Current Cancer Therapy Reviews - Volume 16, Issue 3, 2020

A long time ago, metastatic brain tumors were often not treated and patients were only given palliative care. In the past decade, researchers selected those with single or 1-3 metastases for more aggressive treatments like surgical resection, and/or stereotactic radiosurgery (SRS), since the addition of whole brain radiotherapy (WBRT) did not increase overall survival for the vast majority of patients. Different studies demonstrated significantly less cognitive deterioration in 0-52% patients after SRS versus 85-94% after WBRT at 6 months. WBRT is the treatment of choice for leptomeningeal metastases. WBRT can lower the risk for further brain metastases, particularly in tumors of fast brain metastasis velocity, i.e. quickly relapsing, often seen in melanoma or small cell lung carcinoma. Important relevant literature is quoted to clarify the clinical controversies at point of care in this review. Synchronous primary lung cancer and brain metastasis represent a special situation whereby the oncologist should exercise discretion for curative treatments, with reported 5-year survival rates of 7.6%-34.6%. Recent research suggests that those patients with Karnofsky performance status less than 70, not capable of caring for themselves, are less likely to derive benefit from aggressive treatments. Among patients with brain metastases from non-small cell lung cancer (NSCLC), the QUARTZ trial (Quality of Life after Radiotherapy for Brain Metastases) helps the oncologist to decide when not to treat, depending on the performance status and other factors.

Radiotherapy is an important component of the treatment for primary and metastatic brain tumors. Due to the close proximity of critical structures and normal brain parenchyma, Central Nervous System (CNS) radiotherapy is associated with adverse effects such as neurocognitive deficits, which must be weighed against the benefit of improved tumor control. Advanced radiotherapy technology may help to mitigate toxicity risks, although there is a paucity of high-level evidence to support its use. Recent advances have been made in the treatment for gliomas, meningiomas, benign tumors, and metastases, although outcomes remain poor for many high grade tumors. This review highlights recent developments in CNS radiotherapy, discusses common treatment toxicities, critically reviews advanced radiotherapy technologies, and highlights promising treatment strategies to improve clinical outcomes in the future.

A registry of brain and central nervous system (CNS) tumor patients in Hong Kong comprising of data from both public and private neurosurgical practices (with approximately 98% patients of Chinese origin), suggested geographical or racial variations in disease incidence. The data confers the finding of a comparatively lower incidence rate of meningioma and malignant gliomas as in other parts of Southeast Asia. With data suggesting epidemiological difference, the treatment response, particularly in highgrade glioma, was studied. Patients suffering from glioblastoma (GBM) in Hong Kong received the standard of care, which involves safe, maximal resection followed by the Stupp regime. 5-aminolevulinic acid (5-ALA)-based fluorescence-guided surgery was found to be feasible and safe to adopt in the treatment of local WHO Grade III & IV gliomas patients. Survival benefit was seen in a group of patients using extended adjuvant temozolomide (TMZ) treatment for newly diagnosed GBM as compared to those treated with the standard 6 cycles. Salvage therapies with either single agent bevacizumab or bevacizumab plus irinotecan appeared to be effective treatment options in Hong Kong patients with recurrent malignant glioma, with a good associated 6- month progression-free survival (PFS) rate which was comparable to previously published overseas data in this disease type in the same overall population.

A wide variety of neoplasms can affect the central nervous system. Surgical management is impacted by tumor biology and anatomic location. In this review, an overview is presented of common and clinically significant CNS tumor types based on anatomic location.

Glioma is the most common type of tumor in the central nervous system (CNS). Diagnosis is through history, physical examination, radiology, histology and molecular profiles. Magnetic resonance imaging is a standard workup for all CNS tumors. Multidisciplinary team management is strongly recommended. The management of low-grade gliomas is still controversial with regards to early surgery, radiotherapy, chemotherapy, or watchful waiting watchful waiting. Patients with suspected high-grade gliomas should undergo an assessment by neurosurgeons for the consideration of maximum safe resection to achieve optimal tumor debulking, and to provide adequate tissue for histologic and molecular diagnosis. Post-operative radiotherapy and/or chemotherapy are given depending on disease grade and patient performance. Glioblastoma are mostly considered incurable. Treatment approaches in the elderly, pediatric population and recurrent gliomas are discussed with the latest updates in the literature. Treatment considerations include performance status, neurocognitive functioning, and co-morbidities. Important genetic mutations, clinical trials and guidelines are summarized in this review.

Background & Aims: Celiac plexus neurolysis is an elegant way of reducing pain in patients with pancreatic cancer. The aim of this work was to compare the effectiveness of ultrasound versus fluoroscopy-guided celiac plexus neurolysis in pancreatic cancer management. Methods: This study included 60 patients presenting with pancreatic cancer pain; who were subjected to one session of celiac plexus neurolysis and were divided equally into two groups: - Group (1): included 30 patients (12 females&18 males); who were exposed to ultrasound (US)- guided celiac plexus neurolysis and group (2): included 30 patients (10 females & 20 males) who were exposed to fluoroscopy-guided celiac plexus neurolysis. Abdominal pain was assisted by visual analogue score (VAS). Results: Regarding VAS, our results revealed that all patients showed improvement after celiac plexus neurolysis either through ultrasound technique or via percutaneous fluoroscopy technique. Furthermore, the ultrasound group recorded more significant pain relief with improved VAS than the fluoroscopy group immediately and on long-term follow-up with mean ± SD as follows: - Immediately (9.2 ± 0.8) to (2.5 ± 0.7) vs. (9.1 ± 0.7) to (3.5 ± 0.82, respectively); After 1 week (1.1 ± 0.8 vs. 3.6 ± 1.7, respectively), after 1 month ( 1 ± 0.9 vs. 3.7 ± 1.9), after three months (1.7 ± 1.01 vs. 5.9 ± 1.7, respectively) and after 6 months (2.3 ± 0.6 vs. 7.5 ± 1.6, respectively). Conclusion: The study revealed that ultrasound-guided celiac plexus neurolysis is more durable, tolerable, effective and safe compared to fluoroscopy-guided neurolysis of patient suffering from pancreatic cancer pain.

The hepatitis B virus (HBV) is one of the leading causes of hepatocellular carcinoma (HCC) worldwide. In the endemic region, the infection is commonly spread through vertical transmission in which mother and child possess genetically identical viral genotypes in the setting of similar host genomes. Despite these genetic similarities, clinical outcomes from chronic hepatitis B (CHB) can vary widely, ranging from lifelong asymptomatic infection to terminal HCC. Presented here are the longitudinal observations over multiple decades of three family clusters, including monozygotic twins with non-discordant HCC, that demonstrate the heterogeneity of HBV-related outcomes. These findings emphasize the important need to untangle the role of genetic and non-genetic host factors in the development of HBV-related HCC, as well as highlight the novel research avenues that can clarify the contributions of such factors in HBV-related HCC.