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Year : 2017  |  Volume : 13  |  Issue : 5  |  Page : 785-789

Efficacy and safety of temozolomide plus whole-brain radiotherapy in the treatment of intracranial metastases

Department of Neurosurgery, Affiliated Hospital of Hebei University, Baoding, Hebei Province, PR China

Date of Web Publication13-Dec-2017

Correspondence Address:
Ji-Wei Wang
No. 212, Yuhua East Road, Baoding 071000, Hebei Province
PR China
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_323_17

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 > Abstract 

Objective: This study aimed to explore the clinical efficacy and safety of temozolomide (TMZ) plus whole-brain radiotherapy (WBRT) in the treatment of intracranial metastases.
Subjects and Methods: A total of 72 patients with intracranial metastases were randomly divided into observation group and control group (each n = 36). The patients of observation group received WBRT plus TMZ, while the patients of control group received WBRT. The observation index of both groups included the short- and long-term clinical efficacies, improvement of symptoms and signs, quality of life (QOL), and adverse responses.
Results: After treatment, the objective remission rate in observation group (77.78%, 28/36) was evidently higher than that of in control group (47.22%, 17/36), with significant difference (P = 0.0074). However, the disease control rate in observation group (94.44%, 34/36) was only slightly higher than that of in control group (86.11%, 31/36) (P = 0.4263). Moreover, after treatment, compared to control group, observation group showed markedly better improvement in symptoms and signs, as well as QOL (P < 0.001), with significantly longer overall survival and progression-free survival (P < 0.001).
Conclusion: TMZ concomitant with WBRT can increase the local control, prolong the survival time and improve the QOL of patients with intracranial metastases.

Keywords: Intracranial metastases, quality of life, survival analysis, temozolomide, whole-brain radiotherapy

How to cite this article:
Liu HP, Zheng KB, Wang JW. Efficacy and safety of temozolomide plus whole-brain radiotherapy in the treatment of intracranial metastases. J Can Res Ther 2017;13:785-9

How to cite this URL:
Liu HP, Zheng KB, Wang JW. Efficacy and safety of temozolomide plus whole-brain radiotherapy in the treatment of intracranial metastases. J Can Res Ther [serial online] 2017 [cited 2020 Jul 15];13:785-9. Available from: http://www.cancerjournal.net/text.asp?2017/13/5/785/220470

 > Introduction Top

Intracranial metastases are resulted from primary malignant tumors outside central nervous system (CNS), involving brain parenchyma, cerebrospinal fluid (CSF), cranial nerves, and intracranial vessels. Brain parenchyma metastasis has been the most common type of intracranial metastases, which is often followed by meningeal metastasis. According to the epidemiological investigation, the morbidity of intracranial metastases was much higher than that of primary intracranial tumors and approximately 20%–40% of malignant tumor patients presented with intracranial metastases during disease.[1] The probability of intracranial metastasis in malignant tumor patients mainly depended on the pathological patterns of the primary tumors, including breast cancer, lung cancer, and head and neck squamous cell carcinoma.[2],[3],[4] Among them, breast cancer has been the leading cause of intracranial metastases and accounted for about 32% of all cancers with intracranial metastases.[5]

The clinical symptoms of intracranial metastases were similar to those of other intracranial space-occupying lesions, which were indicated by headache, local weakness, emotional disturbance, and sudden disturbance of consciousness. These severe neurological symptoms would be observed when intracranial metastases occurred, thus leading to poor prognosis, short survival time, and low quality of life (QOL).[6] At present, surgery and stereotactic radiotherapy are the optimal protocols for the palliative therapy of intracranial metastases, which are only advisable for intracranial single nidus. However, multiple nidi were observed in most of the patients with intracranial metastases, for which the whole-brain radiotherapy (WBRT) was still the generally applied therapeutic method.[7] Researches have confirmed that the accurate implementation of WBRT could relieve the symptoms of neurological system, increase the QOL and prolong the survival time of patients with intracranial metastases.[8],[9]

Positive treatment after WBRT has been a critical factor for improving the prognosis of patients with intracranial metastases. However, it was still controversial whether chemotherapy could provide benefits for those patients.[10] The clinical efficacy of chemotherapeutic agents mainly depended on their sensitivity to the primary tumors and whether these agents could pass through the blood-brain barrier (BBB). Temozolomide (TMZ) is a new oral alkylating agent with both broad-spectrum anti-tumor activity and high bioavailability. It has been commonly applied in the treatment of glioblastoma, in which it could enter into CSF through BBB and maintain a relatively high concentration in CNS.[11] To further explore the efficacy and safety of TMZ concomitant with WBRT in the treatment of intracranial metastases, this study analyzed the short- and long-term clinical efficacies and toxic responses of this treatment and compared these with single radiotherapy, hoping to provide reference basis for clinical practices.

 > Subjects and Methods Top

General data

This study was approved by the Ethnic Community of our hospital, and all informed consent forms were signed by the patients and/or their families. A total of 72 patients with intracranial metastases were included as study subjects, who were admitted to Affiliated Hospital of Hebei University from June 2009 to September 2013.

Inclusion criteria: (1) The primary nidi were pathologically diagnosed with the number of metastatic nidi ≥3, which were confirmed by cerebral computed tomography or magnetic resonance image (MRI); (2) age was >18 years; (3) before treatment, Karnofsky performance status (KPS) ≥60 scores and expected survival time was >3 months; (4) before treatment, white blood cell count was ≥4.0 × 109/L, haemoglobin was ≥70 g/L and platelet was ≥100 × 109/L; (5) hepatic and renal function was normal; and (6) no history of chemotherapy or toxic responses from previous chemotherapy was observed.

Exclusion criteria: (1) With a history of radiotherapy for intracranial metastatic nidi; (2) the interval from the previous chemotherapy was <3 weeks; (3) accompanied with primary cardiovascular, renal and hematopoietic diseases; and (4) with severe psychological diseases. Of all the individuals, there were 53 males and 19 females; aged between 19 and 72 years, with the median age of 59. For primary tumors, there were 24 patients with nonsmall cell lung cancer (NSCLC), 13 with small cell lung cancer (SCLC), 21 with breast cancer and 14 with other tumors. There were 21 patients accompanied with other organic metastasis; 43 patients with the maximum diameter of metastatic nidi ≤3 cm. KPS scores: 10 patients were 60–70 scores and 62 were >70 scores. There were 16 patients with a history of chemotherapy. The patients were randomly divided into observation group and control group according to Random Number Table, with 36 cases for each group. There was no significant difference in the general data (gender, age and KPS score) between two groups, which was comparable (P > 0.05).


Both groups received linear accelerator 6MV photonic wire continuous radiotherapy. The position of patients was fix with the pyrolytic plastic mask. The left-right opposed irradiation of routine-level irradiation fields was conducted for the WBRT. The single radiotherapeutic dose was 2.0 Gy, q.d., 5 times every week, with a total dose of 40 Gy. Local boost-dose radiotherapy was performed with irradiation, which was confirmed to the following doses: The single dose was 2.0 Gy, q.d., 5 times every week, with a total dose of 10–20 Gy.

On this basis, for observation group, TMZ was added (Schering-Plough Europe company, Finland; subpackaged with S-P Labo N.V.; registration No.: H20120420; specification: 20 mg × 10 pieces) during radiotherapy, 75 mg/m2/day, q.d. After radiotherapy, complementary chemotherapy was administrated: TMZ of 150–200 mg/m2/day, for continuously 5 days, with 28 days as a cycle, until the disease progression or drug withdrawal due to intolerable toxic responses.

During chemo- and radio-therapy, dehydration therapy was conducted with mannite and dexamethasone according to the patients' conditions, which was aimed to alleviate the edema of cerebral tissues due to WBRT. During chemotherapy, granulocyte colony-stimulating factor, antiemetics, and stomach-protective agents were administrated when necessary. Their administrative dosages were adjusted based on the variations of symptoms and signs during treatment.

After 4–6 weeks of treatment, all subjects were re-examined using various laboratory indicators, symptoms and signs, QOL and cerebral 3.0 T MRI scanning, so as to monitor the nidus states and compare with those of before treatment. And then, the patients were followed up once every 3 months until January 2015 or death of patients.

Observational indexes

The symptoms and signs during treatment, QOL before and after treatment, treatment-associated adverse responses and outcomes after corresponding therapies were observed. Short- and long-term clinical efficacies were evaluated with objective remission rate (ORR), disease control rate (DCR), overall survival (OS), and progression-free survival (PFS).

Evaluation criteria

Evaluation criteria for the short-term efficacy

According to response evaluation criteria in solid tumors 1.1, the clinical efficacy was classified into complete remission (CR), partial remission (PR), stable disease (SD), and progressive disease. ORR = (CR + PR)/total cases × 100%; DCR = (CR + PR + SD)/total cases × 100%.

Improvement of symptoms and signs

Symptom remission was indicated with the decreased dose or withdrawal of symptomatic treatments, otherwise, it indicated no significant remission or aggravation of the symptoms.

Evaluation criteria of quality of life

KPS score was applied to evaluate the objective variations of QOL. After the end of treatment, KPS increase of ≥10 scores reflected improved QOL; KPS decrease of ≥10 scores reflected decreased QOL; and KPS increase or decrease of <10 scores reflected stable QOL.

Evaluation criteria for clinical safety

Referring to the National Cancer Institute Common Toxicity Criteria 4.0, all adverse responses were classified into degree 0–4, and corresponding symptomatic therapies were performed.

Statistical analysis

All data analysis was performed by SAS 9.3 and SPSS 17.0 software package (IBM, Chicago, IL). Classified variables were calculated and analyzed with Chi-square test or continuous calibration Chi-square test, while rank classified variables were analyzed with likelihood ratio Chi-square test. Median OS and PFS were detected with Wilcoxon rank-sum test. Survival analysis was expressed with Kaplan–Meier survival curve and detected by Log-rank test. P < 0.05 was considered as statistically significant.

 > Results Top

Comparison of short-term efficacy on cerebral nidi between two groups

The tumor progression could be effectively controlled with both single radiotherapy and TMZ concomitant with WBRT [Figure 1]. After treatment, the ORR in observation group was 77.78% (28/36), which was evidently higher than that of in control group (47.22%, 17/36), with significant difference (χ2 = 7.1704, P = 0.0074). However, the DCR in observation group was 94.44% (34/36), which was only slightly higher than that of in control group (86.11%, 31/36), without significant difference (χ2 = 0.6330, P = 0.4263) [Table 1] and [Figure 1].
Figure 1: Magnetic resonance image images of re-examination in both Groups. (a) Observation group before treatment. (b) Observation group 6 weeks after the end of treatment. (c) Control group before treatment. (d) Control group 6 weeks after the end of treatment

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Table 1: Comparison of short-term efficacy between two groups

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Comparison of improvement of symptoms and signs and quality of life after treatment

The improvement rates of symptoms and signs during treatment and 4–6 weeks after treatment were 94.44% (34/36) in observation group and 63.89% (23/36) in control group, respectively, with significant difference (χ2 = 10.1895, P = 0.0014). The QOL scores were increased in 32 patients of observation group and 19 patients of control group, respectively, with significant difference (χ2 = 11.3613, P = 0.0007).

Comparison of long-term efficacy between two groups

The median OS and PFS in observation group were 8.5 and 5.0 months, which were significantly longer than that of in control group, which were 5.0 and 3.0 months (P < 0.001) [Figure 2]a and [Figure 2]b.
Figure 2: Kaplan–Meier curves of (a) overall survival and (b) progression-free survival of control group and observation group

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Evaluation of safety

The hematological and gastrointestinal responses were two common acute adverse responses in both groups, and these symptoms were relieved after symptomatic treatment. There was no significant difference in the rates of adverse responses between observation group and control group (P > 0.05). No liver-, kidney-, or heart-related adverse responses were observed in both groups. There was no decreased dosage of chemotherapeutic agents due to adverse responses in both groups. The patterns and degrees of adverse responses were shown [Table 2].
Table 2: Comparison of rate of adverse response between two groups

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 > Discussion Top

In this study, the clinical efficacies and safety were compared between TMZ concomitant with WBRT and single WBRT in patients with intracranial metastases. Our results showed that compared with single WBRT, TMZ concomitant with WBRT demonstrated better efficacy, which could significantly improve the symptoms and signs, increase the QOL and prolong the survival time without increasing the treatment-associated adverse responses.

TMZ is a derivative of imidazotetrazines, and can be transformed into active metabolite 5-(3-methyl triazene-1-base)imidazo-4-amide (MTIC) in the human body. MTIC is a highly active DNA methylating agent and demonstrated cytotoxic effects via methylating the guanine on DNA O6.[12] After oral administration, TMZ would be widely distributed in the whole body without liver metabolism and could enter into CSF through BBB, thus leading to high drug concentration in CNS.[13] A multi-center randomized clinical trial indicated that TMZ concomitant with radiotherapy was superior to single radiotherapy for glioma patients, from the aspects of tumor remission rate, median survival time, and 2-year survival rate.[14]

Some scholars have explored the clinical efficacy of TMZ in the treatment of intracranial metastases. TMZ was high in bioavailability, facile in passing through BBB, mild in adverse responses and favorable in patients' compliance for being orally administrated. Addeo et al. applied WBRT (30 Gy) concomitant with TMZ (75 mg/m2/day, p.o.) in 59 patients with intracranial metastases, followed by maintenance chemotherapy with TMZ (150 mg/m2/day, p.o.). It showed significant improved QOL, with 13 months of median OS and favorable drug tolerance. However, this study has not performed the comparison between single WBRT and WBRT concomitant with TMZ.[15] One Phase II randomized trial on TMZ and concurrent radiotherapy in patients with brain metastases showed that ORR could be significantly improved with TMZ and radiotherapy, compared to single radiotherapy.[16] Another Phase II randomized trial showed that for patients with brain metastases, PFS would be significantly improved in TMZ with WBRT compared with WBRT alone, indicating that TMZ could improve local control of brain metastases.[17] Another study was performed on human epidermal-growth-factor receptor 2-positive breast cancer patients with intracranial metastases who was treated with TMZ and lapatinib. It found that gastrointestinal toxicity was the major adverse response, while the median OS and PFS were 10.94 and 2.60 months, respectively.[18] Furthermore, animal experiments also illustrated that TMZ could inhibit intracranial metastases in breast cancer patients, and the inhibiting rate was closely associated with the dosage and administrative approaches.[19] However, some studies found that TMZ combined with concurrent WBRT could not improve the local control and survival time of breast cancer patients with intracranial metastases; in which the ORR, median OS and PFS of single radiotherapy were 36%, 11.1 and 7.4 months, while those of in combined treatment were 30%, 9.4 and 6.9 months, respectively.[20]

There were still some limitations in this study. First, the primary tumors were heterogeneous, with 24 cases of NSCLC, 13 cases of SCLC, 21 cases of breast cancer and 14 cases of other tumors. Therefore, the efficacies and safety of TMZ concomitant with WBRT might be complex. For example, compared with WBRT alone, TMZ combined with WBRT could improve the ORR in intracranial metastases patients with NSCLC, but not for patients with breast cancer.[21] Second, the sample size was small and the results were not robust enough. Further large cohort study can focus on intracranial metastases patients from one tumor and exclude the heterogeneity of study population. Third, TMZ showed toxicity in conventional schedule. Compared with WBRT alone, WBRT and TMZ combination therapy demonstrated a higher rate of toxicity in intracranial metastases patients.[21] Therefore, TMZ should be combined with other cytotoxic drugs which could cross BBB.[22]

 > Conclusion Top

The combined treatment of WBRT and TMZ showed higher efficacy, which could significantly improve the symptoms and signs, increase the survival quality and prolong the survival time without increasing the treatment-associated adverse responses. Further stratified analysis is needed through deeper investigation on the clinical efficacy of TMZ concomitant with WBRT in the treatment of intracranial metastases patients with different primary nidi, as well as on the clinical efficacy influenced by patients' clinical pathological characteristics.

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Conflicts of interest

There are no conflicts of interest.

 > References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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