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A Neuro-oncologist’s Perspective on Management of Brain Metastases in Patients with EGFR Mutant Non-small Cell Lung Cancer
Management of non-small cell lung cancer (NSCLC) with brain metastasis (BrM) has been revolutionized by identification of molecular subsets that have targetable oncogenes. Historically, survival for NSCLC with symptomatic BrM was weeks to months. Now, many patients are surviving years with limited d...
Autores principales: | , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
Springer US
2017
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5385200/ https://www.ncbi.nlm.nih.gov/pubmed/28391420 http://dx.doi.org/10.1007/s11864-017-0466-0 |
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author | McGranahan, Tresa Nagpal, Seema |
author_facet | McGranahan, Tresa Nagpal, Seema |
author_sort | McGranahan, Tresa |
collection | PubMed |
description | Management of non-small cell lung cancer (NSCLC) with brain metastasis (BrM) has been revolutionized by identification of molecular subsets that have targetable oncogenes. Historically, survival for NSCLC with symptomatic BrM was weeks to months. Now, many patients are surviving years with limited data to guide treatment decisions. Tumors with activating mutations in epidermal growth factor receptor (EGFRact+) have a higher incidence of BrM, but a longer overall survival. The high response rate of both systemic and BrM EGFRact+ NSCLC to tyrosine kinase inhibitors (TKIs) has led to the rapid incorporation of new therapies but is outpacing evidence-based decisions for BrM in NSCLC. While whole brain radiation therapy (WBRT) was the foundation of management of BrM, extended survival raises concerns for the subacute and late effects radiotherapy. We favor the use of TKIs and delaying the use of WBRT when able. At inevitable disease progression, we consider alternative dosing schedules to increase CNS penetration (such as pulse dosing of erlotinib) or advance to next generation TKI if available. We utilize local control options of surgery or stereotactic radiosurgery (SRS) for symptomatic accessible lesions based on size and edema. At progression despite available TKIs, we use pemetrexed-based platinum doublet chemotherapy or immunotherapy if the tumor has high expression of PDL-1. We reserve the use of WBRT for patients with more than 10 BrM and progression despite TKI and conventional chemotherapy, if performance status is appropriate. |
format | Online Article Text |
id | pubmed-5385200 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2017 |
publisher | Springer US |
record_format | MEDLINE/PubMed |
spelling | pubmed-53852002017-04-24 A Neuro-oncologist’s Perspective on Management of Brain Metastases in Patients with EGFR Mutant Non-small Cell Lung Cancer McGranahan, Tresa Nagpal, Seema Curr Treat Options Oncol Lung Cancer (HA Wakelee, Section Editor) Management of non-small cell lung cancer (NSCLC) with brain metastasis (BrM) has been revolutionized by identification of molecular subsets that have targetable oncogenes. Historically, survival for NSCLC with symptomatic BrM was weeks to months. Now, many patients are surviving years with limited data to guide treatment decisions. Tumors with activating mutations in epidermal growth factor receptor (EGFRact+) have a higher incidence of BrM, but a longer overall survival. The high response rate of both systemic and BrM EGFRact+ NSCLC to tyrosine kinase inhibitors (TKIs) has led to the rapid incorporation of new therapies but is outpacing evidence-based decisions for BrM in NSCLC. While whole brain radiation therapy (WBRT) was the foundation of management of BrM, extended survival raises concerns for the subacute and late effects radiotherapy. We favor the use of TKIs and delaying the use of WBRT when able. At inevitable disease progression, we consider alternative dosing schedules to increase CNS penetration (such as pulse dosing of erlotinib) or advance to next generation TKI if available. We utilize local control options of surgery or stereotactic radiosurgery (SRS) for symptomatic accessible lesions based on size and edema. At progression despite available TKIs, we use pemetrexed-based platinum doublet chemotherapy or immunotherapy if the tumor has high expression of PDL-1. We reserve the use of WBRT for patients with more than 10 BrM and progression despite TKI and conventional chemotherapy, if performance status is appropriate. Springer US 2017-04-08 2017 /pmc/articles/PMC5385200/ /pubmed/28391420 http://dx.doi.org/10.1007/s11864-017-0466-0 Text en © The Author(s) 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. |
spellingShingle | Lung Cancer (HA Wakelee, Section Editor) McGranahan, Tresa Nagpal, Seema A Neuro-oncologist’s Perspective on Management of Brain Metastases in Patients with EGFR Mutant Non-small Cell Lung Cancer |
title | A Neuro-oncologist’s Perspective on Management of Brain Metastases in Patients with EGFR Mutant Non-small Cell Lung Cancer |
title_full | A Neuro-oncologist’s Perspective on Management of Brain Metastases in Patients with EGFR Mutant Non-small Cell Lung Cancer |
title_fullStr | A Neuro-oncologist’s Perspective on Management of Brain Metastases in Patients with EGFR Mutant Non-small Cell Lung Cancer |
title_full_unstemmed | A Neuro-oncologist’s Perspective on Management of Brain Metastases in Patients with EGFR Mutant Non-small Cell Lung Cancer |
title_short | A Neuro-oncologist’s Perspective on Management of Brain Metastases in Patients with EGFR Mutant Non-small Cell Lung Cancer |
title_sort | neuro-oncologist’s perspective on management of brain metastases in patients with egfr mutant non-small cell lung cancer |
topic | Lung Cancer (HA Wakelee, Section Editor) |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5385200/ https://www.ncbi.nlm.nih.gov/pubmed/28391420 http://dx.doi.org/10.1007/s11864-017-0466-0 |
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