Journal of Cancer Research and Therapeutics

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 14  |  Issue : 3  |  Page : 578--582

Prognostic factors of patients who received chemotherapy after cranial irradiation for non-small cell lung cancer with brain metastases: A retrospective analysis of multicenter study (Anatolian Society of Medical Oncology)


Ali Inal1, Hilmi Kodaz2, Hatice Odabas3, Ayse Ocak Duran4, Mehmet Metin Seker5, Mevlide İnanc6, Emin Tamer Elkıran7, Yusuf Gunaydın8, Serkan Menekse9, Turkan Ozturk Topcu10, Zuhat Urakcı11, Didem Tastekin12, Mehmet Bilici13, Sener Cihan14, Caglayan Geredeli15, Emel Sezer16, Dogan Uncu17, Erkan Arpacı18, Banu Ozturk19, Oznur Bal20, Mukremin Uysal21, Ozgur Tanrıverdi22, Mahmut Gumus23, Bala Basak Oven Ustaalioglu24, Ali Suner25, Suna Cokmert26, İlhan Hacıbekiroglu2, Kubra Aydın3, Abdurrahman Isıkdogan11,  
1 Department of Medical Oncology, Mersin Hospital, Mersin, Turkey
2 Department of Medical Oncology, Trakya University, Edirne, Turkey
3 Department of Medical Oncology, Dr. Lutfi Kirdar Kartal Education and Research Hospital, İstanbul, Turkey
4 Department of Medical Oncology, Erciyes University, Kayseri, Turkey
5 Department of Medical Oncology, Cumhuriyet University, Sivas, Turkey
6 Department of Medical Oncology, Kayseri Numune Education and Research Hospital, Kayseri, Turkey
7 Department of Medical Oncology, Inonu University, Malatya, Turkey
8 Department of Medical Oncology, Gazi University, Ankara, Turkey
9 Department of Medical Oncology, Celal Bayar University, Manisa, Turkey
10 Department of Medical Oncology, Karadeniz Teknik University, Trabzon, Turkey
11 Department of Medical Oncology, Dicle University, Diyarbakir, Turkey
12 Department of Medical Oncology, İstanbul University, İstanbul, Turkey
13 Department of Medical Oncology, Atatürk University, Erzurum, Turkey
14 Department of Medical Oncology, Okmeydanı Education and Research Hospital, İstanbul University, İstanbul, Turkey
15 Department of Medical Oncology, Konya Numune Hospital, Konya, Turkey
16 Department of Medical Oncology, Mersin University, Mersin, Turkey
17 Department of Medical Oncology, Ankara Numune Education and Research Hospital, Turkey
18 Department of Medical Oncology, Sakarya University, Sakarya, Turkey
19 Department of Medical Oncology, Gaziosmanpasa University, Yozgat, Turkey
20 Department of Medical Oncology, Ankara Onkoloji Education and Research Hospital, Turkey
21 Department of Medical Oncology, Afyon Kocatepe University, Afyon, Turkey
22 Department of Medical Oncology, Mugla Sıtkı Kocman University, Mugla, Turkey
23 Department of Medical Oncology, Bezmialem Vakif University, İstanbul, Turkey
24 Department of Medical Oncology, Haydarpasa Numune Education and Research Hospital, İstanbul, Turkey
25 Department of Medical Oncology, Gaziantep University, Gaziantep, Turkey
26 Department of Medical Oncology, Kent Hospital, İstanbul, Turkey

Correspondence Address:
Ali Inal
Department of Medical Oncology, Mersin State Hospital, Mersin
Turkey

Abstract

Purpose: Almost half of all patients diagnosed with non-small cell lung cancer (NSCLC) have distant metastases at presentation. One-third of patients with NSCLC will have brain metastases. Without effective treatment, the median survival is only 1 month. However, it is difficult to treat brain metastases with systemic chemotherapy since the agents have difficulty crossing the blood-brain barrier. Therefore, it is important to estimate the patient's survival prognosis. The aim of this study was to analyze prognostic factors for survival in Turkish patients who received chemotherapy after cranial irradiation for NSCLC with brain metastases. Methods: We retrospectively reviewed 698 patients with brain metastases resulting from NSCLC. Ten potential prognostic variables were chosen for analysis. Univariate and multivariate analyses were conducted to identify prognostic factors associated with overall survival (OS). Results: Among the 10 variables for univariate analysis, six were identified to have prognostic significance; these included sex, smoking history, histology, number of brain metastases, extracranial metastases, and neurosurgical resection. Multivariate analysis by the Cox proportional hazard model showed that a smoking history, extracranial metastases, and neurosurgical resection were independent negative prognostic factors for OS. Conclusion: Smoking history, extracranial metastases, and neurosurgical resection were considered independent negative prognostic factors for OS. These findings may facilitate pretreatment prediction of survival and can be used for selecting patients for more appropriate treatment options.



How to cite this article:
Inal A, Kodaz H, Odabas H, Duran AO, Seker MM, İnanc M, Elkıran ET, Gunaydın Y, Menekse S, Topcu TO, Urakcı Z, Tastekin D, Bilici M, Cihan S, Geredeli C, Sezer E, Uncu D, Arpacı E, Ozturk B, Bal O, Uysal M, Tanrıverdi O, Gumus M, Oven Ustaalioglu BB, Suner A, Cokmert S, Hacıbekiroglu &, Aydın K, Isıkdogan A. Prognostic factors of patients who received chemotherapy after cranial irradiation for non-small cell lung cancer with brain metastases: A retrospective analysis of multicenter study (Anatolian Society of Medical Oncology).J Can Res Ther 2018;14:578-582


How to cite this URL:
Inal A, Kodaz H, Odabas H, Duran AO, Seker MM, İnanc M, Elkıran ET, Gunaydın Y, Menekse S, Topcu TO, Urakcı Z, Tastekin D, Bilici M, Cihan S, Geredeli C, Sezer E, Uncu D, Arpacı E, Ozturk B, Bal O, Uysal M, Tanrıverdi O, Gumus M, Oven Ustaalioglu BB, Suner A, Cokmert S, Hacıbekiroglu &, Aydın K, Isıkdogan A. Prognostic factors of patients who received chemotherapy after cranial irradiation for non-small cell lung cancer with brain metastases: A retrospective analysis of multicenter study (Anatolian Society of Medical Oncology). J Can Res Ther [serial online] 2018 [cited 2022 Dec 8 ];14:578-582
Available from: https://www.cancerjournal.net/text.asp?2018/14/3/578/176417


Full Text



 Introduction



Lung cancer is the most common cause of cancer deaths in both men and women worldwide. Non-small cell lung cancer (NSCLC) represents 80–85% of all diagnosed lung cancer cases.[1] Almost half of all patients diagnosed with NSCLC have distant metastases at presentation.[2] One-third of NSCLC patients will have brain metastases.[3] Without effective treatment, the median survival time is only 1 month in NSCLC patients with brain metastasis.[4]

Current treatment options include whole brain radiotherapy (WBRT), surgical resection, stereotactic radiosurgery, and combined treatment approaches. WBRT is currently recommended as the standard treatment approach for multiple brain metastases. However, the median survival time following WBRT alone is only 2.4–4.8 months.[5],[6],[7] Systemic chemotherapy, which is commonly accepted as a treatment option for advanced NSCLC, has improved survival. However, it is difficult to treat brain metastases with these agents because of the blood-brain barrier. The selection of the optimal treatment regimen is likely to be influenced by the patient's prognosis.[8],[9],[10],[11],[12] Therefore, it is important to be able to estimate the patient's survival prognosis, which can be facilitated by using prognostic factors.

We performed a retrospective analysis of prognostic factors in patients who received chemotherapy after WBRT for NSCLC with brain metastases.

 Methods



Patient population

We retrospectively reviewed 698 patients with histologically or cytologically proven NSCLC from February 2001 to April 2014. All patients had complete clinical and follow-up records. All of the patients met the following inclusion criteria: (1) histologic or cytologic diagnosis of metastatic NSCLC; (2) 18 years of age or older; (3) had received chemotherapy after WBRT; and (4) had a measurable disease, as defined by the Response Evaluation Criteria in Solid Tumors.

Factors analyzed

Ten potential prognostic variables were chosen based on previously published clinical trials. Each variable was divided into two categories: Gender (male or female), performance status (PS) (0-1-2-3), age (<65 or ≥65), histology (squamous cell carcinoma or nonsquamous cell carcinoma), smoking history (present or absent), number of brain metastases (1–3 or ≥4), extracranial metastases (present or absent), neurosurgical resection (present or absent), synchronous brain metastases (present or absent), and neurological symptoms (present or absent).

All of the analyses were performed using the SPSS statistical software program package (SPSS version 11.5 for Windows, SPSS Inc., Chicago, IL, USA). The differences in the clinical characteristics between the two groups were analyzed by Chi-square tests, and overall survival (OS) was calculated from the date of diagnosis of brain metastases to the date of death from any cause or the date of the last follow-up. OS was estimated using the Kaplan-Meier method. The Cox proportional hazards regression model was used to determine statistically significant variables related to survival. Differences were considered significant when P < 0.05.

 Results



Between February 2001 and April 2014, 698 patients with advanced NSCLC were enrolled in this study.

The median patient age was 58 years (range: 20–95) with 603 (86.4%) males and 95 (13.6%) females.

The number of patients with a PS score 0-1 was 544 (77.9%). Adenocarcinoma was the most common histologic type (56.7%). The estimated median OS was 7.0 months. The patients' baseline characteristics are listed in [Table 1].{Table 1}

Among the ten variables for univariate analysis, six variables were identified as having prognostic significance: sex (P = 0.006), smoking history (P = 0.001), histology (P = 0.007), number of brain metastases (P = 0.03), extracranial metastases (P = 0.002), and neurosurgical resection (P = 0.001). The results of the univariate analysis for OS are summarized in [Table 2].{Table 2}

The results of the multivariate analysis are shown in [Table 3]. Multivariate analysis by Cox proportional hazard model showed that smoking history, extracranial metastases, and neurosurgical resection were considered independent negative prognostic factors for OS (P = 0.006, P = 0.01, and P = 0.004, respectively) [Figure 1], [Figure 2], [Figure 3].{Table 3}{Figure 1}{Figure 2}{Figure 3}

 Discussion



Patients with brain metastases from NSCLC usually have a poor prognosis. The median survival time without any treatment is only 1 month, 2–3 months with glucocorticoid therapy, and 2.4–4.8 months with WBRT.[5],[6],[7]

Systemic chemotherapy, which is commonly accepted as a treatment option for advanced NSCLC, has been shown to improve survival. However, it is difficult to treat brain metastases with these agents because of the blood-brain barrier. Patients eligible for chemotherapy should be selected carefully. Very different prognostic factors for survival have been identified in patients with brain metastases.[13],[14],[15],[16]

Previously, many authors have shown that the presence of extracranial metastasis at the initial discovery of the brain metastases was a significantly negative prognostic factor for the treatment of brain metastases in NSCLC patients.[17],[18],[19] Similarly, our results demonstrated that the lack of extracranial metastasis was a significantly favorable finding that improved the OS. For this reason, these findings suggest that control of the extracranial region is also very important in cases with brain metastases.

According to the current ESMO guidelines, resection of cranial metastases is a treatment option for selected patients with a solitary metastasis.[20] Nevertheless, level 1 evidence promising improved OS after aggressive treatment is lacking, apart from the resection of a single brain metastasis.[21],[22] Patients with symptomatic brain metastases owing to a mass effect may be considered for metastasectomy. Consistent with the published literature,[21],[22],[23] we found that surgical resection could prolong survival. Therefore, surgical resection should be considered in patients with controlled systemic disease, and symptomatic brain metastases.

Smoking is a well-known causative factor in the development of lung cancer.[24] Several previous studies have demonstrated that smokers show a significantly poor prognosis when compared with nonsmokers with regard to NSCLC.[24],[25],[26] There is little information available about the prognostic significance of smoking in patients who have received chemotherapy after cranial irradiation for NSCLC with brain metastases. Griffioen et al. did not observe a prognostic value of smoking status in patients with brain metastases.[21] The current study demonstrated that smoking status was an independent negative prognostic factor of survival.

 Conclusion



Smoking history, extracranial metastases, and neurosurgical resection were considered independent negative prognostic factors for OS. These findings may facilitate pretreatment prediction of survival and can be used for the selecting patients for more correct choice of treatment. Therefore, a prospective trial and larger clinical trials are needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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