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Chemotherapeutic Agents for Brain Metastases in Non-Small Cell Lung

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Chemotherapeutic Agents for Brain Metastases in Non-Small Cell Lung Fuentes et al. Clin Med Rev Case Rep 2016, 3:107 Volume 3 | Issue 5 Clinical Medical Reviews ISSN: 2378-3656 and Case Reports Case Report: Open Access Chemotherapeutic Agents for Brain Metastases in Non-Small Cell Lung Cancer: A Case Report with Eribulin Mesylate and Review of the Literature Alejandra C Fuentes1, Reordan O De Jesus2 and David N Reisman3* 1Department of Internal Medicine, University of Florida, Gainesville, FL, USA 2Department of Radiology, University of Florida, Gainesville, FL, USA 3Department of Medicine, Division of Hematology/Oncology, University of Florida, Gainesville, FL, USA *Corresponding author: David N Reisman M.D., Ph.D, Department of Medicine, Division of Hematology/ Oncology, University of Florida, PO Box 100278, Gainesville, FL 32610-0278, USA, Tel: 352-273-7832, E-mail: [email protected] nervous system (CNS), where systemic chemotherapy has had poor Abstract penetration. Lung cancer accounts for the majority of cases of brain metastases, resulting in higher morbidity and mortality. Surgery and radiation are The standard treatment options for BM include surgical resection the current standard of care for the treatment of brain metastases. or stereotactic radio surgery (SRS) for patients with a limited number However, when brain metastases recur despite these treatments, of lesions (3-4), and whole brain radiation therapy (WBRT) for the management options are limited, especially when recurrent multiple lesions. What has not been well defined in the treatment of metastatic events occur. The role of systemic chemotherapy BM is the role of systemic chemotherapy [5]. Systemic chemotherapy for brain metastases remains undefined, with advances in drug has been found in some evidence-based studies to show no survival delivery and ongoing studies using targeted agents showing benefit in the treatment of BM [5,6]. promising results. We describe the case of a patient with non- small cell lung cancer who had recurrent brain metastases, which BM that is recurrent can become a challenge. Radiation therapy eventually became untreatable due to prior radiation. After using a to the brain is limited by normal tissue tolerance, the threshold at combination of eribulin mesylate, bevacizumab, and erlotinib, the which significant toxicity from radiation therapy may occur. Severe patient’s brain metastases exhibited a remarkable response. This toxicity is rarely seen due to limitations in radiation dosage, as well case highlights the potential of combined agents with low profiles of toxicity in achieving a notable intracranial response. It also as the short overall survival of NSCLC patients, but severe forms of suggests that the activity of eribulin mesylate, a novel treatment toxicity can include brain tissue necrosis, leukoencephalopathy, and currently being studied in non-small cell lung cancer, should be dementia [7-10]. Thus, once a patient with recurrent BM has received further studied on brain metastases. We also review the current the maximum radiation dose, further treatment options for BM are literature on the treatment of non-small cell lung cancer, focusing scarce at best. As a result, the scientific community continues to on the treatments’ reported response rates on brain metastases. study the barriers affecting the use of chemotherapy for BM. Keywords The blood brain barrier (BBB) has been the main proposed Non-small cell, Lung cancer, Brain metastases, Eribulin, mechanism hindering the entry of systemic chemotherapeutic Chemotherapy, Systemic therapy agents. Understanding BBB physiology has been the target of multiple studies, and novel drugs with augmented BBB penetration are beginning to show promising results. The new generations of Introduction targeted molecular drugs have demonstrated some activity in the Lung cancer is the leading cause of cancer-related deaths, CNS. These include tyrosine kinase inhibitors such as erlotinib accounting for nearly 27% in the United States and 20% worldwide (Tarceva) or monoclonal antibodies such as bevacizumab (Avastin), [1,2]. It also accounts for the majority of cases of brain metastases which have been approved in the US for the treatment of non-small (30-50%), which are associated with a poor prognosis and a higher cell lung cancer (NSCLC). Multiple targeted agents are currently morbidity and mortality [3,4]. The reported incidence of brain under investigation; however, there is no consensus on the best agent metastases (BM) is growing due to increased utilization of magnetic or combination of agents for BM. resonance imaging (MRI) during the staging work-up, as well as This article will discuss a patient with NSCLC who had recurrent the advances in therapy leading to a prolonged overall survival brain metastases that were not treatable with radiation or surgery. with enhanced opportunity for dissemination into the central This patient, after triple treatment with erlotinib, bevacizumab, Citation: Fuentes AC, Jesus ROD, Reisman DN (2016) Chemotherapeutic Agents for Brain Metastases in Non-Small Cell Lung Cancer: A Case Report with Eribulin Mesylate and Review of the Literature. Clin Med Rev Case Rep 3:107 ClinMed Received: March 15, 2016: Accepted: May 28, 2016: Published: May 30, 2016 International Library Copyright: © 2016 Fuentes AC. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. and eribulin mesylate, showed first regression and then prolonged cerebellum (1.3cm), confirming stage IV disease. She was otherwise stabilization of brain metastases. While erlotinib and bevacizumab neurologically intact. On May 15th she underwent WBRT for a total have been studied on BM in NSCLC with modest results, no such of 30 gray (Gy) at 3 Gy/fraction. On May 31st she began concurrent studies have been done on eribulin. Eribulin mesylate, a novel agent chemotherapy and radiation, with carboplatin (AUC 2) and paclitaxel with a low toxicity profile that inhibits microtubule dynamics, is (45 mg/m2) weekly for 6 weeks, and a total of 50 Gy (2.5 Gy/fraction) currently FDA-approved for refractory metastatic breast cancer. of radiation to the mediastinum. A follow-up PET scan 3 weeks Eribulin mesylate has shown promising activity in a phase II trial on after completion of radiation on August 9th demonstrated treatment patients with advanced NSCLC previously treated with a taxane, with response, with decreased mediastinal lymphadenopathy. 50% of patients achieving stable disease and a clinical benefit rate An MRI scan of her brain in September 2013 demonstrated (defined as the summation of complete remission, partial remission, overall improvement and response to radiation, with smaller parietal and stable disease for at least three months) of 27% [11]. There has (1.1 cm), basal ganglia (0.9 cm), and cerebellar (0.7 cm) lesions. PET also been one reported case with effective BM regression in breast scan on October 30th showed mixed extracranial response without cancer after treatment with eribulin mesylate [12]. any uptake in the mediastinum but with new FDG-avidity in a level We will also review the current systemic and targeted agents and IV left cervical lymph node (max SUV 2.9 g/mL), as well as increased their documented activity on BM, with the aim of further highlighting radiotracer uptake in the distal left femur. She had associated pain the need for more clinical trials to help establish a consensus on a in her left femur, and received empiric palliative radiation to this chemotherapeutic approach to BM. area (18 Gy). Brain MRI on December 27th showed a stable parietal lesion (1.1 cm); however, the basal ganglia (1.2 cm) and cerebellar Case Presentation (1.1 cm) lesions had enlarged, and there were multiple new smaller A 58 year-old female with a past medical history of hypertension lesions (Figure 1A). Her lesions were still asymptomatic. CT imaging th and tobacco abuse (20 pack-year) was diagnosed with Stage IIIa on December 30 also showed progression of disease, with bony th adenocarcinoma of the lung. She initially presented in January metastases in the left 10 rib and left iliac wing. 2013 at another institution with a complaint of mildly progressive Given her recurrent brain metastases, which at this point shortness of breath and cough. Computed tomography (CT) of the represented the most serious problem facing this patient, we selected chest showed mediastinal lymphadenopathy. Follow-up positron drugs that had a reasonable probability to penetrate into the CNS th emission tomography (PET) scan on February 12 showed a and also to be effective with her lung cancer. Since sequential therapy fluorodeoxyglucose (FDG)-avid, left-sided level III cervical lymph was unlikely to be feasible with this patient, we elected to use a node (sub-centimeter in size) with a maximum standardized uptake simultaneous combination of agents. We selected targeted therapies value (SUV) of 3.3 g/mL, as well as a single FDG-avid mediastinal with a low toxicity profile because if these drugs were effective, we did node in the aorto-pulmonary window (1.8 x 1.4 cm) with maximum not want to discontinue them due to toxicity, which often occurs with SUV of 10.2 g/mL. This left cervical node was biopsied and found the majority of other lung cancer drugs. Hence, she was treated with th to be negative. Hence, on March 4 , 2013 she underwent an aortal a simultaneous combination of three drugs: erlotinib, bevacizumab, pulmonic lymph node excision (2.5 x 2 x 1.5 cm). Immuno- and eribulin. While eribulin is not a targeted agent per se, we used peroxidase studies were positive for cytokeratin 7, monoclonal CEA, it weekly at a lower dose (1.0 mg/m2 every 1-2 weeks for 16 doses) vimentin, and TTF1, and negative for cytokeratin 20, CDX2, estrogen to minimize toxicity. Erlotinib was started at 150 mg PO daily receptors and mammaglobin, consistent with lung adenocarcinoma (continued for 9 months) and the dose titrated for development of stage IIIA.
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