as a novel target for lung adenocarcinoma brain metastasis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4139.

Abstract 1455: In vitro blood brain barrier model for evaluation of brain metastasis

Abstract Introduction: Brain metastasis significantly reduces the patient's quality of life and survival, but there are only a few choices of treatment for brain metastasis. The research for brain metastasis is difficult because of its complex and unique microenvironment, including blood-brain barrier (BBB). The BBB maintains strong cell adhesion of the vascular endothelial cells (ECs) to protect the brain parenchyma. The BBB is composed of three cell types: vascular endothelial cells, pericytes, and astrocytes. As the role of pericytes in maintaining the BBB function has become more evident, the reconstituted models of the BBB in which ECs, pericytes, and astrocytes are seeded on the front and back of the insert membrane have gotten our attention. In the field of cancer, the role of not only ECs but also wall cells, corresponding to pericytes in the brain, has been focused on. In this study, we aimed to create the in vitro BBB models and elucidate the interaction of the BBB and the metastasizing cancer cells. Methods: We applied a reconstituted model of the BBB consisting of ECs, pericytes, and astrocytes of human immortalized cells (Ito R, et al. Mol Pharm 2019) and created the co-culture system for evaluating brain metastasis. We constructed four co-culture systems and compared the migration ability of MDA231 in those models: EPA model (ECs, pericytes, and astrocytes), E0A model (ECs and astrocytes), EP0 model (ECs and pericytes), and E00 model (ECs only). We also analyzed the migration ability of the pairs of parental and brain metastatic (BrM) cell lines. Results: The BBB reconstituted model (EPA model), in which ECs were co-cultured with pericytes and astrocytes, showed higher trans-epithelial electrical resistance and lower permeability than the other co-culture models. When cancer cells were seeded, the EPA model strongly inhibited metastatic invasion of cancer cells compared to the other models. It suggests that both pericytes and astrocytes are essential for regulating cancer cell invasion. In addition, when the BrM cells of MDA231 and Ex3LL were seeded, the BrM cells invaded the EPA model more easily than the parental cells. It indicates that this model can reproduce in vivo brain vascular functions. Conclusion: We created the BBB reconstituted model which mimics the brain vascular microenvironment. This model reproduced the in vivo BBB function to protect brain from cancer cells and evaluated the brain metastatic ability of the cancer cells. Using this model, we showed that pericytes and astrocytes were essential for the BBB barrier function against the cancer cells. We need further investigation to elucidate the mechanism of brain metastasis using this BBB model. Citation Format: Shoko Noda-Narita, Atsu Aiba. In vitro blood brain barrier model for evaluation of brain metastasis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1455.